EEGBasics&Interpretation

A/Prof Ong Hian Tat

SeniorConsultant&AssociateProfessor
DivisionofPaediatricNeurology&DevelopmentalPaediatrics
UniversityChildrensMedicalInstitute
NationalUniversityHealthSystem
Singapore

Outline
1.

EEG and its uses and limitations

2.

EEG electrode placement, 10-20 international system

3.

EEG Rhythms

4.

Normal awake and sleep EEGs in adults and children

5.

Activation procedures for EEG

6.

Common benign variants in the EEG

7.

EEG artifacts

8.

Non-epileptiform abnormalities in the EEG

9.

Epileptiform discharges

What is the EEG?

EEG (electroencephalogram) displays the electrical
activity of the brain created by neurons generating the
electrical signals
The brains electrical activity is
picked up by electrodes attached on
the patients scalp and amplified on
the EEG machine to be viewed as
brain waves

Hans Berger (1873-1941), a

German psychiatrist, discovered
the electroencephalography (EEG)
in 1929

Analog EEG

Digital EEG

Allows more accurate interpretation of

the EEG record by applying different
montages/references, gain/sensitivity,
filters and time constant

Use of the EEG

Helps to confirm Epilepsy Syndrome (diagnosis)
Confirm seizures, classify seizures and epileptic syndrome
Quantify seizures or epileptic bursts
Localising epileptic focus especially for pre-surgical evaluation

Help to indicate abnormalities that may suggest the following

possibilities though definitive diagnosis is by other

investigations/tests:
Acute encephalitis/cerebral abscess
Brain tumour
Intracranial stroke haemorrhage/ischemic infarction
Any other non-specific encephalopathy e.g. Metabolic encephalopathy
Brain death

Limitations of the EEG

(sensitivity)
1. Some abnormal activity may not be detected when:
The area is too small on the brains surface
- need 4 cm2 surface area of cortex to be involved

Foci located too deep in the brain

- mesial aspect and inferior aspect of the cortex (FLE or TLE)

Limited time sampling

2. Poor technical quality

3. Interpretation of the significance of the EEG abnormalities
appropriate to the clinical setting

Limitations of the EEG

(specificity)
1. Some non-specific EEG abnormalities in normal people
- up to 10%

2. Paroxysmal epileptiform activity in the absence of any

clinical seizures
- ~ 1% of normal people
- much higher in patients with non-epileptic neurological disorders
e.g. migraine, cerebrovascular disorders

3. Benign focal epileptiform discharges in children without

seizures
- 2 to 4 %

Electrode Placement
International 10-20 System

Fp1 = left frontal pole

Fp2 = right frontal pole

F3 = left frontal

F4 = right frontal

F7 = left fronto-temporal

F8 = right fronto-temporal

C3 = left central

C4 = right central

T3 = left temporal

T4 = right temporal

P3 = left parietal

P4 = right parietal

T5 = left postero-temporal

T6 = right postero-temporal

O1 = left occipital

O2 = right occipital

A1 = reference to left year

A2 = reference to right ear

G = ground
Fz = mid frontal
Cz = midline
Pz = mid posterior

IPSI

AP Bipolar

EEG montages
based on the
10-20 system
Coronal

The Routine EEG

To include recordings (each at least 15min) of
- awake (eye open/close)
- drowsiness, sleep (following partial sleep deprivation)
- awakening

Activation procedures
- intermittent photic stimulation
- hyperventilation (with breath counting)
- other forms of appropriate activation of reflex seizures
e.g. reading, hot water, somatosensory stimuli, auditory stimuli

The Routine EEG

Simultaneous video-EEG recordings should be made routine
- confirms seizure(s) and diagnosis of epilepsy
- excludes epileptic seizures and arrive at diagnosis of nonepileptic paroxysmal events, which are also very common in
infants & children
- clinical signs during the seizure may be subtle, and not able to be
picked up or recognised immediately by the EEG technologist
e.g. absences during HV, myoclonic jerks, focal seizures

EEG Rhythms
Rhythm

Hertz

Description

Alpha

8-13 Hz

Posterior dominant rhythm

Beta

>13 Hz

Normal in sleep especially in

infants and young children

Theta

4-7 Hz

Drowsiness and sleep

Delta

<4 Hz

Stage IV sleep

Alpha activity

Beta activity

Theta activity

Delta activity

Digital EEG
Interpretation of EEG can be enhanced by
applying changes to the following:
Sensitivity
High frequency filter
Time constant

