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Handbook of ICU EEG Monitoring

Handbook of ICU EEG Monitoring

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Handbook of ICU EEG Monitoring

888 pages
5 heures
Feb 28, 2018


Continuous EEG monitoring is an important tool for assessing brain function and allows clinicians to identify malignant EEG patterns quickly and provide more effective care. The revised and updated second edition of Handbook of ICU EEG Monitoring distills the wide range of technical and clinical issues encountered in successful critical care EEG for the busy clinician. Written by leading experts in this rapidly evolving field, the handbook incorporates the ground-breaking advances that have impacted practice since publication of the first edition.

Concise chapters break down the fundamentals of EEG acquisition and other technical considerations, clinical indications, EEG interpretation, treatment, and administrative concerns. Entirely new chapters on cardiac arrest in adults, neonatal seizures, periodic and rhythmic patterns, and inter-rater agreement for interpretation in the ICU are included, along with new neonatal guidelines and ACNS adult and pediatric consensus statements. All existing chapters have been revised and updated to include the latest information, and coverage of quantitative EEG (QEEG) is expanded to reflect the expanding role of this technology in reviewing ICU EEG recordings. Formatted for maximum utility with bulleted text and banner heads to reinforce essential information.

Key Features:

  • Revised and updated second edition encompasses the current scope of clinical practice
  • Broad but practical reference covering all aspects of ICU EEG monitoring
  • Six entirely new chapters and many new expert authors and topics
  • Thorough discussion of the indications for ICU EEG monitoring and prevalence of seizures in patient subgroups
  • Focuses on the challenges of EEG interpretation that are unique to EEG monitoring in the ICU
  • Key points and future directions/unanswered questions highlighted in every chapter
  • Includes hard-to-find information on technical aspects, indications, billing and coding, and other administrative and procedural concerns
  • Access to downloadable ebook, supplemented with additional EEG examples and clinical cases
Feb 28, 2018

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Equipment for EEG Acquisition and Review

Susan T. Herman


Hardware components of an ICU EEG monitoring system

Computer specifications for EEG acquisition and review

Software for optimization of EEG review


EEG acquisition and review equipment for continuous EEG (cEEG) monitoring in the ICU should meet the technical standards outlined in the American Clinical Neurophysiology Society guidelines.

ICU cEEG acquisition equipment can be installed as either a fixed (wallmounted) unit or portable system.

Simultaneous audio and video recording is strongly encouraged for correlation of behavioral events with underlying EEG patterns and to aid in proper identification of EEG artifacts that can be easily mistaken for electrographic seizures.

Specialized hardware and software increases the utility of cEEG for monitoring at the bedside. Options include the ability to enter nursing notes, pushbuttons for seizures and other clinical events, software to integrate physiologic data (e.g., intracranial pressure, blood pressure), and quantitative EEG software for graphical display of quantitative EEG trends.


A.Technical guidelines

The American Clinical Neurophysiology Society (ACNS) has published a consensus statement for continuous monitoring in the ICU, as well as guidelines for routine digital EEG and long-term EEG monitoring for epilepsy. ICU continuous EEG (cEEG) ­equipment should meet the technical standards defined in these guidelines. Relevant guidelines are available online at www.acns.org.

Guideline 1: Minimum technical requirements for performing clinical electroencephalography (1).

Guideline 4: Recording clinical EEG on digital media (2).

Guideline 5: Minimum technical standards for pediatric electroencephalography (3).

Guideline 6: Minimum technical standards for EEG recording in suspected cerebral death (4).

Guideline 12: Guidelines for long-term monitoring for epilepsy (5).

Consensus Statement on Continuous EEG in Critically Ill Adults and Children, Part II: Personnel, Technical Specifications, and Clinical Practice (6).

B.Components of digital ICU cEEG machines

Figure 1.1 is a schematic of the major components of digital EEG machines, from electrodes to display and storage.

EEG signals are recorded at the scalp via electrodes, which plug into receptacles in the jackbox, or electrode box.

Jackboxes are electrically or optically isolated from the power supply to prevent dangerous currents from passing through electrodes to the patient.

Each jackbox input connects to input 1 of a differential amplifier. Input 2 for each amplifier is a machine reference, or common reference, electrode.

The amplifier contains analog low- and high-frequency filters to exclude extraneous electrical signals.

FIGURE 1.1   Components of digital ICU cEEG acquisition machines. See text for details of individual components.

ADC, analog-to-digital converter; DAC, digital-to-analog converter; HFF, high-frequency filter; LFF, low-frequency filter; QEEG, quantitative electroencephalography.

The EEG signal is then passed to the analog-to-digital converter (ADC), which converts the analog continuous signal into discrete digital values at specified time points.

The digital EEG values (and associated metadata files) are stored on the computer hard drive.

EEG software is utilized to display the EEG signals on computer monitors, including postprocessing, such as montage reformatting, change in time scale and amplitude displays, and digital filtering.

