Clinical Electroencephalography and

Topographic Brain Mapping

 F.H. Duffy V.C.Iyer WW SulWillo

Clinical
Electroencephalography
and Topographic
Brain Mapping
Technology and Practice

With 192 Illustrations, 14 in Color

Springer-Verlag New York Berlin Heidelberg

London Paris Tokyo
FRANK H. DUFFY, M.D.
Associate Professor of Neurology, Harvard Medical Schoo!, Director of Developmental Neuro-
physiology, Director of the BEAM Laboratory, The Children's Hospital, Boston, MA 02115, USA

VASUDEVA C. hER, M.D., D.M.

Chief of Division of Clinical Neurophysiology and Professor of Neurology, University of Louis-
ville School of Medicine, Louisville, KY 40292, USA

WALTER W. SURWILLO, PH.D.

Professor and Director of Psychophysiological Research, Department of Psychiatry and
Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY 40292, USA

Library of Congress Cataloging-in-Publication Data

Duffy, Frank H.
Clinical electroencephalography and topographic
brain mapping.
Includes bibliographies.
1. Electroencephalography. 2. Brain mapping.
I. Iyer, Vasudeva, C. II. Surwillo, Walter W.
III. Title. [DNLM: 1. Brain Mapping- methods.
2. Electroencephalography- methods. 3. Evoked
Potentials. WL 150 D858cl
RC386.6.E43D84 1989 616.8'047547 88-32699

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DOl: 10.1007/978-1-4613-8826-5
Preface

Electroencephalography is truly an interdisciplinary endeavor, involving concepts and

techniques from a variety of different disciplines. Included are basic physics, neuro-
physiology, electrophysiology, electrochemistry, electronics, and electrical engineer-
ing, as well as neurology. Given this interesting and diverse mixture of areas, the train-
ing of an EEG technician, a neurology resident, or an EEG researcher in the basics
of clinical electroencephalography presents an uncommon challenge.
In the realm of technology, it is relatively easy to obtain a technically adequate
EEG simply by learning to follow a protocol and by correctly setting the various
switches on the EEG machine at the right time. But experience has shown that the
ability to obtain high-quality EEGs on a routine, day-to-day basis from a wide variety
of patients requires understanding and knowledge beyond what is learned by rote.
Likewise, knowledge above and beyond what is gained by simple participation in
an EEG reading is necessary to correctly and comprehensively interpret the record.
Such knowledge comes from an understanding of the basic principles upon which
the practice of clinical EEG is founded - principles that derive from the various
disciplines cited.
While it is clear that some understanding of each of these disciplines plays an
important role in the successful training of an EEG technologist, neurology resident,
or EEG researcher, the depth and extent of the understanding pose a dilemma. How
much and what kind of material should go into an introductory text?
The authors have attempted to meet the challenge of this dilemma in three ways.
First of all, the text emphasizes concepts. For example, in discussions of Ohm's law the
reader is not burdened with irrelevant computations of circuit parameters. Instead,
the text shows how Ohm's law provides the basis for understanding EEG-based
problems such as why low impedance leads are essential and how a modern
impedance meter is able to measure the impedance of a single electrode by hooking
it up in series with all the other EEG electrodes connected in parallel. Secondly, the
text leaves out all but essential detail. Aside from material that is of historical interest,
the criterion for inclusion is whether the material is essential for understanding the
concepts. At the same time, special care was taken to avoid the risk of becoming sim-
plistic. Thirdly, the text focuses on topics that are directly relevant to the recording of
EEGs and to the understanding of the fundamental principles upon which EEG
interpretation is based. A case in point is the Chapter 12 discussion of the principles
of localization.
The text is intended for a wide and varied audience interested in electroen-
cephalography. It requires no special knowledge beyond a familiarity with simple
algebra and the elements of biology. To simplify presentation of the material, refer-
vi Preface

ences to relevant literature, for the most part, have been left out. Chapter 19 and
Appendix 7 are notable exceptions, mainly because they deal with newly-emerging
areas of interest for which reference sources may not be readily available.
Chapters 1-9 comprise a useful primer for the beginner learning to record clinical
EEGs for the first time. Those with some previous experience in EEG should also find
these chapters useful, primarily as a review of essentials or a fresh way of thinking
about the topics concerned. EEG technologists preparing for Board Examinations
will find Chapters 10, 11, and 12 and Appendix 2 particularly helpful.
Chapters 10-16 and 21 were written with neurology residents who are just starting
their EEG training in mind. The normal features of the EEG and some of the better-
known, most-frequently encountered abnormalities are discussed and illustrated in
Chapters 14 and 15. Chapter 21 briefly discusses the use ofEEG in clinical diagnosis
and its relationship to other neurologic tests; but detailed questions of interpretation
are not taken up. Such matters are considered in more advanced, specialized texts.
However, taken together with Chapters 1 and 2 - which deal with background
material and basic electrical concepts - this material provides the essentials for train-
ing of neurology residents as well as the elementary basics for training of EEG fellows.
The text includes a chapter each on the topics of seizure monitoring and average
evoked potentials. In recent years, these have become important tools for the neuro-
diagnostician. A unique feature of the text is the inclusion of two chapters dealing with
the topographic mapping of brain electrical activity. These chapters, which take up
the basics of this exciting new method, will be of interest to anyone doing research in
EEG and cortical evoked potentials as well as to clinical neurologists seeking new
ways of interpreting the electrical activity of the brain.

Frank H. Duffy
Vasudeva G. Iyer
Waiter W. Surwillo
Contents

Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . v

1. Brain Electrical Activity: An Introduction to EEG Recording ......... . 1

Historical Perspective. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Recording Bioelectric Activity .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Some Characteristics of the EEG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The EEG Frequency Spectrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Fourier Series and Power Spectral Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Recording EEGs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The EEG Machine: An Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Computerized EEG Machines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

2. Basic Electrical Concepts ........................................ . 11

Electrical Currents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Atomic Structure .................................................. 11
Conductors and Insulators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Potential Difference and Voltage ...................................... 12
Resistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Electrical Circuits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Ohm's Law ....................................................... 13
Series and Parallel Circuits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Circuit Parameters ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Capacitance ...................................................... 15
Transient Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Series R-C Circuit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Time Constant .................................................... 17
AC and DC....................................................... 18
AC Circuits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Impedance ................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Frequency Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

3. The Differential Amplifier ........................................ . 21

Historical Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Single-Ended Amplifier ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Amplifying Bioelectric Activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
The Differential Amplifier- Basic Concept. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Common-Mode Rejection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Sensitivity or Gain ................................................. 26
viii Contents

Amplifier Noise ................................................... . 26

Input Impedance ................................................. . 27
Special-Purpose Connections ........................................ . 27
The EEG Amplifier as a Whole ...................................... . 28

4. Filters .......................................................... . 29
The Need for Filtering ............................................. . 29
Basic Concept and Function ........................................ . 29
Low-Frequency Filter .............................................. . 30
Low-Frequency Response-Asymptote Plot ............................. . 31
High-Frequency Filter ............................................. . 31
High-Frequency Response-Asymptote Plot ............................ . 32
High- and Low-Frequency Response Combined-The True Curve ........... . 32
60-Hz Notch Filter ................................................ . 34
Interpreting the Frequency-Response Curve and the Use of Filters .......... . 34
Summary ........................................................ . 36

5. The Writer Unit ................................................. . 37

Penmotors ....................................................... . 37
Penmotor Frequency Response ...................................... . 37
Pens ............................................................ . 38
Error of the Arc .................................................. . 38
Pen Mounts ...................................................... . 38
Inking System .................................................... . 39
Inking-System Maintenance ......................................... . 39
Chart Drive ...................................................... . 40
Marker Pens ..................................................... . 40

6. Calibration and Calibration Methods .............................. . 42

Purpose and Basic Concept ......................................... . 42
Voltage Calibration - Deflection Sensitivity ............................. . 42
Linearity ........................................................ . 43
Frequency Response ............................................... . 43
Biological Calibration .............................................. . 44
Noise Level ...................................................... . 45
Postcalibration ................................................... . 45

7. Recording Electrodes ............................................ . 46

Basic Concepts ................................................... . 46
Ions ............................................................ . 46
The Electrical Double Layer ........................................ . 47
Polarization and the Double Layer .................................... . 47
Electrode Potentials ............................................... . 47
Residual Potentials ................................................ . 48
Types of Electrodes ................................................ . 48
Application of Surface Electrodes .................................... . 48
Electrode Impedance .............................................. . 49
Factors Affecting Electrode Impedance ................................ . 50
Electrode-Induced Artifacts ......................................... . 51
Detection of Electrode Artifacts ..................................... . 51
Impedance-Measuring Devices ...................................... . 51

8. Electrical Safety ................................................. . 54

Macroshock and Microshock ........................................ . 54
Ground and Grounding ............................................ . 54
Leakage Currents ................................................. . 56
Patient Grounding ................................................ . 56
Contents ix

Effect of Patient Impedance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

The EEG Technician's Role in Patient Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,58
Isolated Ground and Biopotential Isolator. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Ground Loops. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

9. Elementary Practical Troubleshooting Methods ..................... . 60

Basic Principles ................................................... 60
Single-Channel Problems -The Principle of Substitution. . . . . . . . . . . . . . . . . . . 60
Single-Channel Prohlems Observed During EEG Recording. . . . . . . . . . . . . . . . 61
Electrode-Board Artifacts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Prohlems Common to All Channels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Connector and Switch Contacts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Chart-Drive Malfunctions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

10. Neurophysiology................................................. 68
Structure of the Neuron. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Membrane Potential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Nernst Equation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Goldman Equation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
The Sodium-Potassium Pump. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Action Potential. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Synaptic Potentials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Membrane Equivalent Circuit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Membrane Potential Fluctuations and the EEG ..... . . . . . . . . . . . . . . . . . . . . . 72
The Role of Different Types of Neurons in the Generation of the EEG . . . . . . . . 73
Rhythmicity of the EEG Patterns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

11. Recording Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Electrodes as Field Samplers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Historical Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
The 10-20 International System ...................................... 78
Derivations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Montages - Rationale .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Commonly Used Montages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Reformatting of Montages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Extension of the 10-20 System ....................................... 82
Special Electrodes ................................................. 82

12. Localization and Polarity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Volume Conductors ................................................ 84
Concept of a Dipole: Fields and Equipotential Contours . . . . . . . . . . . . . . . . . . . 84
Theory of Localization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Problems of Polarity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
The Five Principles of Localization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Cancellation, Summation, and the Determination of Polarity. . . . . . . . . . . . . . . . 89
Phase Reversal .................................................... 90
Localization in Referential Recording .................................. 91
Commonly Seen Localizing Patterns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Contaminated Average Potential Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

13. Introduction to EEG Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Reading EEGs-An Analogy ......................................... 94
Learning to Read .................................................. 94
Terminology ...................................................... 94
Describing the EEG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Interpreting the EEG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
x Contents

More on Artifacts - Physiological Artifacts .............................. . 97

Writing the EEG Report ........................................... . 98

14. The Normal EEG ............................................... . 99

Features of the Awake EEG in Adults ................................. . 99
Features of the EEG During Drowsiness and Sleep in Adults ............... . III
The EEG in Deeper Stages of Sleep .................................. . 120
Age-Related Differences: The EEG in Relation to Maturation .............. . 124
Age-Related Differences: The EEG in Old Age .......................... . 132

15. Abnormal EEG Patterns .......................................... . 135

General Considerations ............................................ . 135
Abnormalities of the Background Rhythms ............................. . 135
Abnormal Sleep Patterns ........................................... . 143
Abnormal Slow Activity ............................................ . 144
Paroxysmal Epileptogenic Abnormalities ............................... . 151
Abnormal Periodic Paroxysmal Patterns ................................ . 181

16. Activation Procedures ............................................ . 190

Hyperventilation .................................................. . 190
Intermittent Photic Stimulation ...................................... . 194
Sleep ........................................................... . 201
Sleep Deprivation ................................................. . 202
Pharmacological Activation ......................................... . 202

17. Average Evoked Potentials ........................................ . 203

Historical Background ............................................. . 203
Method of Superimposition ......................................... . 204
Signal Averaging .................................................. . 204
Coherent Averaging ............................................... . 205
Instrumentation .................................................. . 206
Display Systems .................................................. . 207
Practical Clinical Methods .......................................... . 207
General Principles of Interpretation .................................. . 209
Visual-Evoked Potential (VEP) ....................................... . 210
Brain-Stem Auditory-Evoked Potential ................................. . 212
Short-Latency Somatosensory-Evoked Potential (SSEP) ................... . 214

18. Seizure Monitoring and Ambulatory EEGs ......................... . 218

Seizure Monitoring ................................................ . 218
Ambulatory EEG Monitoring ........................................ . 220

19. Clinical Use of Brain Electrical Activity Mapping .................... . 222

Why Brain Electrical Activity Mapping? ............................... . 222
The Use of Topographic AnalysiS in Interpretation of EEG and EP .......... . 223
Tips For the Conduct of Successful BEAM Studies ....................... . 224
The Application of BEAM to Clinical Practice .......................... . 226
A Cautionary Note: Potential Errors in Clinical Usage of Topographic Analysis .. 227
Topographic Analysis in the Clinical Setting ............................ . 228

20. Recommended Standards and Practices for Brain Electrical

Activity Mapping and Topographic Analysis ......................... . 238
Personnel ....................................................... . 239
Recommended Standards for Topographic Mapping Environment
and Equipment ................................................... . 240
Summary ........................................................ . 242
Contents xi

2l. EEG in Clinical Diagnosis and Its Relationship

to Other Neurological Tests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 243
Computerized Tomography .......................................... 243
Magnetic Resonance Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 244
Positron-Emission Tomography ....................................... 244
Neurosonography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 244
Brain Electrical Activity Mapping ..................................... 244
Evoked Potentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 244
Role of EEG in Relation to Other Neurodiagnostic Tests . . . . . . . . . . . . . . . . . .. 244
Seizure Disorders - General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 245
Febrile Seizures ................................................... 246
Infantile Spasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 246
Lennox-Gastaut Syndrome ......................................... " 246
Primary Generalized Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 246
Partial (Focal) Epilepsy ............................................ " 247
Nonconvulsive Status Epilepticus (NCSE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 248
Sleep Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 248
The Comatose Patient .............................................. 248
Electrocerebral Silence ............................................. 249
Diffuse Encephalopathies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 249
Metabolic Encephalopathies ......................................... 250
Infectious Encephalopathies ......................................... 250
Dementia ................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 250
Focal Encephalopathies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 251
Cerebrovascular Disorders ......................................... " 251
Head Trauma ..................................................... 252

Appendices

l. Glossary of Major Terms Used in the Text 253

2. Neuroanatomy for EEG Technologists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 262

3. Grounding Checks ............................................... 269

4. Measurement of Chassis Leakage Current. . . . . . . . . . . . . . . . . . . . . . . . . .. 270

5. The 10-20 International System of Electrode Placement. . . . . . . . . . . . .. 271

6. A Glossary of Common Artifacts in the EEG. . . . . . . . . . . . . . . . . . . . . . . .. 274

7. EEG Recording in Patients with Infectious Diseases. . . . . . . . . . . . . . . . .. 282

Index .............................................................. " 285

Chapter 1
Brain Electrical Activity:
An Introduction to EEG Recording

The ability to generate electrical activity is a common if were recorded in a painting by the French artist Alexandre
not ubiquitous property of living tissue. The electrical Fragonard.
activity produced by the heart and recorded in the elec- Despite the apparent setback, scientific interest in
trocardiogram (ECG) and the electrical activity generated animal electricity or bioelectricity, as we call it today, con-
by muscles and recorded in the electromyogram (EMG) tinued. The realization that electrical activity of living tis-
are familiar examples. Less well known is the fact that skin, sue could be used as a sign of its function came in the mid
stomach, and gut also produce electrical activity. Electri- 19th century. In 1848 Du Bois-Reymond, a German phys-
cal activity has even been observed in plants. In view of this iologist, demonstrated that an electrical signal occurred
knowledge, it is not surprising that the brain should also concomitantly with the passage of a nerve impulse. Of his
generate electrical activity. remarkable discovery, Du Bois-Reymond said, "If I do not
greatly deceive myself, I have succeeded in realizing in full
actuality the hundred years' dream of physicians and phys-
Historical Perspective iologists, to wit the identification of the nervous principle
with electricity:'
The existence of electrical activity and its association with Du Bois-Reymond's research served as an incentive to
life processes has intrigued and mystified scholars for more Richard Caton, a British physiologist. Caton reasoned that
than two centuries. In the late 18th century an Italian if activity in a peripheral nerve was accompanied by elec-
physiologist, Luigi Galvani, made some remarkable obser- trical activity, then a similar phenomenon might also occur
vations while working with frogs' legs. Galvani noticed that in the brain. In 1875 Caton reported on some experiments
the leg of a frog would contract violently when the nerve done with monkeys and rabbits. These experiments
going to the muscle was touched by a brass or copper wire demonstrated the existence of feeble electric currents in
that was connected to an iron wire that made contact with the brains of the animals. Nearly 50 years passed, however,
the muscle. Galvani believed the muscle contracted before similar attempts were made to find out whether the
because it was stimulated by "animal electricity" present in human brain also generated electric currents.
the tissue and conducted over the metal wires and nerve. Hans Berger, a German clinical neuropsychiatrist at the
But a contemporary scholar, the physicist Allesandro Volta, University of Jena, was the first to record the electrical
proved that Galvani's explanation of the phenomenon was activity of the human brain. Berger coined the term "elek-
wrong. trenkephalogramm:' which is the German equivalent of
Volta demonstrated that the electrical current in Gal- electroencephalogram or EEG. Publication of his findings
vani's experiment was produced not by animal tissue but in 1929 followed years of careful, painstaking research in
by the contact of the two dissimilar metals placed in a which he attempted to prove the cerebral origin of the
moist or liquid environment. Out of this work the electric phenomenon. However, his modest conclusion, "I there-
battery or Volta's pile was born. The great significance of fore, indeed, believe that I have discovered the electroen-
Volta's finding for the scientific community of the times cephalogram of man and that I have published it here for
can be appreCiated by the fact that in the early 1800s, Volta the first time;' was met with disbelief and mistrust. It was
was called to Paris to demonstrate his discovery to not until 1934, when Adrian and Matthews in England
Napoleon Bonaparte. The events of this dramatic occasion repeated Berger's experiments and confirmed his observa-
2 1. Brain Electrical Activity

tions, that his work became accepted by the scientific

community.
Berger's 14 published articles on the electrical activity
of the human brain contain a large number of original
observations on the EEG. Indeed, Berger was the first to
observe and accurately describe many of the features of
the EEG that we know today. He demonstrated that brain
electrical activity consists more or less of a mixture of
rhythmic, sinusoidal-like fluctuations in voltage having a
frequency of about 1 to 60 oscillations per second. The
waves most easily recognized had a frequency of about 10
oscillations per second, and these he called alpha. Alpha
waves, he reported, tended to disappear with attention.
Waves of frequencies greater than 15 oscillations per
second were designated beta. Berger observed that the
EEG had different features in neurological disorders such
as epilepsy, trauma, and tumors. He was the first to record
an epileptic seizure.
~I rc-
Following Berger's pioneering work, interest in elec-
One Second
troencephalography and brain electrical activity- "brain Figure 1.1. Sample recording of an ECG.
waves" - became widespread in the late 1930s and 1940s.
Frederick and Erna Gibbs, Hallowell and Pauline Davis,
Donald Lindsley in the United States, Herbert Jasper in generated by the heart are amplified some 1,000 times
Canada, and W. Grey Walter in England, to name a few of until they are sufficiently large to drive the writer units
the leaders, showed the importance of the EEG and its that trace out the spikes on a moving strip of paper.
application in neurology and neurosurgery. Since that The recording of most kinds of bioelectric activity fol-
time, the EEG has become a routine clinical procedure of lows the same general plan. Specific methods employed
considerable diagnostic value as well as a powerful and the particular instrumentation needed in a particular
research tool in the neurosciences. application are determined by two considerations: (1) the
magnitude (voltage) and frequency composition of the
bioelectric activity we wish to record, and (2) the nature
Recording Bioelectric Activity and sources of the unwanted signals or artifacts that may
be encountered. For reasons that will later become appar-
There is hardly anyone who has not watched an ECG being ent, the recording of the EEG presents a formidable
recorded or who has not seen the short strip of paper upon challenge to both the instrumentation and the technologist
which the ECG tracing appears. Figure 1.1 shows a sample using it.
of the ECG. The horizontal axis in the tracing represents
time whereas the vertical axis represents amplitude or
intensity of the electrical activity from the heart; the latter Some Characteristics of the EEG
is measured in millivolts (thousandths of a volt, abbrevi-
ated mY). Like the pulse itself, the ECG is a transient Earlier we mentioned that Hans Berger characterized the
phenomenon; a spike-like burst of electrical energy that EEG as a mixture of rhythmic, sinusoidal-like fluctuations
occurs periodically, about once every second in adults. in voltage. Although this description is somewhat of an
Note in the illustration that the ECG consists of some oversimplification and does not admit of all the possible
rapid upward and downward deflections followed by a sin- varieties of fluctuations in voltage that can be encountered
gle, more prolonged deflection. in an EEG, it suffices as a starting point.
The ECG tracing, of course, is taken by making an elec- Sinusoidal fluctuations in voltage are described in terms
trical connection between the patient's body and the ECG of two characteristics or parameters. First, we specify how
machine. This is accomplished by attaching electrodes- many oscillations or cycles occur in a standard time inter-
wires with some kind of conducting medium on one val. The standard time interval universally used is one
end - to portions of the body in the vicinity of the heart. second; so we say that the sinusoidal fluctuations in voltage
The other ends of the wires are plugged into the ECG have a frequency of, or occur at the rate of, so many cycles
machine. With all electrodes connected in this manner, per second. The term cycles per second is designated hertz
the ECG machine is turned on and the millivolt signals or Hz, in honor of Heinrich Rudolf Hertz, the 19th century
Fourier Series and Power Spectral Analysis 3

