CLINICAL EEG

 PAROXYSMAL DISCHARGES AND SEIZURE

DIAGNOSIS
Interictal Epileptiform
Discharges (IEDs)
 IEDs, represented by spike or spike-wave discharges, are
the most sensitive and specific markers for the diagnosis
of seizures.
 We often rely primarily on IEDs for the diagnosis of
epilepsy
 The likelihood of detecting IEDs varies depending on
seizure type, age, and seizure frequency.
 IEDs are found in 1.9% to 3.5% of healthy Children and
0.5% of healthy adults.
 Specificity varies depending on the type of IEDs:
 Benign rolandic spikes of childhood or BECTS_____40%
 Benign occipital spikes of childhood____50%
 Multifocal IEDs and focal IEDs, especially at the midline, frontal, and anterior temporal regions____75-
95%
The International Classification of
Epilepsies and Epileptic Syndromes
 Based on two principles:
Distinguishing first between localized (focal)
and generalized epilepsies;

And secondly between idiopathic and symptomatic

etiologies.
 Normal or near-normal background activity is
characteristic of idiopathic epilepsy.
 Slowing of background activity or multifocal epileptiform
activity is suggestive of symptomatic epilepsy.
 Focal background abnormality and/or focal polymorphic
delta activity likely correlate with symptomatic epilepsy.
LOCALIZED (FOCAL) EPILEPSIES AND
SYNDROMES
 Idiopathic type
Benign childhood epilepsy with centrotemporal spikes (rolandic spikes or
BECTS) .
Childhood epilepsy with occipital paroxysms (benign childhood occipital
lobe epilepsy).
 Symptomatic localized epilepsies and syndromes
Frontal or temporal lobe seizures that are secondary to focal pathology
Benign Epilepsy of Childhood with
Central Midtemporal Spikes
 The waveform is more commonly “sharp” rather than a
true spike, having a triphasic configuration with a
prominent negative peak, preceded and followed by small
positive peaks.
 The negative field centered at the central or midtemporal
electrode is commonly associated with positive fields in
the frontal region.
 These discharges can be unilateral or bilateral .
BECTS in a 12-year-old girl with history of
nocturnal generalized tonic–clonic convulsions with postictal
aphasia and right arm weakness (Todd’s paralysis). EEG showed
spikes maximum at C3 (marked by *).
BECTS in a 10-year-old boy with
history of nocturnal generalized tonic–clonic convulsions. EEG
showed spikes maximum at T4 (marked by *).
 Sleep (non-REM) greatly increases the spikes and about
one third of the patients have spike discharges only in
sleep.
 Also, unilateral spikes in the awake state may progress to
bilaterally independent spikes in sleep.
 Rolandic spikes tend to decrease progressively with age
and eventually disappear by the midteen years.
In wakefulness, there were sporadic sharp-spike discharges from the
right central and midtemporal regions (shown by the star in A).
In
sleep, there was a dramatic increase of sharp-spike discharges from
the left and right central midtemporal regions independently.
Childhood Epilepsy with Occipital
Paroxysms and other Occipital Spikes
 EEG abnormalities consist of Spikes of high amplitude
surface negativity (200 to 300 μV), often followed by a
small positive and negative slow wave.
 Eye opening tends to abolish the spike-wave and eye
closing may precipitate the burst. However, neither
repetitive photic stimulation nor hyperventilation has an
effect
Temporal Lobe Seizures
 Temporal lobe seizures can be divided into those
originating in the mesial temporal lobe and those from the
neocortex.
 Because many candidates for epilepsy surgery have
temporal lobe seizures, it is important to differentiate
these two foci before surgery.
 The interictal EEG of MTLE shows spike or sharp
discharges of maximum negativity at the anterior temporal
electrodes (F7/F8 or T1/T2).
