in the diagnosis of epilepsy International League Against Epilepsy: Commission Report Commission on European Aairs: Subcommission on European Guidelines Introduction The primary diagnosis of epilepsy is clinical but electroencephalography (EEG) plays a major role in evaluating epilepsy, recognizing that a normal routine EEG does not exclude the diagnose of epilepsy. The main indication for performing an EEG is clinical suspicion of an epileptic disorder. EEGs can also be useful in the evalu- ation of encephalopaties (metabolic, infectious, degenerative) and focal brain lesions (cerebral infarction, haemorrhage, neoplasms). In paediat- ric practice, the EEG might help to determine the level of maturation of the brain. The EEG is not useful in following the therapeutic eect of antiepileptic drugs (AEDs) as interictal epilepti- form activity is aected very little by AEDs. An exception is absence epilepsy where the quanti- cation of spike-wave episodes is helpful in following the eect of treatment. Flink R, Pedersen B, Guekht AB, Malmgren K, Michelucci R, Neville B, Pinto F, Stephani U, O
zkara C. Guidelines for the use of EEG
methodology in the diagnosis of epilepsy. International League Against Epilepsy: Commission report. Commission on European Aairs: Subcommission on European Guidelines. Acta Neurol Scand 2002: 106: 17. Blackwell Munksgaard 2002. The Commission of European Aairs of the International League Against Epilepsy published Appropriate Standards for Epilepsy Care Across Europe which contained recommendations for the use of electroencephalography (EEG) in the diagnosis of epilepsy (Brodie et al. Epilepsia 1997; 38:1245). The need for a more specic basic document of EEG methodology was recognized and the Subcommission on European Aairs was asked to produce more detailed guidelines to be used across Europe recognizing the range of practices in EEG laboratories. There are many general guidelines published on EEG methodology but this document focuses on the diagnosis of epilepsy. Details from previously published guidelines are included in references and in an appendix. These guidelines are not meant to be used as minimal standards but recommendations that can be applied to all EEG laboratories despite variations in equipment. R. Flink 1 , B. Pedersen 2 , A. B. Guekht 3 , K. Malmgren 4 , R. Michelucci 5 , B. Neville 6 , F. Pinto 7 , U. Stephani 8 , C. zkara 9 1 Department of Neuroscience, Clinical Neurophysiology, University Hospital, Uppsala, Sweden; 2 Neurologisk Avdelning, Aalborg sygehus Nord, Denmark; 3 Department of Neurology and Neurosurgery, Russian State Medical University, Moscow, Russia; 4 Department of Neurology, Institute of Clinical Neuroscience, Sahlgrenska University Hospital, Gteborg, Sweden; 5 Divisione di Neurologia, Ospedale Bellaria, Bologna, Italy; 6 Neuroscience Unit, Institute of Child Health, The Wolfson Centre, London, UK; 7 Consulta de Epilepsia, Hospital Santa Maria, Lisboa, Portugal; 8 Klinik fr Neuropdiatrie der Universitt, Kiel, Germany; 9 Cerrahpasa Tip Fakltesi, Norosirurji Anabilim Dali, Istanbul, Turkey Key words: Commission Report; European Guidelines; electroencephalography; diagnosis of epilepsy; methodology; EEG reporting Roland Flink, Department of Neuroscience, Clinical Neurophysiology, University Hospital, SE-751 85 Uppsala, Sweden Tel.: +46 18 66 3428 Fax: +46 18 55 6106 e-mail: roland.flink@nc.uas.lul.se Accepted for publication December 6, 2001 Acta Neurol Scand 2002: 106: 17 Printed in UK. All rights reserved Copyright Blackwell Munksgaard 2002 ACTA NEUROLOGICA SCANDINAVICA ISSN 0001-6314 1 The purpose of the EEG recording is to detect interictal activity and localize the region of inte- rictal activity and/or ictal activity or ictal events. In the presence of epileptiform activity, the EEG recording will also help to determine the type of seizure or epilepsy syndrome. A routine EEG recording in a patient with epilepsy will have no epileptiform activity in about 50% of cases. It is necessary therefore to increase the sensitivity by activation procedures such as hyperventilation, photic stimulation, sleep and sleep deprivation. The EEG recording during sleep is particularly useful when there is a suspicion