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Ambulatory EEG

Ambulatory EEG

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Ambulatory EEG

359 pages
3 heures
Mar 24, 2017


With the recent development of new technology and practices in the field of ambulatory EEG (aEEG), the time is right for a practical reference on the application of aEEG in clinical practice. This authoritative guide to prolonged EEG recording outside the hospital or clinic is a valuable resource for anyone involved in long-term EEG monitoring and interpretation. Bridging the gap between routine scalp EEG and in-patient video EEG monitoring, aEEG has evolved to provide cost-effective, high-yield, high-tech recording for evaluation of epilepsy diagnoses, nonepileptic attacks, quantification of seizures or epileptiform burden, and other issues requiring extended EEG observation for paroxysmal neurological events in any environment.

Bringing together top experts from leading epilepsy centers, the book covers equipment, technical aspects of recording, instrumentation and polygraphic event monitoring, artifacts, clinical use in adult and pediatric patients, sleep recording, short-term and chronic ambulatory EEG, and reimbursement. The concluding chapter offers representative case presentations with relevant findings to further enhance the reader’s understanding and implementation of key concepts.

This "start to stop" survey of current applications is essential reading for a wide range of clinicians practicing in the field of clinical neurophysiology and epilepsy management, whether seasoned or in training.

    Key Features:
  • Fills the void of when and how to use aEEG in evaluating patients with paroxysmal neurological events and epilepsy
  • Incorporates aEEG into clinical management at all stages of diagnosis and treatment
  • Contains numerous aEEG illustrations and graphics to emphasize key points
  • Includes a chapter on common artifacts that can complicate the interpretation of an aEEG
  • Details the evolving use of chronic intracranial aEEG and wearable devices
  • Illustrative case studies provide pearls and reinforce best practices in aEEG monitoring
Mar 24, 2017

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Ambulatory EEG - William O. Tatum, IV, DO



Ambulatory EEG Monitoring





Reviewing this history is useful not for the details of technologies that are now obsolete, but for the story of the struggle to bring a new diagnostic procedure to fruition. Hopefully, this will inspire young clinical investigators to accept and address similar challenges in future eras.


To understand the significance of the development of ambulatory EEG (aEEG) and the problems faced and eventually overcome in its evolution, one must go back in time to the clinical neurophysiology of the 1970s. The Grass eight-channel, pen-writing EEG machine was the long-standing clinical workhorse. New on the horizon was a 16-channel EEG machine that would become the latest great thing at the best centers. The value of long-term EEG monitoring (LTM) with video recording was just becoming established. Now seizures could be recorded commonly, not simply spikes, as was usual for laboratory EEG. Early pioneers of LTM had to be creative regarding how to record both EEG and patient behavior in a synchronized fashion. Initially, two cameras were used with split-screen video technology. Remember, this was a predigital era. One camera imaged the moving EEG paper with newly penned waveforms, and the other recorded the patient. Engineering advances eventually included the reformatter that recorded multiplexed EEG on the edge of the videotape recording the patient. These advances in epilepsy diagnosis and characterization were monumental at the time, but they came with some drawbacks. There were only a handful of epilepsy monitoring units (EMUs) in the country, hospitalization was required, it was expensive to keep patients in hospital for days, and the normal day-to-day triggers for seizures were not present in a hospital setting. Patient activity and mobility were restricted often to sitting or lying in bed. Being in the hospital was clearly unnatural and likely to inhibit both real epileptic and nonepileptic episodes. In fact, it was soon realized that a patient’s typical seizure frequency often plummeted when he or she was hospitalized. If there was only a way to obtain the benefits of long-term EEG recording in an outpatient, rather than hospital, setting.

Cardiologists have always faced a similar problem to that of epileptologists, namely the detection of physiological abnormalities that are paroxysmal. Cardiac arrhythmias are often intermittent, and they are often not recorded on a standard duration ECG. Fortunately for them, the ECG is relatively large in amplitude, and one channel of data is usually sufficient to identify the problem. Accordingly, the development of ambulatory ECG monitoring was technically easier, and it preceded that of aEEG. Norman Holter in 1953 devised a system for the radio-telemetry of single-channel ECG from an ambulatory patient. Later this transitioned to long-term, single channel, cassette recordings of ECG, and the famous Holter monitor was born (1).


