INVITED REVIEW
Montages for Invasive Monitoring
Allyson A. Pickard and Christopher T. Skidmore
Department of Neurology, Jefferson Comprehensive Epilepsy Center at Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A.
Summary: Invasive EEG monitoring using subdural strip and
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grid electrodes or stereo electrodes is a valuable tool in
the evaluation of some patients before epilepsy surgery.
Although each patient will receive a custom montage for
data interpretation, an organized and consistent approach
within an institution is necessary. This article will discuss
S ubdural strip and grid electrodes were the predominant
intracranial EEG implantation technique performed in the
United States until recently, whereas stereo EEG (sEEG) was
more commonly used in Europe. Over the last 10 years, the
number of epilepsy centers in the United States performing sEEG
has grown. Regardless of the technique used, intracranial EEG
implantation is tailored to the individual patient, and while there
are standard areas implanted for study, there is no standard
montage. Each patient has a custom montage made to reflect the
relevant areas of investigation that have been implanted based on
clinical and radiographic data. It must be considered whether to
use a bipolar or reference montage, whether to include
extracranial electrodes, and how to arrange the many channels
for review.
ELECTRODE AND CONTACT NAMING
Naming of the electrodes should be consistent within an
institution to allow for clarity in interpretation and should always
be included in the final video EEG monitoring report to permit
other institutions to review the data if needed. Subdural strip,
subdural grid, and sEEG electrodes are named based on their
anatomic localization. For subdural strip and grid electrodes, three-
to four-letter labels are suggested, with the first letter reserved for
hemisphere (L for left or R for right) and the second two to three
for the anatomic structure (AT for anterior temporal, ST for
subtemporal, IH for interhemispheric, SMA for supplementary
motor area, and so forth). An example of subdural grid locations
and names that we use at our institution is provided in Table 1 and
Fig. 1. Subdural grid electrodes that cover a much larger area of
cortex and typically multiple lobes are given a single-letter
designation (A, B, C, etc) based on their anterior to posterior
location with respect to one another, with “A” being the most
anterior. Occasionally, a hemispheric designator is placed in front
of the grid name and/or a “G” is added at the end to designate the
electrode as a grid, both used as is clinically relevant. A large right
The authors have no funding or conflicts of interest to disclose.
Address correspondence and reprint requests to Christopher T. Skidmore, MD,
Department of Neurology, Thomas Jefferson University, 901 Walnut St, 4th
Floor, Philadelphia, PA 19107, U.S.A.; e-mail: christopher.skidmore@
jefferson.edu.
Copyright  2019 by the American Clinical Neurophysiology Society
ISSN: 0736-0258/19/3605-0337
DOI 10.1097/WNP.0000000000000619
clinicalneurophys.com Journal of Clinical Neurophysiology Volume 36, Number 5, September 2019
Copyright © by the American Clinical Neurophysiology Society. Unauthorized reproduction of this article is prohibited.
strategies for organizing, displaying, and interpreting
intracranial EEG.
Key Words: Intracranial EEG, Invasive EEG, Stereo EEG, Subdural
grid, Subdural strip, Montage.
(J Clin Neurophysiol 2019;36: 337–344)
posterior grid may be named RBG, for example. Should two
electrodes be present in the same anatomic structure, an additional
designator is used and named from most anterior to most posterior.
For example, if two electrodes are located in the left subtemporal
region, the more anterior electrode would be named LSTA and the
more posterior would be named LSTB, as in Fig. 1.
In the case of sEEG, the location of the terminal deep
contact is used for anatomic naming of the electrode with the
understanding that the remaining contacts typically traverse other
grey and white matter structures. A detailed understanding of the
anatomic structures through which these electrodes traverse is
critical for proper EEG interpretation, described further below. In
our institution, we use the sEEG labels that were developed by
our European colleagues, as shown in Table 2.
Subdural strip and grid electrodes have contacts that are
arranged in a bed of silicone in one or several rows with an
interelectrode distance of 1 cm.1 Individual contacts are numer-
ically labeled by the electrode manufacturer and may vary
between manufacturers beyond a 1 · 8 strip. Contact number
one is typically in the column furthest from the electrode wires
though its orientation with respect to the outgoing wires may
vary. The contacts are numbered along the row approaching the
side of the wire tail. When moving to the next row, the
numbering begins again at the contact furthest from the wire,
see Fig. 1 for an example. These numerical labels, however, are
not radiopaque and care to properly reorient the contacts in
relation to the wire tail must be taken when reviewing head
imaging such as a postoperative skull x-ray or computed
tomography scan (Fig. 2) to ensure a proper orientation.
Stereo-EEG electrodes typically have 4 to 18 electrodes
arranged 2 to 10 mm apart.1 By convention, the contact furthest
from the wire tail, which is also the most distal from the insertion
point, is numbered first. See Table 3 for an example of a bilateral
temporal and orbitofrontal implant. Individual electrode contact
numbers are then added to the electrode label with a hyphen and
combined on the final montage. For example, a left amygdalar
electrode would have its individual contacts named LA-1, LA-2,
LA-3, and so forth.
ADDITIONAL ELECTRODES
The use of simultaneous scalp and intracranial EEG record-
ings is not routinely performed at all epilepsy centers; however, it
337
 A. A. Pickard and C. T. Skidmore Montages for Invasive Monitoring

