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    Interpretation of Extracranial EEG

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    KamilaSaramak
    EEG

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    CHAPTER 18 ridin eb Wit Wn © 958 Interpretation of Extracranial EEG Electroencephalography (EEG) is the most frequently performed neurodiagnostic study in the patient with se Zures and epilepsy. Because of the paroxysmal nature of seizures, an EEG is usually obtained between seizure epi sodes. The interictal EEG may be useful in diagnosing epilepsy, clasifying seizure type. monitoring response to ‘weament, and localizing the epileptogenic zone in can- didates for focal corticectorny.* Ietal recordings are now routinely obtained during prolonged FEG monitoring to quantif’ seizure activity, assess precipitants, and localize the epileptogenic zone in medically refractory partial epi- lepsy? This chapter discusses the relationship between cextracranial EEG studies and epilepsy. EEG AND EPILEPSY In 1933, shortly after the introduction of this tech- nique, Berge: published his observations of EEG changes in patients during “convulsions” but failed «© recognize the tremendous potential of these studies inter- icaally. This new technique paved the way for noninvasive neurophysiologic research of the human brain, and its findings appeared to validate Jackson's earlier hypothesis that epilepsy was caused by a “discharging lesion.""™ Landmark work by Gibbs et al" in 1985 documented the association of specific interictal and ictal EEG alterations in padients with seizures. These investigators also inc cated that interictal EEG may localize the epileptogenic zone" The different incerictal BEG patterns in patients with partial and generalized epilepsy were subsequently recognized, and attempts were made to classify seizures according to electroclinical correlations."" Authoritative work by Penfield and Jasper lacer revealed the impor- tance of electrocorticography in recording interictal EEG abnormalities during focal cortical resective surgery for intractable partial epilepsy. + References 9, 16, 87, $8, 47-49, 61, 70.78, 78 264. DAVID R. CHABOLLA GREGORY D. CASCINO RECORDING STRATEGIES Recordings should be performed according to the methodology established by the American Electroen- cephalographic Society:° Standard activation proce dures such as hyperventilation and photic stimulation should be included. The recording of drowsiness and non-rapic-eye-movement (NREM) sleep, facilitated by sleep deprivation, may increase the sensitivity of the EEG to demonstrate interictal epileptiform alterations, espe- cially in patients with partial epilepsy.”*2" During the re- cording, the EEG technologist should obtain information regarding seizure manifestations, time of the latest sek ‘ure, and. precipitating events. Such “tigger mecha- nisms" may alter the EEG performance. Current medica tions and antiepileptic drug levels should also be noted. Interictal ‘The recording of interictal epileptiform activity de- pends on the seizure type, localization of the epilepto- {enic zone, recording method, age at seiaure onset, and frequency of seizure activity.® 2925292? Patients with seizures beginning in childhood typically display a higher incidence of EEG abnormalities than do those with adult- onset epilepsy:* The diagnostic yield ofthe interictal EEG may be increased by performing multiple recordings,? increasing the duration of the EEG, and timing the study shortly aftera seizure, because interital epileptiform dis charges may be potentiated following an attack.*° ictal ‘The localizing effectiveness of scalp ictal EEG monitor- ing in partial epilepsy may be increased by altering the recording techniques.* Closely spaced scalp electrodes * References 13, 26, 27,88, $0, $2, 38, 60,62, 64. have been demonstrated to increase the diagnostic accu- racy of such monitoring. Applying the standard exten sion of the 10-20 System, as outlined in the American, Electroencephalographic Society guidelines,*? inferolat- eral temporal electrode positions, ie. Fs, Fro, Ty, and Tio. may be used to record epileptiform activity of anterior ‘temporal lobe origin (see Chapter 20, Fig, 20-1).%* Spe- ial extracranial electrodes also may improve diagnostic ‘effectiveness. Sphenoidal electrodes may reveal the to- pography of interictal and ictal epileptiform discharges In patients with temporal lobe seizures and indicate the ‘mesial temporal localization of the epileptogenic region (see Chapter 76, Fig. 76-1). Nasopharyngeal elec- trodes, however, have not been proved superior to lateral scalp electrodes. Supraorbital electrodes, which record from the orbitofrontal region, may be useful in patients ‘with partial epilepsy of frontal lobe origin. Digital EEG acquisition and storage in a format suitable for subse- quent remontaging and filtering have improved the Speed with which interpretable ictal scalp recordings may be obtained over paper recordings, LIMITATIONS OF EXTRACRANIAL EEG Several limitations of scalprecorded, or extracranial, EEC affect the interpretation of these studies in patients with epilepsy." Epileptiform activity generated in cortex remote from the surface electrodes, e.g., amygdala and hippocampus, may not be associated with interictal extra- ‘cranial EEG alterations.