Video, audio, and other physiologic data streams can be synchronized with the cEEG data.

EEG files are archived to removable digital media, or stored on servers or storage appliances.


A.Comparison of ICU cEEG equipment to standard EEG machines

Table 1.1 summarizes the most important characteristics of cEEG acquisition equipment, compared with routine and video-EEG monitoring equipment (7).

B.Physical configuration

Fixed installation

In fixed installations, computers and monitors are mounted on the walls of the ICU room, sometimes on swing arms allowing the monitors to be moved around the bed.

Equipment can be mounted out of the way of bedside caregivers. Cameras and microphones can be placed in the best recording location.

Fixed equipment is less likely to be damaged than portable equipment that is rolled around the hospital.

If only some ICU rooms have mounted cEEG equipment, however, critically ill patients may need to be moved into a designated room equipped for monitoring.

Despite several advantages, wall-mounted cEEG equipment is generally more expensive and may be underutilized.

Portable equipment

It can be configured on a cart or on a small-footprint pole-mount system (approximately 2.5 feet diameter base, 4 to 8 feet height [taller with camera mount]).

Portable cEEG equipment has the advantage of being able to be moved to where it is needed, but it can obstruct patient care, and camera views are rarely optimal.

Many portable cEEG units now have Internet protocol (IP) addressable cameras that allow remote camera control over standard network jacks, without the expense of special cabling.

Portable equipment should be placed to avoid overlap of electrical cords with other equipment, and, if possible, out of the way of staff caring for the patient.

Some ICU cEEG programs utilize a combination of wall-mounted equipment in high-use areas (e.g., neurological ICUs) and portable equipment for less frequently monitored areas.

Increasingly, ICU EEG equipment is integrated with other ICU monitoring devices, and some systems are optimized for multimodality data collection and display.

Design of EEG equipment components should take into consideration possible rough handling by inexperienced ICU personnel.

Delicate cables with fragile connectors, nonwaterproof components (jackboxes and amplifiers), and systems with portable computer components such as laptops and tablets are especially vulnerable to accidental damage.

Nonproprietary components (cameras, computer components, cables, and connectors) are preferred, as these are generally less expensive.

A patient event button can be used by patients, family, or ICU personnel to mark suspected clinical events.

C.Security and safety features

Failure recovery and protection

Some ICU EEG machines have a feature that allows the EEG acquisition to detect an unexpected termination of a study (such as system crash or temporary power outage) and automatically reboot and start recording again when power is restored.

Uninterruptible power supplies may prevent problems during brief power fluctuations or outages.

Computers should be securely fastened to the wall or pole mounts and disk enclosures should be locked to prevent loss of hard drives or other components ­containing protected health information. Laptops and external hard drives should be locked and encrypted.

EEG machines should have security features such as secure log-in, automatic keyboard/screen lock, and firewall and antivirus protection.

Electrical safety

Patients in the ICU are at increased risk for electrical shock because they often are connected to multiple electrical devices and may have indwelling devices.

All ICU EEG equipment should be certified for clinical use and tested for electrical and mechanical safety by a certified technician or biomedical engineer at least annually. Portable equipment is more susceptible to damage and should be checked more frequently.

Isolation transformers prevent a direct connection between the ground electrode and power line ground. Amplifiers should be electrically or optically isolated.


In the crowded ICU head-of-the-bed environment, small jackboxes may be beneficial.

Jackbox inputs are typically labeled according to the 10-20 International System or modified 10-10 System.

Electrode inputs should be arrayed so that the entire jackbox and electrode pins fit into a waterproof enclosure to prevent accidental damage to the jackbox and inadvertent disconnection of electrodes.

Some jackboxes include amplifiers and have wireless connectivity to the computer, internal storage, and battery power in the jackbox.

Such jackboxes can continue to record EEG while the patient is disconnected from the amplifier (e.g., to go to radiology procedures).

Before deciding on a wireless solution, ensure that there is no significant overlap in wireless signals from other ICU equipment.

E.Amplifier specifications (2)

The primary purpose of the amplifier is to magnify the EEG signal from a range measured in microvolts to a signal of several volts, without distortion. The amplified signal can then be further processed, recorded, or displayed.

EEG machines use differential amplifiers so that common-mode signals (potentials that are the same at different recording sites and presumably artifacts) are rejected, and only differential-mode signals (potentials that are different at different recording sites and presumable of brain origin) are amplified.

EEG amplifiers should have high input impedance compared to electrode impedance, so they provide minimal loading of the EEG signal being measured.


At least 16 referential EEG channel inputs are required.

Thirty-two or more EEG channels are preferred for full 10-20 electrode placement, as well as additional channels for recording EKG, electrooculogram (EOG, 1–2 channels), and electromyogram (EMG).

Additional channels may be needed if simultaneous intracranial EEG recording is planned.

System (or machine) reference input is recommended.

