EEG and

EEG and
epilepsy
epilepsy
Panum
Panum
Institute
Institute
31.5.2007
31.5.2007
J rgen Alving, MD
Danish Epilepsy Center
DK-4293 Dianalund
EEG and
EEG and
epilepsy
epilepsy
Epilepsy is the
name of occasional,
sudden, excessive
rapid and local
discharges of grey
matter
J ohn Hughlings
J ackson, 1873
EEG and
EEG and
epilepsy
epilepsy
What does the clinician want from the
neurophysiologist?
They want him/her to prove or disprove
the diagnosis of epilepsy!
EEG and
EEG and
epilepsy
epilepsy
We will neither prove nor disprove that
our vessels carry nuclear weapons
while visiting your harbours
Standard explanation given by the US Navy to
the Danish Government during the Cold War
EEG and
EEG and
epilepsy
epilepsy
But we can say whether or not there are
epileptiform abnormalities in the EEG
The presence of these will give
important clues as to which type of
epilepsy is most likely (classification)
EEG:
EEG:
what
what
is
is

epileptiform
epileptiform

?
?
Epileptiform EEG abnormalities
focal or/and generalised paroxysmal
abberations from the background EEG which
are strongly correlated to epilepsy
They are rarely seen in persons without
epilepsy or other neurological diseases
EEG and
EEG and
epilepsy
epilepsy
Epileptiform EEG
3 Hz spike-waves
3-6 Hz poly-spike-waves
2 Hz spike-waves + 10 Hz trains during sleep
Hypsarrhytmia
Anterior temporal sharp-wave focus with
prefrontal spread
Centro-midttemporal sharp-waves + 4-5 Hz
Repetitive focal trains of spikes
Generalised
Generalised
spike
spike
-
-
wave
wave
paroxysm
paroxysm
(
(
childhood
childhood
absences)
absences)
Generalised
Generalised
polyspike
polyspike
-
-
wave
wave
paroxysm
paroxysm
(juvenile
(juvenile
myoclonic
myoclonic
epilepsy
epilepsy
)
)
Generalised
Generalised
2 Hz
2 Hz
spike
spike
-
-
wave
wave
paroxysm
paroxysm
(Lennox
(Lennox
-
-
Gastaut)
Gastaut)
Rhythmic
Rhythmic
10 Hz
10 Hz
train
train
in
in
sleep
sleep
(Lennox
(Lennox
-
-
Gastaut)
Gastaut)
Hypsarrhytmia
Hypsarrhytmia
(infantile
(infantile
spasms
spasms
)
)
Mesial temporal
Mesial temporal
epilepsy
epilepsy
Mesial temporal
Mesial temporal
epilepsy
epilepsy
(
(
ictal
ictal
start)
start)

Rolandic
Rolandic

focus
focus
Repetitive
Repetitive
ictal
ictal
train
train
of
of
spikes
spikes
EEG and
EEG and
epilepsy
epilepsy
A pitfall: not all paroxysmal EEG activity
is epileptiform!
Beware of the so-called normal variant
patterns
EEG: normal variants
EEG: normal variants
What are normal variants?
Apparently paroxysmal EEG events, i.e.
alterations with an abrupt and steeply
rising appearance, often with a
tendency to rhythmicity
EEG: normal variants
EEG: normal variants
But they are not infrequently seen in
normal people and have a low
correlation to epilepsy
They are often misinterpreted as
providing evidence of epilepsy
EEG and
EEG and
epilepsy
epilepsy
Normal variants I (wake/drowsy)
6 and 14 Hz positive spikes
6 Hz spike-waves
wicket spikes
rhythmic theta in drowsiness
(psychomotor variant)
SREDA (Sublinical Rhythmic
Electrographic Discharges in Adults)
14 Hz positive spikes (
14 Hz positive spikes (
Common
Common
Average
Average
Reference)
Reference)
14 Hz positive spikes
14 Hz positive spikes
Formerly ascribed to various
neurological and psychiatric
disturbances, including
thalamic/hypothalamicepilepsy, etc.
Nowconsidered a normal variant
mostly in children and young adults
Location posttemporal & parietal,
synchronous/asynchronous
6 Hz
6 Hz
spike
spike
-
-
wave
wave

FOLD
FOLD

(
(
Common
Common
Average
Average
Reference)
Reference)
6 Hz
6 Hz
spike
spike
-
-
wave
wave