** Attenuation of spike activity by the dura, bone, and scalp aso limits the sensitivity ofthese recordings," which may be degraded further by muscle artifacts. Approximately 20% to 70% of cortical spikes are recorded on the scalp EEG.’ Patients with seizure disorders may have repetitively normal interictal EEG studies "2+ Extracranial EEG recordings may also inac- curately localize the epileptogenic zone.” For example, interietal sealp EEG may fail 0 detect specific alterations arising from the amygdala only to reveal distant, more ‘widespread, cortical excitability *®** Localization of the epileptogenic zone as suggested by interictal specific EEG patterns may also be discordant with ictal extracranial oF Jong-term intracranial monitoring.*? Specific EEG Patterns Interictal. EEG abnormalities in patients with seizure disorders may be categorized as specific or nonspecific Specific patterns, i, the spike, sharp wave, spike-wave complex, temporal intermitient delta activity (TIRDA), and periodic lateralized epileptiform discharges (PLEDs), are potentially epileptogenic and provide diag- nostically useful information. **** Other specific EEG pat- (CHAPTER 18: INTERPRETATION OF EXTRACRANIAL EEG 265, ‘terns—small sharp spikes (Fig. 18-1A), 14-and 6-positive spike bursts (Fig. 18-1B), GH spikeandwave (Fig. 18-1C), wicket waves (see Chapter 20, Fig, 20-7), rhythmic temporal theta activity of drowsiness, or psycho- ‘motor variant pattern (see Chapter 20, Fig. 20-9), and subclinical rhythmic epileptiform discharges of adults (SREDA) (see Chapter 20, Fig. 20-8)—are not associ sted with increased epileptogenic potential. #+#+5547- 2 Nonspecific changes, ic., generalized or focal slow. wave actity and amplitude asymmetries, are not unique to epilepsy and do not indicate an increased epilepto- genic potential” Auributing epileptogenic significance to nonspecific and nonepileptiform patterns may lead to erroneous clinical interpretation. Potentially epilepto- genic EEG alterations identified: in patients with sei- zure disorders are rarely detected in nonepileptic pa- tients.” Ultimately, epilepsy isa clinical diagnosis, and the EEG is but an extension of the neurologic evaluation. ‘The main types of epileptiform discharges are spikes and sharp waves, occurring either as single potentials or with an aftercoming slow wave, i.e. aspike-and-wave com- plex. Spike discharges are predominantly negative tran- Sients easily recognized by their characteristic steep as cending and descending limbs and duration of 20 to 70 msec.® Sharpwave discharges are broader, potentials wwith a pointed peak that last beoween 70 and 200 msec.®? ‘These abnormalities should have a physiologic potential field and should involve more than one electrode to ex: clude electrode artifact. Spike-and-wave complexes con- Sist of a spike followed by a slow wave in an isolated or repetitive fashion. The pathogenesis of these discharges and the basic mechanisms of epileptogenesis are dis cussed elsewhere in this volume. dally epileptogenic pattern, TIRDA, has been identified in patients with partial epilepsy of temporal Jobe origin’ ®? and has the same significance as temporal lobe spike or sharp-wave discharges (Fig. 18-2). This pattern, most prominent during drowsiness and NREM sleep, consists of rhythmic trains of low to moderate-amplitude deltefrequency slow waves over the temporal region, unilaterally or bilaterally, without ap- parent clinical accompaniment. Persistent polymor- hic temporal delta activity from a tumor or other struc tural lesion is not necessarily epileptogenic and should bbe differentiated from TIRDA. The focal, unilateral sharpwave discharges called PLEDs may have a wide field of distribution and are peri- odie or quasiperiodic. Typically occurring at 0.5 to 2.0 Hz (Fig. 18-3), they vary in amplitude and duration (100 © 200 msec) and most commonly appear as broad dipha- sic or triphasic waves.’ Repetitive discharge complexes also may be seen.*? An acute or subacute neurologic in- sult, eg, herpes simplex encephalitis, stroke, “head teauma, or tumnor, usually gives rite to PLEDs.”9® This EEG patter is not specific for any one pathologic lesion land is usually transient,” although chronic, persistent PLEDs have been reported.” Alteration of consciousness, focal or secondarily generalized seizures, and acute or subacute neurologic dysfunction may be associated with PLEDs. The prognosis depends mainly on the underiy- ing etiology. 