German physicist. If we include non sinusoidal activity as are seen under a wide range of conditions. Very sharp tran-
well, EEGs consist of voltage fluctuations in the range of 1 sients, like spikes, usually fall into that part of the beta
to 70 Hz. band greater than 35 Hz. Spikes, sharp waves, and other
Second, fluctuations in voltage are described by specify- kinds of nonsinusoidal activity will be taken up later.
ing their magnitude or amplitude, and this is measured in The theta band consists of electrical activity with a fre-
microvolts (millionths of a volt, abbreviated IlV). A quency of 4 Hz to under 8 Hz. Theta activity is normally
microvolt is an exceedingly small electrical signal. From seen in drowsiness and during the lighter stages of sleep,
the standpoint of instrumentation, it approaches the but may also be present in wakefulness. It may be strictly
smallest voltage that may be detected by conventional rhythmic as is the case with the alpha rhythm, or highly
methods of amplification. The amplitude of the fluctua- irregular in character. Irregular theta activity is sometimes
tions in the EEG may range anywhere from two to several referred to as being arrhythmic or polymorphic.
hundred microvolts. For this reason, the EEG machine or The delta band contains frequencies under 4 Hz. Delta
instrument used to record brain electrical activity is a activity is normally seen in the deeper stages of sleep and
sophisticated device indeed. Scrupulous techniques need is a commonly observed abnormality in the waking state in
to be employed by the EEG technician in order to record adults. Like theta activity, it may be either rhythmic or
these tiny signals. irregular, in which case it is sometimes termed poly-
Briefly defined, therefore, the EEG is a fluctuating elec- morphic delta. Delta activity has the highest amplitude of
trical signal produced by the brain. The fluctuations can any activity recorded in the EEG (amplitudes as high as
range in amplitude from two to several hundred microvolts several hundred microvolts are sometimes recorded).
when recorded from electrodes placed on the scalp. As we EEG technicians and neurology residents should
will see later, the waves recorded in this way originate become thoroughly familiar with the different bands in the
mainly from the surface of the cerebral cortex. Some of the EEG frequency spectrum. They should be able to quickly
fluctuations in voltage are sinusoidal in character, some are and accurately recognize the different kinds of activity in
not; these fluctuations cover a frequency range of approxi- an EEG recording. Figure 1.2 shows some samples of the
mately 1 to 70 Hz. The latter is referred to as the band- type of activity discussed. It is important to recognize that
width or frequency spectrum of the fluctuations. these sample recordings illustrate only a small proportion
of the various different features present in the EEG. This
will become apparent when we take up in greater detail
The EEG Frequency Spectrum the features of the normal EEG and describe and illustrate
the more common EEG abnormalities in later chapters.
The frequency spectrum in EEG work is broken down into
four subcategories. The bands of frequencies designated
by these subcategories are identified by the Greek letters Fourier Series and Power
alpha, beta, theta, and delta.
The alpha band defines electrical activity in the range of Spectral Analysis
8 to 13 Hz. This includes the "alpha rhythm" or posterior-
dominant rhythm, which is rhythmic activity normally We have referred to the EEG as a mixture of rhythmic,
recorded in the awake individual. Amplitude is variable, sinusoidal-like fluctuations in voltage, and in the last sec-
ranging from 5 to 100 IlV, but is mostly below 50 1lV. It is tion we considered the frequencies of the principal com-
best seen when the subject's eyes are closed and under ponents recorded. At times, as when recording from a
conditions of physical relaxation and relative mental inac- patient who shows a persistent alpha rhythm, the wave-
tivity. The amplitude of the alpha rhythm is attenuated by form looks a good deal like a pure sine wave. At other times,
eye opening, attention, and mental effort. Other varieties the waveform can be quite complex and bears little resem-
of brain electrical activity are included in the alpha band. blance to a sine wave. Interestingly enough, such complex
One of these is the mu rhythm, which is 7 to ll-Hz rhyth- patterns found in the EEG can be simulated by adding
mic activity occurring over central and centro-parietal together a number of sine waves having different frequen-
regions during wakefulness. The mu rhythm is attenuated cies, amplitudes, and phase relationships. In other words,
not by eye opening but by contraction of muscles on the a complex waveform can be synthesized from a number of
contralateral side of the body. simpler, sine wave components.
The beta band includes frequencies over 13 Hz. The The reverse of this procedure of synthesis of complex
most common component of this band is the beta rhythm patterns is known as frequency or spectral analysis. The
- rhythmic activity consisting of a variety of frequencies method of spectral analysis separates a waveform into its
greater than 13 Hz and sometimes as high as 35 Hz. Ampli- different frequency components; it tells us the amplitudes
tude is variable but is mostly below 30 1lV. Beta rhythms of the different frequency sine waves of which the wave-
4 1. Brain Electrical Activity

SOILV , ' - - - -
1 Sec
Figure 1.2. The four subcategories of the EEG frequency spectrum. The sample tracings show, from top to bottom, typical activity
in the beta, alpha, theta, and delta bands.

tions that are referred to as infinite series.) Theoretically,

E.E.G.
... .... ., ....
an infinite number of frequency components is needed in
order to represent a complex waveform. In actual practice,

i','~>~i
however, an acceptable representation of the waveform fre-
quently may be obtained by combining just the first eight
ANALYSE or ten components in the series. Each component tells us
I
(SPECTRA) Delta 4 Theta 8 Alpha 12 16 the amplitude of the sine wave of specified frequency that
goes into the composite. These data are then plotted, with
frequency on the horizontal axis and amplitude on the ver-
tical axis.
SMOOTH
I~
4 8 12 16
The component amplitudes of a Fourier series analysis
are often expressed as mean square values. When pre-
Hz sented in this way, the resulting plot of the data is called a
Figure 1.3. Diagram illustrating the method of power spectral power spectrum. By expressing the amplitude of each com-
analysis. A schematic representation of an EEG tracing of 4 ponent in terms of its mean square value, the proportion of
seconds' duration is shown at the top, and the bar spectra result- the analyzed waveform that is attributable to each particu-
ing from Fourier analysis by computer is shown directly below. lar frequency in the series can be determined. Figure 1.3
Smoothing of the bar spectra yields the power spectrum seen at illustrates how an EEG tracing containing frequencies in
the bottom. (From Fig. 10, p. 461, of Bickford RG: Newer the delta, theta, and alpha bands becomes transformed
methods of recording and analyzing EEGs, in Klass OW, Daly into a power spectrum.
DO (eds): Current Practice of Clinical Electroencephalography. It should be recognized that the power spectrum of a
New York, Raven Press, 1979, by permission of the author and waveform represents a synopsis of the frequency compo-
publisher. )

I Another infinite series that has been used in EEG analvsis is the
Gram·Charlier series. This series differs from the Four'ier series
form is composed. This method of analysis is known as mainly in the assumptions that are made about the waveform ana-
Ivzed. Thus, while the Fourier series assumes that the waveform
Fourier series analysis and was devised by the 18th to 19th t~ be analyzed is periodic - that is to say, it repeats itself exactly
century French mathematician Jean Baptiste Fourier. A at regular intervals - the Gram-Charlier series does not and can
Fourier series is just one of a variety of mathematical func- deal equally well with aperiodic or periodic waveforms.
The EEG Machine: An Overview 5

nents of but a short segment -1 0 seconds or less - of an

EEG recording. To obtain a coherent picture of what is
going on over a longer time period, the method of com-
pressed spectral arrays was developed. With this method,
a large number of comparable power spectra are plotted in
close proximity to each other on the same graph. When
presented in this fashion, a synopsis of the frequency com-
ponents of 10 or more minutes of recording may be dis- Q)
played on a single page. Figure 1.4 illustrates the method; E
in this case, a total of 48 power spectra are plotted together. r-
Despite its potential value, spectral analysis is not
employed in routine clinical EEG work. Spectral analysis,
however, is used in topographical brain mapping, a topic
that is taken up in later chapters. The interested reader can
consult more advanced texts or the EEG periodical litera-
ture for additional information.

4 8 12 16
Recording EEGs Hz
Having thus defined the EEG and having considered Figure 1.4. Compressed spectral array of a patient's EEC
response to photic stimulation over the range of 1-16 flashes per
briefly some of its major characteristics, let us turn next to
second. Starting from the hottom of the figure, the flash rate was
one of the topics for which this text is primarily intended,
progressively increased, sweeping smoothly across the entire
namely, the recording of clinical EEGs. Up-to-date EEG range. Note the peaks occurring at 4-6 Hz and at 9-10 Hz. The
technique involves obtaining a 20 to 30-minute sample of peaks signify the presence of high-amplitude activity at these fre-
electrical activity from different combinations of 21 elec- quencies and represent instances of photic driving. A separate
trodes placed on the head according to the so-called 10-20 series of smaller peaks can also be seen opposite the main peaks;
International System. Suffice it to say for the present that they represent the second harmonic response. (Taken from Bick-
the 10-20 International System is simply a plan for placing ford RC, Brimm J, Berger L, et al: Application of compressed
electrodes on the scalp over specific strategic areas of the spectral array in clinical EEC, in Kellaway P, Petersen I: Automa-
cerebral cortex. For now let us also assume that the 21 tion in Clinical Electroencephalography. New York, Raven Press,
electrodes have already been attached to a patient and 1973, p. 59, by permission of authors and publisher.)
tested and are ready to be connected to the EEG machine.
After becoming familiar with the EEG machine and with
the details of recording EEGs, we will return to the matter consists of an electrode board, electrode selectors, ampli-
of electrodes, electrode placements, and recording sys- fiers, filters, penmotors, and chart drive. In addition, a
tems. The reason for this backwards approach is methodo- power supply is included for providing electrical power to
logical. Experience has shown that the rationale of the run the different units, and an internal calibrator is fur-
electrode procedures used in taking an EEG is better nished for testing and standardization.
understood after acquiring some knowledge of the work- Figure 1.5 is a block diagram of one channel of a typical
ings of the EEG machine. EEG machine. Let us now briefly consider the function of
each of these units in turn. In later, separate chapters we
will discuss the design and operation of these units in some
The EEG Machine: An Overview detail.

Modern EEG machines are multichannel instruments. Electrode Board

They consist of from 8 to 24 identical channels capable
of recording simultaneously the electrical activity from as Referred to also as the lead plug-in box or input box, this
many different pairs of electrodes. Regardless of the unit is a rectangular or square metal box frequently no
manufacturer, every EEG machine consists of a number of larger than a small paperback book. Coming out of this box
particular structural units. Each of these units has a clearly is a thick cable with a connector on the end that plugs into
defined function. In some machines, they are of modular the EEG console. The electrode board is the means
construction to facilitate troubleshooting and to simplify whereby the electrodes attached to the head are con-
servicing. From input to output end, the EEG machine nected to the EEG machine. The connection is made by
6 1. Brain Electrical Activity

Pair Figure 1.5. Block diagram of

Of :
Leads Electrode I Electrode one channel of a typical EEG
Board Selectors machine.

Filters
Penmotor
&
Amplifiers
I
I

,
I
I
I

Calibrator
Power Chart
Supply Drive

plugging the 1/16-inch diameter pin plugs on the ends of montages are used in EEG recording. Derivations and
the electrode wires into mating pin jacks found on the montages are taken up in detail in a later chapter on
front panel of the electrode board. These jacks are identi- recording systems. For now, we would like to mention that
fied by the symbols used in the 10-20 International Sys- some EEG machines have a montage switch or master elec-
tem, or are simply numbered. Several spare jacks are also trode selector. Such a device permits the EEG technician
included as well as jacks for connecting nasopharyngeal to change from one montage to another simply by indexing
leads. The spare jacks have a variety of uses, among which a single switch from one position to another. This greatly
are connecting electrodes for recording the patient's ECG reduces the possibility of technician error in setting up the
or hooking up leads for recording hislher eye movements. machine. It also saves considerable time since in the case
of a 16-channel machine, the technician may have to repo-
sition a total of 32 switches to change from one montage to
Electrode Selectors another.
We have said that to record the clinical EEG, a total of 21
leads is attached to the scalp over various strategic areas of
the cerebral cortex. As we will see in the next chapter, elec- Amplifiers
tric currents flow in a circuit, not in a single conductor.
This means that a pair of electrodes has to be connected to Amplifiers are the heart of the EEG machine. For present
each channel of the EEG machine in order to record brain purposes, let us say that an amplifier is simply a device for
electrical activity. The process of recording from a pair of increasing the magnitude or amplitude of a voltage
electrodes in an EEG channel and the recording obtained without introducing distortion.
thereby is referred to as a derivation. With 21 electrodes to In an earlier section of this chapter, we stated that the
work with, it is obvious that many different derivations are EEG contains fluctuations in voltage that are exceedingly
possible. small. This is especially true in the case of brain death
To obtain an adequate sample of the electrical activity of recordings in which voltages of the order of 2 JlV are
all of the brain, it is necessary to record from many differ- encountered and need to be detected. To deflect the pens
ent derivations - more than can be displayed at one time on an EEG machine, signals of the order of volts are
even on a 24-channel EEG machine. For this reason, required. This means that amplifications in the range of
several different runs are required when taking an EEG, 100,000 to 1 million times are commonly found in an EEG
and a switching system is necessary to connect the various machine. To achieve this degree of amplification, more
pairs of electrodes to the different channels of the than one amplifier is needed in each channel of the EEG
machine. This function is performed by the electrode machine. And so we find that each channel contains
selectors or electrode-selector switches. These switches several "stages" of amplification.
are designed for maximum flexibility so that the input con- The final stage of amplification is referred to as the
nections to each channel of the machine may be con- power amplifier to distinguish it from the others, which are
nected to any combination of two of the 21 electrodes voltage amplifiers. The purpose of the power amplifier is to
attached to the patient. increase the current level of the amplified signal. This is
A particular arrangement by which a number of differ- necessary because it takes power as well as voltage to drive
ent derivations is recorded simultaneously on an EEG the penmotor, and power is equal to the product of voltage
record is referred to as a montage. A variety of different times current.
The EEG Machine: An Overview 7

Although some of the fluctuations in voltage seen in the an intrinsic source of contaminating electrical activity. The
EEG can be very small, indeed, others may be quite same is true of the heart, which generates a voltage large
large - several hundred microvolts in amplitude. In other enough to be detected almost anywhere on the surface of
words, the EEG is an electrical signal that has a wide the body. Such kinds of activity present in an EEG record-
dynamic range. Now what happens if an amplifier designed ing are collectively referred to as artifacts.
to handle signals in the 5 to 50-~V range is confronted with All sources of artifacts in the EEG are not intrinsic. The
voltages that are five times as large? That some kind of EEG can be contaminated by artifacts from extrinsic
untoward event takes place is intuitively obvious. In sources - electrical activity originating outside the
instrumental language, the amplifier "blocks;' and the sig- body-as well. Such artifacts come from a wide range of
nal becomes distorted so that the output is no longer a different devices: x-ray equipment, relays and solenoids in
faithful, amplified copy of the input. a variety of different instruments, cardiac pacemakers, Ivac
To avoid distortion and to accommodate the wide pumps, and winking fluorescent lamps, to name some of
dynamic range of the voltage fluctuations in the EEG, the the more familiar sources. The most common extrinsic
amplifiers are provided with a means of changing amplifi- source of artifact, however, is the 120- and 240-V electric
cation or "gain:' So you find that each channel of an EEG power lines that are present almost everywhere. These
machine has a conveniently placed switch for doing this. lines radiate 60 Hz electrical activity that is readily picked
By increasing the gain of a channel, you increase the total up and amplified by an EEG machine.
amplification available, with the result that the amplitude Since artifacts represent contaminating and hence
of the voltage fluctuations traced out on the chart appears unwanted electrical activity in the EEG recording, they
larger. The reverse happens when the gain is decreased. In need to be eliminated. The most effective and straightfor-
most EEG machines, gain is referred to as sensitivity and is ward way of accomplishing this is to remove the source. In
expressed in microvolts per millimeter deflection. This some instances, however, this is not practical and in others
means that as gain increases, a millimeter corresponds to not even possible. Thus, for example, while it is possible to
fewer microvolts and vice versa, so that gain and sensitivity paralyze the muscles of the body with curare-like drugs,
defined in this way are inversely related. Machines having such methods of eliminating muscle activity are feasible
a large number of channels incorporate a master gain only under the most unusual circumstances when the
switch or all-channel-control switch so that the amplifica- patient is on a respirator. Similarly, a 60-Hz artifact is read-
tions of all the channels may be changed simultaneously. ily eliminated by removing the 60-Hz power lines in the
Aside from being a convenience, this feature allows the vicinity and operating the EEG machine on batteries. But,
EEG technician to minimize distortion by changing chan- then, how would the electric lights be operated?
nel sensitivities quickly. So we find that in EEG technology, the most direct
The amplifiers in the EEG machine are designed so they method of getting rid of artifacts in recordings is not always
have the same distortionless output over the entire EEG feasible. Other techniques need to be applied to the
frequency spectrum. This means that if the amplitude of problem. One such method uses a device referred to as a
theta activity present at a patient's scalp is four times filter. Speaking in broad, general terms, filters are devices
greater than the amplitude of the patient's beta activity, that selectively remove some components or ingredients of
then the amplitudes of theta and beta activity in the EEG a mixture from other components or ingredients. Familiar
tracing will stand in the same relationship to each other. To examples are a sieve for separating large peas from small
say the same thing but in more general terms, the gain of ones or a piece of filter paper for separating particles from
the amplifiers is independent of frequency over the EEG a suspension.
frequency range. The filters on an EEG machine are discussed in detail in
a later chapter. For now it is sufficient to say that an EEG
filter is an electrical or electronic circuit that is able to pass
Filters
or transmit some frequency components in the electrical
By attaching EEG electrodes to the head of a patient and signal picked up by the EEG electrodes while rejecting or
connecting them to an EEG machine, the EEG technician attenuating others. In other words, an EEG filter is a
expects to record the patient's brain electrical activity. In frequency-selective device that permits some frequency
point oHact, however, brain electrical activity is not all that components to pass on and be amplified while other com-
he or she will record. As we noted earlier, a variety of ponents are removed or diminished in amplitude. There
different kinds of living tissue generates electrical activity. are three different types of filters on modern EEG
Because the EEG electrodes placed on skin and scalp may machines. There is the lowlrequency filter that attenuates
be either over or in the vicinity of some muscles of the frequencies at the low end of the frequency spectrum but
head and face, skin and muscle become sources of con- allows frequencies at the high end to be amplified. This is
taminating electrical activity in the EEG. The eyes are also referred to also as a high-pass filter. The high-frequency
8 1. Brain Electrical Activity

Bandwidth Figure 1.6. Basic function

of the high- and low-
5-15 Hz frequency filters of an EEG
machine in relation to the
EEG frequency spectrum.