TABLE 1. Common Electrode Labels (Fig. 1) TABLE 2. Common sEEG Electrode Labels
LFG: left frontal grid Category Label Description
LTG: left temporal grid
Mesial temporal A Amygdala
LOFA: left orbitofrontal anterior strip
B Hippocampal head
LOFB: left orbitofrontal posterior strip
C Anterior hippocampal body
LAT: left anterior temporal
D Posterior hippocampal body
LSTA: left subtemporal anterior
E Enthorinal cortex
LSTB: left subtemporal mid
Posterior temporal P Anterior basal temporal/pole
LSTC: left subtemporal posterior
Q Posterior basal temporal
Insula I Inferior insula
may have some advantages.2,3 Intracranial EEG, in particular J Superior insula
K Anterior insula
sEEG, has an inherent sampling bias because of the choice of
L Insular apex
implantation sites. The use of scalp EEG complements the Cingulate V Anterior cingulate
precise yet limited coverage of intracranial EEG by providing full U Mid-cingulate
cranio-spatial coverage. This, however, comes at a much lower T Mid-posterior cingulate
sensitivity as scalp EEG spikes are only observable with cortical S Posterior cingulate
activation of at least 10 cm2 of gyral cortex.4 Because of this, Orbitofronal OF Orbitofrontal
intracranial EEG onset should always precede scalp EEG onset. Broca’s BA Pars orbitalis
If it does not, the EEG reader should be concerned that the true BB Pars triangularis
ictal onset is not covered by the intracranial electrodes. BC Pars opercularis
Combined scalp and intracranial EEG can also help confirm Wernicke’s WA Posterior superior temporal
WB Angular gyrus
a falsely lateralized or localized scalp onset. For instance, an
WC Supramarginal gyrus
orbitofrontal seizure confirmed on intracranial EEG may appear Motor ML Leg motor
as a “temporal lobe” seizure on scalp EEG. MA Arm motor
Sensory SL Leg sensory
SA Arm sensory
SMA PA Premotor cortex
PB Posterior superior frontal gyrus
Above outlines nomenclature used throughout many European centers as well as at
our institution.
sEEG, stereo EEG.