However, the development of any reasonable aEEG counterpart would have to await the solution of four technical problems—more channels than just one, preamplification of the much smaller EEG signal, a recording duration that was at least 24 hours, and a means to play back and analyze all the recorded data in an efficient fashion. One by one in the early 1970s these obstacles were overcome. A four-channel, portable tape recorder, weighing approximately 1.5 pounds, was developed by Marson and McKinnon for industrial purposes (2). Ives and Wood later showed that recording EEG on it was feasible (3). These recorders were analog devices that used 1/8-inch tape and four recording heads. Tape speed was reduced to 2 mm/sec, so that a standard C120 cassette could record at least 24 hours of continuous data. However, the problem of amplifying the EEG signals sufficiently before transcription onto tape remained. Theoretically, it made sense to try to amplify the EEG as close as possible to the head in order to minimize lead artifact from movements during wakefulness. In 1978, Quy developed an amplifier chip that could be glued onto the scalp with collodion (4). Each chip represented a single channel and had its own Grid 1 and 2 inputs. Electrode leads were plugged into the chip, so montages were necessarily derived on the head. Electrodes with bifurcated leads were necessary if montages with linked channels, such as a bipolar chain, were desired.

That still left the problem of reviewing hours of recorded data. One solution was to print out the entire recording with a jet ink writer at up to 20× real time. To reduce the volume of paper produced, which was still large, the recording paper speed could be reduced, but this meant that only generalized seizures could be discerned. The paginated, rapid video playback was the conceptual breakthrough that made efficient analysis of aEEG data feasible (5). This new video playback was also an analog device, that is, essentially an oscilloscope. Repeated refreshing of the screen allowed both a static page of data to be visualized and also sequential pages of data at 20× or 60× real time. Video page lengths could be either 8 or 16 seconds. At the fastest replay speed, 24 hours of data could be reviewed in 24 minutes. A critical additional feature of the playback unit was the simultaneous audio reproduction of one data channel. At 20× or in particular 60×, standard EEG frequencies would become audible. If an accurate time registration during the recording was desired, unfortunately one of the four channels had to be sacrificed for that function. Thus, in 1979, Oxford Medilog introduced a completed, commercially available, four-channel aEEG recorder, preamplification system, and paginated video playback (Figure 1.1). However, questions remained as to whether such a system would be clinically useful and how it should be used to extract the most information efficiently.

Now that epileptologists had become accustomed to eight- and soon 16-channel EEG, it was going to be difficult for them to accept four-, let alone three-, channel EEG data. That was clearly a giant step backward. It was accordingly easy to dismiss the new recorders as less than useful toys. It took a bit more insight to see the benefit that a longer recording brought, particularly as and outpatient, even with significantly fewer channels. Convincing neurologists that a three-channel EEG carried any worth would require a controlled comparison. The first study undertaken by Rob Leroy and me was to design rationally aEEG montages that would maximize the detection of focal ictal and interictal abnormalities (6). Proper montages were clearly necessary before even attempting to evaluate the efficacy of the technique. Ambulatory EEG montages had to fulfill two goals. Although the first was spike/seizure detection, equally important was that the data had to be displayed in a form that was conductive to perception on rapid video playback. Nothing would be gained by recording an event that was overlooked on review.

FIGURE 1.1 The Oxford Medilog 4–24 recorder was the first commercial aEEG cassette recorder. It utilized the HDX-82 on-head preamplifier chip. The Oxford Medilog page mode display unit (PMD12) was the first commercial device to enable analysis of rapidly replayed aEEG in both a visual and auditory format.

Source: From Ref. (15). Ebersole, JS (Ed.): Ambulatory EEG Monitoring. New York, NY: Raven Press, Wolters Kluwer Health; 1989:365.

We thought that it might not be necessary to cover the head uniformly, and thus fewer channels would be reasonable. We recorded interictal and ictal EEG abnormalities from over a hundred adult and adolescent patients sequentially admitted to the West Haven VA EMU for monitoring and determined, perhaps really not to anyone’s surprise, that the frontal and temporal head regions bore the greatest percentage of epileptiform abnormalities, namely 78% (6). The central, parietal, and occipital regions, particularly in adults, were relatively quiet. Given that preferential sampling was a technical necessity with a three- to four-channel aEEG, it became clear that we had to concentrate our montages in these areas.

We chose to develop three-channel montages because the fourth channel was commonly used for time/event marking or ECG. Montages with longitudinal temporal and transverse frontal derivations were found to be most useful. When these channels were organized into a chain in left-transverse-right sequence, surface negative potentials in the frontotemporal regions appeared as a phase reversal common to two channels. This afforded enhanced perception of the most common focal abnormalities. Generalized discharges were easily detected, particularly in the frontal channel. We quickly learned that it was not a good idea to use a truly linked three-channel montage utilizing only four electrodes. Loss or significant artifact in one of the frontotemporal electrodes would confound two thirds of the data. Accordingly, separate electrodes were used for each of the three channels.

