Understanding

Electroencephalography

Mohamed Hamdy
Post graduate teaching
Electrophysiology

Objectives of this lecture

To know what is the basic mechanism of the normal and abnormal

EEG
To know the significance of the EEG in the light of the clinical context
To know when to ask for EEG and what activation technique do you
recommend
To know the variability of findings in different age groups
To use the EEG finding in making the decision in epilepsy
management

Mohamed Hamdy

The skeleton of the topic

Physiology of the EEG waves

Normal variants
Interictal epileptiform abnnormalities
Ictal abnormalities
Maturational aspects from neonates to adulthood
Sleep changes in EEG
EEG monitoring
Example tests
Mohamed Hamdy

Recording EEG

EPSP at apical dentritic trees of pyramid

cells
Dentritic membrane depolarized
Potential difference cause a current
flow through volume conductor from the
nonexited membrane of the soma to the
apical dentritic tree
Extracellular currents = secondary /
volume currents

Mohamed Hamdy

Recording EEG

Mohamed Hamdy

The EEG machine

8 64 identical channels recording

simultaneously from as many different
pairs of electrodes

Electrodes & electrode board

Amplifiers
Filters
Pen & chartdrive (screen)

Mohamed Hamdy

The Source of EEG

EEG = a measure of cerebral electrical activity

The generator sources for EEG waves are within the cerebral cortex
Electrical activity recorded on the scalp is produced by extracellular
current flow associated with summated excitatory and inhibitory
postsynaptic potentials (EPSPs and IPSPs)
Individual action potentials do not contribute directly to EEG activity

Mohamed Hamdy

Synaptic Potentials:
The Basis of EEG Activity

Synaptic potentials are of much lower voltage than action

potentials, but the produced current has a much larger distribution
PSPs have a longer duration and involve a larger amount of
membrane surface area than APs

Mohamed Hamdy

EPSPs and IPSPs

EPSP produces a change in membrane permeability within a select

portion of the cell membrane resulting in a net influx of + ions that
depolarizes the cell
IPSP selective activation of either Cl- or K+ channels resulting in a
net outward ionic current with hyperpolarization of the cell

Mohamed Hamdy

EEG: A Reflection of Current

Spontaneous EEG activity occurs when currents flow across charged

neuronal membranes
An EEG waveform reflects a summation of PSPs from thousands or
even millions of cortical neurons
The EEG represents the average behavior of large neuronal
aggregates
The current flow from positive to negative is arranged in a dipole

Mohamed Hamdy

The Dipole

Theoretically, the current flows in a 3-dimensional ellipse with the

greatest current density along a straight line connecting the positive
pole to the negative pole
The complex arrangement of the brain and head, differences in cell
type and function within a region, and physical differences between
brain areas result in an approximate dipole that is not a perfect
model.

Mohamed Hamdy

Rhythmical vs. Arrhythmical

EEG Activity

When EEG waves are rhythmical, most of the cells within the
given neuronal pool are behaving similarly
With arrhythmic activity, there is less correlation with individual cell
behavior

Mohamed Hamdy

Pyamidal Cells:
Principal Current Generators of EEG

Topographical organization within the cortical mantle corresponds

to a dipoles oriented perpendicular to the cortical surface

Mohamed Hamdy

Factors Affecting EEG Waveforms

Voltage of the cortical discharge

Area involved in synchronous activity
Degree of synchrony
Location of the dipole generators in relation to the convolutions of the
cortical mantle.

Mohamed Hamdy

Factors that Attenuate Voltage

Primarily overlying spinal fluid and dura

Scalp to a lesser extent
Scalp recorded activity represents spatial averaging of electrical activity
from a limited area of cortex
20-70% of epileptiform activity may not be seen on scalp EEG
Involvement of small areas of tissue is associated with much greater attenuation
of activity
Activity arising from cortex within the walls or depths of sulci may not be recorded

Mohamed Hamdy

Origin of EEG Rhythmicity

Rhythmical activity sequences of regularly recurring waveforms of similar

shape and duration
Rhythmical activity may be locally generated or occur via projected synaptic
inputs from deeper structures
The thalamus, via an anatomic cellular organization, thalamocortical
projections and mechansims that are not fully understood, governs different
types of rhythmical activity
Sleep spindles
Alpha rhythm in the occipital cortex
3 per second spike and wave associated with absence seizures