1-35 Hz

0.1-70 Hz
VWWNW I
------------
f-c Delta + Theta + Alpha.f-- Beta --l
tt
0.1 1
t
5 15
t t
35 70
Frequency (Hz)

filter does just the opposite; it attentuates frequencies at also reducing the brain electrical activity as well. For-
the high end of the spectrum but allows frequencies at the tunately, the electrical activity of skin and of muscle falls,
low end to be amplified. Filters that perform this function respectively, in the low and high ends of the EEG fre-
are also called low-pass filters. Finally, many up-to-date quency spectrum so that filtering becomes a practical way
EEG machines have a 60 Hz "notch" filter for reducing the of eliminating these unwanted signals from the EEG
artifact due to the presence of power lines in the vicinity of record.
the patient. Figure 1.6 shows the effect of the high- and Aside from eliminating artifacts, the filters on the EEG
low-frequency filters on the EEG frequency spectrum. machine may also be used to accentuate certain features of
The high- and low-frequency filters on an EEG machine the EEG, which is discllssed in the separate chapter on
are variable filters. This means that you can select the par- filters.
ticular point in the frequency spectrum at which they
begin operating-the so-called "cutoff point" or "roll-off
Penmotors
point:' In Fig. 1.6 the vertical arrows show the positions of
some cutoff points in relation to the EEG frequency spec- The pen motors are at the output or busirtess end of the
trum. Details are taken up later in the chapter on filters. EEG machine. There is one for each channel, and they
Adjustment of the filters is accomplished by changing the "drive" the pens that trace the voltage fluctuations in the
position of a multiposition switch on each of the amplifiers; EEG on the chart. The pen motor is quite properly named,
one switch is provided for the low-frequency filter and one for it is indeed a motor; a special kind of motor in which
for the high. In this way the EEG technician is able to the armature rotates back and forth but never turns more
adjust the high- and low-frequency cutoff points indepen- than a fraction of a full circle. When the sensitivity of the
dently, and in so doing determine the bandwidth of the amplifier driving the pen motor is correctly set, the deflec-
amplifier. As with the gain controls, some EEG machines tions of the penmotor accurately describe the voltage fluc-
have all-channel controls for the low- and high-frequency tuations in the EEG.
filters as well. The 60-Hz filter is controlled by a two- As we will see later, the penmotors employ very strong
position filter-in, filter-out switch. In some machines the permanent magnets in their design. Ordinary timepieces
notch filters may be subjected to all-channel control just are easily magnetized by the strong field from these mag-
like the other filters. nets. For this reason, you should avoid wearing your watch
It should be apparent that the filters are effective in or avoid keeping any timepiece close to the penmotors
eliminating unwanted signals from the EEG tracing if and unless they are solid-state digital devices or are specifically
only if the frequency characteristics of the unwanted signal designated as being antimagnetic. Failing to do this will
are different from those of the desired signa\. This is cause the watch or clock either to stop running or to run
because filters are frequency-selective devices. The result, erratically until it is demagnetized.
of course, is that artifacts in the delta, theta, alpha, and beta Pen motors are sometimes referred to as electrical-
frequency bands cannot be reduced by filtering withollt mechanical transducers. A transducer is any kind of device
The EEG Machine: An Overview 9

that can change energy from one form to another, and the tage DC instead. The power supply in the EEG machine
pen motor changes electrical energy to mechanical energy. provides this.
It will be apparent that an electrical generator, which At the input end of the power supply is the thick line-
produces electricity, does the exact opposite and is cord with a three-prong connector on the end that plugs
referred to as a mechanical-electrical transducer. The into a 120-V AC outlet. You can think of the power supply
same is true also of a microphone. It picks up the mechani- simply as a device that takes in 120-V AC house current at
cal energy (vibrations) in a person's voice and transforms one end and puts out 12-V DC, accurate to very close
them into an electrical current. tolerances, at the other. The power supply does this by
transforming the 120-V AC to a lower voltage, converting
the AC to DC by a process called rectification and smooth-
Chart Drive ing, and finally regulating the 12-V DC output so that it is
The chart drive pulls the paper chart (upon which the not only accurate but also stable. Details of this process
EEG is recorded) under the pens and through the need not concern us. Operation of the power supply is con-
machine, depositing it finally in the take-up tray. It does trolled by the main "power on" switch that is located in a
this at a highly accurate speed and with a minimum prominent place on the machine console.
amount of weaving back and forth. One of the first things
that the EEG technician-in-training learns is how to load
Calibrator
paper into the chart drive. Chart paper comes in fan-
folded or "accordion-folded" packs. Note that the chart As we already know, the electrical activity of the brain
paper is perforated at the folds; this is so that the pages fold recorded in a clinical EEG is measured in microvolts.
easily and can be separated readily. A full pack usually Earlier we stated that a microvolt was a very small electri-
consists of 1,000 pages, and they are numbered consecu- cal signal and that the instruments used to detect low-level
tively like the pages in a book. These numbers are a con- voltages were quite sophisticated devices. Because such
venience; knowing the chart speed, the EEG technician sophisticated instruments are subject to failure, the EEG
can estimate the time duration of the recording simply by technician needs to know on a day-to-day basis whether his
determining how many pages have gone through the or her EEG machine is operating properly-whether it is
machine. The page numbers may also be used to identify doing exactly what it was designed to do. This is accom-
the location of interesting or particularly noteworthy plished by the calibration procedure.
events in a recording. Calibration involves feeding a signal of known voltage
The chart drive has a control lever or a row of push and well-defined frequency characteristics into each chan-
buttons that allow the technician to change paper speed nel of the EEG machine and observing the expected out-
easily. Standard EEG chart paper speed is 30 mm/s. The put on the chart. This signal, of course, needs to fall within
reasons for settling on this particular speed will become the dynamic range of the EEG. A calibration is done just
apparent later. All EEG machines have, in addition, a before an EEG recording is started on every patient and is
slower and faster paper speed: usually one-half standard repeated after the recording has been completed. These
speed or 15 mmls, and twice standard speed or 60 mmls, procedures are referred to as the precalibration or "pre-
respectively. Some machines provide for still other chart cal" and postcalibration or "post-cal;' respectively. If the
speeds as well, but these are not essential for routine clini- pre- and postcalibrations are satisfactory and yield identi-
cal EEG recording. cal tracings, we conclude that the EEG machine was func-
It is important to recognize that the accuracy of the tioning properly during the actual recording of the EEG.
chart paper speed is of the utmost importance. Chart This assumes, of course, that nothing changed and then
speed provides the time base in the EEG tracing. In practi- changed back again in the interval between the pre- and
cal terms, this means that the accuracy of our estimates of postcalibrations. Such intermittent faults or failures can
frequency of the brain electrical activity recorded on the occur and will be missed if they fail to show up during
chart is dependent upon the accuracy and reliability of the calibration. But in practice, it is usually only a matter of
chart speed. Methods whereby this important machine time before they are discovered.
parameter may be checked are taken up later. All EEG machines have an internal voltage calibrator
situated on the console. To perform a calibration, a number
of simple steps are carried out. First, you need to connect
Power Supply
the input of each channel of the EEG machine to the
The EEG machine contains a variety of electrical and elec- calibrator circuit by correctly positioning the electrode-
tronic devices that require electrical energy to operate. selector switches or the montage switch if the machine has
But the circuits cannot operate on the 60-Hz, 120-V AC one. Second, you adjust the voltage of the calibration signal
that is available from the power lines. They require low vol- by indexing the calibration level switch to a selected value.
10 1. Brain Electrical Activity

Table 1.1. Relationship between sensi- simultaneously, on every channel of the machine. These
tivity of an EEG channel and pen tracings are then examined carefully for evidences of
deflection for a standard input signal of differences between them. More will be said about this
50~V later.
Sensitivity'l Pen deflection
(~V/mm) (mm)
2
5
25
10
Computerized EEG Machines
7 7
10 5 Although this term has appeared in the descriptive litera-
20 2.5
ture of some EEG machines, it is partly a misnomer. Com-
UNote that sensitivity and gain are inversely puterized in this context refers to the computer control
related; thus. gain or amplification
and display of EEG recording parameters, not to having
decreases as the numbers in this column
increase. the EEG technician replaced by a computer. Modern tech-
nology and computers notwithstanding, a well-trained
EEG technician is essential for obtaining high-quality
EEGs. Nevertheless, recent developments in micropro-
The standard reference calibration signal in EEG work is cessor and microcomputer technology have had a signifi-
50 JlY. Finally, you press and release the CAL button. In cant impact on the design of modern EEG machines.
doing so, the pens are deflected first upward and then The most obvious change is in the physical appearance
downward each time the CAL button is pressed and of some of the new models. There are virtually no more
released. Note that the pens take some little time before knobs to turn or dial plates to look at. Knobs have been
returning to their original positions, so you need to wait replaced by touchpads, and dial plates by the screen of a
before releasing the CAL button. The reason for this cathode-ray tube (CRT). Thus, for example, the filters are
phenomenon and its significance are taken up when filters set by pressing the appropriate touchpads and observing
and calibration methods are discussed in detail. the result on the display of the CRT screen. Such machines
Certain calibration standards are followed in EEG work. have the convenience of being "menu-driven"; they pro-
The gain setting most frequently used in recording clincial vide for automated sequencing of montages and operations
EEGs corresponds to a sensitivity of 7 JlV/mm. This and afford the flexibility of user-programmable montages.
means, of course, that a 7 Jl V signal will deflect the pens While state-of-the-art changes of this kind may be of
exactly 1 mm. Using this sensitivity setting, the standard considerable convenience to some users, they should be
reference calibration of 50 Jl V should produce a 7 mm recognized as conveniences and nothing else. For example,
deflection of the pens. In the same way it will be seen that the characteristics and operation of the low-frequency
the standard reference calibration of 50 Jl V will produce a filter and its effects on the EEG tracing are the same
5-mm deflection at a sensitivity of 10 Jl V/mm and a 10-mm regardless of whether the filter is switched in by turning a
deflection at a sensitivity of 5 Jl V/mm. Note that at the set- knob or by pressing a touchpad. Moreover, the ability to
ting of 10 JlV/mm the machine has less amplification or design and easily program one's own special montages may
gain than at a setting of 5 JlV/mm. Table 1.1 shows these be of value, especially in research, but it is unlikely to have
relationships in tabular form. much impact on routine clinical electroencephalography
Some newer machines provide for AC or sine wave where standardization is essential. For such reasons, these
calibration as well. Details of this method are taken up in modern developments are not considered in the chapters
Chapter 6, "Calibration and Calibration Methods:' dealing with the various basic structural units of the EEG
In examining the calibration record it is important to machine.
verify that the tracings from all the channels of the By this time it will be apparent to the reader that the
machine are alike. This is because much of the information EEG machine is certainly not a simple instrument. Our
derived from an EEG is based on a comparison of the brief survey merely serves as an introduction to what the
recordings from left and right sides of the brain, and for machine does and how it is operated. To use the machine
these comparisons to be valid, the channels recording effectively on a routine basis, it is important to know some-
activity from both sides have to be identical. To assist the thing about how it actually functions and why it functions
EEG technician in recognizing any differences that may be as it does. But this requires some background information.
present between channels, it is universal practice to do a So you will find that it is first necessary to review some
so-called "biological calibration:' This entails recording basic electrical concepts. These are taken up in the next
brain electrical activity from the same pair of electrodes, chapter.
Chapter 2
Basic Electrical Concepts

In the brief survey of the EEG machine in the last chapter, it comes about, we need to review briefly some of the
many terms relating to electrical phenomena were used. basics of atomic structure.
We encountered terms like electric current, voltage, AC,
DC, and electric circuit, to name a few. Thus far, these
terms have gone undefined. To understand how the EEG Atomic Structure
machine does its job, some knowledge of these and other
electrical concepts is essential. This is not to say that the We know that all matter is made up of atoms. These minute
EEG technician or neurology resident need to become particles, which are arranged in an organized structure
adept in the area of physics, electronics, and electrical called a molecule, consist of various kinds of elementary
engineering. On the other hand, without some under- particles. Only the two major kinds of elementary parti-
standing of these concepts the EEG machine becomes a cles, the protons and electrons, need concern us here. They
strange and mysterious device rather than a practical tool are largely responsible for the electrical properties of
for recording a patient's EEG. substances.
But this is not the sole reason for the present chapter. The atom has an interesting structure. At its center is a
The EEG is itself an electrical phenomenon; an electrical relatively small nucleus that contains practically all of the
sign of cortical activity. Much of today's knowledge of the weight of the atom. The particles called protons reside
EEG and of brain function in general came about as the within the nucleus, and they carry a positive electrical
result of important advances in physics, electronics, and charge. Surrounding the nucleus are tiny particles bearing
electrical engineering. Indeed, it has been said that sig- a negative electrical charge; these are the electrons.
nificant advances in neurophysiology have gone hand in Because unlike electrical charges attract each other, the
hand with significant developments in these related areas. electrons are attracted by and bound to the nucleus. The
This being the case, it is appropriate for those concerned total negative charge of the electrons in an atom is equal in
with the technology and practice of clinical electroen- magnitude to the positive charge of the nucleus. Since
cephalography to know something about electrical equal charges of opposite sign exactly cancel each other, an
phemonena per se. atom is normally in electrical balance.
The protons and electrons of which all matter is con-
stituted are identical. The fact that different substances
Electrical Currents display different properties arises in large measure from
the circumstance that the number and arrangement of
When we use the term "electrical activity" in speaking of these elementary particles differ from one element to
the EEG, what we really are talking about is an electric cur- another. It is primarily the different electrical properties of
rent. What exactly is an electric current? For most of us, an substances that concern us here.
electric current is what makes our lamps light and our
motors run. Is this current the same kind of thing that is
generated by the brain? Conductors and Insulators
The physicist says that an electric current is a flow of
electrons - a flow of negatively-charged particles in a con- While the electrons in the atoms of various substances are
ducting medium. To understand what this means and how all alike, the strength with which the electrons are bound
12 2. Basic Electrical Concepts

to the nucleus of an atom differs in different substances. In the presence of a voltage between the two ends of a con-
some substances, the electrons are very tightly bound; in ductor, there can be no flow of electrons; under such con-
others, they are only loosely bound and free to move about. ditions, current flow is equal to zero.
This difference is responsible for one of the important
electrical properties of a substance, namely, its conduc-
tivity. Substances or materials that have electrons that are Resistance
loosely bound to the nucleus are electrical conductors,
while substances whose electrons are all tightly bound and How much current flows in a conductor depends upon the
not free to move from their natural positions in an atom are voltage applied to it and upon the conductivity of the sub-
insulators. From this it follows that the movement of the stance involved. We said earlier that there are good con-
electrons in a conductor is what we refer to as an electric ductors and poor conductors. A good conductor is said to
current. have high conductivity or to have a very low resistance to
Most metals are examples of good conductors. Copper the flow of a current. A poor conductor, on the other hand,
and silver are particularly good conductors, and this is the has low conductivity or a high resistance to current flow.
reason why they are used in electrical wiring. Gold is also Resistance, therefore, is inversely related to conductivity,
an excellent conductor; because gold does not readily cor- or conductance as it is called. It is a parameter derived
rode and is not toxic, it frequently is employed in EEG from the relation between the voltage applied to the con-
electrodes. Glass, mica, and porcelain, as well as most plas- ductor and the current flowing in it. We measure
tics, are examples of poor conductors or good insulators. resistance in ohms, in honor of the 19th century German
Most persons have seen the white porcelain insulators to physicist George Simon Ohm.
which the power lines are attached as they enter a house or
building. The insulators prevent the current in the wires
from leaking in unwanted directions. Electrical Circuits
Electric currents also can flow in liquid media such as
solutions. In such cases, the particles carrying the electri- Connecting a voltage between the two ends of a conductor
cal charge are iOlls. Ions and the important topic of con- constitutes an electrical circuit. This, of course, represents
duction in liquid media are taken up when we discuss elec- the simplest kind of electrical circuit. In actual practice,
trodes in a later chapter. electrical circuits are somewhat more complex; indeed,
they frequently can become quite complicated. Neverthe-
less, the simple circuit does illustrate the important point
Potential Difference and Voltage that an electrical circuit describes a continuous pathway
between the two points of a voltage source.
Although electrons in conducting substances are only Figure 2.1A shows this circuit with a current-measuring
loosely bound and hence free to move about, they normally device or ammeter in series with the conductor. In this
do not do so. To get the electrons in a conductor moving, a instance a good conductor is connected up, and this is evi-
force has to be applied to them. In other words, we need to denced by the meter showing a relatively large current
apply a potential difference between the two ends of the flowing in the circuit. Figure 2.1 B shows the same circuit
conductor. but with a poor conductor connected; note that considera-
An analogy is useful in helping to understand the con- bly less current is flowing than in the previous case. Finally,
cept of a potential difference. The electrons in a conductor in Fig. 2.1 C, the conductor has been replaced by a good
that are free to move are analogous to water in a long, insulator whereupon the meter indicates that no current at
straight, horizontally positioned pipe. The water has the all is flowing in the circuit.
capability of flowing through the pipe; but it will only drib- We already mentioned in the last section that the
ble out the ends as long as the pipe is exactly level. Only current-carrying properties of a conductor are expressed
when one end of the pipe is raised above the other end will in terms of its resistance and that resistance is measured in
a flow occur. In the same way, electrons in a conductor will ohms. For this reason, a conductor is referred to as a resis-
flow only when the electrical charge at the two ends of the tor and is represented by a zig-zag line in a circuit diagram.
conductor differs, that is, when there is a potential differ- This is illustrated in Fig. 2.2 where the circuits shown in
ence between the two ends. The potential difference is Fig. 2.1 are drawn in the conventional manner with the
measured or expressed in volts, after the Italian physicist conductors represented by resistors (abbreviated R).
Volta, whose name was mentioned in the last chapter. Cur- It is obvious from Fig. 2.2 that the current flowing in a
rent flow is measured in amperes (A), milliamperes (mA), circuit decreases as the resistance increases. In other
or microamperes (J.1A) after the 18th to 19th century words, with the applied voltage kept constant, the current
French mathematician-physicist Andre Ampere. Without flowing in a circuit containing a resistor varies inversely
Series and Parallel Circuits 13

Figure 2.1. Simple electrical circuit A. B. c.

containing a good conductor (A), a
poor conductor (B), and an insulator
(C). The arrows show the direction of
current flow.