 This relatively discrete negative field is accompanied by a
more widespread positive field over the contralateral
central–parietal region
 The ictal EEG is often characterized by rhythmic theta or
delta discharges from anterior/midtemporal electrodes at
the onset,with subsequent spread to other electrodes
Temporal spikes (IEDs), maximum at F7/T3, in a 40-year-old woman with
intractable partial complex seizures since age 7, with MRI evidence of right
hippocampal
sclerosis.
The ictal discharges started with rhythmic 3- to 3.5-Hz delta
bursts maximum at T3/T1 electrodes, with subsequent diffuse spread
This was
followed by rhythmic, left-greater-than-right, sharply contoured theta burst
followed
by rhythmic spikes maximally involving left temporal region
NEOCORTICAL TEMPORAL LOBE
EPILEPSY (NTLE)
 The interictal EEG features of NTLE are also less
consistent and less specific than MTLE.
 Interictal spikes of NTLE tend to have a broader negative
field and lack a positive field over the contralateral
central-parietal regions.
 An ictal onset with localized beta activity in the temporal
lobe region suggests NTLE
An example of NTLE secondary to a posterior temporal
lesion
Temporal spikes (IEDs), maximum at midtemporal to posterior temporal
electrodes on the left in a 36-year-old woman with intractable parietal complex seizures.
MRI showed marked cortical atrophy in posterior left temporal lobe with an enlarged left
ventricle.
Ictal discharges started with
beta activity from left parietal region followed by recurrent sharp/spike
discharges from
the left parietal and posterior temporal regions
followed by rhythmic sharp discharges
with progressively slower-frequency covering the entire left hemisphere
There was
postictal delta over the left hemisphere
Frontal Lobe Seizures
 As frontal lobe seizures often arise from the orbital-frontal
cortex, interhemispheric convexity , or cingulate cortex—
all of which are relatively inaccessible to scalp EEG—it is
not uncommon to miss interictal or even ictal discharges
on scalp EEG.
 If IEDs are recorded, however, they may appear
widespread and less localizing because of the deep
epileptogenic source
 About half of the patients with frontal lobe epilepsy have
IEDs in one frontal lobe only or with consistantly
unilateral dominance
Frontal lobe spikes in a 27-year-old woman with
diagnosis of right frontal gliosis and intractable generalized tonic–
clonic convulsions without aura. Note right-greater-than-left
frontal-dominant spike-wave discharges
With routine sweep
speed (10 s/page), spikes appear almost synchronous between left
and right frontal regions, but with the faster sweep speed (5 s/page),
right frontal spikes consistently preceded left frontal spikes
Parietal Lobe Seizures
 As with frontal lobe epilepsy, scalp EEG is often falsely
negative, nonlocalizing or falsely localizing.
 Seizures of parietal origin have no typical clinical
features
Other EEG Abnormalities Associated
with Focal Epilepsy
 Multifocal spikes, either within one hemisphere or from
heterogeneous areas of each hemisphere, generally
correlate with multifocal or diffuse brain diseases.
 Slowing of the background rhythm as well as diffuse slow
waves are common in these patients.
 The majority of patients have frequent seizures that are
often intractable to treatment.
Multifocal spikes in an 18-month-old baby boy with a
history of generalized tonic–clonic convulsions with developmental delay
Multifocal sharp and spike discharges in a 4-year-old
boy with history of partial complex seizure and generalized tonic–
clonic convulsions. There are at least four spike foci appearing as
single or repetitive transients from P3, C4, T3, and T6 electrodes
GENERALIZED EPILEPSIES AND
SYNDROMES
 Idiopathic generalized epilepsies and syndromes include
absence seizures and juvenile myoclonic epilepsy (JME).
 West syndrome and LGS are examples of generalized
epilepsy of a symptomatic type.
 Generalized epileptiform discharges appear in both
hemispheres simultaneously with similar configuration,
symmetric amplitude, and synchronous timing between
homologous electrodes.
 Timing between anterior and posterior discharges may
differ slightly within the same hemisphere.