Mohamed Hamdy

Types of EEG Recording

Routine

analog, digital

with computerized analysis & brain electrical activity

mapping

Long-term Monitoring

Mohamed Hamdy

Routine EEG Techniques

20-min or longer sampling of brain activity
Written out or recorded directly on magnetic tape or digitally by
computer
Disc electrodes are applied according to 10-20 system of
electrode placement
Montages: referential, bipolar, changeable with digital recording

Mohamed Hamdy

10-20 System Of Electrode

Placement

Mohamed Hamdy

International 10-20 System of Electrode

Placement

Established in 1958
Electrodes are spaced at 10% or 20% of distances between specified
anatomic landmarks
Use 21 electrodes, but others can be added
increase spatial resolution
record from specific areas
monitor other electrical activity (e.g. ECG, eye movements)

Odd number electrodes over left and even number over right
hemisphere
Mohamed Hamdy

10-10 System Of Electrode

Placement

Mohamed Hamdy

10-10 System Of Electrode

Placement

Mohamed Hamdy

Routine EEG Techniques

20-min or longer sampling of brain activity
Written out or recorded directly on magnetic tape or digitally by
computer
Disc electrodes are applied according to 10-20 system
Montages: bipolar, referential, changeable with digital recording

Mohamed Hamdy

Mohamed Hamdy

Mohamed Hamdy

Mohamed Hamdy

Activations
Routine

Optional

Eye opening and closure

Hyperventilation
Intermittent photic stimulation

1, 5, 10, 15 & 20 Hz
eyes open
eyes closed
eyes closure

Sleep deprivation
Sedated sleep
Specific methods of seizure
precipitation
video games
visual patterns

AED withdrawal

Mohamed Hamdy

Strength and Advantages of EEG

Is a measure of brain function;
supplement neuroimaging studies

Provides some spatial or

localization information

Provides direct rather than indirect

evidence of epileptic abnormality

Low cost

May be the only test that shows

abnormalities in epileptic patients

Low morbidity
Readily repeatable
Portable / ambulatory

Mohamed Hamdy

The EEG Frequency Spectrum

Waves

Frequenci
es per
second

Amplitude
in V

Characteristics

Beta-waves 14 - 30

5 - 50,
mostly below
30

Sharp spike-waves over 35 Hz,

Frontocentral, precentral &
posterior
Criteria of light sleep stages

Alphawaves

8 - 13

5 - 120,
mostly below
50

Posterior-dominant, awake, eyes

closed, mental inactivity, physical
relaxation

Thetawaves

4-7

20 - 100

Strictly rhythmic or highly

irregular
Awake & drowsiness or light
sleep stages

Deltawaves

0,5 - 3

5 - 250

Abnormality in waking adults,

Accompaniment of deep sleep

Gammawaves

31 - 60

-10 Mohamed Hamdy

Legality of appearance and site
not well established

The EEG Frequency Spectrum

Mohamed Hamdy

Posterior Alpha Rhythm

Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F4
F4-C4
C4-P4
P4-O2

Mohamed Hamdy

Uses Of EEG In The Management of Seizure

Disorders
To support a clinical diagnosis of epilepsy
To help to classify seizures
To help localize epileptogenic focus, especially in presurgical
candidates
To quantify seizures
To aid in the decision of whether to stop AED treatment
Not a good guide to the effectiveness of treatment, except in
absence seizures

Mohamed Hamdy

Analyzing EEG Activities

Morphology
Distribution
Frequency
Voltage
Duration
State of the patient
Background from which activity is arising from
Similarity or dissimilarity to the other ongoing background rhythms

Mohamed Hamdy

Guidelines To EEG Interpretation

Each EEG should be read with maximum possible objectivity
Ideally an EEGer should describe the findings and make an EEG
diagnosis without knowledge of the patient's history
Clinical significance of the findings can then be judged by integrating
the EEG diagnosis with the history