Ground input is recommended.

Direct current (DC) input channels for connection of other physiologic monitors may be needed (thermistors, oxygen saturation monitors, intracranial pressure [ICP] monitors).

Full-scale input range greater than e ± 2 mV, and up to ± 5 mV is ideal.

Bandpass filters 0.1 to 0.3 to 70 to 100 Hz are used for routine clinical recording.

Input impedance at least 100 MΩ (up to 1 GΩ) is recommended.

F.ADC specifications (2)

Input range ± 1 to 5 mV

Sampling rate at least 256 samples per second (3 times higher than the anti-aliasing filter cutoff frequency)

Resolution at least 16 bit, including sign bit

Minimum amplitude resolution 0.5 μV

G.Video and audio (ACNS guideline 12)

Simultaneous video and audio recording is highly recommended to allow correlation of clinical seizures and other behavioral events with EEG patterns, as well as to aid in identification of EEG artifacts (e.g., patting, chest physiotherapy, suction, ventilator artifact) (6).

Video is time synchronized with the EEG data.

Equipment for video recording varies greatly in picture quality and cost.

Video may be color or black-and-white. Infrared cameras may be helpful in low-light conditions.

Critically ill patients are less likely to move off camera than patients in epilepsy monitoring units. Fixed wide-angle cameras therefore may be an option, but may not have adequate resolution for detection of fine motor movements. This is less of an issue with newer high-resolution cameras.

Many modern cEEG units have IP-addressable cameras mounted on a pole. These allow remote pan/tilt and sometimes zoom and focus from remote locations.

Standard digital video is MPEG 4, at 320 × 240 or 640 × 480 resolution.

Higher resolutions are available at the expense of hard disk and server space as well as network bandwidth.

Video recording size is typically 12 to 20 GB/day.

Audio recordings can alert monitoring technologists to clinical episodes and allow assessment of behavior during clinical events.

Systems should include an event button for the patient, family, or staff to mark events of interest.

H.Computer Specifications: Acquisition Machines

Computers used for EEG acquisition should have sufficient processing capability for simultaneous EEG and video acquisition, spike and seizure detection, quantitative EEG (QEEG) analysis, and network tasks.

Minimum specifications

Dual core processor greater than 2 GHz

4 to 8 GB RAM

Discrete graphics card

Network connectivity 100 mbit/sec minimum; Gigabit network interface card preferred

Hard drive large enough to store at least 1 week of EEG and video data (approximately 2 GB EEG and 12–20 GB video/day = greater than 150 GB)

Operating system is typically Windows; version is dependent on hospital information technology specifications.

I.Computer specifications: Review stations

Computers used for EEG review should have sufficient processing capability for simultaneous EEG and video review, review of automated spike and seizure detection, QEEG analysis, and network tasks.

Review computers may also have additional functions, such as report generation (office productivity software, voice recognition software, standardized report databases), access to hospital clinical information systems, and archiving, which may necessitate additional processing capabilities.

Recommended specifications

Dual or quad core processor greater than 2 GHz

8 to 16 GB RAM

Discrete graphics card

Network connectivity: Gigabit network interface card

Hard drive large enough for installation of required software

J.Monitor display: Acquisition machines (2,6)

Fixed and portable installations should have a monitor in the room for EEG set-up and QEEG review by ICU personnel.

Screen size of at least 17 diagonal is recommended (greater than 20 preferred).

Monitor resolution of at least 1,280 × 1,024 pixels is recommended.

K.Monitor display: Review stations (2,6)

Review stations require large high-resolution monitors for accurate EEG interpretation.

Screen size of at least 20 diagonal is recommended (greater than 24 preferred).

Monitor resolution of at least 1,600 × 1,200 pixels is recommended (widescreen 1,920 × 1,200 ­pixels).

More expensive monitors such as Wide Quad eXtended Graphics Array (WQXGA) with 2,560 × 1,600 pixels and Wide Quad Ultra eXtended Graphics Array (WQUXGA) with 3,840 × 2,400 pixels allow display of every stored value at a 256-Hz sampling rate.

Dual monitors may be necessary for simultaneous review of EEG and video data, and especially for simultaneous review of raw EEG and QEEG trends.

L.User interfaces

Keyboard and mouse remain the standard interface devices for EEG.

The interface must make it easy for nurses and other ICU personnel to enter annotations, move the camera, and so on, without interfering with the ongoing EEG recording.

Touchscreen monitors with large buttons for common tasks are easier for nurses to use, but are cumbersome for large amounts of text entry, and may be difficult to adequately disinfect.

Security: Health Insurance Portability and Accountability Act (HIPAA) regulations require individual user log-ons for clinical systems containing protected health information. Security software should provide an audit trail for changes to EEG data. Bedside systems may include a transparent screen lock, which locks the computer, but allows continued viewing of EEG data, video, and QEEG.