266 PART II_-BASIC PRINCIPLES OF ELECTROENCEPHALOGRAPHY SSS 14 86 POSITIVE BURST erect Age: 42 yrs SYSS Li cata ata ca exces enc ehcp Fr A ww T3-A. T.- 3 ili Ta hg ae gam T5- AA 15g enrol ns To nl yA S5Opv ae 4 sec 7 : SOnV Tsec Fagg en mney Aut Whe Q Age: 39 Yr Foy-Fs seer (vara penne Fa-Cg omen ffevirnae ai C3-P3 wean ne FeO ane pursue] erty Foa-Fa onetime sein Fa-Cq wrsnt| pyrene ey VV re Car. apn ewe | mea Amman we wen Yyumtenatn mee ll msn BLED Suman tan Fay ee Lr fo ery YY CF Wavelet tenlantbrshyetired FO aaa a aera tan tin fae FS SP eh Fag ye Fe INN By Ty eh tet we ee yn fA Accel rh oct elon Fig. 18-3. Periodic tateraliting eplepiform discharges, (PLEDS), ‘macimal in the left centrotemporal region in 2 patent with a large ‘Cerebral infarct and epilepsa parials connua. An accelerometer on the nphe lover face records intermittent clonic movements (courtesy Dr. FMW, Sharbrough). 267 (CHAPTER 18: INTERPRETATION OF EXTRACRANIAL EEG Fig, 18-2. Right temporal intermitent rythm dem sesinty (IRDA) in 2 patient trih adulvonsetseimures, The delta acti dt Tg this pordon of the racing didnot persist. ‘The morphology and localization of specific BEG epi- leptiform patterns may provide useful information on the prediciability of seizure recurrence and may influenc the selection of antiepileptic drug therapy. Unfortu. nately, imerictal EEG may produce variable results, and during brief recording periods no specific abnormalities may occur despite several EEGs.? The frequency of spike ing may not be a good predictor of the seizure acuvity and is independent of antiepileptic drug levels *** etal, itis often difficult to differentiate EEG seizures ‘and prolonged bursts of interictal activi. Truc ictal events can be distinguished, however. The electrographic ‘onset of a seizure is characterized by a sudden change of Frequency and the appearance of a new rhythm. The ini- tial change may be desynchronization or attenuation of EEG activiyy asociated with a reduction of interictal epi- leptiform activity." An aura preceding impairment of consciousness (Fig. 184A) may be without obvious elec- trographic accompaniment, and the new EEG rhythm may appear hesitantly at first but evolve into more distinct patterns. Seizure activity may be of delta, theta, a, or B frequency and typically shifts from one frequency to an- other (Fig. 18-5), slowing with increasing amplitudes and developing mare dsinctshythmicwaves, The seizure die ‘charge may or may not have a spiky appearance. ‘a Socal onset electrographic seizure gpically vohes through several phases: (1) focal attenuation of EEG ac- tivity; (2) focal, rhythmic, lowoltage, fasvactivity dis- ‘charge; and (3) progressive increase in amplitude with slowing that spreads (o a regional anatomic distribution. Focal epilepiform discharges, such as repetitive spikr or fast activity recorded at a single electrode, are a rel tively rare, but important, frst ehange localizing the epi- leptogenic zone. 268 EFT TEMPORAL LOBE SEIZURE. emma ee = Fo mae eye t] Fete aa Tey 9-03, ‘Asymptomatic Aura ae" A PART BASIC PRINCIPLES OF ELECTROENCEPHALOGRAPHY LEFT TEMPORAL LOBE SEIZURE ys (8-26.79) Ff OT Ite a For anenenmennninnvirer rye {Frets oer MINA Tyg Nl A Ty nner 0 ny rt mn) F280 ntsc Fg ig x phy a nl tino Fl an narnia ut Teg eerie errno Fig. 18-4, Lack of definite electrographic ateraon in a patient experiencing the slmple partial onset of « complex partalsenure, Ai B. left temporal repeiie sharpwave ducharger(F, Ty Ts electrodes) developing duting the complex partial seizure. (Ty = Tr. T, = Ta. Ts = Py. and he Py as aued ciewhere in tha chapter) (Courtery Dr }.D. Grabow). ‘The sensitivity and specificity of ictal extracranial EEG have been analyzed in patients with partial seizures of temporal lobe origin.*°5-83575.% The localizing value of scalp EEG has ranged from approximately 40% co 90% in reported patient series 0228428 This variability may depend on the ictal EEG change related to the clinical, seizure, i., initial focal discharges as opposed to subse- ‘quent focal abnormalities. Sphenoidal electrodes have been shown to increase the diagnostic yield of ictal extra- cranial EEG."* In a study performed between 1978 and fe Jr viemntericenrrrrnnneneiinde, Bee AAU [MANIA RA Fe ten i een nnn | veennmemnenerennennennnenr ts Pep AAO |r ae NN | NNR AAA AN pee EE eee erence see eects Peer ee ee 2S SS See fer AUN | annie [Amwell ne 10 secon Fig. 18-5. nana re | tre pttgerateprneates rename: (eae A | heer I 20 secanss Scalprecorded left temporal lobe seizure showing dheur, and delunfrequency activity during consecutive phases. 