FOLD
FOLD

(Double
(Double
Banana
Banana
)
)
6 Hz
6 Hz
spike
spike
-
-
wave
wave

FOLD
FOLD

(Transversal)
(Transversal)
6 Hz
6 Hz
spike
spike
-
-
wave
wave
Two variants:
WHAM= wake, high, anterior, male
FOLD= female, occipital, low, drowsy
Lower amplitude & higher wave-
frequency than in generalisered
epileptic paroxysms
Disappear in sleep
Generalised
Generalised
spike
spike
-
-
wave
wave
paroxysm
paroxysm
(
(
sleep
sleep
stage 2)
stage 2)
Wicket
Wicket
spikes (
spikes (
Common
Common
Average
Average
Reference)
Reference)
Wicket
Wicket
rhythm
rhythm
(
(
Common
Common
Average
Average
Reference)
Reference)
Wicket
Wicket
spikes
spikes
Seen in 0.5 1 % of normal people
Usually after age 30 years
Gradual or more abrupt pop-upfrom
background activity
Location temporal, asynchronous
/synchronous, in drowsiness
No aftercoming slowwave or other
disturbance of background activity
Mesial temporal
Mesial temporal
epilepsy
epilepsy

Rhythmic
Rhythmic
temporal
temporal
theta
theta
in
in
drowsiness
drowsiness

Rhythmic
Rhythmic
temporal
temporal
theta
theta
in
in
drowsiness
drowsiness

Occurrence: 0.5 2 % of normal adults

Mostly in younger people
Mostly midtemporal
Synchronous or asynchronous
Disappears in sleep
Mesial temporal
Mesial temporal
epilepsy
epilepsy
(
(
ictal
ictal
start)
start)
SREDA =
SREDA =
Sublinical
Sublinical
Rhythmic
Rhythmic
Electrographic
Electrographic
Discharges
Discharges
in
in
Adults
Adults
SREDA
SREDA
Occurrence: not given but mostly in
persons above age 50 yrs
Duration of trains from 20 sec. to
several min. (usually 40-80 sec.)
Mostly parieto-posttemporal
Focal or asynchonous occurrence
Constant frequency during whole train
EEG and
EEG and
epilepsy
epilepsy
Normal variants II (sleep)
hypnagogoc hypersynchrony
spikeyvertex-sharp-waves
mitten patternK complexes
positive sharp transients in sleep
(POSTs)
Hypnagogoc
Hypnagogoc
hypersynchrony
hypersynchrony
Hypnagogoc
Hypnagogoc
hypersynchrony
hypersynchrony

Spikey
Spikey

V
V
-
-
wave
wave
(
(
Common
Common
Average
Average
Reference)
Reference)

Spikey
Spikey

V
V
-
-
wave
wave
(transversal)
(transversal)

