EEG of Newborn and Infants

Ki Joong Kim MD PhD Pediatric Neurology Seoul National University Childrens Hospital Seoul, Korea

Maturation of EEG

Maturation of EEG patterns parallels brain development Anatomical and physiological development of brain Development of age-specific waking and sleep patterns Most dramatic EEG changes occur between premature age and 1st 3 months of life EEG patterns during 1st 6 months closely correlate with conceptual age (CA)

Neonatal EEG

Function of actual age of brain CA = gestational age + legal (chronological) age A number of age-specific normal EEG features for only several weeks at a time Different clinical implication when seen at later ages Persistence or reappearance of patterns with immature features (dysmaturity) means cerebral dysfunction More mature EEG pattern than expected is usually due to underestimated CA

Neonatal montage

Fp1 Fp3 F7
CH3

Fp2 Fp4 Fz Cz F4
CH5

F3
CH1

F8
CH7

T3

CH9

C3

CH10

CH11

C4

CH12

T4

T5
CH4

P3
CH2

Pz

P4
CH6 CH8

T6

O1

O2

Developmental EEG Characteristics of premature and term baby

CA (wk) Continuity of Background Activity Awake Quiet sleep D Active sleep D Synchrony of Background Activity Awake Quiet sleep ++++ Active sleep ++++ EEG Difference between Arousal and Sleep No 1. Temporal theta bursts 2. Beta-delta complexes in central region 3. Occipital very slow activity 1. Beta-delta complexes in TO region 2. Rhythmic 1.5Hz activity in frontal leads in transitional sleep 3. Temporal alpha bursts replace 4-5 Hz bursts 1. Frontal sharp transients 2. Extremely high voltage beta activity during beta-delta complexes 3. Temporal alpha bursts disappear 1. Continuous bioccipital delta activity with superimposed 12-15Hz activity during active sleep 2. Central beta-delta complexes disappear 1. Occipital beta-delta complexes decrease and disappear by 39wk 2. Trace alternant pattern (NREM sleep) Appearance and Disappearance of Specific Waveforms and Patterns

27-28

29-30

No

31-33

++

No

34-35

+++

+++

No

36-37

++++

++

++++

Yes

38-40

++++

+++

++++

Yes

Mizrahi EM et al Atlas of Neonatal EEG 2004

EEG change in newborn

Less than 29 wks Trac discontinu (continuously discontinuous and bilaterally synchronous) Delta brush emerge at 26 weeks

29-31 weeks

Greater periods of continuous activity, suppression periods les than 30 sec Frequent delta brushes, temporal theta burst pattern

32-34 weeks

EEG reactivity to stimulation established Periods of diffuse attenuation less than 15 sec Abundant multifocal sharp transients and delta brushes Delta brushes appear less often and multifocal sharp transients less frequent Frontal sharp transients appear Trac discontinu pattern is replaced by trac alternant Low voltage irregular (LVI) in waking and active sleep Mixed voltage (MV) pattern in waking, transitional and active sleep High voltage slow (HVS) in quiet sleep Trac alternant (TA) in quiet sleep
Fisch BJ EEG Primer 1999

34-37 weeks

After 38 weeks

EEG of Premature ( GA 24-27 Weeks)

Continuity Interhemispheric synchrony Differentiation of waking and sleeping Posterior basic alpha rhythm Slow activity (awake) Temporal theta burst Occipital theta Fast activity (awake) Low voltage Trac alternant Spindles Vertex waves and K complexes Positive occipital sharp transients Slow and fast activity in sleep REM sleep Discontinuous, long flat stretches Short bursts in synchrony Undifferentiated None Very slow high voltage bursts Present and increasing Prominent Very little beta activity Long flat stretches None None None None Slow activity of high voltage, little slow activity Undifferentiated
Niedermeyer E Electroencephalography 1999

(trac discontinu)

M / GA 26 wk

Trac discontinu

M / GA 27 wk

Trac discontinu

EEG of Premature (28-31 Weeks)

Continuity Interhemispheric synchrony Differentiation of waking and sleeping Posterior basic alpha rhythm Slow activity (awake) Temporal theta burst Occipital theta Fast activity (awake) Low voltage Trac alternant Spindles Vertex waves and K complexes Positive occipital sharp transients Slow and fast activity in sleep REM sleep Discontinuous Mostly asynchronous Undifferentiated None Very slow activity predominant Prominent (temporal sawtooth waves) Decreasing Frequent ripples or brushes around 16/sec (delta brushes) Flat stretches, mainly asynchronous None None (but ripples present) None None Much slow activity, more irregular, little fast activity Undifferentiated
Niedermeyer E Electroencephalography 1999