Ammeter Ammeter Ammeter

Figure 2.2. Simple electrical circuits A. B. C.

shown in Fig. 2.1 drawn in conven-
tional format used in circuit diagrams.
+ ~ +~ t+ ~
Low High Very
v R V R V High
R

Ammeter Ammeter Ammeter

with the magnitude of the resistance. If, on the other hand, 12

we kept the resistance in the circuit constant and allowed I = 50,000 = 0.00024 A
the applied voltage to change, we would discover that the
Note that if you doubled V, the current, I, would also be
current flowing varies directly with the magnitude of the
doubled; but if you doubled R instead, the current would
voltage. The relationship between current, voltage, and
be halved.
resistance in an electrical circuit is defined by a famous for-
Ohm's law is a simple yet powerful formal rule that pro-
mula referred to as Ohm's law.
vides a means of analyzing simple circuits as well as many
complex circuits. Figure 2.3 shows how the simple circuit
in Fig. 2.2 may readily be made more complex by the addi-
Ohm's Law tion of more resistors and branches with additional such
elements. The analysis of these circuits requires two addi-
Ohm's law states that in any electrical circuit, tional rules relating to the way in which separate resistors
in series and in parallel are combined.
current = - -voltage
.--'='--
resistance
or symbolically,
Series and Parallel Circuits
V
1=-
R' When two or more resistors are connected in series - that
is, when one is connected to another in a single chain - the
where I is current in amperes, V is the potential difference
total resistance is simply the sum of the resistances of the
in volts, and R is the resistance in ohms. As with any
individual elements. This rule is expressed by the formula
algebraic formula, if you know the values of any two varia-
bles for a particular circuit, you can compute the third or Rr = RI + Rz + ... Rn,
unknown variable from the formula. Thus, for example, if
in the circuit shown in Fig. 2.2B, V = 12 volts and R = where Rr is the total resistance and R\, Rz, ... Rn are the
50,000 ohms, resistances of the individual elements. The second rule
applies to resistances in parallel. In this case to calculate
V total resistance you add together the reciprocals of the
I
R' branch elements. This yields the reciprocal of the total
14 2. Basic Electrical Concepts

Figure 2.3. Basic forms of series cir-

+ + + cuits and parallel circuits.
Rl Rl

v R v v Rl V

Single R Series Rs Parallel Rs Series-Parallel Rs

resistance from which total resistance is readily computed. In this case, Rr is one half the magnitude of either RI or
This rule is embodied in the formula R 2 • The simplest way of understanding what happens with
resistors in parallel is to recognize that by adding a resistor
in parallel with another, you provide an additional pathway
for current to flow in the circuit. By Ohm's law, you know
that the current flowing in a circuit can be increased only
where Rr is the total resistance of the circuit, and R I , R2,
by (1) increasing the applied voltage or (2) decreasing total
. . . Rn are the resistances of the individual elements in
resistance of the circuit. With voltage remaining un-
parallel with each other.
changed, we have to conclude that adding the resistor in
It should readily be apparent that when resistors are in
parallel results in a decrease in total resistance of the
series, the total resistance will always be greater than the
circuit.
resistance of any of the individual Rs. With resistors in
The value of Ohm's law and of the rules for combining
parallel, on the other hand, the total resistance will always
resistances in series and in parallel will become more
be less than the resistance of any of the individual Rs. Why
apparent when we discuss the topics of electrodes and
this is so may not immediately be obvious from the for-
electrode impedance. In the meantime, the reader will
mula, although a simple example makes it quite clear.
find it helpful for future purposes to analyze the circuit
Thus, if RI = 10,000 ohms and R2 = 10,000 ohms, then,
shown in Fig. 2.4. The variable of interest is V2 , the voltage,
1 = -----
1 1 across R 2 • Figure 2.4 shows the general solution for V 2 ; as
-- + -----
Rr 10,000 10,000 may be seen, this involves the use of Ohm's law and a little
1 2 simple algebra. Now, if RI and R3 are very small with
Rr = 10,000 respect to R2 , the formula for V2 is approximated by the
expression
Rr = 5,000 ohms

Rl
and V2 will very nearly be equal to VI' As we shall see in

7J
later chapters, this simple circuit analysis explains why in
1
VI R.
1
v.
EEG work it is necessary for the impedance of the record-
ing electrodes to be low and the input impedance of the

I
EEG amplifiers to be very high. But more about this later.

R3 Circuit Parameters
By Ohm's Law, Earlier, we referred to resistance as a parameter of an elec-
VI VI trical circuit. Our discussion turns now to the other
1= parameters that are contained in electrical circuits.
RT Rl + R. + R3
There are but two other circuit parameters. They are
Again By Ohm's Law, called inductance and capacitance, and the associated ele-
V. = R. I ments are termed inductors and capacitors or condensers,
respectively. It is surprising and indeed remarkable that
VI )
V. = R. (
R1 + R. + R3
electrical circuits consist only of these three parameters,
no matter how complex they may become. Of course a cir-
Figure 2.4. Application of Ohm's law in analysis of a series circuit. cuit can contain other components like diodes, transistors,
Transient Response 15

and vacuum tubes as well; but these are active elements This is the opposite of the circuit's steady-state response,
and are not referred to as parameters. which refers to the condition of the circuit after it has once
Inductance is a circuit parameter of only minor interest again settled down. You can think of transient response and
in the area of EEG technology. Aside from the trans- steady-state response in terms of what happens to a per-
formers and choke coils of the power supply, and the arma- son's pulse rate as there are shifts in his or her level of
ture coils of the penmotors, there are no other inductors in physical activity. While at rest, your pulse rate is, say, 60 to
an EEG machine. Moreover, inductance does not figure as 70 beats per minute. Suppose that at time zero, you begin
a parameter in the electrical properties of living tissue. running. What happens to pulse rate? You would find that
Therefore, no more will be said about inductance in this pulse rate undergoes a rapid, transient change, shooting up
text. to perhaps 100 to 110 beats per minute. As you continue to
Capacitance, on the other hand, is a parameter of con- run, pulse rate begins to drop, and after a time levels off to
siderable interest to both the technology and the practice perhaps 80 to 90 beats per minute once you attain your
of clinical electroencephalography. Not only are con- normal pace. From then on, until fatigue sets in, it shows
densers essential components in the power supply and only small fluctuations if you maintain a regular pace. This
amplifiers of an EEG machine, but they also are the is the steady-state response.
frequency-selective elements that make a filter work. We With electrical circuits, the same principles are applica-
will hear more about this later in Chapter 4. Finally, living ble. The transient response of an electrical circuit is com-
tissue displays electrical characteristics that resemble the monly observed by applying an instantaneous change in
electrical properties of a capacitor. For these reasons it is voltage to the circuit and then measuring the change in
necessary to examine and to understand the electrical current over the interval of time it takes the circuit to
properties of this circuit parameter. adjust to the change. The instantaneous change in voltage
is referred to as a step function.
Let us begin by examining the transient response of an
Capacitance electrical circuit containing only a resistor. Figure 2.5A
illustrates what happens when this is done. With no voltage
The physicist defines a capacitor as two conductors that applied to the circuit, the current flowing, of course, is
are separated by an insulator. This, of course, is simply a zero. Now, let us instantaneously change the voltage from
structural definition that is reflected in the fact that a sym- zero to some steady, finite value. The plot of voltage versus
bol used for capacitors consists of two short, parallel lines time in Fig. 2.5A shows this as a step increase in voltage. If
of equal length separated by a narrow space. Of considera- the pointer on the current-measuring meter connected in
bly greater interest to the present topic, however, is the series with the resistor had no inertia, you would see an
functional definition, and here the use of an analogy will be instantaneous change in its position from zero to some
helpful. A capacitor or condenser has the same relation- value; there it would remain as long as the step in voltage
ship to electrons that a pail has to water. From this it may continued to be applied to the circuit. The plot of current
be inferred that a condenser is capable of storing electrons. versus time shows this graphically. Note that the transient
This is indeed the case. A condenser's storage capacity is response of the resistance to a step function is itself a step
measured in units called farads (in honor of the 19th cen- function. In other words, the changes in current flowing in
tury English chemist-physicist, Michael Faraday). Because the circuit follow the changes in applied voltage perfectly.
a farad is an enormous quantity, the practical unit used in To put it another way, the circuit attains steady-state instan-
the circuits we deal with is the microfarad or millionth of taneously so that, practically speaking, there is no tran-
a farad (abbreviated IlF or MFD). sient response.
To understand the way in which a capacitor affects the What happens when the circuit contains a condenser
functioning of an electrical circuit, it will be useful to instead of a resistor is quite different indeed. The outcome
return for a moment to the other parameter of electrical is illustrated in Fig. 2.5B. Observe that as with the resistor,
circuits that we have already discussed, namely, resistance. the current changes instantaneously from zero to a finite
For reasons that will later become apparent, we need to value when the step function is applied. It does not remain
address the topic of the transient response of electrical cir- there, however, but begins immediately to fall, first rapidly
cuits. and then slowly until it once again is zero. Note that in
doing so the condenser is displaying the characteristics of
both a conductor and an insulator. At the instant the vol-
Transient Response tage is connected to its terminals, the condenser behaves
like a good conductor; but then as this voltage remains
The transient response of a circuit refers to the behavior of connected, it becomes a poorer and poorer conductor
the circuit during the interval of time that a change is until current finally ceases to flow, and the condenser dis-
applied to it and the circuit is still adjusting to the change. plays the properties of an insulator. This outcome is readily
16 2. Basic Electrical Concepts

A. B. C. Figure 2.5. Transient response

of electrical circuits contain-

1 1
ing (A) resistance only, (B) ca-

l@JC' l@JC'
pacitance only, (C) capaci-
f f tance only with C2 greater
Circuit V R
than Cl'

VoI_ &1 J_
. ·f
Time ~ 0
Time ____
~ Time _ _
~ Time _ _

~ 1~
~--- ~---
Current
a
YS. ..
Time 0
Time _ _ Time _ _

understood by referring to our analogy of the water and and, hence, takes longer to fill up or become charged. The
pail. Assuming that the pail is an enclosed container that fact that the condenser is actually charged may be demon-
cannot overflow, the water will cease to flow in as it strated by connecting it to a voltmeter and observing that
becomes filled. In much the same way, the flow of current a voltage is present between the two terminals. Since very
in the condenser ceases when the condenser becomes large condensers can store large numbers of electrons,
filled with electrons or "charged:' they are capable of generating large currents when dis-
The transient response of a capacitor, therefore, is quite charged. Charged condensers, therefore, constitute a
different from the transient response of a resistor. While shock hazard and can be potentially dangerous if you hap-
the resistor allows current to flow exactly in phase with the pen to touch their two terminals simultaneously; for this
applied voltage, the capacitor exerts a counteracting force reason, they should be handled very cautiously.
upon the flow of current set up by the change in voltage.
For this reason, capacitance is considered to be a reactive
element, and condensers are referred to as capacitive reac-
tance in a circuit. We will go into the question of how
Series R-C Circuit
capacitive reactance is measured later in this chapter in
the section on impedance. In the last section we saw that the transient response of a
After the transient response is over and steady-state has capacitor to a step function was described by a current ris-
been achieved, note that current through the condenser is ing instantaneously to a maximum and then falling off to
zero. In other words, a condenser behaves like an insulator zero, first rapidly and then more slowly. We now consider
or an "open circuit" to a steady or unchanging voltage. This the transient response of an R-C circuit - a circuit con-
characteristic is of considerable practical value as it means taining both resistance (R) and capacitance (C) in series.
that a condenser can be used in a circuit to block a steady This is an extremely important circuit for the EEG
voltage. As we will see later in a chapter on the differential specialist to know about since such circuits are incorpo-
amplifier, the various stages of amplification in an EEG rated in the frequency filters on the EEG machine.
machine are commonly coupled together by means of con- Figure 2.6 gives the circuit diagram of a series R-C cir-
densers. When used in such an application, the con- cuit and shows the response of this circuit to a step func-
densers are referred to as blocking capacitors. tion. As in the case of a circuit containing only capacitance,
What happens to the transient response as we increase the current rises instantaneously to a maximum value and
the size of the capacitance? This is shown in Fig. 2.5C. then falls off, eventually returning to zero. Note in the plot
Note that although the current level attained is the same as of current versus time that the maximum value of current
was the case with C1 in the circuit, the current falls at a is equal to VIR, a value that looks like the right side of
much slower rate. This happens because the larger the equation for Ohm's law. The mathematical function
capacitance has a greater capacity for storing electrons describing the way in which the current varies with time is
Time Constant 17

,"p"':lo~
R C

1~ Time---
V

Output !t 63~1 ~- _
U O~-----~
I

: : Time---
f--Time~

Voltage & t -_L -I Constant I

I

•
I
Vs_ S V
Time ~ O~ Time ___ t ~ RC

, V-..l.. Figure 2.7. Time constant of a series R-C circuit.

Current
Vs....
~ t -fUN-('- R f _"'
R
Time <3 0
Time---
of the formula corresponds to the quantity E taken to an
exponent, or 2. 71S - (tIRC). Since the exponent is negative,
Figure 2.6. Transient response of a series R-C circuit. this quantity will always be equal to 1 or < l. Observe that
when the time t is equal to zero, the whole exponent also
is zero and the quantity 2.71S - (tIRq is equal to exactly 1
referred to as a decaying exponential. It is given by the (remember that any number taken to an exponent that is
formula: zero is always equal to 1). Therefore at the instant the vol-
tage is applied to the circuit, I = (VIR) x 1 or I = VIR.
I V
= - E-(tIRq For values of t greater than zero, the current is equal to
R some fraction of VIR. Note that the current becomes
smaller and smaller as t becomes larger and larger. Theo-
where V = applied voltage, R = resistance, C = capaci-
retically, current approaches but never reaches zero; for
tance, t = time in seconds, and E is the Napierian constant, practical purposes, however, it is equivalent to zero within
the number 2.71S ... 1 the span of several time constants. This term is taken up in
While seemingly complex at first glance, this formula is
the next section.
relatively simple when you consider it by parts. Thus, the
first part, I = VIR, is the now familiar Ohm's law. The rest

Time Constant
IThe mathematically sophisticated reader familiar with the cal-
culus may be interested to learn the origin of this equation. We
already know that for a circuit containing resistance alone, the It will be clear from an inspection of the equation for
current flowing in the circuit varies directly with the applied vol- current in the series R-C circuit that the rate at which the
tage and inversely with the resistance. In other words, I = VIR. In decaying exponential falls depends on the value of the
the case of a circuit containing only capacitance, the current exponent, which, in turn, depends on the values of Rand
varies directly with the capacitance and with the rate of change of
the applied voltage. This means that time is a significant variable
C in the circuit. When RC (the product of Rand C) is
and current has to be expressed as a derit:atire of voltage. The large, the negative exponent is small and the current will
equation for the current, therefore, is: fall to zero slowly. On the other hand, when RC is small,
the negative exponent is large and the current falls more
I = C dVidt
rapidly.
Putting the two parameters together, the basic voltage equation The rate at which current falls to zero during the course
for a circuit with Rand C in series is: of the transient response is conveniently expressed by the
RI + (lIC) f
o
t
I dt = V term time constant. The time constant of a circuit is the
length of time it takes the current to make 63 % of its total
Differentiating this equation with respect to t yields: transition from initial state to steady-state. This is illus-
R dIldt + IIC =0 trated for the series R-C circuit in Fig. 2.7. Notice that
another way of looking at the time constant derives from
From which
the fact that it corresponds to the time at which the cur-
I = (VIR) f. - (f1RC) rent is only 37% of its initial value. In terms of the circuit
18 2. Basic Electrical Concepts

parameters, the time constant is equal to the product of R day in homes, hospitals, and industry is 120-V 60 cycle or
and C.2 60 Hz AC. Because AC is cheaper to produce than DC and
also because it can be transmitted by power lines over long
distances more efficiently than DC, AC is used in prefer-
AC and DC ence to DC as an energy source.
A 60 Hz AC completes one full cycle in 1/60 second (Le.,
Most everyone has at one time or another noticed the iden- 0.0167 second). It flows in a positive direction for half the
tifying plaques that are affixed to electric irons, hair dryers, time and a negative direction for the remaining half cycle.
and a variety of other electrical appliances. Many of these The changes in voltage with time are sinusoidal, that is,
plaques carry the warning "for use on 120-V AC onlY:' The they are described by a sine curve.
AC, of course, stands for alternating current, while the 120 It is important to recognize that AC does not refer only
V refers to the voltage of the electric power that is almost to 60 Hz AC - the electrical energy that lights our homes
universally available from the wall, floor, and ceiling out- and powers our appliances. Alternating current has a much
lets in homes, offices, and hospitals. But what exactly is broader meaning. The EEG is AC. It is not strictly sinusoi-
alternating current? dal, but it is AC nonetheless. The electric current gener-
One way of approaching this question is to consider first ated by a microphone, an audio disc or tape, and a video-
the opposite of AC, namely, direct current or DC. Direct tape is also AC. As a matter of fact, most sources of electric
current is current in which the flow of electrons is in one current are classified as AC sources.
direction only. It results when you apply a steady voltage to
a circuit. Batteries are the most common source of DC;
they produce DC electrochemically. Various different AC Circuits
kinds of batteries capable of generating a wide range of vol-
tages are available. They are found in automobiles, radios, Thus far in this chapter, we have dealt only with the
flashlights, and other appliances. Despite the differences behavior of electrical circuits when a steady voltage is
in their physical appearance, all have one characteristic in applied and with the transient response to a single, instan-
common: they provide a constant voltage so that the cur- taneous change in voltage. All this falls under the heading
rent flowing in the circuit to which they are connected of DC circuit analysis. We now turn to the topic of AC cir-
moves in only one direction. cuit analysis to examine the behavior of the same circuits
Alternating current or AC is a pulsating or fluctuating when alternating instead of steady voltages are applied to
electric current that alternately flows in one direction and them. We will deal only with the steady-state response-
then in another. It results when an alternating voltage is the response after any transients associated with connect-
applied to a circuit. Alternating current is usually pro- ing up the circuit to the source of voltage have subsided.
duced by electric generators - huge rotating machines - at If all the circuits that we needed to deal with contained
electrical power stations. As is the case with DC, we also only the parameter resistance, our discussion could
speak of the voltage of an AC source. But because the vol- quickly be terminated. For circuits containing resistance
tage fluctuates or alternates, it is also necessary to specify only, Ohm's law applies regardless of whether AC or DC is
the frequency of the alternation. The electricity used every involved. A resistor behaves in the same way regardless of
the frequency of the current flowing. In other words,
resistance is independent of frequency of the current flow-
2The reader may demonstrate this fact for him or herself by some ing in a circuit. If, however, a capacitor is added to the cir-
simple algebra. From the last section we know that current in a cuit so that C is in series with R as in Fig. 2.6, Ohm's law
series R-C circuit is:
needs to be modified. The formula in this case is changed
I = (VIR) E - (tIRe)
to
Setting t = RC, we have
V
I = (VIR) 1=-
E - (RCIRC) Z
= (VIR) E- 1
where Z is equal to the impedance of the circuit.
= (VIR) X (lIE)
Since E = 2.718,
I = (VIR) x (1/2.718)
Impedance
I = 0.37 (VIR), The concept of impedance is important for the EEG
which means that when t = RC, the current is 37% of its initial specialist to understand. He or she deals with it on a
value. daily basis whenever EEG leads are attached to a patient
Frequency Response 19

or when an EEG recording is interpreted. Thus, the Computational Example

EEG technician measures the impedance of each lead
or each pair of leads before starting to take a recording. The fact that differences in frequency have a profound
Shelhe knows that the impedance has to be low but not effect on impedance is readily apparent from a simple
too low in order to obtain a satisfactory record. Simi- example. Suppose in series R-C circuit (Fig. 2.6) that R =
larly, the person interpreting the record needs to know 10K ohms and C = 1 ~F. What is the impedance at 1 Hz?
that lead impedances were comparable whenever sig- The answer is obtained by substitution of these values in
nificant amplitude asymmetries show up in the tracings. the formula for Z. Thus,
With all this in mind, let us proceed with a discussion
of impedance. Z = JR2 + (~y
Impedance of an R-C circuit is the combined effect that
the two parameters of resistance and capacitance have on
the flow of current produced when an alternating voltage
is applied to the circuit. Mathematically, impedance is
J.I04)2 + (2 X 3.1~O: 1 X 1 r
equal to