Mohamed Hamdy

EEG Interpretation

Normal
Lack

of Abnormality

Abnormal
Non-epileptiform
Epileptiform

Patterns

Patterns

Mohamed Hamdy

Epileptiform Patterns on Scalp-recorded

EEG

Interictal Epileptiform Pattern

Electrographic Seizure Pattern

Isomorphic seizure pattern

Metamorphic seizure pattern

Mohamed Hamdy

Criteria For Potentially Epileptogenic

Transients

Clearly of cerebral and not artifactual origin

Abnormal for the age and the state of the patient
Have a significant epileptiform character and not
one of the benign epileptiform variants

Mohamed Hamdy

Mohamed Hamdy

Sharp Transients

Physiologic Activities That Can Be Confused With Epileptiform Activities

Vertex transients of light sleep

Hypnagogic hypersynchrony
Positive occipital sharp transients of sleep (POST)
Mu rhythm
Lambda waves
Breach rhythms

Mohamed Hamdy

Mohamed Hamdy

Breech Rhythm

Benign Variants Of Unknown Clinical Significance

Benign epileptiform transients of sleep (small sharp spikes)
6- and 14-Hz positive spikes
Wicket spikes
Psychomotor variants (rhythmic mid-temporal theta
discharge of drowsiness)
Subclinical rhythmic EEG discharge of adults
Phantom spike and wave

Mohamed Hamdy

Mohamed Hamdy

Small Sharp Spikes

FP1
F7
F7 T3
T3
T5
T5
O1
FP2
F8
F8 T4
T4
T6
T6
O2
FP1
F3
F3
C3
C3
P3
P3
O1
FP2

Mohamed Hamdy

Wicket Spikes

Mohamed Hamdy

Psychomotor Variant

Vertex Wave and Sleep Spindles

Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F4
F4-C4
C4-P4

Fp1-F3
F3-C3
C3-P3

P4-O2

P3-O1
Fp1-F7
F7-T3

Fp2-F4

T3-T5

F4-C4

T5-O1

C4-P4

Fp2-F8

P4-O2

F8-T4
T4-T6
T6-O2

Mohamed Hamdy

Examples Of Inter-ictal Epileptiform Patterns

Spikes
Sharp waves
Benign Epileptiform Discharges of Childhood
Spike-and-wave complexes
3Hz Spike-and-wave complexes
Slow spike-and-wave complexes
Hypsarrhythmia
Photo-paroxysmal response

Mohamed Hamdy

Focal Epileptiform Discharges

and Abnormalities
Spikes and sharp waves
Phase reversal localizes the focus
Recorded seizures
Focal slowing may indicate an underlying epileptogenic focus,
structural lesion or injury, or postictal effect

Mohamed Hamdy

Localization: Phase Reversal

Each channel records the potential
difference between two electrodes
G1 G2
Negative is up
If G1 is more negative than G2, the
deflection will be up
If G2 is more negative, the deflection
will be down

FP1-F7

F7-T3

T3-T5

FP1-F7

Mohamed Hamdy

Generalized EEG Abnormalities

Generalized spike and wave

Generalized polyspike-wave or multispike-wave
Generalized slow spike and wave
Generalized 3 Hertz spike-wave
Generalized slowing
Generalized suppression
Generalized burst suppression
Electrocerebral silence

Mohamed Hamdy

Generalized Spike-Wave
Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F4
F4-C4
C4-P4
P4-O2
Fp1-F7
F7-T3
T3-T5
T5-O1
Fp2-F8
F8-T4
T4-T6
T6-O2

Mohamed Hamdy

Generalized Polyspike Wave

Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F4
F4-C4
C4-P4
P4-O2
Fp1-F7
F7-T3
T3-T5
T5-O1
Fp2-F8
F8-T4
T4-T6
T6-O2

Mohamed Hamdy

3 Hertz Spike and Wave

Fp1-F3

F3-C3

C3-P3

P3-O1

Fp2-F4

F4-C4

C4-P4

P4-O2
1 sec

Mohamed Hamdy

50 V

Generalized Delta Slowing

Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F4
F4-C4
C4-P4
P4-O2
Fp1-F7
F7-T3
T3-T5
T5-O1
Fp2-F8
F8-T4
T4-T6
T6-O2