1080 at the Montreal Neurological Institute, 311 seizures ‘were recorded in 30 patients with “mostly temporal lobe epilepsy and complex partial seizures***? by means of ong,term EEG monitoring with supplementary (sphenot dal or nasopharyngeal) electrodes. Focal- or lobar- restricted paroxysmal events characterized 42.7% of set ures, and a lateralized seizure onset characterized an additional 9.4%. Bilateral or generalized alteration was identified in another 22.8% of complex partial seizures. ‘The extracranial EEG recordings were uninterpretable in 27.4%. All patients in this series with complex partial seizures of temporal lobe origin had an ictal elec- trographic alteration, Ictal extracranial EEG in patients with large destructive temporal lobe lesions may incor- rectly lateralize seizure onset” EEG IN PARTIAL EPILEPSY Partial, or localizati activity of focal onset elated, epilepsy implies seizure #8 The majority of patients with partial epilepsy experience complex partial sei zures,”® and the most frequentsite of onset is the anterior temporal region, emanating from the mesiobasal limbic structures (amygdala or hippocampus) or the lateral tem- poral neocortex.’* Results of extracranial EEG monitoring may be unre ‘markable in most patients experiencing simple partial seizures.” In one series,° approximately 80% of patients, had no definite extracranial EEG alteration. Intracranial and extracranial recordings were performed simultane- ‘ously in these patients to assess the efficacy of the scalp recordings; therefore, the lack of EEG changes alone ‘CHAPTER 18: INTERPRETATION OF EXTRACRANIAL EEG 269 should not be used to establish the diagnosis of nonepi- leptic clinical behavior. A localized epileptiform abnor- ‘malty on interictal scalp EEG may assist diagnostic classi- fication of simple partial seizures. Hee ‘One scalp-recorded change during a simple partial sei zrure isa generalized desynchronization with a reduction in interictal epileptiform discharges.'*3** Localized ab terations include focal attenuation at the site of seizure onset with a lowvoltage, rhythmic, fastactivity discharge that progressively increases in amplitude with gradual slowing. Simple partial seizures or auras of mesial tem- poral lobe origin uncommonly invole a sealp EEG alter- ation, Psychic or visual experiential phenomena alone rarely oceur with a precise, focal, extracranial epilepti- form discharge dusing simple partial seizures Temporal Lobe Epilepsy ‘Anterior temporal spikes are highly epileptogenic, and usually appear after the age of 12 co 15 years (Fig. 18-6). This spike discharge has a maximum amplitude over the anterior temporal region (in contrast to the centrotem poral spike) and may prominendy involve the ear, sphe- noidal, oF anteroinfenor tempora! leads. Sleep markedly potentiates the presence to temporal spikes; approx mately 90% of patients with temporal lobe seizures show spikes during sleep ""** Most patients with independent bilateral and bisynchronous temporal spikes are ult= rately demonstrated to have unilateral temporal lobe sei- zures® The morphology of interictal spiking in the tem- poral lobe is clearly distinct from the ietal pattern.™8*- Sphenoidal and inferolateral temporal scalp (Ty, Ta, Fy, Fyo) electrodes, as well as closely placed scalp elec: trodes, may be useful in delineating the topography of LEFT TEMPORAL SPIKES Qage: 48yrs For Fy FT 13-15 4 --_ 15-0, —~l—-—- Fog Fg Fala TeTg Te. Fig. 18-6. Characteristics inteical lft vempora sp TT sow Te tke diacharges (courtesy Dr BF, Wertmoreland), interictl activity.°-S28462* Sphenoidal electrodes ‘hay record epileptiform activity emanating from the me~ ‘Rabasal limbic region and help to localize the epilepto; fgenie zone prior (o an anterior temporal Yobectomy. $E'padents with temporal lobe epilepsy, the sensitivity of sphtenoidal electrodes compared with scalp electrodes is wRticar®" Nasopharyngeal electrodes are artifact prone, poorly tolerated by patients (which may interfere with a Teep recording), and not demonstrated more sensitive to specific than lateral inferior scalp electrodes. Patients with complex partial seizures of anterior tem- poral lobe origin may demonstrate localized laceralized Bp generalized ictal pateras.'*8%2929° Prior to the se Gass, an increase in interictal temporal labe (or bitemp- ral) spiking may be evident; however, robust interictal Spike discharges must be distinguished from elec: tWographic seizure activity.