of epilepsy with partial seizures or the syndrome of benign childhood epilepsy with centrotemporal spikes. Hypsarrhythmia in Wests syndrome is an EEG pattern that changes from wakefulness to sleep. Using activation procedures, abnormalities are found in about 90% of patients with epilepsy (1). If routine EEG and EEG after sleep deprivation still reveals no abnormalities, long-term EEG monitoring may be used, which increases the detection rate of interictal and/or ictal events. Routine EEGs for specic dierential diagnostic purposes should include simultaneous electrocar- diography (ECG) monitoring and where appropri- ate a monitoring of other parameters, i.e. respiration and muscle activity (polygraphic recording). Equipment and electrodes electrode position The modied combined nomenclature derived from the 1020 system should be used for electrode location and the minimum number of electrodes should be 21 regardless of the number of the channels available on the EEG (2). A 16-channel recording is recommended for focal (partial) epilepsies; however, for diagnosing primary generalized epilepsy the number of chan- nels is not crucial. Even with an eight-channel recording it is possible to obtain and locate the epileptiform discharges with the modied com- bined system but a longer sampling time using several montages will be required (3). Although there is no general agreement among EEG laboratories about montages, a routine EEG should (at least) include bipolar montages with longitudinal and transverse chains. These chains should be used with equal electrode distances and side-to-side symmetry to avoid the artefact of false amplitude asymmetry. Additional referential montages should be included in a routine record- ing. The previously mentioned montages are available in dierent settings in the international recommendations and can be used with dierent types of equipment from eight-channel EEG machines and those with more channels. As many EEG recordings are still analog, it is useful to have similar montages and examples of the common ones are given in the appendix (see Appendix). Recording parameters such as sensitivity, lter setting (notch lter) and time base should be in accordance with the international guidelines (4). The use of muscle lters and notch lter should be avoided if possible because of the risk of losing low amplitude spike potentials. The normal paper speed is 15 or 30 mm/s. Reduced paper speed allows better detection of slow wave abnormalities. The duration of recording time should be at least 30 min of artefact-free signals. In digital recordings, which allow remontaging, recording time should not be reduced, because the chances of recording interictal epileptiform activity increases with sampling time. The specic inter- national guidelines for recording clinical EEG on digital media should be used (5). Requirements for paediatric EEG recordings Preterm Although the head may be small, the minimum number of electrodes is nine. The montages per- formed should be bipolar, longitudinal and trans- verse including the Cz electrode. These recordings are often performed in surroundings with a lot of electrical interference, giving artefacts. Such arte- facts can be reduced by using short electrode cables thus placing the headbox and preamplier close to the head of the child. If possible a polygraphic recording should be obtained including ECG, respiration, eye movements and electromyography (EMG) to record muscle activity (6). The duration of the recording in small children should be at least 1 h to be able to evaluate wakefulness and sleep and reactivity. Photic sti- mulation in these children may give additional information and should be performed (7). Activa- tion processes in order to evaluate EEG reactivity could include tapping and auditorial stimuli. Infants and older children The adult electrode placement should be used as young as possible as more electrodes will enhance sensitivity. A sleep recording will increase the chance of recording epileptiform activity and usually reduce movement and muscle artefacts. In all children despite age, recordings in spontaneous sleep are preferred to induced sleep. Flink et al. 2 Recording procedure