Mohamed Hamdy

Interictal Spikes / Sharp Waves

Spikes (<70 msec in duration) or Sharp Waves (70-200 msec in
duration)
Usually surface negative; occasionally bipolar or only surface positive
Monophasic, biphasic or polyphasic
Occur alone or accompanied by an after-coming slow wave (usually
surface negative and higher in amplitude than the spike or sharp wave)
Occurs singly or in burst, lasting at most a few seconds
Focal or generalized
No clinical manifestation

Mohamed Hamdy

Epileptiform Discharges: Spikes

Indicate susceptibility to seizures

May be generalized or focal
Focal spikes cortical spikes are associated with synchronous
paroxysmal depolarizing bursts occurring in neurons within the
focus resulting in extracellular current flow that is recorded as
surface spikes

Mohamed Hamdy

Inter-ictal Epileptiform Patterns

Idiopathic Epilepsies

Symptomatic Epilepsies

Generalized

3 Hz spike-and-wave
Polyspikes
Atypical spike-and-wave

Generalized

Partial / Focal
Benign focal epilepsy of childhood
with centrotemporal spikes
Benign focal epilepsy of childhood
with occipital spikes

Hypsarrhythmia
Slow spike-and-wave
Paroxysmal fast activity
Multiple independent spike foci

Partial / Focal

Temporal
Frontal
Centro-parietal
Occipital
Midline

Mohamed Hamdy

Mohamed Hamdy

3 Hz Spike & Wave Complexes

Mohamed Hamdy

3 Hz Spike & Wave Complexes

Mohamed Hamdy

Polyspikes

The Spike and Wave Complex

The cellular depolarizing bursts are followed by long-lasting

afterhyperpolarization in cells within the focus
Additional inhibition occurs in surrounding cortex, thalamus and other
subcortical areas
This results in a surface slow wave that follows the individual spike

Mohamed Hamdy

Mohamed Hamdy

Polyspikes & Wave

Mohamed Hamdy

Hypsarrhythmia

Mohamed Hamdy

Slow Spike & Wave Complexes

Fp1
F7
F7
T3
T3
T5
T5
O1
Fp2
F8
F8
T4
T4
T6
T6
O2
Fp1
F3
F3
C3
C3
P3
P3
O1
Fp2

Benign Epileptiform
Mohamed Hamdy
Discharges of Childhood

Focal Inter-ictal Epileptiform Pattern

Temporal, frontal, occipital, centroparietal, centrotemporal, or midline
Relative frequency (Gibbs and Gibbs, 1952)

1396 patients; Temporal: 73%; Frontal: 0.8%

Likelihood of seizures (Kellaway, 3526 children)

Temporal : 90-95% (91%)
Frontal : 70-80% (75%)
Parieto-occipital : 40-50% (48%)
Central : 30-40% (38%)

Focal spikes in a patient with a history of epileptic seizures indicates that

the patient is likely to have focal or localization-related epilepsy
syndrome

Mohamed Hamdy

Neuronal Synchronization

The interictal spike may be initiated by a spontaneous burst in one or

a few cells
Each cell has excitatory connections to a number of other cells
Excitatory connections will allow burst propagation if inhibition is
decreased, absent or simply overcome
Loss of effective dendritic inhibitory synapses may occur over time

Mohamed Hamdy

Mohamed Hamdy

Sharp Wave, Regional, Left

Mohamed Hamdy

Sharp Wave, Regional, Right

Sharp Wave,
Regional,
Right
Mohamed
Hamdy
Posterior Temporal

Mohamed Hamdy

Sharp Wave, Regional, Central

Epileptiform Activity In People

Without Epilepsy
Zivin and Ajmone-Marsan, 1980
142/6497 (2.2%) of non-epileptic patients had IEDs
only 20/142 (14.1%) eventually developed epilepsy
Eeg-Olofsson et al, 1971
2.7% and 8.7% of 743 normal children had IEDs during
wakefulness and sleep, respectively
Cavazutti et al, 1980
131/3726 children (3.5%) had IEDs on awake EEG
only 7/131 (5%) eventually developed seizures
Presence of interictal epileptiform discharges (IEDs) is not
diagnostic of epilepsy

Mohamed Hamdy

Normal EEG In People With Epilepsy

I know my patient has epilepsy. How can the EEG be

normal?
If the EEG is normal, am I wrong in thinking that my patient
has epilepsy?