M.Other hardware and/or cables

Inputs for other physiologic monitoring devices are preferred (e.g., pulse oximetry, blood pressure, ICP, temperature, respiratory effort, brain tissue oxygenation).

These data streams must be time synchronized with EEG.

Some ICU EEG machines are true multifunction devices with multimodality monitoring capabilities.

It is important to ensure that adequate channels are available for EEG recording, and that additional software (seizure detection, QEEG) can be installed on the device.


Patient database

A central patient and study database allows management of patient files, archiving, and report generation.

Databases can synchronize information across the hospital network, so that all local machines have up-to-date clinical information.

Databases may also be linked to the hospital electronic medical record to allow import of relevant patient demographic data.

EEG software

Should be easy to use by both EEG and ICU personnel.

Some systems have separate display modes for EEG and ICU staff, with a simplified interface for ICU personnel.

Essential functions include the ability to annotate an ongoing recording, as well as move the camera.

Software should include a look back feature, which is the ability to review an already-recorded EEG without the need to interrupt ongoing recording.

Many systems now include remote access to the live EEG session, which allows for instant messaging features as well as system adjustments from remote locations (e.g., change montage, move camera).

Other useful software features:

Ability to automatically stop the EEG recording at a specified interval or time, and automatically beginning a new day’s recording.

Color-coded displays of 10–20 system highlighting electrodes with significant artifact so ICU staff can provide easy maintenance of affected electrodes.

Automatic synchronization of common settings (montages, recording protocols) from a central location to local acquisition machines.

For research purposes, software should have functions to deidentify EEG data and to save in an open-source EEG data format.

Spike and seizure detection software

Current commercially available spike and seizure detection software is not optimal for detection of common seizure patterns seen in the ICU, and little data are available on their sensitivity and false-positive rates.

May produce many false alerts which prompt inappropriate treatments, and are bothersome to ICU personnel.

Automated artifact identification and reduction

Online (as data is acquired) artifact reduction uses a variety of source decomposition techniques (e.g., spatial filtering, principal component analysis, independent component analysis) to break EEG signals down into individual components that represent EEG and others that represent artifact. Once identified, the artifactual components are removed, and the remaining clean EEG signal is recomposed. Artifact rejection is particularly important prior to QEEG analysis.

QEEG software (see Chapters 27–29) (8)

Allow graphical display of EEG parameters over long time periods (hours).

Can be displayed at the bedside, as well as at a central monitoring station in the ICU or EEG lab.

Many types of commercial QEEG software are available, and most are proprietary.

The main features to consider are ease of use, how well integrated the QEEG software is with EEG acquisition software, and accuracy of event detection and artifact rejection algorithms.

Some systems can be configured to send alerts and images of corresponding trends and raw EEG via email.



The cost of computers and video recording components continues to decrease.

EEG equipment has become more portable and easier to install owing to development of standard network architecture as opposed to proprietary cabling.

Software (special features, seizure detection, QEEG) may add a substantial amount to the cost of ICU EEG equipment.

Information technology and biomedical engineering support is necessary.

Installing, configuring, maintaining, and updating ICU EEG equipment and software requires significant IT and biomedical resources.

Large ICU EEG monitoring programs may require dedicated IT and biomedical personnel.

B.Multimodality monitoring

Device interoperability is an important issue in ICU EEG.

Polygraphic and multimodality data may be clinically useful, by aiding identification of cerebral states (e.g., sleep), recognition of artifacts, and confirmation of EEG abnormalities by correlation with other physiologic changes. Techniques of multimodality recording are discussed in Chapter 39.

Optimally, all physiologic patient data, as well as data from ventilators, cooling devices, and IV pumps, would be able to be incorporated into a single time-synchronized data stream.


1.Sinha SR, Sullivan L, Sabau D, et al. American Clinical Neurophysiology Society Guideline 1: minimum technical requirements for performing clinical electroencephalography. J Clin Neurophysiol. 2016;33(4):303–307. https://www.acns.org

2.Halford JJ, Sabau D, Drislane FW, Tsuchida TN, Sinha SR. American Clinical Neurophysiology Society Guideline 4: recording clinical EEG on digital media. J Clin Neurophysiol. 2016;33(4):317–319. https://www.acns.org

3.Kuratani J, Pearl PL, Sullivan L, et al. American Clinical Neurophysiology Society Guideline 5: minimum technical standards for pediatric electroencephalography. J Clin Neurophysiol. 2016;33(4):320–323. https://www.acns.org

4.Stecker MM, Sabau D, Sullivan L, et al. American Clinical Neurophysiology Society Guideline 6: minimum technical standards for EEG recording in suspected cerebral death. J Clin Neurophysiol. 2016;33(4):324–327. https://www.acns.org

5.American Clinical Neurophysiology Society. Guideline 12: guidelines for long-term monitoring for epilepsy. J Clin Neurophysiol. 2008;25(3):170–180.