Standard EEG recording should attempt to include eye-opening, -closure and -blink procedures to exclude artefacts derived from eye movements. Voluntary hand movements can be useful for testing the reactivity of central rhythms. A standard EEG should aim to include the following activation procedures: (i) Hyperventilation depends upon the develop- mental age, and the level of co-operation of the child and the experience of the sta. (ii) Hyperventilation for 3 min with a continued recording for at least 2 min after cessation of hy- perventilation, which may be worth repeating if absence epilepsy is suspected and the rst recording was negative. If there is unexpected abnormal hy- persynchronization activity during hyperventila- tion, the possibility of physiological hypoglycaemia should be excluded. (iii) Photic stimulation should be performed with separate trains of photo ashes of 10 s duration for each frequency and with minimum intervals of 7 s. Each 10 s train consists of 5 s with open eyes fol- lowed by closure and 5 s with closed eyes. The distance between the lamp and the nose should be 30 cm. The method described below follows the previous recommendation for screening for and identifying photosensitive subjects (8, 9). Photic stimulation should not be performed during or within 3 min of hyperventilation. Photic stimu- lation should start at the frequency of 1 Hz and progress to 20 Hz unless generalized epileptiform discharges are evoked. This is immediately fol- lowed by a sequence with 60 Hz photic stimulation and then decreasing to 25 Hz. The trains should be performed with the following frequencies: 1, 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 60, 50, 40, 30 and 25 Hz and in that order. The total duration of photic activation time recommended is at maximum 6 min in patients without any reaction to intermit- tent photic stimulation. The procedure should be stopped at once if the patient has a warning or if epileptiform activity is evoked in the EEG. Not all EEG machines and photic stimulators can perform ashes up to 60 Hz, but testing using the single train with open eyes, eye closure and closed eyes should use the available frequencies, especially in children. A reduced program of 1, 4, 6, 10, 14, 16 and 20 Hz is used in several laboratories; however, one must be aware of the risk of false negative results. Sleep recordings can increase the accuracy of the diagnoses of epilepsy and should be per- formed when the standard EEG fails to show any epileptiform activity and the level of clinical suspicion justies this investigation. Sleep depriva- tion can be a useful activation procedure. It must be recognized that sleep deprivation may provoke clinical seizures. If natural sleep is not achieved, a number of pharmacological agents can be used to induce sleep. One must be aware of pharmacolog- ically induced EEG changes that occasionally may mimic epileptiform activity (interference of b activity). Adult patients should abstain from sleep the night prior to the recording. In children up to 12 years the sleeping time should be reduced as much as possible before the recording. A procedure used in many laboratories includes partial night sleep deprivation and EEG recording during the postprandial time when a nap is most likely to occur. The sleep recording should include wakeful- ness, drowsiness and at least 40 min of sleep. The depth of sleep should be at least to stages 2 and 3. The montage must include a bipolar montage with transverse chains which allow the identica- tion of vertex waves additional channels should be used for electrooculography (EOG), surface EMG recorded from submental muscles, ECG and spirogram (polysomnography) in order to identify sleep stages and to distinguish between frontal discharges and eye movements. Polysomnography should always be used for all-night recordings in order to record epileptic nocturnal activity and to dierentiate this activity from non-epileptic events. Long-term EEG recording Long-term monitoring refers to EEG recording over an extended period. There are several options in performing long-term monitoring (10). In cases where a standard EEG followed by activation procedures does not show