Normal Awake EEG in

Adults & Children

Normal adult awake EEG

2-3 Hz posterior rhythm seen in a 3 month old baby

5 Hz posterior rhythm seen in a 6 month old baby

6 Hz posterior rhythm seen in a 1 year old child

7.5 Hz posterior rhythm seen in a 2 year old child

9 Hz posterior rhythm seen in a 6 years old child

10 Hz posterior rhythm seen in children >8 years old

Normal Sleep EEG in

Adults & Children

Asynchronous sleep spindles seen in a 2 month old infant

Hypnogogic burst

EEG during
Activation Procedures

Photic driving

Photic Driving
Rhythmic activity elicited by frequencies of 5-30 Hz that
are time-locked to represent a harmonic of the stimulus
frequency
Usually maximal over the posterior regions
Adults tend to drive best at frequencies near their alpha
rhythm whereas children may drive at slower frequencies
An impressive driving response at very low flash
frequencies of 0.5-3 Hz usually indicative of CNS
dysfunction
Asymmetric or absence of photic driving may be seen in
normal individuals

Photomyoclonic Response

Photomyoclonic Response
Consists of muscle spikes over the anterior regions in
response to IPS
Spikes increase in amplitude as stimulation increases
appearing maximal at flash frequencies of 12-18 Hz and
disappearing abruptly with the end of stimulation
Photoconvulsive response is associated with anxiety,
alcohol, or drug withdrawal states and parkinsonism
Considered a normal response

Photoconvulsive Response

slighthandjerk

Photoconvulsive Response

Characterized by generalized or posteriorly dominant spike/polyspikewave complexes produced by photic stimulation

Lapses of consciousness or myoclonic jerks may accompany the spike

discharges

Generalized discharges represent an abnormal response that suggests

a predisposition to an epileptic disorder, particularly if sustained beyond
the stimulus

Photoparoxysmal response is most frequently elicited at flash rates of

15-20 Hz and is elicited most often in people with primary generalized
epilepsy

However, can also be seen in patients with toxic/metabolic or drug

withdrawal states and is observed in 2% of normal persons

Comparison of Photomyoclonic and

Photoconvulsive responses
Photomyoclonic response

Photoconvulsive response

Effective stimulus frequency

8-20 flashes/sec

3-20 flashes/sec

Eyelids, position for maximal effect

Closed

Closed (and open)

Clinical accompaniments

Fluttering of eyelids

Eyes turning, speech arrest

Consciousness

Maintained

Often disturbed

Distribution of electric changes

Face, frontal regions

Diffuse over scalp

EEG response, type

Myoclonic spikes (polyspike)

Spike-wave ot atypical spike-wave

Recruitment

Marked

Less frequent

After-discharge

None

Frequent

Age group

Adult

All ages

Variability of threshold

Large

Slight

Muscle tension

Increases

No effect

Nervous tension

Increases

No effect

Occurrence

Normals frequent

Normals rare

Photoparoxymsal Response

Photoparoxysmal Response
Prolonged (self-sustained) which continues for a short
period after the stimulus has been withdrawn
High incidence of epilepsy
Patients with photoparoxysmal response often had other
epileptiform abnormalities in their resting EEG

Slow waves activated by hyperventilation

Common Benign Variants in the EEG

Mu rhythm, which disappears when patient is told to make a clenched fist

Mu Waves
Central rhythm of 7-12 Hz with arciform morphology
Observed in ~20% of normal young adults and less
common in children and the elderly
Slightly more common in females than males
Mu rhythm does not attenuate with eye opening but does
diminish with movement or tactile stimulation of the
contralateral extremities, fatigue, arithmetic or problem
solving

Lambda Waves

Lambda Waves
Sharp transients characterized as biphasic or triphasic
waveforms having initial small positive phase followed by a
prominent negative component
Appears over occipital regions bilaterally
Elicited by looking at a patterned design in a well-lit room
Most commonly seen in children 2-15 years of age
May be asymmetric and misinterpreted as occipital spikes
Eye closure, reducing illumination of the room or having the
patient stare at a blank card will eliminate lambda waves

Posterior Slow Waves of Youth (PSWY) superimposed

on Posterior Rhythm

Posterior Slow Waves of Youth

Also called sail waves and polyphasic waves
Moderate voltage, fused waves intermixed with the alpha
rhythm that attenuate with eye opening and diminish with
drowsiness
May not appear symmetric or synchronous, but
asymmetries should not exceed 50%
Observed in children and young adults, maximal incidence
between 8-14 years

Positive Occipital Sharp Transients (POSTS)

Positive Occipital Sharp Transients (POSTs)