6.Herman ST, Abend NS, Bleck TP, et al. Consensus statement on continuous EEG in critically ill adults and children, Part II: personnel, technical specifications, and clinical practice. J Clin Neurophysiol. 2015;32(2):96–108. https://www.acns.org

7.Kull LL, Emerson RG. Continuous EEG monitoring in the intensive care unit: technical and staffing considerations. J Clin Neurophysiol. 2005;22(2):107–118.

8.Moura LMVR, Shafi MM, Ng M, et al. Spectrogram screening of adult EEGs is sensitive and efficient. Neurology. 2014;83(1):56–64.

Additional Reading

Alvarez V, Rossetti AO. Clinical use of EEG in the ICU: technical setting. J Clin Neurophysiol. 2015;32(6):481–485.

Fisch BJ. Digital and analog EEG instruments: parts and functions. In: Fisch & Spehlmann’s EEG Primer: Basic Principles of Digital and Analog EEG. 3rd ed. Amsterdam: Elsevier, Ltd. 1999. 35–72.

Guerit JM, Amantini A, Amodio P, et al. Consensus on the use of neurophysiological tests in the intensive care unit (ICU): Electroencephalogram (EEG), evoked potentials (EP), and electroneuromyography (ENMG). Neurophysiol Clin. 2009;39(2):71–83.

Wartenberg KE, Mayer SA. Multimodal brain monitoring in the neurological intensive care unit: where does continuous EEG fit in? J Clin Neurophysiol. 2005;22(2):124–127.


Electrodes and Montages

Jennifer L. Hopp and Chalita C. Atallah


General principles of electrode placement

Electrode types (comparison of invasiveness, reusability, imaging compatibility)

Commonly used montages


Several electrode options exist for use in ICU EEG monitoring that provide high-quality recordings with good resolution.

Cost, EEG technologist time, and ease of use are key factors in the selection of EEG electrodes.

The standard 10–20 system for electrode placement is still widely used although other montage options exist.


A.Continuous EEG (cEEG) monitoring in the ICU is a continually growing and developing diagnostic modality

Digital EEG recording with simultaneous video recording is now widely available, and is considered the standard for diagnosis of subclinical seizures.

Digital video cEEG provides good temporal and spatial resolution.

Current techniques and equipment for cEEG monitoring in the ICU offer real-time review and options for remote access for data analysis.

B.There are specific considerations in the selection of EEG electrodes and montages that are unique to the ICU setting

Critically ill patients often undergo urgent neuroimaging procedures, but traditional gold cup electrodes are not compatible with MRI and CT and, therefore, must be removed prior to imaging.

There is often the need to acquire EEG data quickly and therefore rapid electrode application is desired, but standard electrode placement by trained neurodiagnostic staff can be time consuming, especially if staff must be called in for the procedure.

Patients may require prolonged EEG monitoring resulting in risk of skin breakdown.

Infection risk is increased in critically ill patients, particularly if there are open head wounds.


A.EEG electrodes

Electrodes—general principles and placement

Technical guidelines and consensus statements should be used for the selection, placement, and maintenance of electrodes during cEEG (1,2).

Various electrode materials are available such as tin, silver, silver-silver chloride, gold, platinum, stainless steel, and conductive plastic.

Silver-silver chloride and gold are most commonly used in cEEG monitoring.

The 10–20 International System is the standard for electrode placement (3,4).

Concurrent EKG should be recorded with the option of additional channels for electromyogram (EMG), electrooculogram (EOG), or respiratory belt to help troubleshoot artifact or correlate with clinical findings.

Electrodes should be applied after they are adequately disinfected, or disposable electrodes can be used as an alternative.

Conductive materials are used to adhere the electrodes and lower the impedance at the electrode–skin junction. Although choice of material may be predicated on requirements of the ICU, collodion (glue) is often considered the preferred method of electrode adherence.

Electrode types—noninvasive versus invasive (Figure 2.1)

Noninvasive electrodes are commonly used in centers performing cEEG.

Electrode application methods for noninvasive recordings include individual electrodes as well as cap, net, and template systems.

Cup electrodes are commonly used, but electrodes are also available in web/spider forms.

FIGURE 2.1   Electrode options. (A) Electrode template, (B) CT compatible/MRI conditional electrodes (note, electrodes are disconnected at the yellow hub during transport for neuroimaging. The red hub, clearly marked not MRI safe, remains with the head box), (C) subdermal wire electrode.

Source: Figure 2.1A from Jordan NeuroScience, Inc. Used with permission.

Individual electrodes allow modification and adjustment of placement by a technician to accommodate issues such as craniotomy scars or other equipment used for cerebral monitoring.

Caps, nets, or templates may be used when there are needs for rapid setup and acquisition of EEG.

Electrode caps, nets, and templates can be set up by non–EEG-trained personnel.

Caps are an EEG electrode application technique that includes embedded or detachable leads in a removable cap, while a net is a similar but more open system.