clear evidence of interictal epileptiform activity a prolonged recording time increases the possibility of detection of interictal and ictal events. The duration of such recordings can, depending on the clinical question raised, be from few hours to several days. The standard 1020 system in its modied version is recommended for these recordings. The long-term monitoring can be performed with portable equipment. This type of dynamic EEG recording allows the patient freedom to perform routine activities as an out-patient or in- patient during long-term EEG monitoring. Eight- or 16-channel recordings are available. These EEG recordings may be useful to quantify seizure activity in patients with generalized discharges or for supervised monitoring in certain situations, that cannot be reproduced in the EEG laboratory Use of EEG for the diagnosis of epilepsy 3 or hospital. The disadvantages include the in- creased risk of technical problems and lack of accurate simultaneous behavioural correlation. This type of monitoring may preferably be performed as sleep recordings because the artefacts are less during sleep. In order to correlate clinical behaviour and EEG ndings the recording requires video-equipment with synchronized time code, i.e. split screen video EEG. Digital video EEG systems are currently available. Long-term video-EEG monitoring may be the only way to distinguish epileptic from non- epileptic seizures and is mandatory as part of presurgical evaluation. It is of great value if a trained technician or nurse is constantly present during a video-EEG recording to test patient responsiveness, muscle tone, etc., whenever suspect ictal episodes occur. A set of testing procedures including language tests should be available to the examiner, to be administered during suspected ictal episodes. EEG reporting The EEG report should be a response to the clinical question asked by the referring doctor. Apart from describing the waveforms and frequen- cies of the EEG signal there should be a clinical interpretation. A standardized report form is advocated and should include the following headings: (i) Information concerning the status of the patient, neurological condition, medication, last seizure, and clinical question. (ii) Information concerning the EEG recording; number of electrodes, use of special electrodes, recording conditions, level of consciousness of the patient during the recording, activation proce- dures, artefacts noted. (iii) Description of EEG; postcentral rhythm, background activity, asymmetries, epileptiform activity, specic EEG patterns, eect of activation procedures. (iv) Clinical interpretation; this puts the EEG ndings in a clinical context (the clinical signi- cance of the EEG ndings, prognosis, etc.), and responds to the clinical question. It is strongly advised to use the glossary pro- posed by the International Federation of Clinical Neurophysiology (11). Acknowledgements The authors wish to thank Guiliano Avanzini and Martin Brodie for valuable comments on the manuscript, and EUCARE for providing the subcommission the possibility of a workshop. References 1. BINNIE CD, STEFAN H. Modern electroencephalography: its role in epilepsy management. Clin Neurophysiol 1999;110:167197. 2. KLEM GH, LU
DERS HO, JASPER HH, ELGAR C. The ten-
twenty electrode system of the International Federation. Recommendations for the Practice of Clinical Neurophy- siology: Guidelines of the International Federation of Clinical Physiology. Electroenceph Clin Neurophysiol 1999;52(Suppl.):36. 3. AMERICAN ELECTROENCEPHALOGRAPHIC SOCIETY. Guide- line Seven: a proposal for standard montages to be used in clinical EEG. J Clin Neurophysiol 1994;11:306. 4. EBNER A, SCIARNETTA G, EPSTEIN C, NUWER M. EEG instrumentation. Recommendations for the Practice of Clinical Neurophysiology: Guidelines of the International Federation of Clinical Physiology. Electroenceph Clin Neurophysiol 1999;52(Suppl.):710. 5. NUWER MR, CORNI G, EMERSON R et al. IFCN stand- ards for digital recording of clinical EEG. Recommen- dations for the Practice of Clinical Neurophysiology: Guidelines of the International Federation of Clinical Physiology. Electroenceph Clin Neurophysiol 1999; 52(Suppl.):114. 6. AMERICAN ELECTROENCEPHALOGRAPHIC SOCIETY. Guide- line Two: minimum technical standards for pediatric electroencephalography. J Clin Neurophysiol 1994;11: 69. 7. DE WEERD AW, DESPLAND PA, PLOUIN P. Neonatal EEG. Recommendations for the Practice of Clinical Neurophy- siology. Guidelines of the International Federation of Clinical Physiology. Electroenceph Clin Neurophysiol 1999;52(Suppl.):14957. 8. KASTELEIJN-NOLST TRENITE