Z = JR2 + (-21[fC
10-6 )2
= ~108 + 159,236 2
where R is the value of resistance in ohms, C the value of 159,550 ohms
capacitance in ~F,f the frequency of the alternating vol-
The reader should verify, by similar computation, that
tage in Hz, and 1[ the familiar constant that is equal to
impedance at 35 Hz is equal to 10,986 ohms. Note that
3.14 ... The term 10 6 /21[fC is referred to as the capacitive
there is nearly a 15-fold difference in impedance at fre-
reactance.
quencies of 1 Hz and 35 Hz.
As is the case with resistance, Z the impedance is also
measured in ohms. Let us consider the formula for Z care-
fully and list what it tells us about the characteristics of Z:
Frequency Response
1. The value of Z depends on the values of the three quan-
tities, namely, R, C, and f The fact that impedance of a circuit varies with frequency
2. If C and f are held constant, Z varies directly with R. finds expression in an important measure used to charac-
3. If Rand f are held constant, the term 10 6 /21[fC or the terize the behavior of electrical circuits. This measure is
capacitive reactance increases as C decreases and vice the frequency response of a circuit. Whereas the transient
versa, so that Z varies inversely with C. response of a circuit is its response to an instantaneous
4. If Rand C are held constant, the capacitive reactance step change in applied voltage, the frequency response is
increases as f decreases and vice versa, so that Z varies the response of the same circuit to an alternating applied
inversely with f Note particularly that as f approaches voltage of constant amplitude that is allowed to vary in fre-
zero, Z becomes very large indeed. In the limit when quency. The frequency response of a particular circuit is
f = 0, the applied voltage is no longer alternating but reported as a frequency-response curve, the points for
becomes steady; under these conditions we are dealing which are obtained by measuring the amplitude of the out-
with DC not AC, and the rules of DC circuit analysis put voltage when voltages of different frequency but the
would apply. same amplitude are applied to the input of the circuit.
The concept of frequency response will be familiar to
Let us summarize. Impedance is a frequency-sensitive readers who own or have used high-fidelity audio repro-
quantity. Z varies with changes in frequency of the applied duction equipment. We know that sounds correspond to
voltage as well as with changes in C and R. For this reason mechanical vibrations and that pitch is related to the fre-
it is necessary to specify the particular frequency of the quency of these vibrations. Audible sounds have a fre-
applied voltage whenever we talk about impedance. Thus, quency range of 20 to 20,000 Hz. Audio-reproduction sys-
for example, we say that a particular circuit has an tems simply pick up the mechanical vibrations via a
impedance of 10K ohms at 30 Hz. This property of microphone or phono pick-up, convert the vibrations to an
impedance is uniquely due in the series R-C circuit to the alternating electrical voltage, amplify them, and then con-
capacitive reactance - to the presence of the capacitor. As vert them back to mechanical vibrations in a loudspeaker.
we will see in a later chapter, this property of capacitance The fidelity of such systems is expressed by the frequency-
is the basic principle upon which the operation of the response curve. Systems that reproduce music at very high
filters on an EEG machine is based. fidelity have a frequency-response curve that is essentially
20 2. Basic Electrical Concepts

so that Vout is almost equal to Vin . If we go in the opposite

direction, i.e., allow f to decrease and become small, the
denominator of the fraction becomes much larger than R
the numerator, and Vout is a progressively smaller fraction
of Vin' This is shown graphically by the frequency-
response curve in the lower part of Fig. 2.8. Amplitude is
plotted as the ratio of VoutNino Since this ratio is always
less than 1, we say that this circuit attenuates the input,
with lower frequencies being attenuated more than higher

I
1.000 frequencies. The dividing point between low and high
frequency is arbitrarily taken to be the point at which fre-
.707
quency is equal to 10 6 /21tfC Hz. This point is designated
VOut .500
Vln the cutofffrequency and corresponds to a 30 % attenuation
of Vin ; in other words, VoutlVin = 0.707 (see Fig. 2.8).3
O~---------,----------- What is the cutoff frequency for the series R-C circuit
10'/21rRC considered earlier in the computational example when
R = 10K ohms and C = 1 JlF?
Frequency (H z}----

Figure 2.8. Frequency response of a series R-C circuit. 106

Cutoff frequency = 21tRC Hz

106
flat from 20 to 20,000 Hz. Low-fidelity systems, on the 2 x 3.14 x 10,000 x 1
other hand, severely attenuate frequencies at both ends of
the frequency spectrum so that the range of audible fre- 106 100
quencies actually transmitted may be limited to only 100 6.28 x 104 - 6.28
to 8,000 Hz. = 15.9 Hz
Although the frequency response of a circuit may be
obtained empirically by applying an alternating voltage of This means that a 15.9 voltage applied to the input will be
variable frequency but constant amplitude to the input and attenuated by 30% when it appears at the output of the
then measuring the amplitude of the output, we may also circuit. The practical significance of this finding will
calculate the frequency response from the circuit param- become apparent in Chapter 4.
eters. Figure 2.8 shows the frequency-response curve for
the case of the now familiar series R-C circuit. This curve
is derived in the following manner: taking the output of the 3This is readily confirmed by some simple algebra. We have
shown that
circuit as the voltage across the resistor, we have from
Ohm's law: R
V t
ou =
.JR2 + (I06/27tJC)2 VIn
At the cutoff point,
f = 106/27tRC
and again by Ohm's law Substituting this in the equation for Vout , we have
R R
VOllt = RI = .,JR2 + (10 6!21tjC)2 Vin VOltt = -/",======r1;;<;06;:=====;;;= Yin
vR2 + 27t x 1()6/27tRC x C
Observe in the above formula that, when f is allowed to R
- - - - - - - Yin
increase so that it becomes large, the quantity 106 /21tfC .JR2 + R2
will approach zero. This makes the fraction
R
.,JR2 + (106!21tjC)2
very nearly equal to so that

R V
~ -1, ~ = 0.707
Yin
Chapter 3
The Differential Amplifier

In Chapter 1, we referred to the amplifier as the heart of entirely clear, he also connected a current-measuring
the EEG machine. This chapter returns to the topic to fill meter between the plate and the heated filament. This
in some important details. We begin with a consideration circuit is shown in Fig. 3.1B. Upon connecting it up,
of electronic amplifiers in general, and then continue with Edison discovered that the meter showed a current was
a discussion and analysis of the differential amplifier. As we flowing in the plate circuit. When the battery was discon-
will see, the differential amplifier is a specially designed nected and the filament allowed to cool, the current flow
device for recording bioelectric activity, and it is employed ceased. Edison did not know the explanation for the cur-
universally in EEG machines. Our objective in this chap- rent; nevertheless, he patented the device and the
ter is to find out precisely what this amplifier does and how phenomenon became known as the Edison effect.
it accomplishes its purpose. We now know that this remarkable discovery has a rela-
tively simple explanation. The filament inside the bulb is a
conductor of electricity. As we learned in Chapter 2, con-
Historical Background ductors have electrons that are only loosely bound to the
nucleus. Connecting a voltage to the ends of the filament
Electronic amplifiers have an interesting developmental causes the electrons to move, producing an electric cur-
history, particularly so since their history illustrates the rent. With large currents flowing, the filament heats up,
importance of serendipity as well as careful technological causing the electrons to become more active until some of
development in scientific research. A very brief look at the them are "boiled off" the filament. Electrons, of course,
high points in this history illustrates nicely the principles are negatively charged particles. The plate inside the glass
upon which electronic amplifiers operate. envelope is positive, as it is connected through the meter
Everyone knows that Thomas Edison invented the elec- to the positive terminal of the battery. Since unlike electri-
tric light bulb. Few are aware, however, that he also dis- cal charges attract, the electrons coming off the filament
covered a phenomenon called the "Edison effect;' which are attracted to the plate and flow in that direction. A flow
provided the basis for the development of the electronic of electrons, of course, is an electric current, which
amplifier. The year was 1884 and Edison was experiment- accounts for the deflection observed on the current-
ing with his electric light bulb. Recall that a light bulb is measuring meter.
nothing more than a glass envelope from which the air has Edison can hardly be blamed for not knowing the expla-
been evacuated and which contains a loop of wire called nation of this phenomenon at the time of its discovery.
the filament. Figure 3.1A shows a light bulb with a voltage Indeed, he had no way of knowing precisely what was hap-
source (a battery) connected to the filament. With the pening in his circuit. The correct explanation had to await
battery connected, the filament is made incandescent by the discovery of the electron by Joseph J. Thompson some
the passage of an electric current, thereupon emitting 13 years later.
light as well as heat. The next event in our historical survey concerns the
In the course of his experiments, the purpose of which work of John A. Fleming, a British electrical engineer. In
was to discover a method to prevent the bulb from darken- 1904, while experimenting with the Edison effect, Flem-
ing with use, Edison placed a second element - a metallic ing discovered that Edison's device conducted in only one
plate - inside the glass envelope. For reasons that are not direction. What Fleming did was to hook up a battery in
22 3. The Differential Amplifier

A. B. C. D. E. F. G. Figure 3.1. Development of

Light Bulb Edison Fleming's Fleming's De Forest's Vacuum Tube Transistor the electronic amplifier.
Effect Valve Valve Triode Amplifier Amplifier
(Open) (Closed)

Glass Load
Envelope Resistor
Filament,' Collector
I
I

,
/

I
I

Battery Meter Filament

(Cathode)

series with the current-measuring meter; by this stroke of of negativity. As the grid became more and more negative,
insight, he created the first diode. When the positive pole a point was reached where the current stopped flowing.
of the battery was connected to the plate, as shown in Fig. The explanation of this phenomenon is simple. There is a
3.1 C, the meter registered a flow of current. Moreover, competitive action on the electrode stream. The anode, or
increasing the voltage of the battery resulted in a propor- positive plate, attracts the electrons coming from the fila-
tional increase in the amount of current flowing. When the ment or cathode of the tube, whereas the negatively
polarity of the battery was reversed, however, as in Fig. charged grid repels the electrons. The number of electrons
3.10, no current flowed in the plate circuit. The reason for flowing to the plate is determined, therefore, by the net
this is obvious. With the plate negative instead of positive, effect of these two opposing forces. De Forest found that
the electrons coming off the filament are repelled. The very small changes in grid voltage could produce a con-
upshot of this was that you could control current flow by siderable change in the flow of current in the plate circuit
the voltage on the plate of the device. Fleming likened the of the tube.
action of this device to that of a "valve;' a term used in the From De Forest's grid-controlled triode, it was but a
United Kingdom for a vacuum tube. simple step to the vacuum-tube amplifier. This was accom-
Valves are devices capable of controlling the flow of plished by the addition of a resistor to the plate circuit-
energy, usually with very small changes in energy level at the so-called load resistor. The circuit is shown in Fig.
the control end. In other words, by exerting a relatively 3.1F. Since Ohm's law states that V = JR, it should be clear
small force at the control end of the valve, you can generate that by allowing the changes in plate current to flow
a very large flow through the device. A common water fau- through a resistance, changes in voltage can be developed.
cet is a familiar example; by using only a small force on the The changes in plate voltage are an exact copy of the
faucet, a huge stream of water may be turned on and off. changes in grid voltage, with the exception that they have
Fleming's valve had the capability of doing the same for an been amplified and are considerably larger. We see, there-
electric current. fore, that an electronic amplifier does not, in reality, mag-
Lee De Forest, an American inventor, was impressed nify or amplify a particular voltage. Instead, it uses this vol-
with Fleming's valve and began studying methods for tage to control or modulate the current flowing through a
improving the device. Through a stroke of inventive genius, resistor in a separate circuit. The voltage developed across
he added a third element to Fleming's valve, whereupon the resistance in this circuit (Fig. 3.1F) then becomes the
the triode or three-element vacuum tube was born. The "amplified" voltage.
third element was called the grid, a plate-like object con- The final step in the development of the electronic
sisting of a mesh of fine wire that was positioned between amplifier is the substitution of the transistor for the
the filament and plate. De Forest's triode is shown in Fig. vacuum tube in the circuit. Although it was an eminently
3.1E. The glass envelope in the illustration is drawn in the useful device in its time, the vacuum tube had some seri-
traditional manner of a vacuum tube, i.e., as a closed circle. ous limitations. To obtain the electrons that make it work,
De Forest discovered that the current (I) flowing in the it is necessary to heat a filament to incandescence by pass-
plate circuit of the triode could be controlled by the vol- ing an electric current through it. To do this, large amounts
tage applied between the grid and the filament. With the of electrical energy are expended, which, in turn, generate
gdd at zero volts, the plate current was at maximum. By considerable heat. When a circuit requires a large number
making the grid negative with respect to the filament, the of vacuum tubes, the cost of heating the filaments and then
plate current could be reduced in proportion to the degree cooling the circuits to avoid damage from excessive heat
Amplifying Bioelectric Activity 23

Figure 3.2. Development of the A. B. c.

differential amplifier.

1 (grid) Grid 1 G1
Output
Input Input
2 G2 Output

Input =

Grid 2

Single-Ended Basic Differential Symbol For

Amplifier Amplifier Differential
Amplifiers

can be considerable. These problems were readily over- the change in output voltage to change in input voltage.
come by the development of the transistor that consumes Although this amplifier has two inputs, it is referred to as
no energy in heating filaments. In addition, the transistor a single-ended amplifier because one of the inputs is a
has other advantages over the vacuum tube, namely, its reference point that is connected to the earth or "ground:'l
smaller size, lighter weight, greater efficiency, and ability Note in Fig. 3.1 F that the active input of the amplifier is
to operate with low voltage and current. the grid of the vacuum tube. In the case of a transistor
Transistors are devices composed of solid-state materials amplifier, the active input would be connected to the base
- substances called semiconductors. In terms of their of the transistor. While most amplifiers have abandoned
electrical conductivity, semiconductors fall between con- vacuum tubes in favor of transistors, the term "grid input"
ductors and insulators. The structure of these substances is is still used in referring to the active input. Figure 3.2A
such that not all of their electrons are bound tightly to the shows the symbol used in a circuit diagram to denote a
nucleus; in fact, they can be shaken loose at room tempera- single-ended amplifier. Grid input is input 1; input 2 is
ture. This is accomplished by applying voltages to the connected to earth, as shown by the symbol for ground,
semiconductors; when this is done, the device conducts an which consists of a series of short horizontal lines, one
electric current in a manner analogous to what happens in below the other, with the lower lines being progressively
a vacuum tube. There are important differences in the way shorter than the lines above.
a transistor functions when compared with a vacuum tube.
These differences need not concern us, as the principles of
amplification are basically alike in both devices. Amplifying Bioelectric Activity
Figure 3.1G gives a circuit for a simple transistor ampli-
fier. Note the similarities to the vacuum-tube amplifier Historically, the first amplifiers used to amplify bioelectric
shown in Fig. 3.1F. Like De Forest's triode, the transistor activity were single-ended amplifiers. Although these
has three elements: the base, which corresponds to the amplifiers were adequate for dealing with high-level elec-
grid of the vacuum tube; the collector, which corresponds trical signals like the ECG and the action potentials from
to the plate; and the emitter, which corresponds to the fila- some peripheral nerves, they proved to be of little if any
ment or cathode. value in the case of low-level signals like the EEG. There
were three major reasons for this.
First, the single-ended amplifier is sensitive to outside
Single-Ended Amplifier interference like the 60-Hz activity from the power lines.
This happens because one side of the 60-Hz power line-
The earliest practical electronic amplifier was the single- the neutral or "cold" side - is connected to ground. As
ended or single-sided amplifier. It, of course, employed a input 2 of a single-ended amplifier is also connected to
vacuum tube as its active element and was operated on
batteries. Figure 3.1 F is a circuit for such an amplifier. 1 Ground is used universallv as an electrical reference because
Gain or amplification of the device is equal to the ratio of tbe eartb is tbe most stable ~ource of zero voltage available to liS.
24 3. The Differential Amplifier

ground, the grid (input 1) serves as an antenna and "picks The Differential Amplifier-
up" the 50-Hz activity, which is then amplified. There may
be more than 0.1 V of 50-Hz activity present at the input,
Basic Concept
in which case brain electrical activity would be obliter-
ated. The 50-Hz artifact is all that would be recorded. It is The differential amplifier was uniquely the result of a col-
alleged that during the 1930s, some e1ectrophysiologists laborative effort on the part of electrical engineers, elec-
working in hospitals powered by DC actively resisted the tronic engineers, and neurophysiologists. It was developed
conversion to AC because of the introduction of 50-Hz in the 1930s primarily to meet the needs of multichannel
artifact into their recordings. EEG recording. Numerous well-known persons were
Second, the single-ended amplifier is sensitive to involved; among these were E.D. Adrian, Alexander
artifacts, like the ECG, that are generated within the Forbes, B.H.G Matthews, Franklin Offner, J.F. Toennies,
body. The ECG artifacts can be picked up anywhere on and W. Grey Walter.
the surface of the body and, in some instances, may be In principle, the differential amplifier is nothing more
several millivolts in amplitude on the head. With such than two identical single-ended amplifiers connected
a large voltage present at input 1 of the amplifier, and back-to-back. This is illustrated in Fig. 3.2B. Note that the
with input 2 at ground potential, all but the very highest grids of the two amplifiers become the two inputs of the
amplitude brain electrical activity would be obscured differential amplifier, while the other inputs are joined
by the ECG. This may readily be demonstrated by con- together and then connected to ground. By convention,
verting one channel of the EEG machine to a single- the two inputs are designated grid 1 (G 1) and grid 2 (G2).
ended amplifier as follows: Using the appropriate switch Because the inputs each go to a grid (base in the case of
on the lead selector panel, connect input 2 of a channel transistors), they are isolated from ground and from the
on the EEG machine to ground. Connect input 1 of this power supply. This means that with differential amplifiers,
channel to any EEG lead already on the patient. Now many channels can be connected to the patient simultane-
with all the other leads connected in the normal way, turn ously, without any of the inputs being joined together by
on the machine-first being careful to switch in the 50-Hz the machine. Figure 3.2C shows the symbol used to denote
filter and to turn down the gain of this channel. What a differential amplifier.
you see on the chart is an ECG whose voltage is so large A second important feature of the differential amplifier
that the gain of the amplifier cannot be raised sufficiently derives from the fact that the two halves of the amplifier
to bring the channel within the dynamic range of any are balanced, with one half being the "mirror image" of the
EEG voltages. This dramatic effect is simply the result of other half.2 The result is that the differential amplifier
grounding the differential amplifier, thereby converting it amplifies the difference between the voltages simultane-
into a single-ended amplifier. ously present at the two inputs. This means, of course, that
Third, the single-ended amplifier does not permit simul- the output of this amplifier will be zero whenever identical
taneous, independent recording of EEGs from multiple voltages are present at both inputs and either negative or
placements on the scalp. This results from the fact that positive when the voltages at the inputs are different. Elec-
input 2 of a single-ended amplifier is connected to ground; troencephalographic convention dictates that all channels
if several amplifiers are involved, all will be connected to on the EEG machine deflect upward when the voltage at
the same common point. Removing the ground connection Gl is negative with respect to the voltage at G2 and down-
has little effect since input 2 of the amplifiers is also con- ward when the voltage at G1 is positive with respect to the
nected to the power supply of the machine, which is a voltage at G2. Another way of saying the same thing is that
point common to all the channels. Thus, an event that a channel deflects upward when G2 is positive with
occurs at any of the electrodes connected to input 2 of the respect to G1 and downward when it is negative with
amplifiers will appear in each and every channel. This respect to Gl. Note that we say positive or negative "with
means that it is all but impossible to obtain multichannel, respect to:' This means that the polarity at any point is not
bipolar recordings using single-ended amplifiers. an absolute quantity but is the polarity relative to the vol-
It should be clear from the foregoing discussion that tage present at another point.
EEG recording as we know it today would not be feasible The unique ability of the differential amplifier to
if only the single-ended amplifier were available. To over- amplify the difference between the voltages simultane-
come the serious shortcomings of the single-ended ampli-
fier, the push-pull amplifier and the differential amplifier
2 Because of this. differential amplifiers are sometimes referred to
were developed. We will consider onlv the differential as "balanced" amplifiers. or amplifiers with a balanced input.
amplifier as the push-pull amplifier wa; merely a step in This is in direct contrast to single-ended amplifiers. which are
the development of the differential amplifier. also referred to as amplifiers having an unbalanced input.
Common-Mode Rejection 25