 When discharges have consistently higher amplitudes in
one hemisphere or generalized discharges are consistently
preceded by focal discharges, this may suggest a focal
onset to a secondarily generalized seizure type, but clear-
cut differentiation between a primary and secondary
generalized seizure pattern is not always possible.
Absence Seizures
 Characterized by rhythmic cycles of spike and wave
complexes at a frequency of about 3 Hz, usually lasting a
few to several seconds.
 The spike-wave complexes are generally maximum in the
frontal region and may start with 3 to 3.5 Hz and end with
2 to 3 Hz
Three Hertz spike-wave bursts associated with absence
seizure in a 7-year-old boy (childhood absence). Note spike-wave
bursts started with slightly faster than 3 Hz and ended with slightly
slower than 3 Hz.
An example of a rhythmic (monomorphic) paroxysmal
discharge shown as 3-Hz spike-wave burst in an absence seizure
Typical 3-Hz spike/wave bursts, characteristic for
absence seizures, induced by hyperventilation in an 8-year-old girl.
 About 20% to 40% of patients with absence seizures show
3-Hz rhythmic delta bursts in the occipital regions
(OIRDA; Occipital intermittent rhythmic delta activity)
An example of OIRDA in a 9-year-old boy with history
of absence seizures. Note occipital-dominant 3-Hz spike-wave burst
(shown by oval circle) mixed with 3 Hz OIRDA (shown by
rectangular box).
Three-Hertz spike-wave bursts with initial polyspike
component in an 18-year-old girl (juvenile absence). The patient had
absence seizures in the past, and recently started having generalized
tonic–clonic convulsions.
Generalized Tonic–Clonic Seizures
 Multiple spike-wave (polyspike-wave) bursts lasting less
than one to several seconds are usually an interictal
expression of a generalized seizure .
 The interictal EEG of idiopathic (primary) generalized
tonic–clonic seizures consists of a variety of waveforms
which are more irregular and of faster frequency than the
3-Hz rhythmic spike-wave discharges seen in absence
seizures.
 Spike-wave bursts are usually, but not always, symmetric
and synchronous.
Four to six Hertz, somewhat irregular, bilaterally
synchronous generalized spike-wave bursts maximum at midline (A)
in a 30-year-old woman with history of generalized tonic–clonic
convulsion
The patient also had more
irregular polyspike-wave bursts during stage 2 sleep
 There are two features which may help point toward a
diagnosis of primary generalized epilepsy.
 One is a photoparoxysmal response.
 Other is generalized spike-wave bursts resembling K
complex
Generalized irregular spike-wave bursts (A) in a 10-
year-old boy with history of absence seizures and recent grand mal
seizure.
Photic stimulation produced photoparoxysmal response at
16-Hz frequency flashes with generalized irregular spike-wave bursts
Bilaterally diffuse synchronous and symmetric spikewave
bursts with bifrontal dominance in a 31-year-old man with
history of grand mal seizures. Note that the spike and wave bursts
were followed by spindles (A). With exception of the spikes, the
epileptiform bursts had similar wave form and distribution with K
complex induced by noise (B).
 Onset of the ictal event in a generalized seizure consists of
low-voltage rhythmic beta-range fast activity, with
progressively increasing amplitude and decreasing
frequency.
 This is followed by generalized spike-wave bursts which
become progressively slower in frequency and less
rhythmic toward the end of the seizure. The EEG becomes
suppressed during the immediate postictal period and is
then followed by the appearance of postictal delta activity.
 Clinically, the initial fast activity corresponds to the tonic
phase and the subsequent spike-wave bursts coincide with
the clonic phase of the seizure.
 During the ictal events, EEG activities are largely
obscured by muscle and movement artifacts, making it
difficult to differentiate genuine seizure from
pseudoseizure.
 The presence of postictal flattening or slowing provides
evidence of genuine seizure. Conversely, immediate
normalization of the EEG favors pseudoseizure, especially
if the patient remains unconscious or confused.