Having our montage, we proceeded with a series of studies addressing the relative diagnostic yield of three-channel aEEG versus eight-channel LTM (which was standard at the time) (7,8). These were inpatient studies where the same EEG data were bifurcated into the LTM system and the aEEG recorder. In such direct comparisons with simultaneous recordings, aEEG fidelity was completely adequate and detection of abnormalities was consistent with the montage study. In a more practical comparison, 16 to 24 hours of three-channel aEEG (simulating the typical outpatient study) was compared with 24 to 72 hours of eight-channel cable telemetry. Seventy-seven percent of those recordings thought to contain epileptiform abnormalities by LTM were correctly identified by aEEG. Moreover, 79% of focal and 100% of generalized EEG abnormalities were identified.

We had developed what seemed to be an optimal, though compromised, montage, and we had proved that even a three-channel EEG recording could detect a high percentage of abnormalities, including those focal, nearly as well as the current LTM setups and far better than routine EEG. A remaining question was how best to review 24 hours of recording with the new paginated video playback device. Turning 24 hours of video pages at the standard rate for examining routine EEGs would be very lengthy. Somehow we would have to learn to take advantage of the rapid replay capabilities and especially the audio transformation of EEG that was available.

We quickly learned that during active wakefulness, there was an abundance of movement and muscle artifacts that made confident visual identification of interictal potentials difficult. When listening to the audio reproduction of EEG during active wakefulness played at rapid speeds, one heard only a cacophony of white noise elements. However, seizure rhythms, which are typically regular and evolving in frequency, would produce a clearly identifiable, changing pure tone that stood out even amid the noise of movement and muscle artifact. It became evident that we could safely scan through the 16 or so hours of active wakefulness at the fastest replay, 60×, by listening to the EEG rather than by looking at it. Seizures could easily be detected, and the problem of likely false identification of interictal spikes would be avoided. This meant that most of the recording could be reviewed at a 1 min/hr rate.

Sleep on the other hand brought with it two advantages, namely little artifact and a natural increase in spikes. This was the time to identify interictal abnormalities. To do so would require slowing the replay to the 20× rate and looking for spikes. Montages that produced phase reversals for common frontotemporal spikes helped in this perception. If no spikes were found in the first one or two cycles of slow-wave sleep, the replay could be gradually increased in speed to lessen the total review time safely. This was so because the late phases of sleep are usually dominated by REM that characteristically contains fewer spikes. In fact, a later study, in which we attempted to provide statistics for this approach, showed that a careful visual analysis of simply the first hour of sleep would detect 92% of interictal abnormality types (9,10). Accordingly, the most time-efficient analysis, if that were necessary, would involve listening to 23 hours of a 24-hour recording for seizures and closely watching only the first hour of sleep for spikes.

It was only a matter of a few years (1983) until the next significant development in continuous aEEG, namely the eight-channel recorder and playback unit. This recorder was only slightly larger than the four-channel device, but it allowed the recording of eight channels of EEG and one channel of accurate time and event for 24 hours on the same 1/8-inch cassette tape. This was only possible with a new technology called blocked analog (essentially a form of multiplexing), whereby more than one channel was recorded by the same recording head. This allowed for a more complex montage. There was the temptation to use long-standing eight-channel bipolar montages, but having learned lessons with the three-channel montages, as well as the benefits of the new montage design, we decided to maintain the same overall montage schema and place continued increased emphasis on the temporal and frontal areas (see Figure 1.2). The same channel sequence of left to right with mirror image symmetry continued to make the distinction between sleep complexes and focal spikes easier. The new playback unit also offered a number of improvements. These included digital real time as a separate channel, automatic search to a specific time, up to 64 seconds of memory, so that approximately 30 seconds before and after the present screen can be viewed without tape movement, gain and filter adjustments without tape movement, alphanumeric registry of channel gain and filtering status, and continuous printout of data as well as epoch printout. A new sound system was also provided for listening to the EEG. A channel mixer gave the ability to mix any number of channels into the right and/or left headphone. In so doing, one could listen to the left hemisphere activity in one ear and the right in the other. This produced a stereophonic perception that made the detection of ictal rhythms easier as well. With a full eight channels, it was safer to use a true linked bipolar montage. However, because the channels were linked, it was essential to listen only to every other channel, so that there was not audio cancellation of any event or rhythm because of phase reversals in adjacent channels (Figure 1.3).

FIGURE 1.2 Three-channel, four-channel, and eight-channel aEEG montages that all provide variations of the same frontal and temporal coverage. Channels are arranged to produce a display with mirror-image symmetry. Eight-channel montages are of linked configuration. Three-channel montages have separate electrodes for each channel.

Source: From Ref. (15). Ebersole, JS (Ed.): Ambulatory EEG Monitoring. New York, NY: Raven Press, Wolters Kluwer Health; 1989:365.