ously present at the two inputs gives rise to two important where the in-phase and out-of-phase input voltages are of
concepts in EEG technology, namely, the phenomena of equivalent amplitude. The EEG amplifiers may have
cancellation and summation. The importance of these con- CMRRs ranging from 1,000:1 to 20,000:1.
cepts can hardly be overemphasized as they determine the A simple example will help to clarify what CMRR means
size, shape, waveform, and polarity of the tracing seen in and how it is used. Suppose that your EEG machine has a
the EEG record. They are discussed in detail in a later CMRR of 1,.500:1. This means that common-mode vol-
chapter that deals with the topics of polarity and localiza- tages are not amplified - or multiplied by 1, which is the
tion. For the present, we will be concerned only with the same thing-while out-of-phase signals are amplified
phenomenon of cancellation. Moreover, we deal here spe- 1,500 times. Now consider an EEG voltage that is 7 1lY.
cifically with cancellation as it relates to the problem of 60 Amplifying this voltage 1,500 times yields 7 x 1,500 =
Hz and ECG artifacts in an EEG recording. In this con- 10,500 IlY or 10.5 mY. So we see that a 7-IlY EEG voltage
text, cancellation comes under the heading of an impor- produces the same deflection on the chart as a 10.5-mY
tant descriptive term applied to differential amplifiers. ECG voltage. If the EEG machine is set to the standard
This is the term common-mode rejection. deflection sensitivity of 7 11Ylmm, it is apparent that an
ECG voltage as large as 10.5 mY would have to be present
between each of a pair of EEG leads and ground before
Common-Mode Rejection being detected as a I-mm deflection in the tracing.
The CMRR of the amplifiers in an EEG machine has
the same effect on external sources of voltage as well,
We said earlier that a differential amplifier consists of that is, if they are common-mode signals. Of these, the
two balanced, single-ended amplifiers appropriately most troublesome for the EEG technician is the 60 Hz
joined together and that the output of this device is artifact from the AC power lines. The simple example
proportional to the difference between the voltages simul- used to explain what happens in the case of an ECG
taneously present at the two inputs. These inputs can artifact applies equally well to 60 Hz artifact. It is im-
be either out-oj-phase signals or in-phase signals; in-phase portant to recognize in this context that the degree of
signals are also referred to as comnwn-mode signals. Out- rejection that may be realized applies to the common-
of-phase signals are signals in which the voltages simul- mode voltage only. If the source of the common-mode
taneously present at both inputs of the differential am- voltage is from within the patient's body, as in the case
plifier are different, whereas in-phase signals are signals
of the ECG, it can happen that the voltages at the two
in which the voltages at both inputs are the same. Brain
inputs of the amplifier will not be exactly identical. This
electrical activity is a good example of the former, as
comes about mainly because the electrodes on the patient
there may be gross differences in the voltages present are not the same distance from the heart, which is the
even at two closely spaced points on the scalp. The ECG
source of the voltage, or because there is a wide gap
and 60 Hz artifacts are examples of in-phase or common-
between the electrodes. The important thing to recognize
mode signals. here is that voltage, at any point, varies inversely with the
The result is that brain electrical activity, being pri- distance from the source. This is one reason why ECG
marily an out-of-phase signal, gets amplified by the artifacts in the EEG are always larger with widely spaced
differential amplifier. On the other hand, 60-Hz activity electrodes and vice versa.
and the ECG are cancelled out. The degree to which An additional point that will be taken up in detail later
the in-phase voltages are cancelled out is determined when we discuss the topic of electrodes and electrode
largely by the extent to which the two halves of the ampli-
impedances deserves brief mention here. In order to real-
fier are balanced. How well common-mode voltages are
ize the CMRR quoted in the speCifications of a particular
cancelled out or rejected by a particular differential ampli-
amplifier, it is essential for the input circuit of the amplifier
fier is expressed in terms of the amplifier's common-mode
to be balanced. This means that the impedances of both
rejection ratio or CMRR. The CMRR of an amplifier is esti- leads in the pair need to be very nearly the same. If the
mated from the equation:
impedance of one lead happened to be substantially
higher than the impedance of the other, say 4 or 5 times
CMRR = voltage out for out-of-phase voltage in
voltage out for in-phase voltage in higher, the input circuit would become unbalanced and
the common-mode rejection capabilities of the amplifier
or, alternatively, would be significantly degraded. We see, therefore, that
when correctly utilized, the differential amplifier's ability
CMRR = Out-of-phase gain to reject common-mode voltages constitutes a powerful
In-phase gain method of eliminating artifacts from an EEG tracing.
26 3. The Differential Amplifier

3-Position
Switch
Input or
>-----Hi /"1
--V /
v=
2!3V
..
t
$ E>
RJI + R21 + R31
which means that V, the output voltage of the amplifier, is
I
• Output equal to the sum of the voltages across each of the resistors.
In other words, the total voltage divides itself across the
three resistors in proportion to their values. If R J , R 2 , and
R3 were all equal to each other, the voltage at the top of R3
would be equal to 1/3 V. With the three-position switch at
the top of R2 , as shown in Fig. 3.3, the output of the switch
is 2/3V. The chain of resistors wired to a switch in this
fashion is referred to as a voltage divider. The selector
Figure 3.3. Output of a differential amplifier connected to a switch may employ any number of different positions. For
three-position voltage divider. each additional position, an additional resistor is con-
nected in series with the rest.

Sensitivity or Gain Amplifier Noise

As was mentioned in Chapter 1, the voltages commonly Ideally, the tracings on the chart corresponding to each
recorded in the EEG cover a wide dynamic range. At the channel of the EEG machine should each be a completely
low-amplitude end of the scale, voltages as small as 2 /lV straight, horizontal line when the inputs of the amplifiers
need to be detected in brain death recordings, while at the are connected to zero volts.3 Although this should be the
high end voltages as large as 2,000 /lV or 2 mV are encoun- case for a properly operating EEG machine switched to a
tered in hypsarrhythmia. To provide for this wide dynamic standard gain of 7 /l V/mm, it is rarely true when the
range, all EEG amplifiers have a switch for changing the machine is adjusted for the maximum gain of 1 /lV/mm.
sensitivity or gain to accommodate these different vol- Note that at such high gains, the pens do not describe an
tages. A frequently used design employs a 12-position even trace but appear to wander about randomly. This is
rotary switch that permits the EEG technician to select the so-called internally generated noise and is normal for
deflection sensitivities from 1 /lV/mm to 70 /lV/mm. Some all machines at maximum gain. For routine clinical work,
EEG machines also employ a two-position gain multiplier noise level should be less than 2 /lV peak-to-peak referred
switch. When this switch is in the "/l V/mm" position, to the input.
deflection sensitivity is read from the 12-position rotary Where does this noise come from? Noise or random vol-
switch in microvolts per millimeter. When, on the other tage fluctuation is an inherent characteristic of all resistors,
hand, the gain multiplier switch is in the "mV/cm" position, vacuum tubes, and transistors of which an amplifier is con-
deflection sensitivity is in millivolts per centimeter. The structed. Some of these devices produce less noise than
latter range of sensitivities gives flexibility to the machine. others of their kind by reason of their construction. Thus,
When hooked up with the appropriate transducer, these for example, so-called low-noise resistors are used in cer-
settings are used to record other physiological phenomena tain sensitive portions of the circuit of an EEG amplifier.
like pulse rate, respiration rate, body temperature, blood The connections in a rotary switch, or for that matter any
pressure, etc. kind of switch, can also generate noise. This is the reason
The gain changes are accomplished by a simple applica- why EEG technicians are frequently seen to be repeatedly
tion of Ohm's law. Figure 3.3 shows how this is done. The indexing the switches on a noisy channel of the EEG
output of the differential amplifier is connected to one end machine. By this maneuver they hope to clean the switch
of a chain of three resistors (R(> R2, and R3) in series, the contacts and hence reduce the noise level. A leaky capaci-
other end of which is connected to ground. With an out-of- tor can also produce noise, and even the solder joints used
phase voltage applied to the input of the amplifier, a cur-
rent will flow through the resistors. By Ohm's law,
3 How do you go about connecting the inputs of a differential
amplifier to zero volts? A little thought will show that the sim-
I =
v plest way of doing this is to connect Gl and G2 together. This
maneuver is referred to as "short-circuiting" the input of the
amplifier; it brings both inputs to the same voltage so that the
Solving the equation for V, we have difference between the two is zero volts.
Input Impedance 27

Figure 3.4. Schematic of the A. B.

connections from scalp to Scalp-Amplifier Equivalent
electrodes to amplifier in Interface Circuit
EEG recording (A), and
equivalent circuit of the
same (B).

Scalp

to connect the various components found in an amplifier and amplifier to the source. To satisfy this requirement, the
may be noisy. Modern technology notwithstanding, the input impedance or impedance looking into the input of the
maximum noise-free gain required by an EEG amplifier is amplifier must be very high - many, many times higher
close to the theoretical limit available by ordinary methods. than the impedance of the electrodes. Input impedance of
the differential amplifiers in an EEG machine is com-
monly 20 million ohms (abbreviated 20 megohms, or 20M
Input Impedance ohms) or higher.
Why is a high-input impedance essential? The reason
We have discussed a number of important characteristics may be understood from a perusal of Figs. 3.4A and B. The
of a differential amplifier- common-mode rejection, gain, circuit in Fig. 3.4B will be recognized as a voltage divider
and noise. One very important characteristic remains to be to which V, the true EEG voltage is connected. This vol-
considered and that is input impedance. We have already tage divides itself across the electrode impedances and the
discussed impedance in general. Recall that impedance is amplifier impedance in proportion to their magnitudes. If
designated by the symbol Z; in the circuits that the EEG the amplifier impedance is not very high with respect to
specialist deals with, Z consists of two components, resis- electrode impedance, then a substantial fraction of V will
tance and capacitive reactance. appear across the electrodes and the voltage appearing
It will be helpful to begin our discussion of this topic by across the amplifier will be significantly less than V. We
considering an important property that is shared by all speak of this as a condition in which the signal being
measuring instruments. To yield valid measurements, a observed is "loaded" by the input circuit of the measuring
measuring instrument must not have any backward effect device. It is obvious that as amplifier Z increases and
on the phenomenon being measured. By way of example, becomes very large, the voltage appearing across the
suppose that you wished to measure a patient's respiration amplifier will very closely approximate the voltage at V, the
rate by tying a loop of wire containing a strain gage trans- true EEG voltage. Refer to Fig. 2.4, Chapter 2, for com-
ducer around the patient's chest. Each inspiration and putational formulas.
expiration would be picked up by the strain gage. By To obtain the high input impedances required for an
appropriately displaying these on a channel of the EEG EEG amplifier, a specially designed transistor is used in
machine, you could count the number of waves occurring the input stage. This device is referred to as a field-effect
in a minute's time and, in so doing, estimate the respiration transistor or FET. Recent advances in transistor technol-
rate. But the respiration rate estimated in this way would ogy have resulted in the development of new and even
only be the true rate if the loop of wire had no effect upon better FETs. Among them are the junction field-effect
the patient's breathing. If, for example, the wire were too transistor (JFET) and the insulated gate FET (IGFET).
tight, it could interfere with normal breathing and yield a But these are highly technical subjects that are unlikely to
spurious result. This is an example of the backward effect be of concern to the EEG specialist.
of a measuring instrument upon the phenomenon being
measured.
Each channel of the EEG machine may be considered Special-Purpose Connections
an instrument for measuring various features of the EEG.
Among these features is the voltage of the waves recorded. Most modern EEG amplifiers have an output jack that is
To validly measure voltage, the voltage appearing at the used for connecting the amplified EEG voltage to some
scalp must not be modified by connecting the electrodes peripheral device such as, for example, a cathode-ray oscil-
28 3. The Differential Amplifier

loscope, an instrumentation tape recorder, a computer, or The EEG Amplifier as a Whole

the like. This jack can be found somewhere on the front
panel of the amplifier or in a central location on the The differential amplifier is employed only at the first stage
machine console. The voltage available at this jack is of amplification in an EEG machine. Once the advantages
referred to as the IRIG output, which is nothing more than of the differential amplifier have been realized, the
a 2.S-V (peak-to-peak) signal that corresponds to a 25-mm differential signal is converted to a single-ended signal and
pen deflection on the EEG chart. The letters IRIG stand the rest of the necessary gain is provided by single-ended
for Inter-Range Instrumentation Group.4
amplifiers. Details of the conversion process need not con-
Some EEG machines have an IRIG input jack as well.
cern us here. The various stages of amplification are cou-
This jack is used to play back signals from a tape recorder pled together by means of capacitors. These so-called
onto the EEG chart. A 2.S-V (peak-to-peak) signal fed into
blocking capacitors are used to prevent any DC voltages
this jack will result in a 25-mm pen deflection.
from being transmitted from one stage to another and
These special-purpose connectors are not used in most thereby being amplified. More will be said about the oper-
clinical EEG laboratories. They are mentioned here, ation of blocking capacitors in the chapter on filters.
however, because a few laboratories do store EEG records
on magnetic tape. Moreover, their use is essential
whenever video display techniques are used, as in seizure
monitoring (See Chapter IS).

4 The Inter-Range Instrumentation Group was a group of recorder as it is called. For this reason, standardization proce-
engineers from various guided-missile-testing ranges around the dures included specifications for mag tape recorders. Among the
country. This group felt the need for standardizing the telemetry specifications called out is the standard input voltage operating
systems that were being used in guided-missile testing so that a level. Therefore, when we say that an EEG amplifier has an !RIG
system used on one range would be interchangeable with a sys- output available or is !RIG compatible, this means that the ampli-
tem used on another. One device used extensively in telemetry fier may be directly connected to (interfaced with) any modern
systems is the instrumentation tape recorder, or "mag" tape mag tape recorder.
Chapter 4
Filters

If the amplifier is the heart of the EEC machine, then the Basic Concept and Function
filters could rightly be referred to as the brain. The filters
are the selective devices that screen out unwanted signals
and determine which features of the EEC will appear in Ideally, a filter should admit, without modification, vol-
the tracing. As we already mentioned in Chapter 1, there tages of all frequencies that are of interest; at the same
are three different types of filters on modern EEC time, it should completely reject voltages of unwanted
machines: low-frequency filters, high-frequency filters, frequencies. Thus, for example, if we were interested in
and 60-Hz "notch" filters. All three types operate accord- voltages within the frequency range of 1 to 35 Hz, the
ing to the same basic principles. We will consider the prin- "ideal" filter for this purpose would function as shown in
ciples of operation first before going into the details of how Fig. 4.1. But as we will see, there is no such thing as an
they actually function. ideal filter. Indeed, the filters commonly found on an EEC
machine are far from ideal. For this reason the individual
interpreting EECs, as well as the EEC technician, needs
to be thoroughly familiar with the way in which filters
The Need for Filtering function.
In Chapter 2 we showed that the impedance of an elec-
In our treatment of amplifiers in the last chapter, little was trical circuit varies with changes in frequency of the vol-
said about the frequency characteristics of the voltages tage that is applied to it. A simple computational example
that were amplified. Indeed, aside from the fact that the revealed that the impedance of a series R-C circuit, where
60-Hz power line voltage is discriminated against, the R = 10K ohms and C = 1 IlF, changed from a value of
differential amplifier we discussed amplifies - within cer- 159,550 ohms at 1 Hz to a value of 10,986 ohms at 35 Hz.
tain practical limitations - voltages over the entire spec- The reason for this difference in impedance is that the
trum of frequencies as well as any DC voltages. This means capacitive reactance, which is a component of the imped-
that we would see all varieties of electrical activity in the ance, is a frequency-sensitive quantity. The fact that
output in addition to the EEC voltages. For example, there capacitive reactance changes with frequency is the oper-
could be static (DC) potentials from the electrodes, sweat ating principle upon which the filters in an EEC machine
artifacts, galvanic skin potentials, and eye movement work. This makes the capacitor the most vital part of the
artifacts in the low end of the frequency spectrum. In the filter circuit.
intermediate range of frequencies, there could be muscle The EEG filters are just one of a class of so-called
action potentials present, while at the high-frequency end "tuned" circuits. A more common type of tuned circuit is
we could observe transmissions from local radio stations the frequency-selective circuit in a radio or television
that send out especially strong signals. In other words, receiver-the circuit that is adjusted when you tune in a
aside from the common-mode rejection feature, the ampli- particular station or channel. Such circuits, which in real-
fiers in an EEC machine have little or no selectivity as far ity are sharply tuned filters, admit only a very narrow band
as frequency of the input voltage is concerned. The filters of frequencies while sharply attenuating all the rest. These
provide the necessary selectivity. circuits, along with all other filter circuits, follow the same
30 4. Filters

100% voltage from getting into the amplifier and being ampli-
fied . This is accomplished by an interesting property of
capacitors that was discussed in Chapter 2. This property
is simply that a capacitor has the unique ability to block
Frequencies Frequencies
Rejected -r..A~omlltleltt-I--Rejected · - - the transmission of steady or unchanging voltages.
The impedance of each half of the circuit is given by the
expression

0% ' - - - ---"=
0.1 1.0 10 35 100
Frequency (Hz) _ _

Figure 4.1. Response of an "ideal" filter. To simplify the analysis, we consider only one half of the
filter; the other half being identical, the same analysis
applies. Taking the voltage between electrode A and elec-
basic design concept, namely, that impedance of an elec- trode C (ground) as V in , the input to the upper half of the
trical circuit varies with changes in frequency. filter, and the voltage across Rl as Vou!> the output, we
have, by Ohm's law,

Low-Frequency Filter
Although it was not pointed out at the time, the circuit and again by Ohm's law,
(Fig. 2.8) that was analyzed in our discussion of frequency
response is, in reality, a low-frequency filter. Let us return
now to this circuit and discover how the circuit is used to
prevent voltages at the low end of the frequency spectrum
The ratio of V out to V in , which is referred to as the transfer
from getting into the EEG tracing.
characteristic of the filter, is equal, by simple algebra, to
Figure 4.2 shows a low-frequency filter with its input
end connected to a pair of electrodes attached to the scalp
of a patient and the output connected to the differential
amplifier of one channel of an EEG machine. The filter cir-
cuit is balanced, that is, Rl = R2 and C 1 = C2. As we Note in this formula that for large values off, the capacitive
pointed out in an earlier section of this chapter, the signal reactance or l06/21tfC I can become quite small so that
led off from the scalp by the electrodes consists of a variety VoutNin approaches its maximum value of 1. The opposite
of electrical phenomena in addition to the EEG voltages. effect takes place at the other end of the frequency spec-
This signal can include a wide range of frequencies and trum. Thus, as f decreases and attains smaller and smaller
may include a DC voltage from the electrodes as well, as values, capacitive reactance becomes larger, the overall
we will discover in a later chapter (Chapter 7). One pur- impedance increases, and VoutI'V in becomes smaller and
pose of the low-frequency filter is to prevent any such DC smaller.

