164

ELECTROENCEPHALOGRAPHY

1st Recorded in humans Hans Berger

Electrodes are placed according to International 10 20
Nasion system Jasper
Fk
c Central
Fp Fk F Floutal
Ep Froutopolar
A
F3 Fz 4 Fs Gsd Ground
O Occipital
Grd
p parietal
T Temporal
17
b k h Ts Tp Tempore parietal
left Right FyoFg Ant temporal
dd uz Py Ps Post temporal
Ho TMI Tpr
K
13
Pz Pl
Ps
Evennumber MONTAGE Multiple deviation
acquired in an EEG Sleordin
displayed in anatomic format
01 02
02
Trion
sources constantly shifting 1 fluctuating dipole btw dendrites of
cortical cells cell bodies
BERGER WAVES
BETA RHYTHM
ALPHA RHYTHM 18 25 H2 5 20 MV
Fronto central location
8 13 H2 20 100mV Rhythmic waxing waning
posterior dominant symmetric
seen in awake c eyes open
Rhythmic alert
Regular waxing a waning i
seen in awake ein Quiet eyes closed
THETA RHYTHM
- f u of rhythm
low blood low
4 842
glucose body temp parietal or temporal
"

glucocorticoids
,
or Panoz Children
y

Hyponatremia
-
vit Biz deficiency emotional stress in adult
Afc intoxicate dfs
I
Degenerative
1
Alcohol i

Amphetamines
.

phenytoin
Barbiturates
r

DELTA WAVES
.

Antipsychotics
3.5 HZ
MU RHYTHM Seen in deep sleep
7 11 H2 20 100 UV
rhythm organic brain dfs
Attenuates E 4C limb movement or occur in cortex Endependani
thought of movement activities in lower brain
regions

165
 GAMMA RHYTHM LAMDA RHYTHM
30 80112 Occipital region
seen when individual is Aroused Represents evoked
focuses attention on something response to visual
seen Eu Irregular in stimuli
problem solving Alzheimer's
Meditation Parkinson's BREACH RHYTHM
6 il H2 780kV
working memory schizophrenia
learning Epilepsy An c Defection skull
Attention a mental sharpness
cognitive phenomena
BENIGN VARIANTS ON NORMAL EEG
wicket waves
seen in N1 Sleep
Benign small sharp spikes
1 2 see trains crescendo decrescendo low voltage short durath
Piranha teeth appearance N2 N2 Sleep
6 11 H2
6 H2 spike wave
Rhythmic temporal theta of Drowsiness phantom2 spike wave
lasts I Sec
Rhythmic Acta hauge bursts Ns sleep
midtemporal regions
Monomorphic appearance 14hr6 Positive spike bursts
waves may have notched appearance subclinical rhythmic
epileptiform discharge
EPILEPTITORM INSCHARGES

slow

Edo
spike sharp waves
spike a wave

70ms To 20ms 200ms

A
f r NAIF Slow
Fa
l 2.51Sec

1305,112
y µ
Biphasic
monophasic
4 20698Iiazutes
4 642
µ Htt Biphasic griphasic
t
MyoclonicIJME
biphasic
I
polyphasic
20 601Sec MM
metabolic wave
polyspiker
encephalopathy'es

uh unmmunmm
Burst status epilepticus
166
 FOCAL GENERALISED Slowing
Slowing
focal persistent delta
activity Delirium
tumor Dementia
seen
infarcts
white huge
make involved
if Delirium tremens
PERIOMC DISCHARGES I
j3 prominence
High amplitude
in intervals
Recurring periodic
02 2142 HYPSARRYTHMIAS
Duran 7150 Msec
Cms dis waves
ongoing
or
infection Diffuse giant
voltage 7400 µV
SSPE periodic waves chaotic background
Interval high
4 voltage
15 Sec
Jesus irregular multifocal
wave
Accompanying
No
body Shmulath spike
change painful
c
DID pep overdose Asynchronous
CTD B c sharp wares
1.5 2 per second
Early
late
slowing
Tn phasic o
COMA
qeach.ve to painful stimulation
Background aelivity
does not show
Herpes periodic latrealizing
PIEDS
epileptiform
evidence
discharge
Temporal predominant
of stimuli
to external
reactivity

