INVITED REVIEW
Normal Variants Are Commonly Overread as Interictal Epileptiform
Abnormalities
Joon Y. Kang* and Gregory L. Krauss*
*
Department of Neurology/Epilepsy Division, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.
Summary: Electroencephalographers may misclassify benign
variant EEG patterns as epileptiform discharges, resulting in
delays in the diagnosis and appropriate treatment of other
paroxysmal disorders, such as psychogenic nonepileptic seizures,
anxiety/panic disorders, and near syncope. These benign variant
patterns include wicket spikes, small sharp spikes, and rhythmic
mid-temporal theta of drowsiness. Cautious interpretations of
semi-rhythmic sharp transients, usually gradually rising from the
EEG background in drowsiness, can help avoid misdiagnosing
patients as having seizures. Viewing the EEG as confirmatory for
a clear clinical diagnosis is also helpfuldelderly patients with
INTRODUCTION
One of the most challenging aspects of interpreting EEGs is
distinguishing between pathologic activity and similar appearing
normal physiologic findings called “normal” or “benign var-
iants.” When benign variants appear in small fragments with
sharp morphology, the normal patterns can easily be misinter-
preted as epileptiform discharges. Benign variantsdwhich are
especially susceptible to overinterpretationdinclude the follow-
ing: wicket spikes/rhythms, benign epileptiform transients of
sleep (small sharp spikes), and rhythmic mid-temporal theta
bursts of drowsiness. Overinterpretation of these patterns often
results in misdiagnosisdwith subsequent inappropriate and
costly treatment.1–4
The main purpose of this article was to provide an overview
of several normal variants that are often mistaken as interictal
epileptiform discharges (IEDs) and to provide basic points on
how to differentiate physiologic patterns from pathologic
findings.
Wicket Spikes and Wicket Rhythms
Wicket rhythms are medium to high voltage (60–210 mV),
theta to alpha range (6–11 Hz), monophasic wave bursts that
usually evolve from the background as arcuate-shaped, brief
(0.5–1 second) rhythmic discharges (Fig. 1).5,6 Wicket rhythms
occur most commonly in drowsiness, are usually maximal over
the temporal regions, and can occur unilaterally or bilaterally
with shifting asymmetry, although one side can be more dom-
inant than the other.7,8 Wicket spikes occur as single fragments of
wicket rhythms (Fig. 2). Azzam et al.9 recently reviewed 133
The authors have no funding or conflicts of interest to disclose.
Address correspondence and reprint requests to Joon Y. Kang, MD, 600 N Wolfe
Street Meyer 2-147, Baltimore, MD 21287, U.S.A.; e-mail: Jkang50@jhmi.
edu.
Copyright Ó 2019 by the American Clinical Neurophysiology Society
ISSN: 0736-0258/19/3604-0257
DOI 10.1097/WNP.0000000000000613
clinicalneurophys.com Journal of Clinical Neurophysiology Volume 36, Number 4, July 2019
Copyright © by the American Clinical Neurophysiology Society. Unauthorized reproduction of this article is prohibited.
syncope, for example, often have microvascular disease and EEG
wicket rhythms in drowsinessda careful review of the clinical
history and the paroxysmal EEG pattern usually help distinguish
normal variant patterns from interictal sharp waves and spikes
and avoid misdiagnosing epilepsy.
Key Words: Benign or normal variant EEG patterns, Wickets
rhythms/spikes, Small sharp spikes, Rhythmic mid-temporal
theta of drowsiness, Interictal epileptiform discharges, Epilepsy
misdiagnosis.
(J Clin Neurophysiol 2019;36: 257–263)
prolonged video EEGs from an epilepsy monitoring unit and
reported that wicket spikes occurred most commonly in the left
temporal region (69%), possibly in association with cerebral
microvascular disease. Auditory stimulation and arousal can
attenuate wicket patterns, while drowsiness or light sleep and
rapid eye movement sleep can activate wicket spikes.10,11
Wicket spikes are commonly misinterpreted as IEDs be-
cause of their unilateral distribution, temporal location, and
spike-like appearance when occurring as single discharges. A
number of features can be used to distinguish wicket spikes from
temporal IEDs. Unlike IEDs, wicket spikes do not disturb the
background activity and do not have an after-going slow
wave.3,12 Single wicket spikes may be difficult to differentiate
from IEDs. Wicket spikes are single fragments of wicket rhythms,
and an important clue is that most recordings with wicket spikes
have longer duration wicket rhythms present elsewhere in the
recording with a similar arcuate morphology. While light sleep/
drowsiness activates both epileptiform discharges and wickets,
rapid eye movement sleep suppresses IEDs and activates wicket
spikes.13,14
Wickets are seen infrequently on routine EEG recordings,
with a reported incidence range of 0.03% to 2.9% in several large
case series.15 The rarity of this pattern is most likely the reason
why wicket spikes are most often mistaken for IEDs; most EEG
readers do not gain enough experience identifying wickets during
formal training.16 White strictly defined that wickets may be rare,
unspecified temporal “wicket-like” temporal sharp transients are
very common, and the main cause of overinterpretation.3
Fluctuations of background activity in the temporal region with
anterior or mid-temporal phase reversals may be mistaken for
sharp waves.3 The presence of phase reversal does not make
a discharge epileptiform or even abnormal. Phase reversal is a
relative measure of maximum surface polarity (usually negative)
used for localization and can be seen with normal physiologic
patterns and artifact.
Wickets are most commonly seen in adults older than 30
years and are used to be believed to be more frequent in patients
257
 J. Y. Kang and G. L. Krauss Normal Variants Are Commonly Overread as Interictal