Templates are used as a substitute for head measurement by the technician and provide a typically color-coded map for accurate electrode placement.

There are reusable and disposable options which may have cost differences compared to individual electrodes.

Limitations in the ICU setting are significant and include the lack of ability to modify electrode placement in settings when scalp access is paramount such as with wound care or intracranial monitoring devices.

Advantages may include relative ease of use, particularly for non–EEG-trained personnel, as well as the lack of adhesive materials needed for application, but this may not be enough to warrant their use in ICU settings.

One study (5) in 32 patients in an ICU setting showed that the use of an EEG template by non-EEG staff resulted in no clinically significant differences in impedance or quality of recordings compared to technologist-applied electrodes.

The study also demonstrated that the template shortened time to initiation of EEG recording by 3 hours.

Study limitations included the lack of evaluation of quality of long-term recordings, defined as greater than 8 hours.

Invasive electrodes are an alternative to noninvasive electrodes although many are not currently recommended for routine clinical use.

Subdermal needle electrodes are single-use, disposable electrodes that are used in some centers for long-term recordings in unconscious patients.

Advantages include speed of application, relative lack of scalp breakdown, and stable recordings.

Disadvantages to needle or wire electrodes include risk to technicians during placement, higher impedance, and potential patient discomfort.

They may be more typically used for shorter length recordings.

Subdermal wire electrodes are single-use, disposable Teflon-coated silver wire electrodes.

Advantages include reduction of skin breakdown and better recording of EEG than disc or needle electrodes, as well as the ability for some to be CT and/or MRI compatible.

Disadvantages include cost and discomfort for some patients.

Pressure-placed electrodes are a newer form of invasive electrodes that provide an alternative to needle or wire electrodes.

Advantages include rapid application without the need for skin prep or adhesives. There is also less risk to technicians than with needle electrodes.

Disadvantages include cost and skin irritation.

Intracranial grid/strip/depth electrodes have been used for cEEG monitoring, but are not commonly utilized in the ICU setting.

Electrodes—reusable versus disposable

Most centers use reusable electrodes that are cleaned and disinfected after each use.

Specific measures must be taken after recordings on patients with transmissible diseases.

Disposable electrodes provide an option to reduce infection risk as well as technologist’s time in cleaning electrodes, but may be associated with higher costs.

Cost effectiveness must be determined for each center and may include options of utilizing both reusable and disposable electrodes for different patients in the ICU.

Electrodes—imaging compatibility

Many patients in the ICU undergoing cEEG require urgent and recurrent imaging with CT and MRI during their ICU stay, and imaging-compatible electrodes should be considered (6,7).

Removal and reapplication of electrodes in the ICU may contribute to skin breakdown and require additional EEG technician time.

Traditional gold cup EEG electrodes are not CT or MRI compatible owing to their effects on image quality and/or safety concerns.

Gold cup EEG electrodes are typically considered to be safe in CT scanners, but create artifact owing to deflection of x-rays that may significantly affect the images (Figure 2.2).

EEG electrodes with ferrous or magnetic material also cause susceptibility artifact on MRI images.

EEG electrodes with ferrous materials or long leads are not considered to be safe in MRI owing to heating and possible physical movement of the electrodes in the scanner.

FIGURE 2.2   CT artifact from metal/gold cup electrodes. Typical starburst artifact pattern seen on CT with use of traditional metal/gold cup electrodes.

Alternatives to traditional electrodes that are imaging compatible include CT compatible/MRI conditional electrodes, electrode caps, and invasive electrodes.

Low-density, plastic, or nonmetal (carbon) electrodes can be used to avoid starburst artifact on CT.

MRI-conditional electrodes are nonmagnetic with short electrode wires and specialized connectors. EEG and MRI technicians must be trained in appropriate techniques. Of note, not all commercially available MRI-compatible electrodes are U.S. Food and Drug Administration (FDA) approved.


Montages are designed on the basis of standard electrode placement and should conform to American Clinical Neurophysiology Society (ACNS) guidelines (8).

The international standard for scalp electrode number and placement is the 10–20 system with 16 electrodes used at minimum.

The use of fewer than 16 electrodes may result in poor quality owing to inadequate spatial sampling and difficulty in identification of artifact.

A modified 10–10 system that uses additional electrodes is also accepted as a standard and is used more often for localization for epilepsy surgery, although it may also be useful for localization of frontal lobe epilepsy.

The 10–10 system provides better spatial resolution than the 10–20 system, but may be less practical in the ICU setting.

Limitations of the 10–10 system include increased time and effort for electrode placement, increased cost, and reduced availability of jackboxes to support a system with additional electrodes.

Most recordings also include a single channel ECG.

Some recordings may also include channels for airflow and respiratory monitoring or EMG.

An isolated ground electrode should always be placed and never connected to the EEG equipment or earth ground.

