normal variants - epilepsy society of thailand · nonphysiologic artifacts causes of altered...
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Normal variants
Kanokwan Boonyapisit, M.D.
Division of Neurology
Department of Medicine
Siriraj Hospital
LOGO
What do you need to know about
the patients before reading their EEG?
Patient’s age
State of consciousness
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What do you see on EEG?
Normal physiologic activity
Abnormal physiologic activity
Artifacts
What do you see on EEG?
Normal physiologic activityNormal activity
Normal variants
Abnormal physiologic activityEpileptiform abnormalities
Nonepileptiform abnormalities
Artifacts
Physiologic artifacts
Nonphysiologic artifacts
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EEG waveform characteristics
Frequency: delta (<4 Hz), theta (4-7 Hz), alpha
(8-13 Hz), Beta (>13 Hz)
Voltage
Waveform
Occurrence: intermittent, continuous
Location
Reactivity
Interhemispheric coherence: symmetry,
synchrony
Normal variants in the
posterior head region
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Alpha variants
First described by Goodwin in 1947
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Alpha variants
Fast alpha variants
Slow alpha variants
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Fast Alpha variants
Superimposed harmonic rhythm,
twice the frequency of basic
posterior background
LOGO
Slow alpha variants
Superimposed subharmonic rhythm
(half of the frequency of the
posterior background)
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LOGO
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Alpha variants
Both patterns show the same
reactivity to eye opening and eye
closure as normal posterior
background
Unknown significance
Not correlate with epilepsy or other
disorders
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Normal variants that mimic
sharp waves
LOGO
Small Sharp spikes
Anterior to mid temporal single
transients
Wide spread electrical field
Occur in drowsiness, light sleep
Amplitude <50 uV, duration <50
msec
No disruption of background
Unilateral or bilateral (if the record
duration is long enough)
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LOGO
Small Sharp spikes
Occur in 3 to 20-25% of normal
person, more common between age
30 -60 years old
Also known as benign epileptiform
transients of sleep (BETS)
LOGO
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LOGO
Wicket spikes
Monophasic, Archiform 6-11 Hz temporal
sharp transients
No disruption of background, no following
sharp waves
Always temporal in location
Amplitude 60-200 μV, may occur in runs
LOGO
Wicket spikes
Seen in awake or drowsy states
Unilateral or bilateral
Usually seen more on one side
Seen in 1-3% of normal adult >30 yo.
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RMTD (Rhythmic midtemporal
discharges)
Rhythmic 4-7 Hz temporal burst of
monophasic sharp transients with
notched appearance
Maximum over the midtemporal region
May be some spreading to the
parasagittal region
Unilateral or bilateral
Awake or drowsy states
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LOGO RMTD (Rhythmic
midtemporal discharges)
May occurs in trains
Not evolve in frequency but may evolve
in amplitude
Occur 0.5-2% of normal
In younger or middle age adults
Also known as rhythmic theta bursts of
drowsiness
LOGO
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LOGO
LOGO
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Normal variants that were
seen as bursts of rhythmic
activities
LOGO
14 and 6 positive spikes
Rhythmic, archiform, positive waves, maximal amplitude over posterior temporal region
14 Hz (more common) or 6-7 Hz
Occur in burst, lasting 0.5-1 sec
“Comb like” shape
Unilateral or bilateral
Deep drowsy state or light sleep
Best seen on referential montage
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14 and 6 positive spikes
Best seen in reference
10-30% of normal aldolescents
LOGO
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LOGO
6 Hz spike and waves (Phantom
spikes)
Burst of 5-7 Hz slowing intermixed
with low amplitude sharp transients
Burst last 1-2 seconds
Awake or drowsy states
Sharp transients are very small do
not map out nicely
LOGO
6 Hz spikes and waves (Phantom
spikes)
Two spatial distribution patterns
WHAM
W: waking record
H: high amplitude
A: anterior
M: males
FOLD
F: female
O: occipital
L: low amplitude
D: drowsy record
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LOGO 6 Hz spikes and waves
(Phantom spikes)
Seen in 0.5 -1 to 2-3% of normal
adults
During relax wakefulness or
drowsiness
LOGO
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LOGO
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Rhythmic midline theta
Rhythmic 6-8 Hz midline activity
Smooth, archiform, spiky or mu like
appearance
Wax and wane in amplitude
Central vertex electrodes
Occur during drowsiness and sleep
Can occur in wakefulness
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LOGO
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SREDA (subclinical rhythmic
electrographic discharges of adult)
Rhythmic 5-7 Hz burst of sharp
transients
Seen in parietal or posterior
temporal region
Abrupt onset, lasting 40-80 seconds
May evolve in pattern or amplitude,
resemble seizure
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LOGOSREDA (subclinical rhythmic
electrographic discharges of adult)
Occur in old age (>50 yo)
Seen in awake, drowsy
May be enhanced by
hyperventilation
Rare!!
LOGO
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Artifacts
LOGO
Artifacts
Type?
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LOGO
Artifacts
Nonphysiologic artifacts
Physiologic artifacts
LOGO
Nonphysiologic artifacts
Artifacts from instrument
Amplifier’s Noise
Small random fluctuation of the electricity within the amplifier
Seen only when sensitivity is low 1-2 uV/mm
Amplifier’s noise should not exceed 2 uV
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LOGO
Nonphysiologic artifacts
Artifacts from instrument
Problem with pin connection, loose
board contact
Improper alignment of pen
Error in setting amplifier, low and
high frequency filter of each channel
LOGO
Nonphysiologic artifacts
Electrode artifacts
Electrodes’ impedance mismatch
When using differential amplifier, the
amplifier will receive signals from 2
electrodes, which impedance between
2 electrode should match quite well to
reduce artifacts
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LOGO
Nonphysiologic artifacts
Causes of altered impedance
Changes in composition of the electrolyte
eg. Sweating
Poor contact of the electrode to the skin
Movement of the electrode
Guideline of the American EEG society
suggested that impedance for each electrode
should not be >5000 ohms
LOGO
Nonphysiologic artifacts
Electrodes artifacts
Electrode “popping”
Most common type of electrode artifacts
Occur from abrupt changes in electrode’s impedance when the electrode moves
Seen as single or multiple spike like discharges with very steep upslope (abrupt take off)
Sometimes seen as an irregular slow activity that strickly confined to that electrode
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LOGO
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Nonphysiologic artifacts
Electrode artifacts
Photoelectric response
Occur during photic stimulation from
photochemical reaction of the electrode
with high impedance
Seen as brief spike like sharp
transients happens simultaneously with
the flash
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LOGO
LOGO
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LOGO
Nonphysiologic artifacts
Environmental artifacts
Cutting/coagulating electrode in the
operating room
Static or capacitative potentials
IV drips
Machines
respirators
LOGO
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LOGO
Physiologic artifacts
EKG
Ocular artifacts
Arise from steady (DC) potentials in the
eyeball and sometimes together with EMG
potentials from muscles in/around the orbit
Positive pole towards cornea and negative
pole towards retina
Lateral rectus spikes
LOGO
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LOGO
Physiologic artifacts
EMG
Glossokinetic artifacts
LOGO
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