Generalized ictal event in a 25-year-old man with
history of grand mal seizure. Note sudden flattening of EEG activity
at the onset, followed by beta activity peaking through the massive
EMG (muscle) artifact during the tonic phase of seizure
Toward
the end of the seizure, ictal discharges changed to periodic spikewave
discharges, which were contaminated by muscle artifact
(clonic phase). Afterward, there was postictal suppression of EEG
activity
Juvenile Myoclonic Epilepsy
 Interictal EEG patterns consist of generalized polyspike and
polyspike-wave discharges with frontocentral predominance
.
 These patterns are not distinguishable from other idiopathic
generalized epilepsies but may include more polyspike
components.
 Background activity is usually normal.
 Spike-wave or polyspike-wave bursts are usually faster than
the typical 3-Hz spike-waves seen in absence seizures, but
in some patients, 2.5- to 3-Hz spike-wave bursts may occur
that are indistinguishable from typical absence seizures
An example of JME in a 14 years old girl. Brief,
generalized irregular polyspike-wave discharges were noted in sleep
 Hyperventilation may activate epileptiform activity in
JME but less often compared to absence seizures.
 About 30% to 40% of patients also have photoparoxysmal
seizures
Photic stimulation induced 3 HZ rhythmic spike-wave bursts
Myoclonic Seizures
 EEG correlates of myoclonus/myoclonic epilepsy vary
between sudden flattening of EEG activity to irregular
polyspike-wave bursts.
 The epileptiform discharges may be focal,associated with
focal myoclonus, or may be generalized, with irregular
polyspike-wave bursts.
 It should also be noted that myoclonus often occurs
without detectable epileptiform activity.
Focal myoclonic seizure in a 42-year-old man
presenting with recurrent jerking in the right leg. Periodic delta
mixed with fast activities (PLEDs) correlated consistently with EMG
activity recorded from quadriceps muscles in EMG channel
(indicated by arrows).
Myoclonic seizure in a 10-year-old boy presenting with
brief body jerking in sleep. EEG showed generalized irregular
polyspike-wave bursts associated with movement artifacts recorded
by the EKG channel.
Serial arrhythmic polyspike-wave bursts in a 25-year old
man with history of myoclonic seizures.
Atonic Seizures
 Epileptiform activity consists of brief, generalized,
irregular polyspike-wave bursts which are
indistinguishable from interictal discharges seen in
generalized tonic–clonic epilepsy or myoclonic seizures.
 In the long form, discharges may be associated with slow
(1.5 to 2 Hz) spike-wave activity.
Generalized irregular polyspike-wave bursts in 22-
year-old woman with past history of absence seizures and recent
“drop attacks,” occasionally associated with loss of consciousness.
Note the decrease of muscle artifacts during spike and wave bursts
indicating the decrease of muscle tone.
Lennox–Gastaut Syndrome
 LGS represents a characteristic triad comprising
(i) severe generalized seizures,
(ii) mental retardation, and (iii)
an EEG showing slow spike and wave (SSW) complexes.
 The SSW complexes consist of biphasic or triphasic sharp
or spike waves followed by high-voltage (300 to 400 μV or
greater) slow waves .
 Frequency of SSW complexes is between 1.5 to 2.5 Hz,
and is slower and often more irregular than the 3-Hz spike-
wave complexes associated with idiopathic absence
seizures.
Generalized 2-Hz spike-wave bursts in an 18-year-old
mentally disabled male patient with a history of intractable
generalized tonic–clonic, tonic, and atypical absence seizures
(Lennox–Gastaut syndrome). Note high-voltage slow (2 Hz) spike
and wave complexes associated with abundant irregular delta-theta
activity in this awake EEG.
 The bursts are usually bilaterally synchronous, but may
show shifting or persistent asymmetries.
 Asymmetric bursts may be associated with a unilateral
lesion.
 In contrast to idiopathic absence epilepsy which is usually
associated with normal background activity, background
activity in LGS is slow in more than 70% of the patients.