Patients often undergo an initial presurgical workup using

FIG. 1. Lateral and inferior view of typical subdural strip and grid
electrode configuration. See Table 1 for electrode label descriptions.
The filled black rectangles associated with each grid or strip represent
the wire tail. This can be visualized on x-ray imaging, which permits
confirmation of the orientation of the electrodes in the brain. LAT,
left anterior temporal; LFG, left frontal grid; LOFA, left orbitofrontal
anterior strip; LOFB, left orbitofrontal posterior strip; LSTA, left
subtemporal anterior; LSTB, left subtemporal mid; LSTC, left
subtemporal posterior; LTG, left temporal grid.
scalp EEG recordings to capture seizures. It may be helpful to
add scalp recording during intracranial EEG monitoring to
confirm the seizures currently being recorded match those
captured during the presurgical workup. When scalp electrodes
are used, the conventional 10-20 or 10-10 system should be used.
However, scalp electrode locations will often need to be altered
because of the presence of the surgical incisions used for
intracranial electrode placement.
Defining clinical onset is helpful in determining that the
ictal EEG onset recorded truly represents the ictal onset zone.
For intracranial EEG, clinical onset should always be pre-
ceded by (or rarely simultaneously with) ictal onset. Clinical
onset occurring before ictal onset would suggest that an
electrode is not residing in the true ictal onset zone. Video
recording, electromyography, and electrocardiography may
be used to help determine clinical onset. Subtle changes in
motor behavior (detected with electromyography electrodes)
or a rapid onset of tachycardia (seen on electrocardiography)
may precede changes in behavior that are observable clini-
cally or on video review. Video recording, like scalp EEG
recordings, can also help confirm that the seizures captured on
intracranial EEG are similar to those previously recorded or
observed clinically.

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 Montages for Invasive Monitoring A. A. Pickard and C. T. Skidmore

FIG. 2. Lateral and anteroposterior skull x-ray

demonstrating the electrodes depicted in Figure 1.

This can be used to an advantage when choosing a reference

REFERENTIAL VERSUS BIPOLAR when it is compared with the much higher amplitude cortical
A referential montage is only as useful as the quality of the electrode recordings. Stereo-EEG electrodes often have contacts
reference. The choice of an adequate, electrically silent reference that pass through white matter that had previously been thought
is therefore essential. There exist a number of options. An to be electrically neutral and therefore a good referential
earlobe or similar extracranial ground electrode may be used but, candidate. However, there is now evidence that white matter
as in scalp recordings, is subject to the same contamination by signals may be contaminated with distant gray matter signals,
electromyographic activity. Unique to sEEG are choices of possibly because of white matter fiber tracts.5 This creates an
reference in the bone or white matter.2 Stereo EEG electrodes unreliable area of reference and therefore white matter contacts
typically have contacts that reside in the white matter or within must be carefully chosen. Regardless of the reference electrode
the burr hole space of the skull (“in the bone”), or both. Both chosen, the same principles that apply to scalp electrodes apply
locations may be chosen by review of the individual contacts to intracranial electrodes, a topic covered by Dr. Kalamangalam’s
passing through these structures, usually with postoperative article in this issue.
imaging discussed later in this article. Bone has low electrical The use of a bipolar montage circumvents concern regarding
conductance and is responsible for the lower amplitude of scalp the contamination of an external reference. The potential between
recordings as it is able to resist fluctuations in electrical activity. two nearby contacts cancels contamination and electrical fluctu-
ation from a remote source that is presumed to affect each contact
equally, called common mode rejection.6 This also allows
smaller, more local activity to be highlighted. At the intracranial
TABLE 3. Example of Implanted sEEG Electrodes
level, this allows the measurement of electrical potentials across
1 LOF Left orbitofrontal 180319-093 D08-15AM areas of 1 cm2 or less, helping to increase spatial resolution and
2 LP Left temporal pole 181002-072 D08-10AM precisely define ictal onset where focal high-frequency activity is
3 LA Left amygdala 180961-033 D08-12AM seen. It is perhaps reassuring then that epileptiform activity at
4 LB Left hippocampus head 180961-040 D08-12AM ictal onset may be observed at one intracranial electrode and not
5 LC Left hippocampus body 200004-003 D08-15AM
in its contiguous contacts, at least initially.7,8 However, more
6 LQ Left temp postbasal 180961-046 D08-12AM
7 ROF Right orbitofrontal 200004-077 D08-15AM
diffuse cerebral activity, such as theta activity in the hippocam-
8 RP Right temporal pole 200001-068 D08-10AM pus, may be minimized or even lost because of common mode
9 RA Right amygdala 180961-045 D08-12AM rejection.7 This can be visualized as diffuse attenuation of the
10 RB Right hippocampus head 180972-006 D08-15AM background EEG across multiple electrical contacts. Remontag-
11 RC Right hippocampus body 180372-038 D08-15AM ing into a referential montage will confirm a diffuse clinical onset
12 RQ Right temp postbasal 180961-042 D08-12AM and highlight the actual ictal activity in these cases.
The table above names the sEEG electrodes which were implanted and the terminal
target that was selected for each. The unique serial number for each inserted electrode is
included in the second to last column. This can be seen on the extracranial portion of the
electrode and permits the EEG technician to properly identify the electrodes when
connecting the patient to an EEG machine. The last column identifies the type of CREATING THE MONTAGE
electrode implanted, with lettering and numbering determined by the manufacturer. In
this example, DIXI Medical electrodes were used. For the left orbitofrontal electrode, the When many electrodes are implanted, there are naturally
“D08” listed in D08-15AM designates that each electrode has a diameter of 0.8 mm, the many channels (128–256 or more) to be placed into the final
“15” designates 15 contacts in the electrode, and the “AM” designates constant spacing patient montage. Subdural strip and grid electrodes can often
of the contacts along the length of the electrode.
sEEG, stereo EEG. cover a large anatomic area of cortex. As such, a montage of
channels involving contiguous contacts across each row is often