(trac discontinu)

M / GA 28 wk

Trac discontinu

F / GA 29 wk

Temporal theta

F / GA 29 wk

Delta brush

M / GA 30 wk

Ripples including delta brush

M / GA 31 wk

Ripples

EEG of Premature (32-35 Weeks)

Continuity Interhemispheric synchrony Differentiation of waking and sleeping Posterior basic alpha rhythm Slow activity (awake) Temporal theta burst Occipital theta Fast activity (awake) Low voltage Trac alternant Spindles Vertex waves and K complexes Positive occipital sharp transients Slow and fast activity in sleep REM sleep Continuous in waking and REM, discontinuous in NREM Partly synchronous, especially in occipital leads Waking distinguished from sleep early in the period None Slow (delta) with occipital maximum Decreasing and disappearing Decreasing Frequent ripples or brushes (16-20/sec) Low voltage records suspect of serious cerebral pathology Present in NREM (quite) sleep None (but ripples present) None None Irregular slow activity of occipital predominance Continuous slow activity
Niedermeyer E Electroencephalography 1999

M / GA 32 wk

Discontinuity

M / GA 32 wk

Asymmetry and asynchrony

M / GA 32 wk

Continuity

F / GA 33 wk

Continuity

F / GA 33 wk

Asynchrony

M / GA 34 wk

Status change

F / GA 34 wk

Ripples and frontal sharp transient

F / GA 35 wk

Continuity

F / GA 35 wk

Trace alternant

EEG of Full-term Newborn (36-41 Weeks)

Continuity Interhemispheric synchrony Differentiation of waking and sleeping Posterior basic alpha rhythm Slow activity (awake) Temporal theta burst Occipital theta Fast activity (awake) Low voltage Trac alternant Spindles Vertex waves and K complexes Positive occipital sharp transients Slow and fast activity in sleep REM sleep Continuous except for trac alternant in NREM (quiet) sleep Minor asynchronies still present Good None Slow (delta) mostly of moderate voltage Disappearing or absent Absent Decreasing ripples, sparse fast activity Very low voltage records due to serious cerebral pathology Present in NREM (quite) sleep None (but scanty ripples) None None Much delta and theta activity, continuous in REM sleep Continuous slow activity
Niedermeyer E Electroencephalography 1999

M / GA 36 wk

F / GA 37 wk

M / GA 38 wk

Trac alternant

F / GA 39 wk

Frontal sharp transient

F / GA 40 wk

M / GA 40 wk

Anterior dysrhythmia

M / GA 42 wk

Appearance and disappearance of developmental EEG landmarks

Trace Alternant

Frontal Sharp Transients Occipital Dominant Alpha Rhythm Vertex Transients

Temporal Alpha Bursts

Temporal Theta Bursts

Beta Delta Complex

Sleep Spindles

26

28

30

32

34

36

38

40

42

44

46

48

50

52

54

Conceptual Age (weeks)

Mizrahi EM et al Atlas of Neonatal EEG 2004

F / GA 38 wk

Excessive suppression in HIE

F / GA 38 wk

Rhythmic epileptiform activity in HIE

F / GA 38 wk

Rhythmic epileptiform activity in HIE

F / GA 41 wk

Focal spike discharges

F / GA 40 wk

FST vs. epileptiform spike

F / GA 40 wk

Repetitive spike discharges

F / GA 40 wk

Neonatal seizures

F / GA 40 wk

Neonatal seizures

F / GA 40 wk

Neonatal seizures

M / GA 33 wk

Neonatal seizures

M / GA 33 wk

Neonatal seizures

M / GA 33 wk

Neonatal seizures

Early Infantile Epileptic Encephalopathy with Suppression-bursts (EIEE)

Pseudoperiodical suppression-bursts pattern High amplitude bursts alternating with and nearly flat suppression phases Bursts of irregular 150-350 V high voltage slow waves mixed with spikes for 1-3 seconds Suppression phase for 3-4 seconds Burst-burst interval 5-10 seconds Appearance regardless of waking and sleep states