Mohamed Hamdy

Normal EEG In People With Epilepsy

Ajmone-Marsan & Zivin, 1970

only 56% of 1824 EEGs from 308 patients (1-64 years) with known
seizures showed IEDs on first EEG
IEDs recorded in another 26% in subsequent records
Holmes, 1986
25% of 24 paediatric patients with documented seizures on longterm monitoring had no IEDs
first and only EEG abnormalities recorded was complex partital
seizures
Patients with well-documented seizures may have normal EEGs

Mohamed Hamdy

Factors Responsible For Detection Of Epileptiform

Discharges

Characteristic of Generator Source

Voltage of cortical discharge which is directly related to size/area

of cortex involved in generation of synchronous activity

Distance between electrodes and the generator source

Orientation of dipole

Sampling Time
Activation
Mohamed Hamdy

Factors Which Modify Spike Frequency

Sleep
Photic stimulation
Hyperventilation
Temporal relation to a seizure
Age of patient
Effect of anticonvulsant withdrawal

Mohamed Hamdy

Recording of Focal Interictal Spikes

Yield of recording focal interictal spikes increases

during NREM sleep, especially stage 3/4

after sleep deprivation
after seizures
during long-term monitoring
? using supplementary electrodes (e.g. sphenoidal)

Occurrence of focal interictal spikes is not affected

by increasing or decreasing the AED dosages or level
by hyperventilation or photic stimulation
before seizures

Mohamed Hamdy

Does the Frequency of IEDs Tell Us

Anything?

Probably not
Increases after a seizure
Does not predict severity of epilepsy
Relationship between spikes and ictal activity is not known

Mohamed Hamdy

Routine EEG
Concluding Remarks
EEG is the most valuable tool in the evaluation of patients with a
seizure disorder
Interpretation of clinical significance of EEG abnormality(ies) can
only be made by a physician who

is evaluating the patients history and physical findings

has an understanding of the benefits and limitations of EEG recording

Mohamed Hamdy

Epileptiform Patterns on Scalp-recorded

EEG

Interictal Epileptiform Pattern

Electrographic Seizure Pattern

Isomorphic seizure pattern

Metamorphic seizure pattern

Mohamed Hamdy

Electrographic Seizure Pattern

Rhythmic repetition of components that may or may not have an

epileptiform morphology
Lasting more than several seconds
When this pattern produce clinical symptoms and/or signs, it is called a
clinical electrographic seizure discharge
When it does not produce clinical symptoms, it is called a subclinical
electrographic seizure discharge

Mohamed Hamdy

Generalized Spike-and-Wave

A pathological exaggeration of cortical excitability is the basic disturbance

and appears to initiate the process
Cortical spikes precede epileptiform discharges in depths
Thalamocortical connections are necessary for triggering and phasing the
spike-and-wave bursts
The brainstem reticular formation appears to modulate spike-and-wave
activity by modifying the level of cortical excitability.
Substantia nigra involvement in some way is essential in the production of
generalized convulsions.

Mohamed Hamdy

Isomorphic Seizure Pattern

Ends as it begins, without progressing through multiple phases

into a postictal phase
Ictal morphology is usually similar to interictal epileptiform
patterns
Differ only in having greater rhythmicity, duration, spatial extent
and amplitude
Almost exclusively seen in generalized seizures
Prototype: 3/s spike-and-wave complexes

Mohamed Hamdy

Metamorphic Seizure Pattern

Ends differently from its beginning, commonly progressing

through 2 or more different ictal phases into a postictal state
Ictal morphology can also be dissimilar to interictal epileptiform
patterns
Ictal morphology may consist of smooth sinusoidal rhythms and
has no spike or sharp wave
Seen both in generalized seizures and focal seizures