Scalp
/
Electrodes
I I
f-- Low Frequency
Filter
--l ~ Differential
Amplifier
1
/ I
/

\
/ I
/ I /
I
/ /
I / I
/ I I
I C1
/ I /
I I

A /
/
I
'
I /
/ I
/
7
/ Output
B I
Figure 4.2. Circuit for a low-
C2 frequency filter in an EEG
- machine.
High-Frequency Filter 31

Figure 4.3. Asymptote plots 0 100 r--------

~
I
I
showing the frequency response I
c I
of a low-frequency filter. Solid .2 I
i 80 /
line, cutoff frequency = 1 Hz; :::J I
dashed line, cutoff frequency = c 3 II I
! "g
/
0.3 Hz. :( ~ I
III ii. 60 /
Ii E /
~ 6 c(
uII C 40 I
0 II I
~
t
I
I
12 I
20 I
I
I
/
0
0.1 0.25 0.5 1.0
Frequency (Hz) .. 10

As was mentioned earlier in Chapter 2, the ratio of Figure 4.3 also shows that changing the cutoff point of
Vou/Vin when frequency is allowed to vary is termed the the low-frequency filter from 1 to 0.3 Hz simply shifts the
frequency response of the circuit. Frequency-response asymptote to the left by 0.7 Hz at the 100% amplitude
curves are plotted with frequency in hertz units on the point. This is shown by the dashed lines that meet at the
horizontal axis and amplitude on the vertical axis. Fre- 0.3 Hz point. Note that in this case as well, the line defin-
quency is always plotted on a logarithmic scale, while ing the cutoff falls at the rate of 6 dB/octave, which means
amplitude is plotted on a linear scale as a ratio or percen- that when frequency is halved or equal to 0.15 Hz, ampli-
tage of the maximum voltage, or on a logarithmic scale in tude is also halved or attenuated by 50%. The same princi-
decibels (abbreviated dB). In the case of a filter, Vin is the ple applies to the other settings on the low-frequency filter.
maximum voltage so that the ratio Vou/Vin comes out to be Thus, for example, in the case of a cutoff frequency of 5 Hz,
less than 1. the asymptote plot is shifted to the right.
In Chapter 2 we learned that in terms of the circuit
parameters, the cutoff frequency of a series R-C circuit is
Low-Frequency Response- equal to 10 6 /2nRC Hz. In practical terms this means that
when you switch from one low-frequency filter setting to
Asymptote Plot another, what you are doing is changing the values of C or
R, or the values of both in the circuit. Larger values of C or
Although the frequency response of a circuit is described R go along with lower cutoff frequencies, whereas smaller
by a curve and not by a straight line, for the sake of simplic- values go along with higher cutoff frequencies.
ity it frequently is approximated by straight lines. Figure
4.3 shows the straight-line approximation for the low-
frequency filter shown in Fig. 4.2. The two solid lines in High-Frequency Filter
the graph define the response of the filter when it is set for
a cutoff frequency of 1 Hz, the standard EEG setting. Surprising as it may seem, the high-frequency filters on
Observe that these lines meet at the cutoff point, with the an EEG machine employ the same kind of circuit as the
line to the right of the cutoff point being parallel to the low-frequency filters. Both use a series R-C circuit, the
horizontal axis. The straight line to the left of it falls off at only morphological difference between the two being
the rate of 6 dB/octave; which means that when frequency the position of the circuit parameters with respect to the
is halved, amplitude is also halved or attenuated by 50%. output. As we have seen in Fig. 4.2, the output of the
Thus, the amplitude at 0.5 Hz is one half the value at 1 Hz. low-frequency filter is taken across the resistor. In the case
The straight-line approximation of the frequency- of the high-frequency filter on the one hand, the output
response curve is called the asymptote plot. This name is taken across the capacitor in the circuit. Another dif-
derives from the fact that the straight lines define the ference between the two kinds of filters is their loca-
asymptotes of the actual or true frequency-response curve. tion within the EEG amplifier. Thus, while the Iow-
Characteristics of the true curve are discussed later in frequency filter is commonly placed at the input to the
this chapter. differential amplifier or in the very early stages of amplifi-
32 4. Filters

cation, the high-frequency filter is located down the line the capacitance in the amplifier circuit. An examination of
from the input. Fig. 4.4 shows that C is in parallel with the input to the next
Figure 4.4 gives the basic circuit for a high-frequency stage of amplification. This being the case, the current
filter. Note that the circuit is placed after the differential flowing through R must divide between C and the ampli-
amplifier and after the voltage of interest has been con- fier of the next stage. Since impedance due to the capacitor
verted to a single-ended signal. This being the case, only a decreases with increasing frequency, the C branch of the
single R-C branch is required. As in the instance of the circuit is a low-impedance pathway for the high frequen-
low-frequency filter, the current in the circuit is given by cies. Therefore, increasingly higher frequencies may be
the expression thought of as being shunted away from the amplifier input
by the C.
I Vin
= .JR2 + (10 B/21tjCY
and VR, the voltage across the resistor, is High-Frequency Response-
R Asymptote Plot
VR = RI = .JR2 + (10B/21tjC)2 Vin'
The frequency response of a high-frequency filter can be
Since Vin divides between the two elements in the circuit, approximated by straight lines, as with the frequency
response of the low-frequency filter. Figure 4.5 shows the
straight-line approximation or asymptote plot for the high-
or, rearranging terms, frequency filter in Fig. 4.4. The two solid lines in the graph
define the response of the filter when it is set to a cutoff fre-
quency of35 Hz. These lines meet at the cutoff point, with
Substituting for VR in this equation, we have the line to the left of the cutoff point being parallel to the
horizontal axis. The straight line to the right falls off at the
R rate of 6 dB/octave, which means that the amplitude is
V out = V in - .JR2 + (106/21tjC)2 V in
attenuated by 50% at a frequency of 70 Hz.
The dashed line in Fig. 4.5 shows the corresponding
Vout = Vin ( 1 - .JR2 + (~OB/21tjC)2) asymptote plot when the cutoff frequency of the filter is set
instead to 70 Hz. Observe that the result is to shift the
and entire graph to the right. The dashed-line graph is inter-
preted in the same way as the solid-line graph.
Vout _ 1 R
Vin - - .JR2 + (10B/21tjC)2
In the formula for Vou/Vin it is apparent that when f is High- and Low-Frequency Response
very small, the quantity
Combined -The True Curve
.JR2 + (10B/21tjC)2
can become quite large. This causes the fraction If the reader will visually combine the asymptote plots of
Figs. 4.3 and 4.5, it will be apparent that the combined
R frequency-response curve of the amplifier-filter combina-
.JR2 + (106/21tjC)2 tion is described by a flat-topped pyramid. This pyramid
to become very small, with the result that Vou/Vin becomes flatter and flatter as the bandwidth of the
approaches the maximum value of 1. On the other hand, amplifier - which is to say, the range of frequencies that are
as fbecomes larger and larger, the fraction amplified - becomes wider. Referring back to Fig. 4.1, it is
obvious that there is a vast difference between the fre-
R
quency response of a real filter and the ideal filter. While
.JR2 + (106/21tjC)2
real filters - the filters on the EEG machine - attenuate
approaches a value of 1 and Vou/Vin approaches zero. In the unwanted frequencies at a rate of 6 dB/octave, the ideal
other words, higher frequencies are increasingly attenu- filter achieves 100% attenuation instantaneously. The
ated by the circuit. Note that this is the exact inverse of ideal filter is analogous to an ideal racing automobile - a
what happens in the case of the low-frequency filter. car that would be capable of accelerating from zero to say
Another way of interpreting the manner in which the 150 mileslhour instantaneously. For obvious reasons, such
high-frequency filter works is to focus on the position of a racing car is only a dream. So also is the ideal filter.
High- and Low-Frequency Response Combined 33

Figure 4.4. Circuit for a high- Differential High Frequency

frequency filter in an EEG I" Amplifier "I I.. Filter _I
machine.

Output R To Next
Input Stage Of
Amplification

I
Figure 4.5. Asymptote plots 0 100 ----, \
showing the frequency \
\

1
response of a high-frequency c:

•
.2 \
80
filter. Solid line, cutoff fre- \
:l \
quency = 35 Hz; dashed line, c: 3 "
'g \
cutoff frequency = 70 Hz. ~
."
~
a. 60
\

\
'i E
\
.c 6 c(
'u E 40 \

"
Q "
~
\
\

~ 12 "
\
11. \
\
20 \

0
10 50
Frequency (Hz)
100
- 250 1000

But we have been speaking only of the asymptote plot of (low-frequency cutoff of 1 Hz, high-frequency cutoff of 35
the combined low- and high-frequency filters. The true Hz) for the amplifiers plus filters of most EEG machines.
plot - the true frequency-response curve - represents yet The single exception to this occurs in the EEG machines
an additional step removed from the ideal. Figure 4.6 made by the Grass Instrument Company. By virtue of a
shows the difference between the asymptote plot and the somewhat different design, the true curve of their filters is
true plot of the combined curve for a low-frequency setting down only 20% from the asymptote plot at the cutoff fre-
of 1.0 Hz and a high-frequency setting of 35 Hz. By con- quencies. Also, when the cutoff frequency is halved, the
vention, the standard points of reference in dealing with amplitude is down by exactly 50%. This imparts an "S"
the true curve are the amplitudes at the high and low shape to the curves of the Grass machines.
cutoff points. We see in Fig. 4.6 that the amplitudes at 1.0 It is important to point out that the frequency-response
Hz and at 35 Hz in the true curve are only 70% of the curves as discussed in this chapter are for the amplifiers
amplitudes in the asymptote plots at the corresponding plus filters with the appropriate high- and low-frequency
points. In other words, amplitude is down 30% at the settings. In other words, the response curves do not reflect
cutoff frequencies. Note that amplitude is also reduced, the effects due to the writer unit and pen. The pens on the
but to a progressively lesser and lesser degree, on either EEG machine, of course, have inertia, and for this reason
side of the cutoff frequencies. they have a profound effect on the overall high-frequency re-
Figure 4.6 defines the true frequency-response curve sponse. This topic is discussed in detail in the next chapter.
34 4. Filters

100 .- "-
Figure 4.6. High- and low-
/
"-
frequency response curves
""
/
/
combined. Solid line, asymp-
1
/ \
/
80 \

I
/ \
\
tote plot; dashed line, true
II
'tI I \
\
frequency-response curve.
/
~ \
ii 60
/
I \
E / \

""E 40 I
I
I \

II
I
~ /
II
11. /
/
20

0
1.0 10 100 1000
Frequency (Hz) -----i~
..

60-Hz Notch Filter l Figure 4.7 shows the frequency-response curve of such
a filter. This is a true curve. Note in the figure that although
the cutoff is considerably sharper than the 6 dB/octave
Despite the common-mode rejection feature of the
cutoff of the other filters, a substantial proportion of the
differential amplifiers used in an EEG machine, 60 Hz
adjacent frequencies is attenuated by the 60-Hz filter.
artifact can be a formidable problem when EEGs are
Thus, for example, we see that amplitude at 40 Hz is
recorded. There are three major reasons for this. In the
attenuated by about 30%. If the high-frequency filters on
first place, some environments in which the EEG machine
the EEG machine happened to be set to a cutoff frequency
is operated have such high 60-Hz levels present that the
of 70 Hz, it is clear that the overall high-frequency
common-mode rejection ratio cannot eliminate them.
response would be determined primarily by the 60-Hz
Second, although 60-Hz activity is a common-mode or in-
notch filter and not by the former. For this reason, routine
phase signal, there are times when the amplitudes at both
use of the 60-Hz filter is discouraged.
inputs of the differential amplifier are not identical. When
The 60-Hz notch filters are a fairly recent addition to the
this happens, we end up with some out-of-phase 60-Hz
EEG machines used in routine clinical electroencephalog-
activity that gets to be amplified along with the EEG vol-
raphy. Their presence is attributable to some technological
tages. Finally, the circuit connected to the inputs of the
advances that were not readily available in the 1960s. For
differential amplifier may not be balanced, as when the
this reason, some machines in use may not have the notch
impedances of the two electrodes are different. This
filter available. The technological advances and the
degrades the common-mode rejection ratio of the ampli-
methods whereby the sharper cutoff of the notch filter is
fier and results in an elevated 60-Hz level in the EEG
accomplished need not concern us here.
recordings.
The answer to all these problems is the 60-Hz notch
filter. This type of filter is referred to as a band-elimination
Interpreting the Frequency-Response
filter or trap since it attenuates a narrow band of frequen-
cies that are unwanted. Here, again, we can think of an Curve and the Use of Filters
"ideal" case. The ideal 60-Hz filter is a device that would
Suppose that the filter settings on an EEG machine are
remove only the 60-Hz activity without affecting any adja-
as shown in the frequency-response curve of Fig. 4.6. In
cent frequencies. Although the ideal is not attainable, the
other words, the low-frequency filter switch is set to 1 Hz
60-Hz filters on present-day EEG machines are more
and the high-frequency filter switch is set to 35 Hz. Sup~
sharply tuned than the low- and high-frequency filters that
pose, also, that the machine is calibrated and set for a
we have been discussing.
deflection sensitivity of7 IlV/mm. This means that a 10-Hz
signal at 50 Il V will yield a pen deflection of 7 mm on the
I Some countries, including all of Europe, lise 50-Hz instead of
chart. What pen deflection will a I-Hz signal at the same
60-Hz AC. In such cases, the problem is 50 Hz artifact and a voltage yield?
50-Hz notch filter is employed. The answer to this question comes directly from Fig.
Interpreting the Frequency-Response Curve and the Use of Filters 35

!"
Figure 4.7. A 60-Hz notch 100
;-
----
,-
filter as used in an EEG "-
,-
,-
"-
machine. 80 "- ,, /
II
,, /

a
I
I
Q. 60 \ I
E \ /
C \ /
C \ I
II 40 \
I
t!
:.
\

20
,, III
,I
,I
0
20 40
"
60 100 200 400 1000
Frequency (Hz) •

4.6-from the frequency-response curve. Observe in Fig. the tracing will be reduced without appreciably changing
4.6 that amplitude at 1 Hz is only 70% of the amplitude at the amplitude of the alpha rhythm. Other examples of a
10 Hz. Therefore, the deflection for a I-Hz signal will be similar nature could be mentioned. We leave these for the
0.7 times the deflection of a 10-Hz signal or 0.7 x 7 mm reader to discover.
= 4.9 mm. This means that when we observe delta activity The standard settings for the filters in routine clinical
at 1 Hz in a tracing with the low-frequency filter of the electroencephalography are I-Hz low-frequency cutoff
machine set to 1 Hz, this activity is in reality somewhat and 70-Hz high-frequency cutoff. However, as we will see
larger than it appears in the tracing. in the next chapter, the upper limit of the high-frequency
The same logic may be applied to electrical activity of response with the high-frequency filter set to 70 Hz is
any frequency. For example, Fig. 4.6 shows that a 35-Hz limited by the inertia of the writer unit and pen. Standard
signal also will yield a 4.9 mm deflection for an amplitude practice requires that the 60-Hz notch filter be used only
of 50 Il V. The frequency-response curves for all filter set- when it is absolutely necessary.
tings will be found in the instruction manual that goes with The recommended high-frequency setting requires
an EEG machine. The EEG technician and interpreter some explanation. Knowing that the upper limit of beta
alike should become thoroughly familiar with these activity is about 35 Hz, why is a 70-Hz cutoff frequency
curves. employed? The answer is that spikes, which are a feature of
Although we have spoken of the filters primarily as a seizure activity, are equivalent to high-frequency activity
means of eliminating artifacts or unwanted voltages from and cannot be recognized in a tracing unless the maximum
the EEG voltages, the filters have another important use. high-frequency response is employed. The reader can
Some features of the EEG may be accentuated while verify this for him or herself by recording spike activity on
others may be reduced by careful use of the filters. For adjacent channels of the same machine, with the high-
example, suppose that some portions of a patient's sleep frequency filter of one channel set to 70 Hz and the high-
record suggested that there may be an asymmetry in the frequency filter of the other to 15 Hz. If this is done, it will
sleep-spindle activity, but that the recording was partially be apparent that the character of the spikes is profoundly
obscured by the high-amplitude, slow-wave activity of changed at 15 Hz. By comparison with the tracing at 70
sleep. Here is where the low-frequency filters come in. Hz, the spikes are rounded and have lost an important fea-
Switching the low-frequency filter from 1 to 5 Hz will ture of their identity. For this reason, the standard filter
eliminate a greater portion of the slow-wave activity with- settings should be strictly adhered to. There should always
out significantly attenuating the sleep-spindle activity. be a good reason for using settings that are not standard.
This simple device permits a closer appraisal of the possi- Filters should never be used to indiscriminately "clean up"
bly asymmetry. a record.
Similar use may be made of the high-frequency filter at On some of the older vintage EEG machines, the high-
the opposite end of the EEG frequency spectrum. Thus, frequency filter occasionally was referred to as a "muscle
it may happen that a patient's alpha rhythm becomes filter:' Should this filter be used to remove muscle-activity
obscured by excessively high-amplitude beta activity. By artifacts from the EEG? The answer to this question is a
switching the high-frequency filter from a cutoff frequency qualified yes. The high-frequency filter is used for this
of 70 Hz to a cutoff frequency of 35 Hz, the beta activity in purpose only when all other methods of eliminating
36 4. Filters

muscle-activity artifacts have failed. The reason for this is Summary

that the tips of any remaining muscle spikes become sig-
nificantly rounded when the high-frequency filter is set At this point the reader may find it useful to refer back to
below 70 Hz. This being the case, the muscle activity- Fig. 1.5, which summarizes the basic function of the high-
especially that appearing in the anterior regions - can eas- and low-frequency filters in relation to the EEG frequency
ily be mistaken for beta activity. By providing the patient a spectrum. This figure shows the way in which the EEG
comfortable cot or lounge chair to recline on and helping tracings differ when different bandwidths are used. How
him or her to relax, it is frequently possible to eliminate the frequency response of an EEG machine is assessed and
muscle artifacts at their source, thereby avoiding use of the the role played by the time constant in assessing frequency
high-frequency filters. More will be said about this in response are taken up in Chapter 6, "Calibration and
Chapter 13. Calibration Methods:'
Chapter 5
The Writer Unit