Also referred to as occipital V-waves of sleep, lambdoids of
sleep and rho waves
Surface positive sharp waves in stage I and II sleep most
commonly in young adults (15-35 years)
Waves consist of sharp, surface-positive peak followed in
some instances by low voltage surface-negative peak
Initial deflection has a slower duration than the ascending
phase resulting in a checkmark morphology
Typically occur in runs of bilaterally synchronous 4-5 Hz
waves that may be asymmetrical

14- and 6-Hz Positive Spikes

14- and 6- Hz Positive Spikes

Bursts consists of rhythmic arciform waveform of 0.5-1.0
second duration during drowsiness and light sleep
Maximal in amplitude over the posterior temporal regions
Usually unilateral or independent over both sides, but
may be bilaterally synchronous
Appear most often in adolescents between 13-14 years
but have been seen in children as young as 3-4 years

Phantom spike-waves

Phantom Spike-Wave
Characterized by brief burst of 5-7 Hz generalized spikewave discharges seen primarily in young adults in
relaxed wakefulness or drowsiness
Hughes subdivided this pattern in 2 subgroups: FOLD &
WHAM
FOLD occurs primarily in Females, maximal in the
Occipital regions, Low in amplitude and present in
Drowsiness
WHAM occurs in Waking state, is Higher in amplitude,
more Anterior and observed primarily in Males
Observed in 2-3% of normal persons >50 years

Wicket spikes

Wicket Spikes
Consists of monophasic arciform mu-like 6-11 Hz
transients occurring singly or in trains in the temporal
regions during wakefulness or sleep
Typically bilateral and independent, usually having a
unilateral predominance
Seen in adults >30 years in ~1-3% of normal population
Wicket spikes are not associated with an aftercoming
slow wave or background slowing

Small Sharp Spikes (SSS)

Small Sharp Spikes (SSS)

Also referred to as benign epileptiform transients of sleep (BETS) and

benign sporadic sleep spikes (BSSS)

Benign transients of low amplitude (<50uV) and short duration

(<50msec) seen in adults during drowsiness and light sleep

Monophasic or diphasic spike with abrupt ascending and a steep

decending limb occasionally followed by a lower amplitude slow wave

Seen best in the anterior to mid-temporal regions

Unilateral or bilateral and may demonstrate opposite polarity on the two

hemispheres

Seen in 20-25% of normal individuals and have no clinical significance

Breech Rhythm (Skull Defect)

Breech Rhythm (Skull Defect)

Associated with skull defects are focal mu-like
rhythms in Rolandic or temporal region with
sporadic slow waves and spiky or sharp
transients
Rhythms are unrelated to epilepsy and do not
indicate recurrence of a tumor

Rhythmic Mid-Temporal Theta of Drowsiness

Rhythmic Mid-Temporal Theta of Drowsiness

Also known as rhythmic midtemporal discharges
(RMTDs)
Characterized by burst or trains of rhythmic 4-7 Hz theta
waves in the temporal region
Often have flat-topped or notched appearance due to the
superimposition of faster harmonic frequencies
Burst may be unilateral or bilateral, but often appear
independently with shifting emphasis in the relaxed or
drowsy state
Pattern evolves in amplitude, increasing at the beginning
and gradually decreasing at the end
Found in 0.5 to 2% of normal adults

Central Theta
Description: The prominent
feature here is the rhythmic 6
Hz activity at the vertex
(arrow). This discharge
spreads to the paracentral
regions. The background
frequencies are in the theta
range with superimposed
beta.
Significance: Normal, state
transition

Mitten
Description: This shows a
mitten discharge during stage
2 sleep (arrows). The sharp
component precedes the slow
wave, with resulting
appearance similar a sharp
and slow wave complex.
These may appear
spontaneously or with
auditory stimulation, and are
best demonstrated with an
ear reference
Significance: Normal, may
be mistaken for pathological
bifrontal sharp and slow wave
complex

EEG Artifacts

EEG Artifacts
Physiological

Eye movements
Lateral rectus spikes (muscle action potential)
Eyelid flutter
Sweat
Glossokinetic
ECG

Non-physiological
Electrode pop
Movement
60 Hz artifacts

Fp1

Fp2

F7

F8

Eye movements

Asymmetrical slow eye movements of drowsiness (F7, F8), not to be

mistaken for focal delta activity

Lateral Rectus Spikes (muscle action potentials)

Eyelid flutter

Sweat artifact

Prominent glossokinetic
potentials resembling
frontal intermittent
rhythmic delta activity