Brain death
Burst suppression cerebral anoxia clinical osis
Burst Absence seizures not osed
patton
EEG alone
by
HEPATIC ENCEPHALOPATHY
8 scalp electrodes
stage consciousness EEG c 10cm bw
I Alert Normal any
11
Drowsy slow in poor K complexes Electrocerebral silence
sleep spindles No reactivity to
111
Stupor 0 frontal infamiltent stimulation
rhythmic 8 activity FRIDA
Absence sleep patton
w coma of wave
Triphasic
Delta wave
Deep coma
VI Deep coma
flat EEG
After 4 EEG Normalizes
167
 EVOKED POTENTIALS

D8
Assess functional integrity of pathways
OMATOSENSORY EVOKED POTENTIAL BRAINSTEM AUDITORY
EVOKED RESPONSE BAER
proprioceptive pathway
posterior column wave potential generator
Medial heminiscus
I 815 Nerve
short latency response after a cochlear nucleus
a mixed
limulating peripheral Nerve in sup olivasy nucleus
N lateral tenriniscus
Naming of response v colliculus
v1 ing
medial
N geniculate
waveform Negative
P Vil
body
Thalamocortical
Number positive
time in Msec
avg for projections
response
Response Electrode location VISUALEVOKEDPOTENTIAL
CED
Median N
Ns in antecubital
Erb's point
fossa waveform is generated by
Hg travelling wave
of signal
NB cervical spine CT in project
bw
geniculocalcarine
visual codex
Nao scalp Lgbt
Tibial N L
Ns in popliteal fossa ve wave
large
N 22
N 30
4 overlying onus
CT
ex 100 Msec
H after stimulus
P 38 scalp Hoo waveform
Eg if Nao is prolonged sensitive for lesions anterior
Ns 9,13 to
optic chiasma
lesion is b w Cg Clc somato No definable Poo in patients
sensory cortex c ocular blindness
Normal in corneal
May be blindness

168
 NERVE CONDUCTION STUDIES
-

Stimulation Nerve compound action Potential

of fibers
Types
L v g
Motor sensory Mixed
t t t
compound muscle sensory
nerve mixed nerve action
action potential action potental potential
CMAP SNAP MNAP

amplitude amplitude
Duration latency
Area conduction velocity
latency
conduction velocity
uses precise lesion location
Accurate charachtoization of Nerve
function
NEEDLE ELECTROMYOGRAPHY

E I
Assesses electrical activity c the muscle
fibres
fibrillation Potential Myokymic Discharges
muscle denervation complex bursts of grouped
necrotizing myopathies repetitive discharges
30 40112
2 10 spikes
I 5 Sec
Fasciculation Potentials Regular interval
spontaneous discharges of motor unit Brainstem glioma facial
MS muscles
Anterior horn cell DIS GBS
Radiculopathies CIDP immusbdes
entrapment neuropathy G daaintggincah.fm
Tetany
Thyrotoxicosis
Neuromyotonic Discharges
Myotonic Discharges
Tetany
Anticholinestrease poisonin
Myotonic Dystrophies
muscular
myotonia congenita spinal atrophy
paramyotonia
Pompe's Dls
polymyositis Stalin colchicine
myopathy
169
 Needle
Eng summary

Voluntary Motor
unit
fction Potentials
Extracellular electrode
recording of small portion
of motor unit

170
 Pawns
Common
of Electro
diagnostic Abnormalities

SPECIALISED STUDIES
-

=
F Wave H Reflex
A supramaximal stimulus
course
applied along
motor Nerve
Hoffmann
any point along of stimulates tibial
elicits small late motor responsef wave nerve
after F ConAp
Recording solens
wave latencies S arc
Prolong polyneuropathy
1 reflex
GBS Absent in GBS
A wave
after CMAP preceeds f wave
tibial Nerve
Pathological Motor neuron Dts Radiculopalities