DGA, BINNIE CD, HARDING
GFA, WILKINS A. Photic stimulation: standardization of screening methods. Epilepsia 1999;40(Suppl. 4):759. 9. KASTELEIJN-NOLST TRENITE
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GFA et al. Medical technology assessment photic stimu- lation. Standardization of screening methods. Neuro- physiol Clin 1999;29:31824. 10. AMERICAN ELECTROENCEPHALOGRAPHIC SOCIETY. Guide- line Twelve: guidelines for long-term monitoring for epi- lepsy. J Clin Neurophysiol 1994;11:88110. 11. NOACHTAR S, BINNIE C, EBERSOLE J, MAUGERIE ` RE F, SAKAMOTO A, WESTMORELAND B. A glossary of terms most commonly used by clinical electroencephalographers and proposal for the report form for the EEG ndings. Rec- ommendations for the Practice of Clinical Neurophysiol- ogy. Guidelines of the International Federation of Clinical Physiology. Electroenceph Clin Neurophysiol 1999; 52(Suppl.):2141. Appendix Recording montages Basic rules for choosing montages: (i) Use the full 21 electrode placements of the 10 20 System, even if only an eight-channel recording machine is available. Flink et al. 4 (ii) Use longitudinal bipolar, transversal bipolar and referential montages during each EEG recording. (iii) Duration of recording with one montage should be at least 2 min. (iv) The electrode connections (bipolar) should run in straight (unbroken) lines and the interelec- trode distance should be kept equal. (v) Use a left above right order of deriva- tions, i.e. on the recording page left-sided leads should be placed above right-sided leads for either alternating pairs of derivations or blocks of deri- vations. (vi) Tracings from the more anterior electrodes should be placed above those from the more pos- terior electrodes on the recording page. (vii) During photic stimulation, frontopolar, frontal and occipital regions should be explored. (viii) During hyperventilation, frontal, central, occipital and middle temporal regions should be explored. Pediatric montages Because of the size of head, a reduced number of electrodes is usually used in neonates and young infants. A minimum of nine electrodes should be used (including Fp1, Fp2, C3, Cz, C4, T3, T4, O1 and O2). An eight-channel EEG machine is usually not enough as most of these recordings will require two or even more channels devoted to record polygraphic variables such as ECG and respir- ation. Montage using nine electrodes, combining longitudinal and transverse derivations. The lon- gitudinal derivation block can be used with an Proposed montages for eight- and 16-channel EEG machines Eight-channel recordings Bipolar montages Channel Longitudinal Transverse Referential montages 1 Fp1-F3 Fp1-F7 F7-Fp1 F7-F3 T3-C3 F3-A1 Fp1-A1 2 F3-C3 F7-T3 Fp1-Fp2 F3-Fz C3-Cz C3-A1 F7-A1 3 C3-P3 T3-T5 Fp2-F8 Fz-F4 Cz-C4 P3-A1 T3-A1 4 P3-O1 T5-O1 C3-Cz F4-F8 C4-T4 O1-A1 T5-A1 5 Fp2-F4 Fp2-F8 Cz-C4 T3-C3 T5-P3 F4-A2 Fp2-A2 6 F4-C4 F8-T4 T5-O1 C3-Cz P3-Pz C4-A2 F8-A2 7 C4-P4 T4-T6 O1-O2 Cz-C4 Pz-P4 P4-A2 T4-A2 8 P4-O2 T6-O2 O2-T6 C4-T4 P4-T6 O2-A2 T6-A2 Sixteen-channel recordings Bipolar montages Channel Longitudinal Transverse Referential montages 1 Fp1-F3 F7-Fp1 Fp1-Fp2 F7-Fp1 Fp1-A1 Fp1-A1 2 F3-C3 Fp1-Fp2 F7-F3 Fp2-F8 F3-A1 Fp2-A2 3 C3-P3 Fp2-F8 F3-Fz F7-F3 C3-A1 F3-A1 4 P3-O1 F7-F3 Fz-f4 F3-Fz P3-A1 F4-A2 5 Fp2-F4 F3-Fz F4-F8 Fz-F4 Fp2-A2 C3-A1 6 F4-C4 Fz-F4 A1-T3 F4-F8 F4-A2 C4-A2 7 C4-P4 F4-F8 T3-C3 T3-C3 C4-A2 P3-A1 8 P4-O2 T3-C3 C3-Cz C3-Cz P4-A2 P4-A2 9 Fp1-F7 C3-Cz Cz-C4 Cz-C4 F7-A1 F7-A1 10 F7-T3 Cz-C4 C4-T4 C4-T4 T3-A1 F8-A2 11 T3-T5 C4-T4 T4-A2 T5-P3 T5-A1 T3-A1 12 T5-O1 T5-P3 T5-P3 P3-Pz O1-A1 T4-A2 13 Fp2-F8 P3-Pz P3-Pz PZ-P4 F8-A2 T5-A1 14 F8-T4 Pz-P4 Pz-P4 P4-T6 T4-A2 T6-A2 15 T4-T6 P4-T6 P4-T6 T5-O1 T6-A2 O1-A1 16 T6-O2 O1-O2 O1-O2 O2-T6 O2-A2 O2-A2 Use of EEG for the diagnosis of epilepsy 