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 A. A. Pickard and C. T. Skidmore Montages for Invasive Monitoring

FIG. 3. A, EEG showing half of the electrodes included in the full montage. This spacing of channels permits more accurate interpretation
of the involved electrodes, but requires scrolling of the screen up and down. Note how the LTG grid is only partially displayed. B, The second
half of electrodes including the completion of grid LTG. Alternately, the computer monitor may be rotated 908 into a portrait orientation to
allow for display of more channels. Please note additional depth electrodes LA, LB, and LC are included in the full montage that are not
included in Figure 1. LTG, left temporal grid.

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 Montages for Invasive Monitoring A. A. Pickard and C. T. Skidmore

FIG. 4. A, EEG showing only the LTG. This montage is created based on the numerical order of the contacts. The black arrows represent
focal spikes. B, Now the LTG grid has been remontaged to group the temporal contacts together in the lower part of the montage. The
epileptiform discharges (black arrows) are now more obviously temporal in origin with a negative phase reversal at contact LTG-49. C, The
same epileptiform discharge is remontaged into a referential montage with the LTG contacts listed in numerical order. Contact LA-4 is
chosen for reference as it is located in white matter and found to be electrically silent. Note the epileptiform discharges (black arrows) are
again seen best at contact LTG-49. D, The same epileptiform discharges are remontaged into a referential montage with the LTG contacts
listed in anatomic order (temporal electrodes near the bottom). LTG, left temporal grid.

used. Typically, the montage will begin with the most anterior Figure 3 demonstrates the EEG montage that was initially created
electrodes and then subsequent posterior electrodes are included. for the intracranial implant depicted in Fig. 1. As you can see,

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 A. A. Pickard and C. T. Skidmore Montages for Invasive Monitoring

FIG. 5. A, Bitemporal, cingulate, and orbtiofrontal sEEG implant. In this montage, the mesial temporal electrodes from the right and left
(separated by an ECG channel) were selected with removal of the other electrodes from the montage once the mesial onset pattern was
identified. This permits a more focused review of the critical electrodes. Ictal onset (black arrow) was localized to contacts LB-4 and LC-2,
which were located in the head and body of the hippocampus, respectively. B, The next EEG page demonstrates ictal spread to the
amygdala, most prominent in contact LA-1. sEEG, stereo EEG.