Mitten
Mitten
pattern
pattern

K
K
complex
complex

Mitten K
Mitten K

and
and
paroxysmal
paroxysmal
activity
activity
Gradual transition: spindles -> mitten K
complexes -> generalised polyspike-
wave paroxysms (E. Niedermeyer)
Generalised
Generalised
polyspike
polyspike
-
-
wave
wave
paroxysm
paroxysm
POSTs
POSTs
(
(
Common
Common
Average
Average
Reference)
Reference)
POSTs
POSTs
(Double
(Double
Banana
Banana
)
)
EEG and
EEG and
epilepsy
epilepsy
Epileptiform EEG in epilepsy
Epileptiform interictal standard EEG
First recording 50 %
Repeated with relevant provocations 85 %
No further yield after 4.-5. recording
(Salinsky, Kanter & Dashieff, Epilepsia 1987)
EEG and
EEG and
epilepsy
epilepsy
Epileptiform standard EEG in epilepsy
1. recording 38 %
2. recording 49 %
4. recording 66 %
6. recording 77 %
7. recording no more!
Doppelbauer et al, Acta Neurol Scand 1993;87:345-52
EEG and
EEG and
epilepsy
epilepsy
Epileptiform standard EEG in epilepsy
Time since latest seizure
< 24 hours 53 %
24 hours - 1 week 42 %
later 36 %
NB only standard EEG (20 min., wake +
hyperventilation & photic stimulation)
Doppelbauer et al, Acta Neurol Scand 1993;87:345-52
Standard EEG and
Standard EEG and
epilepsy
epilepsy
Sensitivity of 1. EEG (positive
EEG/patients with epilepsy): 35-50 %
Specificity of 1. EEG (negative
EEG/very healthypersons):
Adults 99,5 %
Children 98 %
EEG
EEG
after
after
first
first
afebrile
afebrile
seizure
seizure
?
?
Epileptiform EEG -> 2-3 times
increased recurrence risk
Often seizures before the index
seizure, making the case more
complex
Specific epilepsy syndromes may be
diagnosed at this early stage
EEG
EEG
after
after
first
first
afebrile
afebrile
seizure
seizure
?
?
Subtle seizures (absences and
myoclonias) can be recorded on the
EEG (simultaneous video)
Provoking factors (e g photosensitivity)
can be demonstrated
EEG and
EEG and
epilepsy
epilepsy
EEG AND EPILEPSY: WHICH PROVOCATION IS
PREFERRABLE?
Seizure/syndrome Best method
Absence epilepsies hyperventilation
J uvenile myoclonic epilepsy photic stimulation,
sleep/awakening,
sleep deprivation
EEG and
EEG and
epilepsy
epilepsy
EEG AND EPILEPSY: WHICH PROVOCATION IS
PREFERRABLE?
Seizure/syndrome Best method
Complex focal seizures Sleep
Rolandic epilepsy
Temporal lobe epilepsy
CSWS
EEG and
EEG and
epilepsy
epilepsy
Sleep: howmuch is needed?
Focal and generalised paroxysms in general:
ca. 30 min. (sleep stage 2-3)
CSWS: for quantitation, a whole-night EEG
with EOG is needed (paroxysmal activity
decreases later in the night and especially
during REM sleep)
EEG and
EEG and
epilepsy
epilepsy
What to expect from a sleep EEG if first EEG
is negative (children)?
Negative 1. EEG: 44 % (243/552)
Positive sleep EEG: 34 % (61/177)
Total positive EEGs: 67 % (370/552)
Carpay et al, Epilepsia 1997;38:595-599
EEG and
EEG and
epilepsy
epilepsy
What to expect from a sleep EEG if first EEG
is negative (children + adults)?
Negative 1. EEG: 57 % (171/300)
Positive sleep EEG: 35 % (55/158)
Total positive EEGs: 61 % (184/300)
King et al. Lancet 1998;352:1007-1011
EEG:
EEG:
strengths
strengths
EEG is a noninvasive windowto the brain,
and gives as regards temporal resolution an
unsurpassed image of normal and abnormal
cortical activity
In the definition of epileptic syndromes, EEG
is essential
Often difficult to differentiate between focal
and generalised epilepsies without EEG
EEG:
EEG:
strengths
strengths
Subtle seizures like absences og eyelid
myocloniasonly detectable by EEG
EEG is the best method of investigation
in neonatal seizures
EEG:
EEG:
weaknesses
weaknesses
Unspecific and non-diagnostic EEG
alterations in about 10 % of normal
persons
More or less epileptiform EEG in 2 to 4
% of children and 0.5 to 1 % of adults
without epilepsy
EEG:
EEG:
weaknesses
weaknesses
Epileptiform EEG are frequent in
patients with neurological and
psychiatric disorders
Often weak or no correlation between
the amount of EEG paroxysmal activity
and the clinical condition
This correlation varies very much
between syndromes
Correlation
Correlation
EEG
EEG
-
-
seizures
seizures
Examples:
Rolandic and benign occipital epilepsy: often
massive (multi)focal pathology in patients
with very fewseizures and a good prognosis
and despite drug tratment
Absence epilepsies: optimal treatment
requires eradication of generalised
paroxysmal activity
Correlation
Correlation
EEG
EEG
-
-
seizures
seizures
Epilepsy is essentially a clinical diagnosis,
based upon observed seizure phenomena
But the EEG has provided insight into some
obscure and enigmatic conditions dominated
by massive paroxysmal activity with no or
minimal clinical seizures, e.g. Landau-
Kleffners syndrome and Continuous Spike-
Waves during slowSleep (CSWS)
CSWS
CSWS
Problems in
Problems in

routine
routine

interictal
interictal
EEG
EEG
Limited recording time (30 - 60 min.)
Limited number of electrodes
Limited part of cortex in proximity to
electrodes
EEG
EEG
-
-
seizures
seizures
and time
and time
EEG
EEG