Mohamed Hamdy

Mohamed Hamdy

Seizure, Regional, Left Temporal

Mohamed Hamdy

Seizure, Generalized

ICTAL EEG
Always abnormal in generalized seizures
Almost invariably abnormal during a partial seizures especially
with loss of consciousness
Might be normal for simple partial seizures

Should be correlated with behavioral changes

Mohamed Hamdy

Long-term EEG Monitoring

In- or out-patient setting

Methods
Prolonged Conventional
Ambulatory
With video recording of behavior

analog, digital

Telemetered EEG recording

radio, cable

Mohamed Hamdy

Video/EEG Monitoring

To obtain a prolonged interictal EEG sample

To record habitual seizures or spells
To make precise EEG / behavioral correlation
To classify seizures (e.g. absence vs. complex partial)
To localize epileptogenic focus, especially in epilepsy surgery
candidates
To quantify seizures when they occur frequently
Evaluate seizure precipitants

Mohamed Hamdy

Questions To Be Answered After

Video/EEG Monitoring

Does the patient have epilepsy?

Where do the seizures come from?
Is the patient a candidate for surgical treatment?

Mohamed Hamdy

EEG in Neonates

Premature newborn due to the incomplete development of

neuronal connections, synapse formation, myelination, etc., EEG
activity prior to 30 weeks estimated gestational age (EGA) is
disccontinuous and very abnormal appearing
Focal sharp discharges in frontal and temporal regions are normal to
some extent until about 44 weeks EGA

Mohamed Hamdy

Trace Discontinue in 27 week EGA Neonate

Fp1-F7
F7-T5
T5-O1
Fp1-F3
F3-P3
P3-O1
Fp2-F4
F4-P4
P4-O2
Fp2-F8
F8-T6
T6-O2

Mohamed Hamdy

2 month old with Enterococcal meningitis and left posterior

temporal focal electrographic seizure
FP1-F7
F7-T5
T5-O1
FP1-F3
F3-P3
P3-O1
Fp2-F4
F4-P4
P4-O2
Fp2-F8

50 V
1 sec

F8-T6
T6-O2

Mohamed Hamdy

2 month old with Enterococcal meningitis with an

electrographic seizure discharge, maximal right frontal
FP1-F7
F7-T5
T5-O1
FP1-F3
F3-P3
P3-O1
Fp2-F4
F4-P4
P4-O2
Fp2-F8

50 V
1 sec

F8-T6
T6-O2

Mohamed Hamdy

2 month old with Enterococcal meningitis and right posterior

temporal focal electrographic seizure
FP1-F7
F7-T5
T5-O1
FP1-F3
F3-P3
P3-O1
Fp2-F4
F4-P4
P4-O2

50 V
1 sec

Fp2-F8
F8-T6
T6-O2

Mohamed Hamdy

2 month old with Enterococcal meningitis and bilateral

independent focal electrographic seizures
FP1-F7
F7-T5
T5-O1
FP1-F3
F3-P3
P3-O1
Fp2-F4
F4-P4
P4-O2
50 V

Fp2-F8
1 sec

F8-T6
T6-O2
Mohamed Hamdy

Progression of EEG in Childhood

Occipital rhythmical activity = Alpha rhythm

3-5 months
12 months
3 years
9 years

3.5-4.5 Hertz
5-6 Hertz
7.5-9.5 Hertz
>9 Hertz

Mohamed Hamdy

EEG During Sleep

Stage I sleep
Dropout of alpha rhythm
Intermixed slowing

Stage II sleep
Increased intermixed theta and delta slowing
Vertex waves, sleep spindles and K-complexes
Positive occipital sharp transients of sleep (POSTs)

Mohamed Hamdy

Progression of Sleep

Stage III sleep

Increased delta slowing
Central vertex activity diminishes

Stage IV sleep
Marked delta slowing
Absence of vertex activity

Stage III and IV = Slow wave sleep

Mohamed Hamdy

Stage 3-4 Sleep

Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F4
F4-C4
C4-P4
P4-O2
Fp1-F7
F7-T3
T3-T5
T5-O1
Fp2-F8
F8-T4
T4-T6
T6-O2