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 Montages for Invasive Monitoring
a decision was made to list the orbitofrontal electrodes first (left
orbitofrontal) followed by the 4 · 6 frontal lobe grid and then the
8 · 8 grid that is covering the frontal and parietal peri-rolandic
cortex and the superior aspect of the left temporal grid. Often the
individually numbered rows of the grid are connected in a bipolar
fashion in a linear numbered sequence, as in the montage
channels for left frontal grid and left temporal grid in Fig. 3.
Care must be taken to avoid connecting the end contact of one
row with the first contact of the next row because this will lead to
confusing findings on the bipolar montage. Larger grids, such as
8 · 8 grids, often cover multiple lobes, and a decision needs to be
made as to whether the individual contacts should be connected
in a linearly numbered method as shown in Fig. 4A or instead use
an anatomic method that groups contacts based on the lobe
or region they cover. In Fig. 4B, the same 8 · 8 grid depicted in
Fig. 4A was remontaged to group the contacts over the temporal
lobe separately from the frontal and parietal groups. On initial
review of the EEG sample displayed in Fig. 4A, there seems to
be a spike that is widely distributed over the grid; however, in the
remontaged view in Fig. 4B, the spike is maximal in the contacts
over the temporal neocortex. Creating a montage based on the
anatomic location of the electrodes permits the EEG reader to
quickly differentiate the involved lobe of the cortex and aids in
localization of the ictal onset zone.
The decision to read the intracranial EEG using a bipolar or
referential montage is a personal decision, and each method has
its strengths and weaknesses as outlined above. In our center, we
review the EEG using a bipolar montage but create a referential
montage when needed if we suspect a large generator or if we
need to confirm the findings noted on the bipolar montage.
Figures 4C and 4D demonstrate the same interictal spike seen in
Figs. 4A and 4B but now in a referential montage to an
uninvolved electrode. Figures 4C and 4D demonstrate the
numerical montage and the anatomic montage approaches,
respectively, which were previously highlighted.
Stereo-EEG electrodes reach many areas of the brain in
addition to cortex, so it must be considered whether to take an
electrode-based approach as with the subdural contacts of smaller
grids or to prioritize their anatomic location as with larger grids.
The anatomic model has the advantage of grouping channels in
close structural proximity together for review. This lends itself to
sEEG interpretation, where a more three-dimensional map can be
obtained. In Figures 5A and 5B (consecutive EEG pages), there
is a focal onset in the left hippocampus that eventually spreads to
the left amygdala but does not involve the right side. The
proximal contacts sitting in the temporal neocortex are also not
involved. The patient had orbitofrontal and cingulate electrodes
as well, but this review montage was created to highlight the
mesial temporal region. This permits the reviewer to quickly
determine spread within the mesial temporal structures and
spread, if any, to the contralateral regions.
Naturally, accurate localization of electrode contacts is key
to designing an anatomic-based montage. Electrode locations
must first be confirmed to allow identification of cortical and
subcortical contacts and an appropriate reference to be chosen if
desired. There are several methods used that often include co-
registration of a preoperative brain MRI with intraoperative
photos, skull x-ray, postoperative head CT, or postoperative
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A. A. Pickard and C. T. Skidmore
brain MRI using one of the many software tools available.9,10
This will give a visual representation of the implanted electrodes
and often allows individual contacts to be selected for localiza-
tion. Contiguous contacts within an electrode that exist in an area
favorable for study are grouped within the montage. Then all
electrodes within that same area of brain are grouped together in
the final array.
VISUAL DISPLAY
Once a montage has been created, there are several ways to
improve its display for high-yield interpretation. The computer
monitor may be rotated 908 into a portrait orientation. This allows
for more channels to be seen on the screen at one time with
reasonable spacing between channels to permit proper visualiza-
tion and interpretation. It may also be helpful to insert a one-
channel gap between electrodes to improve visual analysis. Filter
settings are often not recommended during EEG acquisition.2 On
EEG review, however, the typical 60-Hz filter may be applied if
a malfunctioning electrode is identified. A low-frequency filter of
0.01 Hz may also be helpful to detect infraslow activity and
negative baseline shifts that may occur 1 to 10 seconds before
initial ictal EEG discharges.11,12 Choice of sampling rate
becomes important to ensure high-frequency activity such as
ripples ranging from 80 to 250 Hz,13 and fast ripples greater than
250 Hz14 are observed. The sampling of these signals must be
twice the highest frequency of interest according to Shannon
theorem.15 Therefore, a sampling rate greater than 500 Hz is ideal
to capture the majority of ripples. To capture fast ripples,
a sampling rate greater than 1,000 Hz is needed. At our
institution, we routinely record all intracranial data at a sampling
rate of 2,000 Hz.
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