® Tobar onset of a seizure is the most common scalp- recorded alteration in complex partial seizures of ante- Hor temporal lobe origin (Fig, 18-4B):a lateralized mod- Crate: to highamplitude rhythmic paroxysm of theta ac- Gvity is most prominent in the lateral temporal scalp Electrodes and may progress to generalized rhythmic Slowing maximal on the side of seizure onset Focal tem- poral lobe or generalized arrhythmic slowivave activity Fray occur postictally. Interictal temporal lobe. spiking may increase at the termination of the seizure. Frontal Lobe Epilepsy ‘The second most common site of seizure onset in par tial epilepsy in adults isthe frontal lobe.1°5*"* This region presents difficult challenges in attempts wo localize the Pplleptogenic zone with interictal recordings." {nterietal EEG is not as sensitive or specific in frontal lobe epilepsy as itis in temporal lobe epilepsy."""” Interictal EEG ‘activity recorded by way of prolonged extracranial monitoring in 34 patients who remained seizure frec fok Towing frontal corticectom identified a localized specific EEG pattern in the frontal lobe in only 9% of patients.”* Alateralized, but not localized, interictal abnormality was moved n 59% of patents No interictal abnormality was observed in 11.7% of those studied. Epileprogenic zones QPS ‘Gotal lobe remote fom exraranial electrodes (orbitofrontal and mesiofrontal regions) may not be asso hated with interictal activity despite multiple or pro- Tonged EEG recordings"? ‘Supraorbital surface electrodes may increase the sensi sivity and specificity of EEG scalp recordings in patients ‘with frontal lobe epilepsy associated with seizures origi ating from the orbitofrontal region.*°** These clec- trodes are preferred for noccurnal recordings because of the artifact generated by eye movement and blinking.” ‘In frontal lobe epilepsy, seizures may begin in the dorsolateral frontal cortex. orbitofrontal region, cingue late gyrus. supplementary cortex, or frontal pole.”*** 72% Frontal lobe spikes indicate epileprogenicity and may be associated wnith simple partial, complex partal, ‘or secondarily generalized tonic-clonic. se- 169 ictal behavior in frontal lobe epilepsy i highly ART It-BASIC PRINCIPLES OF ELECTROENCEPHALOGRAPHY variable, and establishing the diagnosis based om clinical Seizure activity alone may be difficult."¥4°"> Frontal lobe SGiaures may be confused with nonepileptic behavioral events." OCCIPITAL LOBE EPILEPSY Cccipital spike acsvity occurs less frequently in adults than does epileptiform activity that emanates from the temporal or frontal regions (Fig. 18-7). Interictal occipi tal epileptiform activity is most common in children and indicates only moderate epileptogenicity; approximatelt 40% to 50% of patients with occipital spikes have sei ‘rares.* Occipital “needle sharp spikes” may also occu in congenitally blind individuals (usually children) who ido nochave epilepsy Interictal spiking may be unilat- tral or bilateral over the occipital region and may be asso- ‘Gated with simple or complex parual seizures.977° was described by Gastaut in'1982,"” occipital spikes also may occurin patients with idiopathic age-related occipital Epilepsy. a less common variant of benign rolandic epi. Tepsy. The seizures begin wich a visual phenomenon and mar be followed by generalized tonic-clonic episodes." Headache may occur during or after the seizures.”” The ‘nterictal occipital spikes attenuate with eye open- Patients with this “benign partial” disorder have fan excellent prognosis, and the seizures usually do not persist into adulthood. 747° Central Epilepsy (Rolandic Epilepsy) “The interictal EEG pattern is a highwoltage diphasic cor polyphasic spike followed by a slow wave with a dure Gon of 200 to 300 msec (Fig. 18-8).°4" Spike active appears to be maximal over the lower rolandic and mic: temporal regions." The discharges may be unilateral. bi lateral shift from side to side, and may not correspon to the hemisphere associated with ictal symptoms. Spik ingis usually more abundant during drowsiness and slee and is nota good predictor ofthe severity of seizure activ ig.” The central midtemporal spike may exhibit a Sur rounding region of positivity, suggesting the presence o Etangential dipole source "+" Central spikes have a mod crate degree of epileptogenicity, with approximately 40% to 60% of patients having clinical seizures.4**"5" Benign childhood epilepsy with centrotemporal spikes or “rolandic epilepsy," is a common and fairly distinc! Sciaure disorder. Seizure onset is typically between 2 anc 12 years of age and disappears between ages 15 and 18." ‘The seizures typically respond well to antiepileptic drug therapy, The ictal behavior includes focal motor or ser Sony seures, often with excessive salivation and drooling ‘long with motor speech arrest!