5 eight-channel EEG machine, and when switching to the transverse block of derivations (channels 912) there will be possibilities for polygraphic channels even with the eight-channel machine. Recording parameters Electrodes The impedance (contact resistance) in the elec- trodes should be less than 5 kW, to reduce the noise artefacts and other interference. Amplication The EEG machine is equipped with dierential ampliers with common mode rejection. A typical setting for the gain for the EEG is 7 lV/mm leading to deections of 320 mm for input voltages of 20140 lV. The ability of the ampliers to suppress voltages common to both electrodes is called the common mode rejection, it will for example reduce the noise from 50 or 60 Hz line current. The ability of an amplier to reject in phase and amplify out of phase potentials denes the common mode rejection ration of the amplier, which is always >80 dB. Channel Montage 1 Fp1-T3 2 T3-O1 3 Fp2-T4 4 T4-O2 5 Fp1-C3 6 C3-O1 7 Fp2-C4 8 C4-O2 9 T3-C3 10 C3-Cz 11 Cz-C4 12 C4-T4 ECG Respiration EOG Optional Recording procedure Awake, test reactivity, intermittent eye-opening Drowsy/sleep Hyper-ventilation Photic stimulation 10 min 10 min 3 + 3 min 6 min (maximum) Photic stimulation Time 5 s 5 s 7 s 5 s 5 s 7 s 5 s 5 s 7 s 5 s 5 s 7 s Flash Rest Rest Rest Rest Frequency 1 Hz 2 Hz 4 Hz 6 Hz Eye open open open open open Eye closed closed closed closed closed Continued Time 5 s 5 s 7 s 5 s 5 s 7 s 5 s 5 s 7 s 5 s 5 s 7 s Flash Rest Rest Rest Rest Frequency 8 Hz 10 Hz 12 Hz 14 Hz Eye open open open open open Eye closed closed closed closed closed Continued Time 5 s 5 s 7 s 5 s 5 s 7 s 5 s 5 s 7 s 5 s 5 s 7 s Flash Rest Rest Rest Rest Frequency 16 Hz 18 Hz 20 Hz 60 Hz Eye open open open open open Eye closed closed closed closed closed Continued Time 5 s 5 s 7 s 5 s 5 s 7 s 5 s 5 s 7 s 5 s 5 s 7 s Flash Rest Rest Rest Rest Frequency 50 Hz 40 Hz 30 Hz 25 Hz Eye open open open open open Eye closed closed closed closed closed Flink et al. 6 Polarity The polarity convention in recording with dier- ential ampliers is the following: (i) If input 1 is negative with respect to input 2, there is an upward deection. (ii) If input 1 is positive, there is a downward deection. (iii) If input 2 is negative with respect to input 1, there is a downward deection. (iv) If input 2 is positive, there is an upward deection. Filtersetting For the majority of EEG recordings the signal frequency lies between 1 and 70 Hz and the bandwidth of the recording channels should there- fore correspond to this frequency range. If a narrower bandwidth is used information will be lost and with a wider bandwidth, noise in the recorded data will contain irrelevant information. The low frequency lter should not be higher than 1 Hz (corresponding time constant of 0.16 s) and the high frequency lter should be 70 Hz. The use of notch lters (50 or 60 Hz) can distort sharp signals (i.e. spikes and sharp waves) and should only be used if other measures to reduce 50 or 60 Hz noise fail. The use of additional channels recording EMG, ECG, EOG, respiration, movements, etc., requires individual setting of gain and lters for each channel. Paper speed The print out of the recording (whether analog or digital) should use a time base (paper speed) of 15 or 30 mm/s with the option of 60 mm/s. The lower paper speed is preferably used in order to detect slow-wave abnormalities. The use of the higher paper speed might help in detecting asynchronicity in bilateral discharges. Report form Information by referring physician Patient ID Clinical history Neurological condition Medication Clinical question Information by EEG technician Level of consciousness, vigilance, co-operation of the patient Clinical symptoms (jerking, moving, etc.) Activation procedures Technical artefacts EEG description Background activity Postcentral rhythm Asymmetries Focal ndings Epileptiform activity, type, appearance and loca- tion Special EEG patterns Eect of activation procedures EEG interpretation (keep it short) Interpretation of the EEG results in light of the clinical diagnosis and questions of the referring physician (clinical signicance, prognosis, etc.). Use of EEG for the diagnosis of epilepsy 7