Lennox–Gastaut syndrome associated with
asymmetric slow (2 Hz) spike-wave bursts in a 7-year-old girl with
diagnosis of Angelman’s syndrome. The patient presented with a
variety of intractable seizures including tonic, atypical absence, drop
attack and tonic–clonic types. Note the rhythmic, 2- to 2.5-Hz spikewave
discharges starting from the right hemisphere, then
generalizing. This is likely an ictal (seizure) event. (A and B are
consecutive recordins)
Progressive Myoclonic Epilepsy
 There are several clinical entities which account for
progressive myoclonic epilepsies.
 They are myoclonic epilepsies with ragged red fibers
(MERRF syndrome),Lafora disease, Unverricht–
Lundborg disease (Balic myoclonic epilepsy), neuronal
ceroid lipofuscinosis (Batten’s disease) and sialidoses
(Cherry red spot myoclonus syndrome).
 Epileptiform activity consists of generalized spike-wave,
polyspike-wave, and multifocal spikes.
 Background activity becomes progressively slower as the
disease progresses.
 Photo-paroxysmal responses are common in patients with
Lafora disease, Unverricht–Lundborg disease, and
Batten’s disease.
 In Batten’s disease, single or low-frequency intermittent
photic stimulation characteristically produces prominent
spike discharges at occipital electrodes with a one-to-one
relationship with the light flash
Photic stimulation induced spikes in a 5-year-old boy
with a diagnosis of Batten’s disease. The time-locked spikes with
slow photic stimulation are characteristic for this diagnosis as
shown in rectangular box.
SECONDARILY GENERALIZED SPIKE
AND WAVE DISCHARGES
 The following features suggest secondary generalized
seizures:
1. Spikes or spike-wave discharges in one hemisphere
consistently preceding those in the other hemisphere.
2. Amplitude of spikes or spike-wave discharges is
consistently larger in one hemisphere.
Frontal lobe spikes in a 27-year-old woman with
diagnosis of right frontal gliosis and intractable generalized tonic–
clonic convulsions without aura. Note right-greater-than-left
frontal-dominant spike-wave discharges (A). With routine sweep
speed (10 s/page), spikes appear almost synchronous between left
and right frontal regions
With the faster sweep speed (5 s/page),
right frontal spikes consistently preceded left frontal spikes
Secondary generalized spike-wave discharges in an 8-year-old boy with
diagnosis of Fragile X syndrome and mental retardation, and with history of grand mal
seizures (A). Note left-sided frontal-dominant spikes consistently precede right side
spikes, which is better visualized by faster sweep speed (B).
3. In addition to bilaterally symmetric and synchronous dis
charges, focal spikes consistently appear in one location.
4. Morphology of focal interictal discharges is more variable
in secondary than in primary generalized epilepsy.
5. Interictal discharges are multifocal.
6. Background activity is abnormal, either diffusely or
focally.
PERIODIC DISCHARGES
 Diffuse Periodicity
SUBACUTE PANENCEPHALITIS
 The periodic burst activity in SSPE consists of high-
amplitude slow waves mixed with sharp waves,
occasionally including spike discharges, maximum in the
frontocentral region.
 The bursts repeat at 4 to 15 s intervals and tend to be more
prominent during the awake state.
 Because of the relatively slow periodicity, a slower sweep
speed (20 to 30 s/page) makes it easier to rate the repetition.
 Patients with SSPE often have myoclonus coinciding with
the EEG bursts. Background activity becomes slow as the
disease progresses
Generalized periodic discharges in a 15-year-old boy
with diagnosis of SSPE (subacute sclerosing panencephalitis). Note
two bursts of irregular delta waves occurring in about 5-s intervals
(indicated by arrows)
Because of slow recurrence, the
periodicity was not clear with routine sweep speed of 10 s/page but
this became more evident (indicated by arrows) with slower sweep
speed of 30 s/page
CREUTZFELD–JACOB DISEASE
 Early EEG changes include reduction of normal background
activity and an increase in slow waves. These slow waves are
usually bilaterally diffuse but may start with a focal or
lateralized prominence
 As the disease progresses, diphasic or triphasic sharp and
sharp-wave discharges appear.
