EEG Epilepsia y Sueño 2

Psychiatry Review Course The Osler Institute ©2021
EEG, Epilepsy, Sleep EEG – 6, Ques 3
Neurology Board Review

§ EEG in a 35 years-old with episodes of
staring, unresponsiveness, and lip
smacking. The EEG shows
Charles J. Marcuccilli, PhD, MD
Section Chief, Division of Pediatric Neurology
Director, Pediatric Epilepsy
Rush University Medical Center
Ques 3
A. Normal variant – “Wickets”
B. Intermittent right and left temporal slow
C. Right temporal sharp waves
D. Evidence of prior surgery
E. EMG artifact
Ques 3
A. Normal variant – “Wickets”
B. Intermittent right and left temporal slow
C. Right temporal sharp waves
D. Evidence of prior surgery
E. EMG artifact
Y}Marcucilli (8/23/2021) EEG, Epilepsy and Sleep II page 1

Temporal Spikes/Sharp Waves
§ Most commonly seen focal epileptiform

discharges in adults
§ Most common pathological association
with mesial temporal sclerosis
§ May be better recorded with sphenoidal
electrodes
Temporal Lobe Epilepsy Temporal Lobe Epilepsy

§ Most common partial epilepsy in adults
§ EEG: temporal lobe sharp waves
§ Typical seizures:
§ MRI:
§ Aura: Abdominal aura, Deja vu’ (psychic), Olfactory
§ Mesial temporal (hippocampal) sclerosis (most
§ Complex partial seizures with automatisms common in adults)
§ Secondary GTCS § Low grade tumor
§ Lateralizing signs § Malformation of cortical development
§ Ictal dystonia - contralateral § Others trauma, postinfectious etc.
§ Ictal unilateral automatisms – ipsilateral § Rx: OXC, CBZ, LTG, Surgery, LEV, TPM,
§ Head version before secondary GTCS – contralateral ZNS,
§ Ictal speech – non-dominant hemisphere
§ Epilepsy surgery considered early (only
§ Post ictal aphasia – dominant hemisphere
randomized trial for efficacy of surgery)
Ques: This brain MRI shows This brain MRI shows:
A. Normal MRI
B. Bitemporal volume loss
C. Bilateral intraventricular
hyperintensities
D. Right mesial temporal sclerosis
E. Polymicrogyria

This brain MRI shows: EEG - 7
§ A 36-years-old woman arrives in

A. Normal MRI emergency in stupor. Toxic coma due to
B. Bitemporal volume loss over dose is suspected. What abnormality
C. Bilateral intraventricular in her blood biochemistry is expected?
hyperintensities
D. Right mesial temporal sclerosis
E. Polymicrogyria
Ques 3
A. Hypoglycemia
B. Hypercalcemia
C. High ALT
D. Leukopenia
E. Acute hemolytic anemia
Triphasic Waves
Ques 3
§ Described classically in hepatic failure
§ Also seen in other toxic, metabolic, renal or
A. Hypoglycemia anoxic encephalopathies
B. Hypercalcemia § Clinically correlate usually to Stupor
C. High ALT § Triphasic waves are periodic pattern
D. Leukopenia § Triphasic morphology
§ 300-500ms duration
E. Acute hemolytic anemia
§ Semi-periodic trains every 1.5-2.5 seconds
§ Synchronous
§ Maximum bi-frontal, fronto-occipital lag

EEG - 8
§ EEG in a 52 years-old with bizarre

behavior, hallucinations, altered
awareness for 3 days. Had one seizure
this morning.
EEG In HSV Encephalitis EEG - 9

§ Early to late changes are:
§ Uni-temporal irregular continuous delta
slow
§ Decrease background and diffuse slow § EEG in a 71 years-old who had
§ PLEDs appear 2-15 days after onset undergone cardiac valve replacement.
§ Semi-periodic, frontal or fronto-temporal Neurology consult was called as the
§ Usually unilateral initially patient is not waking up 48 hours after
§ May become synchronous
surgery.
§ Become less sharp, less frequent with time
§ Progression of diffuse slow with worsening
encephalopathy
Bi-PLEDs
§ When PLEDs are
§ Bilateral and independent
§ Pervasive through out the record
§ Epileptic Encephalopathic pattern
§ High probability of associated seizures
§ Comatose or deep stupor
§ Seen in
§ Post hypoxic encephalopathy (most common)
§ Bi-PLEDs Signify poorer prognosis (compared
to PLEDs)

EEG - 10
§ A 65 years-old man with rapid loss of

memory, agitation, confusion, and
stimulus sensitive jerks
EEG in CJD EEG - 11

§ Classical description
§ Periodic pattern (PLED like)
§ Initially may be unilateral
§ Eventually becomes bilateral synchronous or § A 17-years-old with history suggestive of
bilateral independent fainting spells and post-syncope
§ Broad waves, sometimes triphasic convulsions. Does this EEG shows any
morphology abnormality? If yes, then what is it?
§ 2.5Hz or slower
§ Pervasive
§ No one to one correlation with myoclonic
jerks
Posterior Slow Wave Of Youth
§ Young age
§ Awake EEG
§ Occipital distribution
§ Delta with over-riding normal alpha
§ No disturbance of background
§ Usually synchronous
§ Common finding mistaken for
pathological slow