® Secondary generalica ton is common, and the majority of children present with 2 history of a nocturnal generalized tonic-clonic convut ‘Sion, Not all patients, however, who have seizures anc OCCIPITAL SPIKES Qage: 5yrs For Fs i. C5-Py (TERPRETATION OF EXTRACRAMIAL EEG 271 Bethe parities, me Foor F Fa-Cy na Ce ye iret em 0, ale emda mal Seizures ——_Joow Tee terictal spiking in a child with a seizure disorder (courtesy Dr. BF. Wesmore- Tana), centrotemporal spike discharges have benign rolandic background activity and include 3-Hz generalized spike epilepsy. tnd wave slow spike and wave, atypical generalized spe dd nave, ypu and generale paronrmal EEG IN GENERALIZED EPILEPSY eae eee gtte tienes as symptomatic or idiopathic, depending on etiology, sei- zure activity, and EEG alterations." Seizure types include The specific interictal patterns associated with general- absence, generalized tonicclonic, atonic, myoclonic, ized epilepsies are easily distinguishable from normal tonic, clonic-tonieclonic, and atypical absence." Exper RIGHT CENTRAL SPIKES age: 12yrs er pene eee epee Fie C3 rete nent nmr mage C3-Ps enone veel yeansttnmmeetnvnnnnnenyare PO ane mnnatf ir annoy Me Fg Fg ote para er pee, | FaG foe pe ae 4 4 afi atman pannel iH C4 Py yd rt ear eryerntenainmmemym ane FO) oar dir peamrrel\ earndyranmnsennnnenernnlrane Fig. 18-8. polar EEG tracing showing interetal spiking In the right central region in 2 patent th benign ‘relandic epilepsy Note normal background EEG ac tiny (courtery Dr BE. Westnore- Inne), 272 PART SBASIC PRINCIPLES OF ELECTROENCEPHALOGRAPHY ABSENCE SEIZURI (Hyperventilation: 80 seconds) Foe ammmnenne—aV fp Ramen TA 5B apenas i ANAS Cia mneentramncerty YY Py Wntenmnaneneemnsy YY WN Pe ngnmrenrner dt NYY A, Oe mae ARR ye re “Remember cor” ig. 18-9. Elecrographic coreat of the pasent topped pressing the bution apical absence seizure precipita ‘mental models of generalized epilepsy indicate patho- logic cortical hyperexcitability as the basic mechanism for epileptogenesis.>® Thalamacortical connections are necessary for the development of typical spikeandavave epileptiform activity. 3-Hz Generalized Spike-and-Wave and Absence Seizures This morphologic pattern of the spikeand-vave com- plexes is similar in both intericial and ictal recordings Fhe EEG alteration consists of generalized, often anterior predominant, repetitive, bisymchronous, symmetric Spike: and slow-wave discharges occurring at approx- mately $He (Fig. 18-9) 697439 The rpical pattern often varies, however. The frequency may be faster than 440 He at the beginning of the discharge and slower than 25 Hz at the end® Shifting minor asymmetries may occur over homologous head regions and, at mes, dou- ble spikes associated with an aftercoming slow wave.” Hy- perventilation, hypoglycemia, drowsiness, and eye clo- Ture may potenuate the generalized spikeandwave Gischarge-*! During sleep. the morphology of the in- terictal abnormality may appeat as fragmented or asym- metric spikeand.wave bursss*® Background activities are “usually normal; however, some intermittent, Thythmic, bisynchronous slow waves may be present over the posterior head regions." “This highly epileptogenic pattem occurs ypicaly in children 5 t0 15 years old with idiopathic generalized pilepsy and absence seizures.*** Staring, automatism, rapid eye blinking, and myoclonic movements of the ox- tremities are closely correlated to the scalp EEG record- ing and may occur when EEG changes persis for $ 10 4 seconds.!3! N Nyy Vo yin IIA erent AN IRI ae ene IIIA rneatienmnenetonne Nene RAR A nna atte — xed by hyperventilation, Response testing during the seizure shows that Vinen a ciching sound was made ip bis eat fcourtes Dr. ].D. Grabow Slow Spike and Wave These generalized, repetitive, bisynchronous. sharp wave or spike discharges occur at a rate of 1.5 to 29 Hiz*970788 and are electrographically and clinically dis- tinct from the Hz patter described in Chapter 20, Fig. 3024 The discharges may occur asymmetrically, with even a shift in focal emphasis® and may be prolonged. Often no clinical manifescations are apparent, although appropriate testing may disclose some alteration in psy- ‘chomotor performance. Focal spikes and focal or gener- alized background slowing berween the spikeand-wave bursts may also be present This pattern is less likely than the $¥iz discharge to be activated by hyperventila: tion and hypogiycemia.® Sleep recordings may show gen eralized spikes and multiple spike-and-wave discharges? ‘Most common in children with mental retardation, this pattern may persist into adulthood.“"? Compared with the SHiz spike and wave, which rarely is present before 44 years of age. the slow discharge may begin as early as 6 months. Arypical absence, generalized tonic-clonic, atonic, tonic, and myoclonic seizures may occur** that are poorly responsive to antiepileptic medications.“ Siow spike-and-wave discharges, mental retardation, and mult- ple generalized seizure types make up Lennox-Gastaut syndrome."® Multiple Spike-and-Wave Discharges ‘Also called atypical spike-and-wave discharges and fast spike and wave, this generalized mixture of intermittent, brief spike and polyspike complexes is associated with slow waves of variable frequency (3.5 to 6 Hz), morphol GENERALIZED TONG CLOW SEIZURE Siman ten oh ‘ote Tresor E8 pooner Conic ghose ‘orem Wyo Wie eR ee eee Pst al sty jew Sloning of crc jerks Fig. 18-10. Muldple scalpcecorded EEG phases of a generalized tetlcconicseinare (rom Westmoreland with permision) ‘ogy, and spatial distribution (Fig. 18-10)."