FIG. 1. Wicket rhythm observed in an 83-year-old man with a history of small multiple small strokes. There is a wicket rhythm present over
the right temporal area, occurring during drowsiness. Wicket rhythms are 6 to 11 Hz normal variants occurring over temporal regions mostly
in drowsiness.

with cerebrovascular disease, dizziness/vertigo, headaches, and
migraines,7,9,12,17,18 but this is doubtful. Wickets typically first
are seen in mid to late adulthood, while epileptic IEDs often has
an earlier age of onset (Fig. 3).19,20 However, wickets have no
association with epilepsy; in one study, wickets were four times
more likely to be present in patients without a history of seizures
than in those with a history of seizures.5
Small Sharp Spikes
Small sharp spikes (SSS), named by Gibbs and Gibbs in
1952, are synonymous with benign epileptiform transients of
sleep21 and with benign sporadic sleep spikes. SSS are small
amplitude (,50 mV), brief (,50 ms), electronegative spikes in
the broad temporal region that appear almost exclusively during
drowsiness or light non-rapid eye movement sleep (Fig. 4). SSS
may occasionally be accompanied by an after-going slow wave;
this slow wave usually has a smaller amplitude relative to the
spike.16 When multiple SSS are present in a patient’s record, the
overall lateralization should be symmetric. SSS are usually seen
in adults (2.9% between 30 and 40 years of age) and are almost
never seen in children younger than 10 years.22 SSS may be best
seen with nasopharyngeal electrodes, but these are no longer
commonly used.
SSS are one of the most common benign variants, appearing
in up to 24% of scalp EEG recordings that include sleep.15,21,23 It
is therefore essential that electroencephalographers carefully
distinguish SSS from IEDs. Compared with IEDs, SSS have
a simple morphologic appearance with little variation in duration
and amplitude when occurring within the same recording. SSS
tend to appear as single, sporadic transients and, when repeated,
are often separated by more than 10 seconds. Interictal epilep-
tiform discharges often occur in repetitive clusters and may be
associated with accompanying focal slowing with disruption of
background rhythms. Unlike anterior temporal sharp waves, SSS
may have a broader distribution within the temporal lobe. While
IEDs during wakefulness may be seen occasionally, SSS never
appear during wakefulness and appear mainly in drowsiness. The
appearance of stereotyped, isolated, small-amplitude spikes that
do not disrupt the background and appear only in drowsiness
strongly suggest that the transient is SSS.
The clinical significance of SSS used to be controversial.
SSS were originally thought to be a pattern associated with
clinical seizures22–24 and as indicators of moderate epileptoge-
nicity.25 This view has been disputed by several larger studies
that found that SSS occur as frequently26 or more frequently in
patients without seizures as in patients with epileptic seizures.21
Sleep deprivation has been shown to increase the frequency of
benign epileptiform transients of sleep in normal patients without
epilepsy, which reinforces the thought that SSS are state-dependent,
nonpathologic variants.27 However, a recent study with hippocam-
pal implanted electrode investigations demonstrated that in some

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 Normal Variants Are Commonly Overread as Interictal J. Y. Kang and G. L. Krauss

FIG. 2. Wicket spikes and wicket rhythms observed in a 63-year-old man with a history of HIV, a seizure, hypertension, and cerebrovascular
disease. A, There are several medium-voltage sharp wicket patterns recorded over the right temporal region with phase reversals at T4 and
F8-T4 leads. Isolated wicket spikes such as these appear similar to focal sharp waves. B, As seen later in the recording, most wicket spikes
also occur in brief runs of wickets with an arcuate appearance located over the temporal areas. Identifying these longer wicket discharges
can help identify the wicket spikes.