171
-
S KV L L X RAY -

plain Skiagram
WATER'S VIEW CALDWELL'S VIEW

occipito frontal
150Caudad

Frontal
Ethmoid sinus
superiororbital
rim

occipito mental view

Best to visualize maxillary sinus

TOWNES VIEW
Fronto occipital
300 caudad

Best for LATERAL VIEW

Base skull
of bone
petrous
Acoustic neuroma
Angiography
Sphenoid sinus

SCHULLER'S VIEW

TM Joint
mastoid air cells
inner ear

petrous
long bone

172
 CT
ORBIT
inferior
border superior border
REID'SBASELINE External auditory canal
f
CT 0 Line

HOUNSFIELD UNITS

Bone 600 1000

cat 100 300
Spine CT
Enhanced vessels 90 100
Blood clot 75 80 Disc density 22 1544 Sac
gray math
white matter
30 40
20 35
edema 10 14
CSF 5
water 0

Fat 35 40

Air two

M R l

TW T2 W
spin echo
spin spin
corresponds to anatomy Bettor
for pathology
CSF Dark lteypointence while CHyperiutense
Fat white
Hyperiniense less white

Brain Grey matte grey Reversal

while matter while
Dark 0hboth T K 12
corticalbone
calcification
blood
flowing
Air
Hemosiderin
tendons ligaments
173
 FLAIR

0
Fluid attenuated inversion recovery
Resembles Tzw except CSF is hulled out dark
Ms plaques
while Mattie Ab
Tumors
edema
gliosis
Nyc infarcts
µ
Bright
food for CSF Ab

GRADIENT ECHO T2 DIFFUSION WEIGHTED IMAGING

Ltc
GRASS gradient recalled WD
acquisition in steady state j
est k vessels white Detects ischemia
Bone flowing
Cat Dark early
Two images
ADCmap Taace
DWI image
cerebral abscess DWI
bright
ADC Dark

fMRI
BOLD Blood oxygen level
dependent imaging
caveenoma
DIFFUSSION TENSOR IMAGING
conversion
blue superior inferior tracts
Red mediolatual tracts
Green Anteroposterior tracts

174
 MAGNETIC RESONANCE SPECTROSCOPY

Important peaks on proton MRS

Moeity ppm
tepid 0.5 I 5

lactate 1.3 Not in brain

ischemia Demyelinating dis
infection IEM
Nacetyl aspartate 2 Neuronal market
NAA 1 in all focal segional brain Ab
tumor Epilepsy Alzheimer's
MS Abscess
µ Canavan D1
creatinine 3
choline 3.2 Marker of membrane synthesis
A neoplasms
j stroke

MYEWGRAPHY
contrast
Non ionic
water soluble
iodine based
Dose G 17mL

lumbar puncture cervical puncture

13 Ci Cz
ly
phone or left lataali Erect or
spine flexed phone c head flexed

175
 Csf ANALYSIS

I
Extent
of spinal cord
Adults 4 Lower border LP Iz Ly
children 13 upper border LP Ly L5
Extent of Durac Sac Subdural Subarachnoid space
Adults 52
Children Sz

structures pierced in Lumbar puncture

S skin
S subcutaneous tissue
s supraspinous ligament
1 Intuspinous ligament
L sound
D
Ligamentum
Dura flavum popping
A Arachnoid
CSF collection Order
of tubes
1
chemistry Ilmmunology Frozen
glucoseprotein
serology
2 Microbiology Room temperature
3
Hematology
cell count Refrigeration
4 Microbiology Refrigeration
Specimen control
Glucose Furriae container
Total volume 150mL
formation Rate 450 750m11Day
turnover 3 times
Day
Rate of production Independent of ICP
Rate of absorption Pressure dependent
176
 CSI composition lumbar

Et
ventricular AF
lower protein
Higher Glucose
Serum Glucose
Obtained Ihr before
LP
for
comparison

CSF in pathology

177