* The usually, I to 3second bursts are mostly subclinical. The back- ground between bursts may be normal or contain focal (oF generalized slow irregularities, ‘The interictal and ictal EEG patterns may appear si Jar, but distinct features may arise ictally. The most com- mon seizure types are generalized tonic-clonic, myoclo- nic, a atonic, or atypical absence. Tonic-Clonic Seizures ‘These generalized seizures may affect patients with a generalized or partial seizure disorder. Prior to the se zure, the EEG may reveal an attenuation in interictal epi- leptiform discharges. Ictal scalp recordings have been performed on partially paralyzed patients, reducing the electromyographic interference. In idiopathic general- ized epilepsy, sudden myoclonic jerks, the so-called clonie‘tonic-clonic seizure, may precede the tonic-clonic, seizure.'*1* The ictal extracranial alterations are bila eral, symmetric, and synchronous. The tonic phase be- gins with generalized, low-voltage fast activity (the “epi Teptic recruiting rhythm") that progresses to a generalized spike and polyspike burst (Fig. 18-11).'*1* ‘The spike discharges gradually slow in frequency and in« crease in amplicade. The clonic phase is associated with ‘muscular relaxation and generalized EEG suppression with intermixed generalized spike and polyspike dis- charges. Postictally, at the termination of the seizure, prominent generalized background slowing gradually re- tums to baseline. Partialonset, generalized, tonic-clonic seizures may begin with simple partial or complex partial seizure activ- ity, or both. At seizure onset, therefore, the extracranial EEG in these patients may reveal a partial or localized alteration." (CHAPTER 18; INTERPRETATION OF EXTRACRANIAL EEG 273 Atypical Absence Atypical absence seizures occur in patients with symp- tomatic or secondazy generalized epilepsies with the slow spikeand-wave of multiple spikeand-vave patterns (Fig. 18-10). Multiple seizure types are often present, and pa- ents gpically have underlying organic disorders. The ictal EEG usually is similar to the intericual pattern, TONIC SEIZURES In tonic seizures, the ictal scalp EEG reveals a general- ized, synchronous, symmetric alteration, usually in the form of low-voltage fastfrequency (approximately 20 to 125 Hz) acciviy that progressively increases in amplitude (generalized paroxysmal fast activity) (Fg, 18-12). Gen- eralized moderate- to high-amplitude 10-Hz activigy is a potential pattern, as is prominent generalized atenua- tion or desynchronization.'#* Atonic Seizures In patients with generalized seizures, atonic seizures may be a major source of disability. The clinical manifes- tations vary from a brief head nod to a sudden fall with impairment of consciousness. The ictal EEG reveals gen- ‘eralized spike and polsspike discharges, interrupted by generalized ‘flattening’ or desynchronization of activity, ‘with prominent slow waves that may be maximal in the vertex (Fig. 18-13). The degree of EEG suppression may depend on the duration of the seizure and the alteration in mentation. At seizure onset, the extracranially recorded changes are bilateral, symmetric, and synchro- nous. Muscle artifact may make interpretation difficult when the atonic seizure is brief.!2* Myoclonic Generalized myoclonic seizures usually consist of a massive, bilateral, brief jerk of one or more muscle groups with (pically preserved consciousness. The EEG shows Giffuse, highamplitude, bilaterally synchronous, spike- wave or multiple spikeandwave bursts that are ime- locked to the muscle contraction seen on EEG (see Chap- ter 20, Fig. 20-21). Hypsarthythmia ‘This EEG alteration actually involves multifocal spikes rather than a generalized pattern, The term refers to cha- otic high-amplitude (>300 iV), generalized, continuous, arrhythmic slow-srave activity intermixed with spike and ‘multifocal spike discharges (Fig. 18~14).!922# During NREM sleep, the pattem becomes more discontinuous, with high-voltage spikes and sharp waves alternating with lowervoltage irregular slow-wave activity." Epileptiform 274 PART IIBASIC PRINCIPLES OF ELECTROENCEPHALOGRAPHY ATYPICAL ABSENCE SEIZURES (NAN AOULT (Qaom 45 12-3-85/12-4-85) for Fs amity ASEM Ste Fy Cs mem yyend ipl C5 Ps AY hyd ncn P50 amen AWWA pe ra tintin Foo-Fa eal hwy Seaameara Fa Oy nmin rd Day Cy Py mmr Yad yal Wa Womens Fa Oy nnn y lly Lal pref nem Fig, 18-11. Generalized ales! spike and wave Jn patient with a mixed seizure disorder that im ‘des aypeal abuence seizures (courtesy Dr. EW. ‘Sharbrough B activity decreases during rapid-eye-movement sleep. The specific interictal EEG alteration resolves, or changes wa different epileptiform pattern, usually between 2.5, to 3 years of age.515? ‘Hypsarshythmia is most common in children 4 months to 5 years of age with infantile spasms (West syndrome). Nevertheless, not all patients with infantile spasms have this EEG alteration, and not all patients with hypsarrhyth- mia have infantile spasms. Infantile spasms may be symp- [sow Tee tomatic if the cause can be determined, or cryptogenic if the cause is unknown; however, the EEG cannot distin- guish one etiology from another.