Montages are a method of organizing electrical activity for lateralization and localization. EEG waveforms are a representation of the difference in electrical potentials between two electrodes in a pair and a montage helps to organize those waveforms for visual analysis.

Initial recordings are made from a referential montage.

The reference electrode should be an additional electrode beyond those placed for the 10–20 or 10–10 system.

Common placement of the reference electrode is between Cz and Pz.

Alternatives include Cz or an average reference constructed from all cerebral electrodes.

Montages can be reformatted using digital systems.

Montages can be modified to accommodate limitations in electrode placement due to skull defects or other intracranial monitoring equipment. Modifications should be symmetric if possible and clearly labeled by the EEG technician.

Although the number of possible montages is limited primarily by the number of electrodes and electrode positions (21 possible montages in the 10–20 system), standardization is useful to provide a common language and method of information exchange among technicians and electroencephalographers.

Unique montages are used for neonatal EEG and studies requested for determination of electrocerebral inactivity.

Standard guidelines for nomenclature of each electrode placement system are available and should be routinely used (8).

There are variations in nomenclature, but standard terminology includes electrodes at positions Fp1/2, F3/4, C3/4, P3/4, F7/8, T3/4, T5/6, Fz/Cz/Pz, A1/2 with a ground/reference pair.

Some centers use reduced montages and coverage for seizure detection in the ICU setting (Figure 2.3).

Most reduced coverage montages include 10, 11, or 13 electrodes.

In the ICU setting, where seizure detection is more important than precise localization and mapping, reduced montages may be sufficient.

Several studies have examined the use and sensitivity of reduced coverage montages.

Kolls et al. (5) evaluated the use of a hairline EEG reduced montage to determine the sensitivity of reduced coverage in the screening of nonconvulsive status epilepticus (NCSE) (9).

EEG data was reformatted with electrodes Fp1/2, F7/8, T3/4, and T5/6 in three 6-channel montages and compared with original EEG interpretation.

Sensitivity of seizure detection was 72% and authors did not recommend this format to screen for NCSE.

Karakis et al. compared the sensitivity of a 7-electrode montage (Fp1/2, T3/4, O1/2, Cz) with a hairline montage described by Kolls et al. with 38 reformatted records reviewed by blinded attending physicians and residents (9).

FIGURE 2.3   Comparison of full vs. reduced electrode montages. FM and RM using the 10–20 system, and spatial zones of the scalp surface.

FM, full electrode montage; RM, reduced electrode montage.

Source: Reproduced with permission from Tekgul H, Bourgeois BF, Gauvreau K, Bergin AM. Electroencephalography in neonatal seizures: Comparison of a reduced and a full 10/20 montage. Pediatr Neurol. 2005;32(3):155–161.

The average sensitivity for seizure detection was 92.5%, with specificity of 93.5% for the 7-electrode montage.

The average sensitivity and specificity for the hairline montage was 85% and 97%.

A recent study concluded that a 10-electrode reduced montage did not affect EEG interpretation or clinical prognosis in a group of 142 patients with postanoxic encephalopathy (10).

EEG classification and prognosis were compared in the reduced 10-channel montage to the full 21-electrode montage.

Interobserver agreement was good between reviewers who evaluated EEG using each montage.


A.Choice of electrodes

The cost of EEG electrodes, whether noninvasive or invasive, continues to decrease and may offer the opportunity for a greater number of centers to offer cEEG monitoring.

Increasing options for disposable electrodes may lead to the need to balance issues of patient safety and technician time with environmental concerns about disposable materials.

The growth of imaging-compatible electrodes may improve the ability for patients to get urgent scans in the ICU and may improve technician efficiency.

B.Options for montages and additional electrodes

Although there have not been many changes in recent years with regard to the standardization of montages for cEEG, options are increasing for the addition and use of multimodality monitoring in the ICU and the correlation of these physiologic parameters with EEG signals.


1.Sinha SR, Sullivan L, Sabau D, et al. American Clinical Neurophysiology Society Guideline 1: minimum technical requirements for performing clinical electroencephalography. J Clin Neurophysiol. 2016;33(4):303–307. doi:10.1097/WNP.0000000000000308

2.Herman ST, Abend NS, Bleck TP, et al. Consensus statement on continuous EEG in critically ill adults and children, Part II: personnel, technical specifications and clinical practice. J Clin Neurophysiol. 2015;32(2):96–108. doi:10.1097/WNP.0000000000000165

3.Acharya JN, Hani A, Cheek J, et al. American Clinical Neurophysiology Society Guideline 2: guidelines for standard electrode position nomenclature. J Clin Neurophysiol. 2016;33(4):308–311. doi:10.1097/WNP.0000000000000316

4.Kuratani J, Pearl PL, Sullivan L, et al. American Clinical Neurophysiology Society Guideline 5: minimum technical standards for pediatric EEG. J Clin Neurophysiol. 2016;33(4):320–323. doi:10.1097/WNP.0000000000000321

5.Kolls B J, Husain A. M. Assessment of hairline EEG as a screening tool for nonconvulsive status epilepticus: response to Bubrick et al. Epilepsia. 2007;48(12):2375.