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 J. Y. Kang and G. L. Krauss Normal Variants Are Commonly Overread as Interictal

similarities with epileptiform discharges that may be seen

FIG. 3. Distribution of age at onset of clinical episodes (n ¼ 25 for
each group). Adapted from Ref. 19.
patients (15 of 27), scalp SSS were time-locked to hippocampal
epileptiform discharges and to high-frequency oscillations.28
Thus, it is possible that in some patients with mesial temporal
lobe epilepsy, SSS may be an early indicator of hippocampal
pathologic condition.
Rhythmic Mid-temporal Theta of Drowsiness
Rhythmic mid-temporal theta of drowsiness (RMTDs), or
the psychomotor variant, are so called because they share
during temporal lobe seizures (psychomotor seizures).12,29 This
normal variant consists of paroxysmal, medium- to high-
voltage (50–200 mV), theta (4–7 Hz) rhythmic bursts that are
maximal over the mid-temporal region.12,16,30 The square-
shaped 6-Hz waves may appear notched by a small, overriding,
10 to 12 Hz rounded component or flat-topped waves (Fig. 5).
There is little variability in morphology and frequency during
the bursts, but the amplitude may rise and fall at the onset and
end of the burst.16 Bursts may occur unilaterally or bilaterally in
an independent and synchronous fashion. If the bursts occur
unilaterally, there may be a left-sided predominance.31 Rhyth-
mic mid-temporal theta of drowsiness are best seen during early
drowsiness and disappear during deeper stages of sleep. Burst
duration is typically about 5 to 8 seconds, but can be as short as
1 second or last longer than 1 minute.12,16 Rhythmic mid-
temporal theta of drowsiness appear in about 10% of recordings
in healthy, awake adults who are older than 60 years6 and in
about 1% of recordings in younger populations.30 Children
have higher amplitudes than adolescents.
Rhythmic mid-temporal theta of drowsiness may be con-
fused (or overlap) with wicket rhythms in that both rhythms
appear maximally in the temporal regions during light drowsi-
ness; however, RMTDs are slower in frequency and have longer
duration (greater than 1 second) than wicket rhythms. The
waveforms of RMTDs may also appear notched rather than
sharp because of the overriding, faster frequency.

FIG. 4. Small sharp spikes (benign epileptiform transients of sleep) observed in a 31-year-old man with a single tonic–clonic seizure. Small sharp
spikes in the recording are maximal first over the right temporal area (T4) and then the left temporal area (T3). These brief, low-amplitude spike
and slow wave discharges are ,50 ms duration and 50 mV amplitude, occur in early sleep in adults, and are not associated with epilepsy.

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 Normal Variants Are Commonly Overread as Interictal J. Y. Kang and G. L. Krauss

FIG. 5. Rhythmic mid-temporal theta of drowsiness (RMTD). A 37-year-old man has thrashing movements during sleep. A run of RMTD
occurs over the left temporal region, maximal over the mid-anterior temporal region. Also called “psychomotor variant,” RMTD occur in
drowsiness and may spread from side-to-side as waxing and waning rhythmic discharges.