*!* The most common scalpxecorded change during spasms is an interruption in the hypsarrhythmie pattern, with generalized attenua- on o suppresion (electrodecremental event) tha mt be preceded by a high-amplitude, generalized, sharp- ot slow-wave discharge (Fig. 18-15). The EEG desynchroni zation may last longer than the clinical seizure."® TONIC SEIZURE FOLLOWED BY ATYPICAL ABSENCE 9 age: 20% Ferrera | re Ana fe M Fig. 18-12, Higharplide gem Cried sharpwarefoloweaby de. Cy Sqnchroniagon and. generaoed Faroemal ft acy dung =Car {one tenure (couneny Drs ‘Sharbrough). Pe et Ns eens rinnnren ay Fre | eet ale eee ~w YAS Pan Nene falbianatinfen wy? Pe (irene ncnitbnhtinnf olen ahwrecnat Or] wren atntene nner nN 8 weeny peer nrmnatttanyt hres fie werd posting feast Pipa 8 ‘CHAPTER 18: INTERPRETATION OF EXTRACRANIAL EEG 275 9 ye tsa Stee cals ing se, reer! by Fig. 18-13, tna patent with ahisory ofatonie seizures. generalized, frontal maximum, spike-and polypikeundarave discharges are interrupted ty generalized attenuation (courtesy Dr. BF. Westmoreland) Generalized Paroxysmal Fast Activity Gibbs and colleagues*™ called this EEG pattern the ‘grand mal discharge’ because of the association with gencralized tonic-clonic seizure activity Itisalso observed during sleep in older children and adults with general Jed seizures (sce Chapter 20, Fig, 20-25). Associated sei ure ‘pes are tonic, atonic, and generalized wonic- clonic.” The generalized discharges represent repeti- tive spike activity occurring at 10 10 20 Hz. The duration of the epileptiform acuity may correlate with the pres tence of seizure activity, ie., bursts longer than 5 seconds ‘may be associated with tonic seizures. Manges 12013688 fork Aw aa con yal lit remy) Corky, pa tl Nea) ten N Pachay/~ hallay trae remanlanien Mi cra honnyaral mien SPECIFIC EPILEPTIC SYNDROMES Neonatal Seizures Ictal extracranial EEG seiaure discharges in neonates ‘may varyin frequency, amplitude, morphology, and dura- tion. These paroxysms of rhythmic sharp-wave discharg or rhythmic acdvity in the theta, alpha, or beta frequency anges may occur in 2 focal or multifocal distribution (Fig, 18-16). The seizure discharges may shift from one location to another. The epileptiform activity may be 2ss0- ciated with clinical seizures; however, subclinical phe- Ya v" it AWS he \\ a ae eso ya, WN ae Fig, 18-14. tnterictal EEG reveals high amplinude generalized background acing with intermixed multifocal spike discharges (hypsarrorthmia) fn child wih infanle spasms (coureesy Dr. BF. Westmoreland), 276 PART ASIC PRINCIPLES OF ELECTROENCEPHALOGRAPHY ELECTRODECREMENTAL EPISODE Age: 2 months Ty Fon ayn ant Pi ri Ta Fey if Fae, nm NAT Fara yp ee ntl CoP 5 ay, phe pi tly Aan CaP Ret mr At al lll A PaO Ne NN tN FeO A et a ei Onset infantile spasms age 3 weeks, cause unknown et t00p Tee Fig, 18-15, Elecirodecremental epiode asseciated with Infante spasms (courtesy Dr. DW. Kis) ‘nomena without an observed clinical accompaniment is not uncommon, The intericral background activity is prognostically important in this population. Neonatal sei- ‘ures associated with symptomatic neurologic disease, such as anoxic encephalopathy, may feature alonwoltage ‘background abnormality or a burst-suppression pattern indicative of a poor prognosis. Photoparoxysmal Response ‘This abnormal cerebral response to photic stimulation consists of generalized multiple spikeandawave com- plexes and is likely 2 variant of the aypical spike and wave (see Chapter 17, Fig. 17-13).*°Ieis best seen at the ver, Sia 8 dam: Corbina Tela ann nnn feet Ft | Fig. 18-16. sealprecorded right hemisphere seizure in @ neonate with hypocalcemia (courcesy Dr. BF West roreand) ort) | oo em “ting © foe riddle flash frequencies of between 10 to 20 Hz, and the resulting seizure discharge may outlast the stimulus br 2 few seconds; however, frequencies shift and generally become slower as the amplitude increases. The response may be accompanied by brief body jerks or impaired con sciousness,!555 may be seen at any age, and may occur as a familial trait, with maximal expression between ages 8 ‘and 20, of as an acquired phenomenon, °° Photopar- ‘oxysmal responses may be seen in patients following with-

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