 Initially, the sharp discharges occur sporadically and may be
focal or lateralized.
 With further deterioration of the clinical picture, these
paroxysmal discharges develop into a characteristic pattern
with periodic and stereotyped sharp triphasic discharges of
200 to 400 ms duration in recurring intervals of 0.5 to 1 s
EEG shows increased delta-theta
slow waves, more prominent in the right posterior head region
Two weeks later, delta slowing increases
By the fourth week
after the first EEG, the patient started to show myoclonic
movements of her hands. At this time, the EEG shows intermittently
periodic triphasic sharp discharges with right-greater-than-left
posterior dominance (shown by box)
At 3 months after the first
EEG, periodically recurring diffuse triphasic sharp discharges at
intervals of 1 to 1.5 s become evident
POSTANOXIC CEREBRAL INSULT
 The EEG may show diffuse slowing, frontal intermittant
rhythmic delta activity (FIRDA), continuous spikes,
periodic spikes, burst suppression pattern, alpha coma,
severely depressed EEG activity, or electrocerebral
silence.
Burst suppression pattern in a 65-year-old man in
comatose state after postanoxic cerebral insult. The patient
exhibited frequent facial muscle twitches, which contaminated EEG
Because it was not certain if the discharge-associated twitches
are of muscle or cerebral origin, the patient was paralyzed by
pancuronium. Recurrent bursts of sharp/theta continued after the
patient was pharmacologically paralyzed, verifying that the bursts
were of cerebral origin
Recurrent sharp discharges and suppression in a 72-
year-old man in comatose state after postanoxic cerebral insult. The
EEG showed recurrent, frontal-dominant sharp discharges
alternating with suppression periods. The patient showed repetitive
left arm twitches but they were not associated with EEG discharges.
Note the dissociation of sharp discharges and EMG activity recorded from the left arm
Periodic Lateralized Epileptiform
Discharges
 PLEDs are periodically recurring paroxysmal discharges
of sharp waves, spike-waves, or complex discharges
consisting of mixed theta-delta waves arising from one
hemisphere or a relatively restricted area within one
hemisphere.
 The discharges may repeat as fast as 3/s or as slow as
10/min.
 PLEDs occur most often after acute , relatively large
destructive cerebral lesions.
Typical PLEDs in a 77-year-old woman after severe
postanoxic cerebral insult. CT scan was negative for cerebral
infarct. Note periodically recurring sharp discharges at a rate close
to one/s from right hemisphere.
 PLEDs may be associated with simultaneous contralateral
focal motor seizures, called epilepsia partialis continua
(focal motor status)
Focal myoclonic seizure in a 42-year-old man
presenting with recurrent jerking in the right leg. Periodic delta
mixed with fast activities (PLEDs) correlated consistently with EMG
activity recorded from quadriceps muscles in EMG channel
(indicated by arrows).
Periodic lateralized epileptiform discharge (PLEDs) in a 16-yearold
boy with diagnosis of herpes simplex encephalitis. The periodic discharges
consist of delta mixed with sharp and theta discharges (indicated by arrows).
Two independent PLEDs from the right hemisphere in a 75-year-old
woman with large right intraparenchymal hematoma . Note two independent
PLEDs, one from F4 (indicated by #) and the other from F8
(indicated by *).
Bilateral independent periodic lateralized epileptiform discharges
(BiPLEDs) in a 62-year-old man with diagnosis of herpes simplex encephalitis. Two
independent PLEDs from right and left temporal regions are evident; the left hemisphere
shows periodic large delta activity (downward arrows) and the right hemisphere shows
periodic sharp discharges (upward arrows)
The periodicity was better visualized
with slower sweep speed (20 s/page)
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