Rhythmic mid-temporal theta of drowsiness are generally
considered benign variants, largely because of lack of associated
clinical change. Hughes and Cayaffa29 reported that 8 of 11
subjects with RMTD had diminished latency in response, raising
concerns about RMTDs’ ictal potential. A later study by Hughes
et al.,32 however, confirmed that RMTDs are the least epilepto-
genic of temporal discharges. Subsequent case studies have
consistently shown that prolonged, continuous runs (lasting up to
several hours) of RMTDs do not seem to impair function when
the patient is tested.33,34 Rhythmic mid-temporal theta of
drowsiness have been thought to be associated with psycholog-
ical symptoms32,35 and in one case, with an underlying temporal
lesion.31 Magnetoencephalography studies of RMTDs in non-
epileptic and epileptic patients localized a maximum source for
RMTD activity in the fissural cortex of the posterior inferior
temporal region.36
General Indicators of Benign Variants
One of the best ways to differentiate a benign variant from
an IED is to first thoroughly understand the criteria for IED.37
The IEDs represent summated hypersynchronous neuronal firing
with a paroxysmal depolarization shift with after-going hyper-
polarization, corresponding to a paroxysmal surface-negative
spike/sharp activity with an after-going slow wave that can be
clearly distinguished (and has a different frequency) from the
background activity. The IEDs often have a spiky/sharp mor-
phology (often with steep upslope and more gradual downslope)
on scalp EEG and occurs over several milliseconds (spikes 20–70
ms, sharp waves 70–200 ms). On scalp EEG, the approximate
source of the spikes/sharp waves can be inferred from the
physiologic field reflected in nearby electrodes (corresponding
voltage gradients are usually congruent with the amplitude of the
IED). Interictal epileptiform discharges may also be accompanied
by focal slowing in the same region, which may be caused by an
underlying deep-seated interictal spike,38 but the focal slowing is
not specific for epilepsy.
To help further differentiate benign variants from IEDs, one
can also examine the background patterns relative to the
transient. Benign variants such as wickets, SSS, and RMTDs
do not cause a paroxysmal disruption in the background, but
instead typically emerge from and fade into the background,
without any slowing or disruption of the underlying physiologic
rhythms. Variants also have a simple morphologic appearance.
When sharp transients such as wickets occur in isolation, it is
useful to examine the rest of the recording carefully to see
whether similar, longer bursts of the pattern exist. The presence
of prolonged fragments within the same recording helps identify
normal benign variants and is a reassuring sign. Benign patterns
also tend to have broader topography than focal IEDs; they can
appear in a broad region (i.e., the temporal lobe) and may shift in
lateralization within the same record. Last, the state of the patient
can help guide the interpretation. Most benign variants, such as
SSS and wicket spikes, are activated by drowsiness and light

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 J. Y. Kang and G. L. Krauss Normal Variants Are Commonly Overread as Interictal

FIG. 6. Rhythmic temporal activity in drowsiness. The recording is from a 24-year-old patient with probable syncope. A brief period of
drowsiness (stage I sleep) with relatively flat EEG is followed by brief arousal with a 10-Hz rhythmic pattern present for 3 seconds over the
left temporal area. This is followed again by brief drowsiness. Normal background patterns intermixed with drowsiness may be misidentified
as epileptiform discharges because of the focality, phase reversal, and rhythmicity of the discharges.

sleep. SSS, however, are never seen during wakefulness and
rapid eye movement suppresses wicket spikes.
Sharply contoured simple fluctuation of background activity
can be misinterpreted as epileptiform discharges, especially if there
are anterior or mid-temporal phase reversals3 (Fig. 6). These
background patterns may be ascribed to extension of the alpha
activity into the temporal region, which during drowsiness may
become isolated or fragmented, and combine with other frequen-
cies (theta and beta) to create spike-like waveforms.39 Incomplete
alpha attenuation may also resemble rhythmic temporal sharp
activity. As with other benign physiologic patterns, these fluctua-
tions do not disrupt the background rhythms and should not be
considered abnormal based on phase reversals.
CONCLUSION/RECOMMENDATIONS
An estimated 20% to 30% of patients who are referred to
tertiary epilepsy centers are eventually diagnosed with non-
epileptic psychogenic seizures.40 Overreading of benign variant
patterns can frequently contribute to misdiagnosis in pa-
tients.2,19,41 The diagnosis of epilepsy should not be made or
ruled out on the basis of a nonspecific finding on a single
outpatient EEG. Careful history-taking and analysis of clinical
events is critical to properly diagnosing epilepsy; the role of the
EEG should be supportive.37 When nonspecific transients occur
only once during an EEG finding, it may not be possible to
determine whether a transient is an IED or a benign variant.
When this occurs, the finding should be described within the
report with a comment that a suspicious transient was observed16
and the study should be repeated if possible. It has been reported
that repeating studies can increase the yield of detecting IEDs if
the first EEG demonstrates nonspecific findings.42 If the above
methods do not apply, we recommend thatdwhen deciding the
significance of an isolated findingdelectroencephalographers
resort to the basic tenet of EEG interpretation: It is best not to
“overcall” a finding as being abnormal, and to err on the side of
“undercalling” labelling the finding as a normal variant, and to
place the possible finding in the context of the clinical history.
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