spatial
spatial
aspects
aspects
EEG
EEG

spatial
spatial
aspects
aspects
Intensive
Intensive
neurodiagnostic
neurodiagnostic
monitoring (INDM)
monitoring (INDM)
Aim: to record EEG during seizures
Recording time: until a technically and
clinically satisfactory recording of
sufficient number of episodes in
question are obtained, i.e. highly
variable in duration
Not necessarily a long-time monitoring
Intensive
Intensive
neurodiagnostic
neurodiagnostic
monitoring (INDM)
monitoring (INDM)
Indications
Differential diagnosis
Seizure classification
Seizure frequency
Focus localization (epilepsy surgery)
Clinical correlates of paroxysmal EEG
Seizure-provoking factors, e.g. reflex epilepsy
INDM
INDM

contributions
contributions
to
to
diagnosis
diagnosis
Retrospective study 199 adults (in-ptt.)
Recording time 72 hours (median)
Episodes recorded in 167 (84 %)
Clarified diagnosis: 151 (76 %) -
hereof
PNES 91 (45 %)
Epilepsy 37 (19 %)
Lobello et al., Epilepsy & Behavior 2006
INDM
INDM

contributions
contributions
to
to
diagnosis
diagnosis
143 (88 %) of episodes on day 1 or 2
No difference between PNES and epileptic
seizures in time to first event
No difference in alleged seizure frequency
before INDM and time to first event
Positive correlation between epileptic
seizures and: epileptiform EEG & abnormal
MRI
Lobello et al., Epilepsy & Behavior 2006
What the EEG cannot do
What the EEG cannot do
Prove the diagnosis of epilepsy
Exclude the diagnosis of epilepsy
Monitor anti-epileptic treatment
Evaluate the severity or frequency of seizures
Decide when to stop AED treatment in
seizure-free patients
Evaluate developmental and neuropsycho-
logical problems
What the EEG can do
What the EEG can do
Support clinical suspicion of epilepsy (if other
cerebral diseases can be excluded)
Diagnose (or exclude) epileptic syndromes
(e.g. childhood absences, Rolandic epilepsy)
Detect photosensitivity
Detect non-convulsive status epilepticus
What the EEG can do
What the EEG can do
Monitor status epilepticus in anaestetised
patients
Monitor treatment of absence seizures and
photosensitive epilepsy
In some cases predict risk of relapse after
stopping AED
Help localizing the epileptogenic zone
(epilepsy surgery)
Other
Other
utilisations
utilisations
of
of
the
the
EEG
EEG
signals
signals
Dipole or multiple source modelling for focus
localisation
DC-EEG for detection of ictal alterations
Non-linear analysis for prediction of seizures
Dipole
Dipole
source
source
modelling
modelling
for focus
for focus
localisation
localisation
Multiple
Multiple
source
source
modelling
modelling
for
for
focus
focus
localisation
localisation
MUSIC (Multiple Source Classification)
Correlates well with ictal SPECT in
focus localisation (temporal lobe
epilepsy)
Beniczky et al, Neuroreport 2006;17:1283-87
Interictal
Awake
Interictal
Asleep
Interictal
Before
Seizure
DC
DC
-
-
EEG
EEG
shifts
shifts
DC shifts in ictal recordings (temporal lobe
epilepsy) is seen together with beginning of
ictal rhythmic discharges (also in intracranial
studies)
May reduce the need for invasive pre-surgical
EEG recordings?
Vanhatalo et al, Neurology
2003;60:1098-1104
DC
DC
-
-
EEG
EEG
shifts
shifts
Non
Non
-
-
linear
linear
analysis
analysis
for
for
prediction
prediction
of
of
seizures
seizures
May be able to predict seizures up to
four hours before occurring
Also feasible in scalp EEG recordings
Lehnertz et al, J Clin Neurophysiol
2007(2):147-53; Drury, Smith & Savit, Exp
Neurol. 2003 Nov;184 Suppl 1:S9-18.
EEG
EEG

patterns
patterns
and interpretation
and interpretation
To some people, the first movement of
Beethovens Eroica Symphony
symbolises Napoleon, to others Hitler
and to others again Mussolini. To me, it
is just Allegro con brio.
Arturo Toscanini