Evaluation of EEG Foundation Models for Event-Based Burst-Suppression Detection in ICU
Authors: Elisa Vasta, Thorir Mar Ingolfsson, Andrea Cossettini, Luca Benini, Tilman Beck, Emanuela Keller, Una Pale
Organizations: Neurocritical Care Unit, Institute for Intensive Care Medicine and Department of Neurosurgery, University Hospital Zürich and University of Zürich, Zürich, Switzerland · Integrated Systems Laboratory, ETH Zürich, Zürich, Switzerland · DEI, University of Bologna, Bologna, Italy
Burst suppression (BS) is a clinically relevant electroencephalographic (EEG) pattern used to monitor sedation depth and brain activity in critically ill patients, particularly during induced coma in Intensive Care Units (ICUs). Automatic burst detection remains challenging because BS patterns vary substantially between patients and annotated datasets are scarce. Recently, EEG Foundation Models (FMs) have shown promise across several downstream EEG applications, but their usefulness for BS detection remains unexplored. We present the first study to evaluate EEG FMs for burst detection in reduced-montage ICU EEG without patient-specific calibration. We compare REVE-base, LUNA-large and LuMamba-Tiny with an adaptive thresholding baseline and a task-specific EEGNet baseline. Additionally, we complement conventional EEG window-based classification with event-based burst detection evaluation. This helps assessing clinically whether burst episodes are correctly detected, reducing the impact of expected annotation variability. The best model, REVE-base, achieved the highest event-based F1-score (0.868±0.167) and reduced burst-per-minute error by 52.1% and 36.2% compared to EEGNet and adaptive thresholding respectively, supporting FMs for scalable EEG monitoring in ICU. Ablation experiments showed that full fine-tuning was the most effective adaptation strategy with respect to frozen-backbone training, two-step fine-tuning, and LoRA-based adaptation, improving event-based F1-score over frozen-backbone training by up to +0.102 for LUNA-large. With reduced labeled datasets, pretrained REVE-base outperformed random initialization by +0.723 event-based F1 points at 25% of the cohort, demonstrating the benefit of pretraining FM representations when adapted to burst detection with limited labeled data.
Foundation models (FMs) promise to extract unified representations that generalize across downstream tasks. They have emerged across fields, including electroencephalography (EEG), but it is less clear how effective they are in this particular field. Published evaluations differ in datasets, in the EEG-specific preprocessing that might influence reported results, and in the reported metrics, frequently obscuring the clinical relevance in EEG. We introduce NeuroAtlas, the largest EEG benchmark to date: 42 datasets and 260k hours covering clinical EEG (epilepsy, sleep medicine, brain age estimation) and brain-computer interfaces, and include multiple datasets per task along with bespoke clinical evaluation metrics. Besides evaluating EEG-FMs with respect to supervised baselines, we present results from generic time-series FMs. We report three findings. First, EEG-specific FMs do not consistently outperform time-series FMs, which have neither EEG-focused architectures nor been pretrained on EEG. Second, standard machine learning metrics are insufficient to assess clinical utility: thus, we thoroughly evaluate more appropriate measures such as the quality of event-level decision-making, hypnogram-derived features, and the brain-age gap in the domains of epilepsy, sleep, and brain age, respectively. Third, model rankings and performance can vary substantially within domains. We conclude that pretrained models perform largely on par, with only narrow advantages for a few, and that current models do not yet deliver on the promise of an out-of-the-box unified EEG model. NeuroAtlas exposes this gap and provides the datasets and metrics for the next generation of unified EEG FMs.
Konstantinos Kontras, Trui Osselaer, Stylianos G. Mouslech +12
Deep learning for EEG-based seizure detection faces critical challenges: severe annotation scarcity and extreme class imbalance, where ictal events comprise less than 10% of clinical recordings. We present DiffEEG, a 9.6M-parameter self-supervised foundation model that addresses both limitations through denoising diffusion pre-training and reinforcement learning (RL)-based fine-tuning. Pre-trained on 1.3M unlabeled segments from the Temple University Hospital Seizure Corpus (TUHSZ), DiffEEG learns generic neural representations via a 1D U-Net with multi-head self-attention. For downstream adaptation, a reinforced decision layer employs policy gradient optimization to directly maximize F1-score, prioritizing sensitivity to rare seizure events over overall accuracy. Under strict patient-wise evaluation (279 patients, Leave-One-Fold-Out), DiffEEG achieves 61% accuracy and 59% F1 for 4-class seizure subtyping, and 81% accuracy with 85% weighted F1 for binary detection, maintaining clinically viable seizure recall (59%) despite extreme imbalance (6.7% prevalence). Segment-level evaluation establishes an upper bound of 97.6% accuracy, confirming strong architectural capacity. DiffEEG demonstrates that diffusion-based pre-training combined with metric-aware reinforcement learning enables clinically deployable seizure monitoring with minimal labeled data requirements.
Abdulkader Helwan, Lina Abou-Abbas, Hussein El Amouri +2
EEG foundation models (EEG-FMs) have been evaluated predominantly on clean, in-distribution accuracy, leaving their robustness, interpretability and representational quality largely unexamined. This study addresses these gaps by benchmarking six EEG-FMs against a baseline deep learning model across eight datasets. Beyond clean accuracy, we conduct three layers of analysis: (i) Robustness: we apply test-time perturbations including additive noise, random and region-based channel dropout and region-specific noise injection. Our analyses show that no single model dominates all failure modes. The most noise-robust model is among the most fragile under channel dropout and much of the dropout fragility disappears when channels are removed rather than zero-padded. (ii) Interpretability: we present the first application of Attention-Aware Layer-Wise Relevance Propagation (AttnLRP) to EEG-FMs and show that models broadly concentrate relevance on task-appropriate brain regions consistent with known neurophysiology. However, attribution maps remain spatially stable under perturbation while predictions degrade, suggesting that the models attend to the correct brain regions but decode corrupted content. (iii) Expressiveness: With block-wise probing we show that late blocks are repurposed during fine-tuning, while early blocks already hold task-related information. Furthermore, we demonstrate that the poor head-only performance previously attributed to low-quality pre-trained representations is largely explained by pooling and that EEG-FMs possess sufficient representational capacity when their token-level embeddings are preserved. Together, these findings provide the first systematic assessment of robustness, interpretability and expressiveness for EEG-FMs and highlight critical considerations for their development.