Chewing

ECG artifact

Electrode Pop

Head movement

60 Hz Artifact

60 Hz Artifact (after using filter)

Non Epileptiform Abnormalities

Non Epileptiform Abnormalities

Intermittent slowing
Generalized
Focal

Intermittent rhythmic slowing

Generalized
Focal

Continuous slowing
Focal (regional)

Non Epileptiform Abnormalities

Intermittent slowing
generalized
focal

Intermittent rhythmic slowing

generalized
focal

Generalized intermittent slowing

Focal intermittent slowing

Non Epileptiform Abnormalities

Intermittent slowing
generalized
focal

Intermittent rhythmic slowing

generalized
focal

Occipital Intermittent Rhythmic Delta Activity (OIRDA)

Frontal Intermittent Rhythmic Delta Activity (FIRDA)

Focal intermittent rhythmic slowing

Left temporal region (F7-T3)

Non Epileptiform Abnormalities

Intermittent slowing
Generalized
Focal

Intermittent rhythmic slowing

Generalized
Focal

Continuous slowing
Focal (regional)

background asymmetry, continuous slowing right hemisphere

Epileptiform Discharges

Definition of Epileptiform Discharges

Should be unarguably discrete events, not just accentuation of part
of an ongoing sequence of waves
Should be clearly separable from ongoing background activity, not
only by their higher amplitude but also by their morphology and
duration
Have bi- or triphasic waveform and have more complex morphology
than even high-voltage background rhythms
Not sinusoidal but rather show asymmetric, rising and falling phases
Most spikes and sharp waves followed by slow wave
Should have a physiological potential field involving more than one
electrode that helps distinguish them from electrode-related artifacts
or muscle potentials

Bipolarmontageshowingphasereversal

Rightcentrotemporalspikes(BFEDC)

BFEDC

staring

Characteristics of Ictal pattern

Repetitive EEG discharges with relatively abrupt
onset and termination
Pattern of evolution lasting at least several
seconds
Generally rhythmic, frequency displays
increasing amplitude, decreasing frequency and
spatial spread during the seizure

Grading of EEG Abnormalities in Diffuse Encephalopathy

Grade I (almost normal)

Dominant activity is alpha rhythm with minimal theta

activity

Grade II (mildly abnormal)

Dominant theta background with some alpha and delta

activities

Grade III (moderately abnormal)

Continuous delta activity predominates, little activity of

faster frequencies

Grade IV (severely abnormal)

Low-amplitude delta activity or burst-suppression

pattern

Grade V (extremely abnormal)

Nearly flat tracing or electrocerebral inactivity

Continuous Slow Waves

Triphasic Waves

Periodic Lateralized Epileptiform Discharges (PLEDS)

BiPLEDs

Bilateral Independent Periodic Lateralized Epileptiform Discharges

(BiPLEDS)

Generalized Suppression
(low amplitude delta)

Burst Suppression Pattern

Burst Suppression Pattern

Differential Diagnosis
1.

Severe diffuse encephalopathy e.g. hypoxia, metabolic disorders

2.

Iatrogenic e.g. general anesthesia e.g. thiopentone treatment for

GCSE

3.

Normal pattern in prematurity

4.

Early infantile epileptic encephalopathy:

- Othahara syndrome
- Early myoclonic encephalopathy
- West syndrome (EEG in sleep)

Summary
1.

EEG and its uses and limitations

2.

EEG electrode placement, 10-20 international system

3.

EEG Rhythms

4.

Normal awake and sleep EEGs in adults and children

5.

Activation procedures for EEG

6.

Common benign variants in the EEG

7.

EEG artifacts

8.

Non-epileptiform abnormalities in the EEG

9.

Epileptiform discharges

Take Home Message

1.

Not all sharply contoured transients or rhythmic activity

are epileptiform, but may represent normal findings or
benign variants with no clinical significance.

2.

Use various montages and references for analysis of the

field potential (maximum negativity) instead of relying on
visual pattern recognition.

3.

Do not miss the wood for the trees, being over-interested

in each individual spike but missing the big picture,
especially in the presence of encephalopathy.

4.

Conservative reading and interpretation should be the

rule, as more damage is done by over-reading or overinterpretation of an EEG record.

References
Comprehensive Clinical Neurophysiology
Cleveland Clinic Foundation

Atlas of Electroencephalography
Ed: MR Sperling & R Clancy

EEG Activation & Artifacts

American Society of Electroneurodiagnostic Technologists

Pediatric EEG
American Society of Electroneurodiagnostic Technologists

University Childrens Medical Institute

Thank You