6.Vulliemoz S, Perrig S, Pellise D, et al. Imaging compatible electrodes for continuous electroencephalogram monitoring in the intensive care unit. J Clin Neurophysiol. 2009;26(4):236–243.

7.Herman ST, Abend NS, Bleck TP, et al. Consensus statement on continuous EEG in critically ill adults and children, Part II: personnel, technical specifications and clinical practice. J Clin Neurophysiol. 2015;32(2):96–108.

8.American Clinical Neurophysiology Society Guideline 3: proposal for standard montages to be used in clinical EEG. J Clin Neurophysiol. 2016;33(4):312–316. doi:10.1097/WNP.0000000000000317

9.Karakis I, Montouris GD, Otis JA, et al. A quick and reliable EEG montage for the detection of seizures in the critical care setting. J Clin Neurophysiol. 2010;27(2):100–105. doi:10.1097/WNP.0b013e3181d649e4

10.Tjepkema-Cloostermans MC, Hofmeijer J, Hom HW, et al. Predicting outcome in postanoxic coma: are ten EEG electrodes enough? J Clin Neurophysiol. 2017;34(3):207–212.

Additional Reading

Hirsch LJ, Brenner RP, eds. Atlas of EEG in Critical Care. Chichester, UK: John Wiley & Sons; 2010.


Networking, Remote Monitoring, and Data Storage

Joshua Andrew Ehrenberg


Review of different types of network configurations

Comparison of remote EEG monitoring and review systems

Options for storage of digital EEG and video


There are various options for network configurations including stand-alone EEG networks, virtual local area networks (VLANs), and facility-integrated networks.

Major considerations when choosing a method of remote access to EEG data include speed and ease of access, security, cost, resources available for maintenance, and number of concurrent users. Remote monitoring options include desktop mirroring, terminal services, and virtualized review systems.

There are various archiving and data storage strategies that can be utilized to store the vast amount of data that is acquired with continuous EEG and video recording. The best method of data storage depends on what resources are available (time and equipment) as well as how much of the data is considered necessary to keep for prolonged periods.


A.Growth of networks in health care settings and clinical neurophysiology

Computer networks and remote monitoring have been increasing in use in clinical neurophysiology.

Computer networks in the health care setting have become essential. The majority of the growth has been driven by the need to view radiologic images, examine lab results, and create system-wide electronic medical records.

Over the past few decades, local networks in epilepsy monitoring units (EMUs) and remote monitoring in intraoperative monitoring (IOM) have become commonplace.

EMU implementations

In the traditional EMU setting, networks are usually physically separate from the hospital or facility network, and have no shared connections. The EMU network usually connects to EEG recording units, data storage servers, and reading stations.

This physically separate network configuration allows for collection of large amounts of video and EEG data as well as fast data transmission without impacting the hospital network.

The disadvantage to this configuration is the inability to view data remotely, even from physicians’ offices within the hospital, unless directly connected to the EMU local network.

Remote monitoring has been utilized in IOM for many years.

IOM monitoring is typically arranged in a point-to-point configuration where the reviewer is connected directly to a single data acquisition unit and able to view data in real time.

Remote monitoring in IOM was originally accomplished through phone line data connection, but is currently through a facility network where viewing takes place from a separate location, either a physician’s office or sometimes as distant as other states.

This point-to-point configuration is not as effective for prolonged EEG monitoring where there are typically multiple patients, multiple EEG reviewers, and the need to review previously recorded data.

B.Network configurations

There are many network configurations and remote monitoring options that can be utilized in ICU continuous EEG (cEEG) monitoring.

As with any aspect of clinical neurophysiology, there is no perfect design any more than there is a perfect montage, so applying knowledge of strengths and weaknesses as well as available resources is vital to determining the optimum design.

C.Data storage

EEG data storage has undergone many changes over the years.

In the past, data storage has ranged from collections of piles of paper in large storage rooms to stacks of video cassette tapes.

One of the major benefits of digital EEG is the ease of storing large amounts of data on fairly small media. This began as optical disks, then archiving to CD and later to DVD. More recently, storage to large external USB hard drives and centralized network storage has become popular.

Recently, cloud storage has become prevalent which refers to a network, Internet-based service for hosting data storage across multiple sites. Advantages include ease of use, scalability to needs (pay as you use), and access from multiple devices. However, patient privacy and data security must be thoroughly evaluated. Data breaches, ransomware, and data integrity (speed of use for real time, and redundancy of raw data transfers) are serious concerns that must be weighed.

Regardless of which data storage media is used, it is vital to ensure appropriate safeguards are in place to protect patient privacy (e.g., encryption), but these should be weighed against increased complexity and additional steps (1).

Data file sizes

Data file

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