Mohamed Hamdy

REM Sleep
Low voltage mixed frequency activity with faster components
Absent vertex activity
Decreased EMG activity

Mohamed Hamdy

EEG in the Evaluation of

Possible Epilepsy

For patients with epilepsy, a single EEG will reveal epileptiform

activity in:
30-40% with an awake EEG only
60-70% with wakefulness and sleep
Some patients will only have an abnormality detected if an actual
seizure is recorded
A normal EEG does not rule out a diagnosis of epilepsy

Mohamed Hamdy

EEG Monitoring in Critical Care

Many patients with head injury, any form of encephalopathy, or severe

illness are at risk for seizures
Patients who are mechanically ventilated are often sedated and
pharmacologically paralyzed and seizures can only be diagnosed with EEG
The diagnosis of nonconvulsive status epilepticus can only be detected and
monitored with EEG
Monitoring progression of coma and potentially cerebral death

Mohamed Hamdy

11 y/o boy with severe cardiomyopathy on ECMO following

cardiac electromechanical disassociation
Fp1-F7
F7-T3
T3-T5
T5-O1
Fp2-F8
F8-T4
T4-T6
T6-O2
Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F4

50 V
1 sec

F4-C4
C4-P4
P4-O2

Mohamed Hamdy

11 y/o boy with severe cardiomyopathy on ECMO with right temporal

electrographic seizure
Fp1-F7
F7-T3
T3-T5
T5-O1
Fp2-F8
F8-T4
T4-T6
T6-O2
Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F4
1 sec

F4-C4
C4-P4
P4-O2

Mohamed Hamdy

50 V

Focal Status Epilepticus

Fp1-F7
F7-T3
T3-T5
T5-O1
Fp2-F8
F8-T4
T4-T6
T6-O2
Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F4
F4-C4
C4-P4
P4-O2

1 sec

Mohamed Hamdy

50 V

11 y/o boy with severe cardiomyopathy on ECMO with left

hemispheric suppression due to infarction
Fp1-F7
F7-T3
T3-T5
T5-O1
Fp2-F8
F8-T4
T4-T6
T6-O2
Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F4

50 V
1 sec

F4-C4
C4-P4
P4-O2

Mohamed Hamdy

EEG Monitoring and

Epilepsy Surgery
20% of patients with epilepsy cannot be controlled with
medications
Focal onset seizures can sometimes be selected and treated with
surgical resection of the epileptogenic focus
Multiple methods are can be employed

Mohamed Hamdy

EEG: Recorded Seizure

*Fp1-F3

*F3-C3

*C3-P3

*P3-O1

Fp2-F4

F4-C4

C4-P4
50 V
1 sec

*P4-O2

Mohamed Hamdy

*Fp1-F3

*F3-C3

*C3-P3

*P3-O1

Fp2-F4

50 V
1 sec

F4-C4

C4-P4

*P4-O2

Mohamed Hamdy

*Fp1-F3

*F3-C3

*C3-P3

*P3-O1

Fp2-F4

50 V
1 sec

F4-C4

C4-P4

*P4-O2

Mohamed Hamdy

Electrocortical Seizure Recording

41-42
42-43
43-44
44-45
45-46
49-50
50-51
51-52
52-53
1 sec

53-54
54-55

Mohamed Hamdy

50 V

41-42
42-43
43-44
44-45
45-46
49-50
50-51
51-52
52-53
1 sec

53-54
54-55

Mohamed Hamdy

50 V

41-42
42-43
43-44
44-45
45-46
49-50
50-51
51-52
52-53
53-54

1 sec

50 V

54-55

Mohamed Hamdy

Examples of Clinical cases

Please give me your interpretation

Mohamed Hamdy

Mohamed Hamdy

Mohamed Hamdy

Female patient 20 ys, with attacks of confusional

state, she is awake with the eye closed

Mohamed Hamdy

Mohamed Hamdy

Mohamed Hamdy

Mohamed Hamdy

Male patient
aged 28 years. He has recurrent
Awake
record
attacks of lapses of consciousness

Mohamed Hamdy

Male patient 57 Years with recurrent GTCS

that developed only in the last year

Mohamed Hamdy

Thank you