EEG - 12
§ A 29-years-old woman referred for

stiffening episodes with pain in her left
hand.
Mu Rhythm EEG - 13
§ Normal rhythm in ~ 25% normal EEG
§ Characteristics
§ Awake rhythm, usually asynchronous § A 36-years-old man with history of
§ 7-12Hz, arciform (comb like) spacing out episodes. Complex partial
§ C3 or C4 maximum seizures are suspected.
§ Disappears: move or touch extremity
§ Commonly mistaken for runs of sharp
waves due to spikiness.
Wickets
§ Benign physiologic variant
§ Seen > 30 years, 3-5% of normal EEG
§ Commonly mistaken for temporal
epileptiform discharges
§ Characteristics
§ Drowsy or awake resting
§ Theta-alpha range (6-11Hz)
§ Usually asynchronous and shifting sides
§ Not disturb background, no after-slow
§ In trains or isolated

EEG - 14
§ A 40-years-old woman with history of

episodes where she feels spacing out
while talking to people. Complex partial
seizures are suspected.
Psychomotor Variant SREDA: Subclinical Rhythmic

EEG Discharge in Adults
§ Also called Rhythmic Mid-temporal
Theta Bursts of Drowsiness (RMTD) § Infrequent, < 2% EEG
§ Rhythmic 4-7Hz bursts § Awake > drowsy (not sleep)
§ Uni- or bilateral maximum temporal § Abrupt onset or rapid temporal evolution
§ Some evolution of amplitude with wide spread distribution
§ Notched morphology § Centroparietal, vertex, temporo-parietal-
§ Drowsiness or awake occipital – could be synchronous,
§ ~ 2% of normal EEG asymmetric
§ Commonly mistaken for temporal lobe § Sharp, rhythmic 4-7/s, rarely delta
sharp waves or epilepsy § Could be longer (~30 seconds or more) in
duration
SREDA SREDA + 10s

EEG - 15
§ A 35 years-old woman with previous

history of brain tumor.
Breach Rhythm
§ Rhythm over previous craniotomy/injury
signifying “breach” in the layers of skull
§ Usually beta, >15Hz, >30uV amplitude
§ Usually focal and pervasive in the record
§ Mixed with sharp transients
§ Sometimes hard to differentiate from
epileptic sharp waves
§ May be confused with ictal pattern or
paroxysmal fast
§ I had EEG tracing of breach in my exam
EEG
§ A 18-month-old male with developmental

delay and cerebral palsy. EEG to rule out
seizures.

Artifacts From Movements are

common in Infants
§ Usually seen in posterior leads
§ Movements, crying (hyperventilation)
§ Sucking while supine
§ Pat, rub, stroke, thumps while on shoulder or lap
§ Mistaken for slow or epileptiform activity or
background
§ Careful review of waveform distribution
§ EEG technician’s comments could be helpful

EEG
§ A 12-year-old boy had episodic dizziness,

syncope, and nonspecific cephalic
sensations. You order a routine EEG.
14/6 HZ Spikes Occur In ~15% of

6-15 year-old EEGs
§ 14 and/or 6 Hz spikes
§ Sharply contoured
§ Occipital (surface) positive
§ Could be asynchronous
§ Predominantly occur in drowsiness
§ 14 Hz are more common
§ Commonly misinterpreted as
Epileptiform discharges
§ Leading to erroneous diagnosis of seizure
order

Thank you
Additional Reading:
Swaiman’s Pediatric Neurology, 6th ed. (2017)
Epilepsy Continuum; 22(1): February 2016
Wyllie’s Treatment of Epilepsy, 6th ed. (2015)

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Psychiatry Review Course The Osler Institute ©2021

EEG, Epilepsy, Sleep EEG – 6, Ques 3

Neurology Board Review

Y}Marcucilli (8/23/2021) EEG, Epilepsy and Sleep II page 1

Temporal Spikes/Sharp Waves

§ Most commonly seen focal epileptiform

Temporal Lobe Epilepsy Temporal Lobe Epilepsy

Ques: This brain MRI shows This brain MRI shows:

Y}Marcucilli (8/23/2021) EEG, Epilepsy and Sleep II page 2

This brain MRI shows: EEG - 7

§ A 36-years-old woman arrives in

Y}Marcucilli (8/23/2021) EEG, Epilepsy and Sleep II page 3

§ EEG in a 52 years-old with bizarre

EEG In HSV Encephalitis EEG - 9

Y}Marcucilli (8/23/2021) EEG, Epilepsy and Sleep II page 4

§ A 65 years-old man with rapid loss of

EEG in CJD EEG - 11

Posterior Slow Wave Of Youth

Y}Marcucilli (8/23/2021) EEG, Epilepsy and Sleep II page 5

§ A 29-years-old woman referred for

Y}Marcucilli (8/23/2021) EEG, Epilepsy and Sleep II page 6

§ A 40-years-old woman with history of

Psychomotor Variant SREDA: Subclinical Rhythmic

SREDA SREDA + 10s

Y}Marcucilli (8/23/2021) EEG, Epilepsy and Sleep II page 7

§ A 35 years-old woman with previous

§ A 18-month-old male with developmental

Y}Marcucilli (8/23/2021) EEG, Epilepsy and Sleep II page 8

Artifacts From Movements are

Y}Marcucilli (8/23/2021) EEG, Epilepsy and Sleep II page 9

§ A 12-year-old boy had episodic dizziness,

14/6 HZ Spikes Occur In ~15% of

Y}Marcucilli (8/23/2021) EEG, Epilepsy and Sleep II page 10

Y}Marcucilli (8/23/2021) EEG, Epilepsy and Sleep II page 11

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