The evaluation of partial epilepsies benefited from the introduction of eight-channel aEEG systems. Compared with simultaneous 16-channel cable telemetry records, the standard of the day, both three- and eight-channel aEEG reviews correctly identified 93% of the records as either normal or epileptiform (11). Lateralization of abnormalities was equally good with either cassette system, but more detailed characterization was achieved with eight-channel aEEG. Although 100% of seizures were detected on both systems, there were more false positive errors when only three data channels were available. Better ability to differentiate real abnormalities from artifacts was the most significant advantage of eight-channel over three- to four-channel aEEG.

By 1988 and the beginning of the digital era, a PC-based replay system made its debut, and 16-channel continuous EEG recordings became possible by electronically linking two cassette recorders. Within the next decade, further progress was made. In 1996, a 17-channel continuous recorder was developed. This was possible by the introduction of large capacity removable hard disks, originally designed for use in notebook computers. With this new recorder, 16 channels of EEG and one channel of EKG could be recorded for 24 hours (at a 200-Hz sampling rate) onto a miniature hard drive within the device. Montage reformatting became possible during replay. EEG analysis could be performed by rapid video review, audio transformation of signals from selected channels (up to 120× real time), and offline, computer-assisted spike and seizure detection. In addition to on-screen interpretation, sections of EEG containing features of interest could be printed onto individual sheets via laser-jet or onto continuous paper via thermal printer.

FIGURE 1.3 The Oxford Medilog 9000 was the first commercial eight-channel aEEG cassette recorder. Recorded data were reviewed on the Oxford Medilog 9000 rapid video/audio replay unit that offered stereo EEG sound.

Source: From Ref. (15). Ebersole, JS (Ed.): Ambulatory EEG Monitoring. New York, NY: Raven Press, Wolters Kluwer Health; 1989:365.

Before the turn of the century, 24- to 32-channel continuous recorders were introduced using flash memory chips for data storage. Various schemes were devised for analyzing the data. Most systems used offline spike and seizure detection software (12,13). The new continuous recording systems offered additional operational features. Originally, it was impossible to archive any EEG data other than the entire tape, since the complex tape recording scheme did not allow the data to be copied. Digital storage of EEG epochs by the new PC-based replay units eliminated this problem. Stored with these files might be patient information, review comments, and the final report, if desired. Direct, online patient monitoring became possible with some systems. Isolation electronics built into the replay unit allowed the ongoing EEG of patients, who were attached to recorders, to be displayed on the replay screen as scrolling waveforms. Alternatively, an optional laptop computer could be configured to serve as a display of ongoing EEG. In either case, the electronic EEG display could be used in lieu of a polygraph to test the quality of an ambulatory recording. Several systems also had the capability of displaying, editing, and analyzing (either manually or automatically) polysomnographic data, including oximetry.


Historically, aEEG also developed along another line, namely the discontinuous or epoch recorder. The original concept in this evolution was that more channels could be recorded at a higher sampling rate, if only discrete epochs of EEG were recorded rather than continuous data. Ives introduced the first such recorder in 1982 (14). The recorder was like a commercial Walkman and used standard tape speed in order to achieve the frequency response necessary to record faithfully 16 multiplexed channels. The recording was done in selectable periodic epochs, such as 15 seconds every 10 minutes over 24 hours or the recorder could also be turned on by a push button, which the patient activated when he experienced a spell. An electronic buffer memory allowed recording of EEG prior to the button push. Approximately 45 minutes of EEG could be recorded on a tape. Both the amplifiers and multiplexing device were incorporated into one small box that was usually worn on the patient’s head and secured by a gauze turban. The 16-channel epoch recorder did not use a video playback device; instead, the recorded epochs were transcribed onto paper in real time. Analysis was like that of standard EEG.

Many of the deficiencies of intermittent and push-button EEG sampling were later overcome by linking the epoch recorder to a portable computer. This device monitored the ongoing EEG and used spike and seizure detection programs to identify segments of abnormal EEG that were stored to its hard disk. Although these computers were portable, they were not truly ambulatory, for they required mains power. They were appropriate for use in a setting where the patient moved only a limited distance, such as from bed to chair. For a number of years, the most common discontinuous systems recorded 16 channels of EEG and two channels of other physiology, such as EKG, electromyogram (EMG), and electrooculogram (EOG). Up to 15 hours of data were recorded on the attached portable computer. This includes push-button actuations (with 2 minutes pre- and postpush), periodic sampling, and spike and seizure detections. The EEG was recorded in one of three bipolar montages, including a standard double banana montage. Data were routinely printed out on a laser-jet and reviewed like standard EEG or copied to a CD and reviewed digitally on any computer. These systems could also be configured with more polygraphic channels, in lieu of EEG channels, in order to record polysomnographic data (Figure 1.4).

By the mid-1990s, an enhanced version of this 18-channel recorder was developed that contained within the waist worn recorder sufficient computing power to perform the spike and seizure detection. It was no longer necessary to attach the recorder to a portable computer in order to obtain online EEG analysis. Before

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