F / 1 mo

Burst suppression in EIEE

F / 1 mo

Burst suppression in EIEE

Normal EEG in Infancy

Delta and theta equally prominent Transient asymmetries Central rhythms develop during the 1st year Posterior rhythms equivalent to alpha of older age during eye closure V waves of higher voltage and briefer than in adults (spike-like) begins at 3-4 months Spindles of more numerous and longer than later expressed at 3-4 months

EEG of Infancy (2-12 Months)

Continuity Interhemispheric synchrony Differentiation of waking and sleeping Posterior basic alpha rhythm Slow activity (awake) Temporal theta burst Occipital theta Fast activity (awake) Low voltage Trac alternant Spindles Vertex waves and K complexes Positive occipital sharp transients Slow and fast activity in sleep REM sleep Continuous No significant asynchrony Good Starting at 3-4 mos (4/sec) reaching about 6/sec at 12 mos Considerable None None Very moderate Uncommon, usually abnormal Disappears in 1st (seldom 2nd) mo Appear after 2nd mo (12-15/sec, sharp, shifting) Appear mainly at 5 mos, fairly large, blunt None Much diffuse 0.75-3/sec activity with posterior maximum REM portion decreasing
Niedermeyer E Electroencephalography 1999

M / 1 mo

M / 3 mo

M / 5 mo

Sleep spindle

M / 8 mo

A-P gradient

West Syndrome (Infantile Spasms)

Hypsarrhythmia Disorganized and chaotic background activity Irregular high amplitude 1-3 Hz slow waves with multifocal asynchronous spikes or sharp waves Appear during awake and light sleep states Modified or atypical hypsarrhythmia possible Electrodecremental event (EDE)

M / 6 mo

Hypsarrhythmia in IS

M / 13 mo

Hypsarrhythmia in IS

Changing EEG Patterns from SB through H to SSW

Awake

SB

SSW

SSW

Sleep

SB

SB

SSW

F / 2 mo

Early phase of IS

F / 2 mo

EEG progression of IS

Patterns of Atypical Hypsarrhythmia

Asymmetrical or unilateral hypsarrhythmia Hypsarrhythmia with constant focal discharges Hypsarrhythmia comprising primary, high-voltage, bilateral asynchronous slow activity with minimal epileptiform potentials Hypsarrhythmia with partial conservation of basal rhythm and focal or generalized sharp and slow waves Hypsarrhythmia similar to suppression-bursts

F / 15 mo

Asymmetric hypsarrhythmia

F / 7 mo

Hypsarrhythmia with constant focal discharges

M / 3 mo

Hypsarrhythmia with constant focal discharges

M / 3 mo

Hypsarrhythmia with constant focal discharges

M / 4 yr

Hypsarrhythmia with prominent fast activity

HF 12Hz

M / 16 mo

Hypsarrhythmia with rare epileptiform discharges

M / 7 mo

Hypsarrhythmia with prominent slow activity

F / 4 mo

Hypsarrhythmia with conservation of normal BG

F / 10 mo

Hypsarrhythmia with normal BG due to status change

F / 2 mo

Hypsarrhythmia like burst-suppression

F / 4 mo

Hypsarrhythmia like burst-suppression

F / 10 mo

Electrodecremental event (EDE)

F / 7 mo

Ictal EEG in IS

EEG of Early Childhood (12-36 Months)

Continuity Interhemispheric synchrony Differentiation of waking and sleeping Posterior basic alpha rhythm Slow activity (awake) Temporal theta burst Occipital theta Fast activity (awake) Low voltage Trac alternant Spindles Vertex waves and K complexes Positive occipital sharp transients Slow and fast activity in sleep REM sleep Continuous No significant asynchrony Good Rising from 5-6/sec to 8/sec Considerable None None Mostly moderate Uncommon, usually abnormal None In 2nd yr sharp and shifting, then symmetrical with vertex max Large, becoming more pointed Poorly defined Marked posterior maximum of slow activity Mostly slow, starting to become more desynchronized
Niedermeyer E Electroencephalography 1999

M / 13 mo

Vertex sharp transient

Summary

Within broad normal limits of variability for age Marginal patterns should be interpreted in a prudent manner Rash link between brain and psyche do more harm Deviation from normal, immaturity or structural insult ? Careful correlation with clinical status for significance

Thank You for Your Attention