The writer unit is the business end of the EEG machine. whom we had occasion to mention in Chapter 2. Faraday
Although the workings of the rest of the EEG machine are showed that changing the magnetic field surrounding a
easily forgotten or taken for granted, the writer unit and its conducting circuit caused a current to flow-to be
problems are a part of an EEG technician's day-to-day rou- induced - in the circuit. By way of example, consider the
tine. To make the best use of the writer unit and to aid in illustration in Fig. 5.1. If you rotate the armature through
the interpretation of the tracing, some knowledge and an arc of, say, 10 degrees, a change is produced in the mag-
understanding of the way in which it functions is valuable. netic field surrounding the coil of wire wound around the
Regardless of its design or manufacturer, the writer unit armature. Because the magnetic field is "cut" by the arma-
consists of four major units: (1) the penmotors or direct- ture, a current is induced in the armature circuit. In other
writing oscillographs, sometimes referred to as galvanome- words, mechanical movement produces an electric cur-
ters; (2) the pens and pen mounts; (3) the inking system; rent.
and (4) the chart drive. We consider each of these in turn. Now it happens that the phenomenon just described
works in the opposite direction as well. If you connect the
armature circuit to an external voltage, so that current
Penmotors flows in the coil of wire, the armature will move (rotate).
Briefly, this happens because the current flowing in the
The pen motors are electromechanical transducers that coil of wire sets up a magnetic field that interacts with the
convert electrical energy into mechanical movement. field of the magnet. This interaction of forces produces a
Movements of the pen - the deflections from the base- rotation of the armature. The amount and direction of the
line - are proportional to the voltage of the signal applied rotation depend on the strength and direction of the cur-
to the input of the machine. This being the case, the pen- rent flow.
motor functions basically as a recording voltmeter. As we
already mentioned in Chapter 1, a pen motor has the attrib-
utes of an electric motor. Like an electric motor, it consists Penmotor Frequency Response
of an armature mounted between the poles of a magnet in
such a way that it is free to rotate. Wound around the arma- It was mentioned in the chapter on filters that the high-
ture is a coil of wire that turns with the armature when it frequency response at a cutoff frequency of 70 Hz is deter-
rotates. This arrangement is shown in schematic form in mined largely by the characteristics of the penmotor. The
Fig. 5.1. One major difference between a pen motor and reason for this will be apparent from a careful perusal of
the common variety of electric motor is the range of rota- Fig. 5.1. Note that the armature terminates in a shaft to
tion that is possible. Whereas the armature in an electric which the pen is attached. Not shown in the schematic dia-
motor makes a complete, full-circle rotation, the armature gram is the structure-the rod and bearing-that supports
in a penmotor is limited to a rotation of less than 45 the armature and pen assembly. Although this assembly is
degrees of full circle. designed and fabricated in such a way so as to be as light as
The operation of a penmotor depends on the principles possible, its weight nevertheless is not negligible. This
of electromagnetic induction. Most important of these is being the case, the armature and pen assembly cannot be
the principle discovered in the 1830s by Michael Faraday, driven without Significant loss of amplitude at the higher
38 5. The Writer Unit

, /
Pen Stylul between this arc and a line perpendicular to the baseline
is referred to as the error of the arc. The magnitude of this
error depends on the length of the pen and is best
o
appreciated by deflecting a pen on one channel of the
\
\ machine when the paper is not moving. Note that the error

" is the distance between the position of the pen and the
location of a corresponding spot on the perpendicular line
drawn from the pen's baseline position. Error of the arc
increases in magnitude as the amplitude of the pen deflec-
tion becomes larger; it can readily be perceived when
there are large pen deflections.
It is essential to keep the error of the arc in mind when
making comparisons between tracings on different chan-
Mlgnet
nels, as when a record is examined with the purpose of
determining the origin of multifocal spike activity. If the
Current From Power amplitude of the activity displayed on the channels that are
Amplifier Output
compared is not the same, some misleading conclusions
Figure 5.1. Schematic diagram of a typical penmotor. may be drawn. Consider, for example, a spike that appears
as a 5-mm deflection from the baseline position on channel
I and that also appears on channel 4 as a 5-mm deflection
frequencies, or frequencies above 70 Hz; thus, at 95 Hz the from the peak or trough of a slow wave. Although the spike
amplitude on most machines is already down by 50%. appears to occur earlier in time on channell than on chan-
Although this is not objectionable in EEG work, it is nel 4, the appearance is clearly an artifact resulting from
important to keep these facts clearly in mind when the the error of the arc.
high-frequency filter is set to a cutoff frequency of 70 Hz. Problems associated with the error of the arc are
avoided by the use of rectilinear recording. Indeed, a rec-
tilinear recording is the only tracing that shows the true
Pens waveform of the EEG. Rectilinear recording is accom-
plished with the use of pens that are attached to the arma-
A variety of different kinds of pens and pen mounts are ture shaft of the pen motor via a coupling mechanism that
found on different EEG machines. The pens may provide corrects for the error of the arc mechanically. Unfor-
either curvilinear or rectilinear tracings, although cur- tunately, this mechanism is quite delicate and easily
vilinear tracings are standard on most machines used for damaged by heavy routine clinical recording with restless
routine clinical work. Pens are narrow-gage metal tubes, patients. For this reason, rectilinear recording is not in
one end of which is curved and drawn out to a fine tip - the common use.
writing tip. The metal tube is glued or soldered to a thin
metal strip that serves as a stiffener. The end of the
stiffener opposite the writing tip is fitted with a shaft, Pen Mounts
rigidly mounted at right angles to the tube, which snaps
into place in the pen mount. Sometimes the pen has a The pen mounts, or cradles as they are sometimes called,
sapphire tip inserted into the writing end of the tube. A serve two purposes. First, they hold the pens firmly to the
sapphire tip provides for considerably longer wear but is armature shaft while at the same time providing for quick
more fragile than the metal writing tip. removal and replacement. Second, they provide a means of
adjusting the amount of pressure that the pens exert on the
chart paper while the recording is going on. Sufficient
Error of the Arc pressure is needed for the ink to flow properly. At the same
time, too much pressure can reduce the high-frequency
Curvilinear tracings are produced by straight pens that are response of the channel and, in some cases, modify the
rigidly attached to the shaft of the armature. Such a pen is time constant.
shown in the diagram of Fig. 5.1. When this pen is The manual that comes with the EEG machine should
deflected, it does not trace out a line perpendicular to the be consulted for information about pen-pressure adjust-
baseline but describes, instead, an arc of a circle having a ment. Some machines provide a gage - a scale-like device
radius equal to the length of the pen. The difference - for measuring pen pressure.
Pens 39

Inking System irregular schedule or only on a casual basis. Under such

conditions, drying and caking of ink in the pens is inevita-
Virtually all machines used in routine clinical electroen- ble. To a degree, this can be avoided if the machine is
cephalography make use of ink-writing pens. The chief turned on daily and a calibration is run so that there is
reason for this is cost. By utilizing ink as the recording some flow of ink through the pens. By carefully observing
medium, the chart on which the EEGs are traced can be the density of the tracings at this time, the EEG technician
made oflow-cost paper. This is an important consideration can usually predict which pens may be in jeopardy of clog-
as large quantities of charts are used up in recording ging. These pens will display a tracing that is slightly
EEGs. For example, at the standard chart speed of 30 ragged and a bit darker than the others. To avoid eventual
mmls, a 30-minute recording requires a strip of recording clogging in such cases, most experienced EEG technicians
chart 54 m long-which is a lot of paper. use the priming mechanism to force a small quantity of ink
Some inking systems have a single, common ink supply through the pens. This simple expedient will usually
for all the pens on the machine, whereas others have a restore the inking to an acceptable level.
separate inkwell for each pen. Systems using a common While actual clogging of pens is rare if the procedures
supply have the advantage of being easier and faster to already outlined are followed, pens sometimes do get
fill. Only one inkwell needs to be filled rather than 16, stopped up. When this happens, a number of steps should
18, or 24 separate inkwells. On the other hand, the prim- be followed. The first is to find out exactly where the
ing mechanism for systems having a separate inkwell blockage resides. Although the problem is usually in
for each pen is simpler in design and much less likely to the pen itself, it is good practice to remove the plastic
malfunction. Technological improvements notwithstand- tube that feeds ink to the pen and then prime the ink-
ing, the simple cup-type inkwell fashioned from metal well to verify that ink is flowing freely through the tub-
or plastic, with a tight-fitting cover that fits the inkwell ing. If ink does flow freely, the problem is clearly in
like the wall of a cylinder, is difficult to improve upon. the pen.
To prime the pen, you simply lift up the cover, place your At this point a simple tool is useful. Attach a short length
finger tightly over the small hole in the top, and press of the plastic tubing that is used on the pens to the blunt
down briskly. needle of a 3-mL hypodermic syringe. Short lengths of this
Although the inking systems on routine clinical EEG tubing are usually provided as spare parts with the EEG
machines employ a capillary-feed system for delivering ink machine. Now, fill the syringe with water and attach the
to the paper, in some instruments the ink is sprayed as a jet tubing over the writing tip of the blocked pen, which has
stream. It is not at all clear whether the advantages of a jet been removed from the machine. With the tube firmly in
stream outweigh its higher cost and complexity. place, try to force the water through the pen by exerting
pressure on the syringe. In most cases minor blockages are
cleared immediately by using this procedure.
Inking-System Maintenance If this method fails, try threading a fine steel wire
through the pen to clear the blockage. Most troubleshoot-
One of the most bothersome and frustrating experiences ing or repair kits that come with an EEG machine contain
for the EEG technician is to have the inking of one or a supply of such fine wires. Because the writing tip is a
more channels fail during the course of taking an EEG. smaller bore than the rest of the pen, the wire should be
Unless there is some foreign material present or bacteria threaded from the tip end. Care should be taken that the
growing in the ink, this should not happen - assuming, pen does not get bent out of shape or that the wire is not
of course, that the inkwells are kept filled, that the kinked or broken off inside the pen. Some practice is
machine is used on a daily basis, and that a rubber or needed before the procedure can be carried out success-
plastic "dam" is placed under the tips of the pens when fully. If this method also fails to clear the clogged pen, the
the machine is not actually in use.} Some commercially only alternative is to soak the pen in a detergent solution
available inks contain chemical additives that retard bac- overnight and then repeat the procedure using the fine
terial growth. Use of such inks reduces the possibility of wire.
unforeseen clogging. When inking problems do arise, they The EEG technician should always make a determined
usually are the result of the machine being used on an effort to clear a blocked pen rather than replace it with a
new one. There are a number of reasons for this. First, pens
are expensive. Second, the pens supplied are not all exactly
1 Some newer EEG machines have a device that automatically
lifts the pens and moves the pen dam into place when a switch is the same length. This means that the time-axis alignment
closed. The dam is automatically retracted when recording is needs to be checked whenever a pen is replaced and the
initiated or resumed. penmotor realigned, if necessary, to bring the new pen into
40 5. The Writer Unit

alignment with the others.2 Finally, the tip of the new pen multifocal spike activity. It should be recognized that the
may not be exactly parallel with the writing surface, in higher chart speeds place greater demands on the inking
which event the pen may skip. To correct this condition, system. This means that inking problems are more apt to
the tip may need to be lapped. show up; thus, a channel functioning only marginally at 30
Obviously, the technician will have no choice but to mmls may fail completely at 60 mm/s.
replace a blocked pen if it cannot be cleared. When this To ensure proper tracking of the chart paper through the
happens, helshe should consult the instruction manual machine, paper should be loaded and tensioning devices
accompanying the machine for information concerning set in exactly the manner spelled out in machine's instruc-
pen motor realignment and the technique for pen lapping. tion manual. Seemingly small matters such as the position
of the pack of paper on the feed tray can affect perfor-
mance. When properly functioning, the chart drive should
Chart Drive operate smoothly and quietly, without excessive chattering
or scraping of the paper. Two common problems encoun-
The purpose of the chart drive is to pull the chart paper tered are weave of the chart paper as it goes through the
through the machine at a constant rate and at the speed machine and breakage of the paper under the drive roller
selected by the operator. Standard EEG chart speed is 30 or rollers. In severe cases of weave, the chart runs out of
mmls, but all machines have a number of other speeds. For line so badly that it buckles and tears up at the drive roller.
routine clinical EEG work, only one-half standard speed Although different EEG machines employ somewhat dif-
(15 mm/s) and twice standard speed (60 mm/s) are essen- ferent designs for their chart drives, all are subject to these
tial. The reader should recognize that the use of 30 mmls problems if the mechanisms are not precisely adjusted.
as a standard is not a purely arbitrary choice. At 30 mmls, Adjustments should be carried out carefully and only after
activity in the theta, alpha, and beta bands (which includes reading the instruction manual andlor consulting with the
frequencies in the range of 4-35 Hz) is readily appreciated manufacturer. It is not uncommon for a slight turn of an
and easily identified by eye. adjustment screw to make the difference between a mal-
The slower chart speed of 15 mmls is used mainly to aid functioning or a perfectly functioning chart drive.
in identifying delta activity. Thus, while activity at fre-
quencies less than 4 Hz is difficult to resolve visually at the
standard chart speed, it stands out clearly at the slower Marker Pens
speed. For example, if a delta wave focus appears to be
present when the chart is run at standard speed, a short
run at 15 mmls may be helpful in confirming its existence. Although they are not essential in routine EEG work,
The slower chart speed may be thought of as functioning some EEG machines have one or two additional channels
much like a high-frequency filter. By using a speed of 15 that serve as markers. These are the so-called marker pen
mmls, the closely spaced waves at the high end of the EEG channels. The pens for them are placed at the very top and
frequency spectrum merge together and become less obvi- very bottom of the chart, and as they deflect only a few mil-
ous to the eye. At the same time, the widely spaced waves limeters, they take up little additional space. One of them
at the low end become more obvious by being pressed is invaribly a time marker that produces a small, sharp
closer together.3 deflection on the chart at regular intervals - commonly
A chart speed of 60 mmls has two major uses. In the first once every second. This marker provides an on-going,
place, it provides an easy way of verifying the presence of minute-by-minute check on the accuracy of the chart
60 Hz artifact in the tracing. At this speed, the individual speed - assuming, of course, that the timer activating the
60-Hz waves are readily identified and can be counted. pen is both accurate and reliable. The time-marker chan-
The faster speed is also helpful in assessing whether one nel is also useful in identifying the particular chart speed
focus fires before another when a record shows evidence of being used. It is especially helpful if there is a shift back
and forth between different chart speeds during the course
of a recording.
2 Because all pens are not exactly the same length, the EEG tech- Various other kinds of information can also be displayed
nician should also be especially careful not to mix up the pens if on a time-marker channel at the same time. To avoid confu-
they are removed from the machine. In other words, the pen used sion, the pen deflections are in the opposite dirction to the
on channell should remain there and should not inadvertently
be connected up and used on another channel.
time marks. For example, the particular montage currently
being run can be identified by a coded deflection pattern
'The slower chart speed is also useful in polysomnography. In
addition to rendering the slow activity of the deeper stages of appearing at regular intervals on the chart. This feature is
sleep more readily interpretable, the slower chart speed con- a convenience for the person reading the record as he or
serves chart paper-a consideration during all-night recording. she need not go back to the beginning of the run to find
Chart Drive 41

out what derivations are being displayed. Of considerably Such an arrangement is useful for having the patient signal
greater importance is the use of the time-marker channel his or her response to questions when recording during
to indicate the light flashes during photic stimulation (see absence seizures.
Chapter 16). This information is essential in order to iden- The EEG technician should recognize that marker pens
tify and document the presence of photic driving; unless a are more likely to present inking problems than the pens
suitable marker channel is available for this purpose, one of tracing out the EEGs. The reason for this is that with
the EEG channels must be sacrificed. deflections of only a few millimeters, marker pens use up
If an EEG machine has a second marker channel, it ink at a much slower rate than the pens on the EEG chan-
usually is under the control of the operator. This additional nels. When this happens, evaporation becomes a signifi-
marker pen may be activated by manually pressing a but- cant factor, and ink in the wells gradually becomes thicker
ton or moving a switch. The variety offunctions that can be and thicker-a process that ultimately leads to clogging.
displayed on this marker channel is limited only by the This problem is easily avoided by periodically drawing out
imagination and ingenuity of the user. For example, a but- (with a syringe) and discarding the ink from these inkwells
ton for activating the pen can also be given to the patient. and refilling with fresh ink.
Chapter 6
Calibration and Calibration Methods

Every EEG begins and ends with a calibration. Fre- 6. All channels are in accurate alignment - in other words,
quently, the calibration becomes so routine a procedure the deflections of the pens on all the channels fall on a
that it is easy to pass over it with little thought to its mean- vertical, straight line of the chart.
ing and purpose. This is especially easy to do when the
The foregoing address the question of the validity of the
machine used contains from 18 to 24 channels, and one is
instrument. If all the requirements are satisfied, the
eager to get on to the important part of the record, namely,
machine is a valid instrument. The degree to which these
the EEGs themselves. Nevertheless, the calibration is a
standards are reproducible on a day-to-day basis refers to
vital part of every EEG and for this reason we devote a
the reliability of the instrument. If the machine behaves
chapter to it.
differently from one day to the next - for example, if noise
level of one channel was acceptable yesterday but is exces-
sive today- it is not reliable. Validity, of course, is meaning-
Purpose and Basic Concept less without reliability. An unreliable machine simply can-
not be trusted.
The purpose of calibrating any instrument is to demon- Some of the six requirements listed above are self-
strate that it is a valid and reliable device for measuring the explanatory; others require additional discussion. We take
phenomenon of interest. Calibrating an EEG machine these up in turn.
involves connecting voltages having known characteristics
to the inputs of the machine and verifying that the pen
deflections traced on the chart conform to certain specific Voltage Calibration - Deflection
standards. The calibration voltages, of course, should be
capable of testing the machine within the spectrum of Sensitivity
frequencies for which it will be used. During the course of
a routine calibration, the following points need to be This is accomplished by connecting a signal of known vol-
verified: tage to the inputs of all the channels. The calibration signal
is accurate to ± 2 %, and on most machines a range of
1. A standard input voltage yields a standard pen deflec- calibration voltages is available - 2, 5, 10, 20, 50, 100, 200,
tion. For example, at a deflection sensitivity of 7 and 500 1lY. Usually, the calibration voltage is produced by
IlVlmm, a 50-IlV calibration signal should deflect the pressing a button on the machine console. Direct current
pens a total of 7 mm. and sometimes AC calibration signals as well are used,
2. The deflection sensitivity is linear. This means that if a although most EEG machines employ only DC calibra-
50-IlV calibration signal deflects the pens by 7 mm, a tion. The reason for this will become apparent later in
100-IlV Signal should produce a 14-mm deflection. this chapter.
3. The frequency response conforms to the conventions When AC calibration is used, the calibration signal is
employed in clinical EEG work. usually a lO-Hz sine wave derived from a signal generator
4. The noise level is within acceptable limits. (referred to as an oscillator) inside the EEG machine. The
5. There are no perceptible differences in deflection sensi- calibration signal as displayed on the chart is measured
tivity, frequency response, and noise level among the from the very top of the peaks of the waves to the very
channels of the machine. bottom of the troughs. If a 50-IN, 10- Hz signal is used, we
Frequency Response 43

Callbr8llon
Bullon Hold
,t plifier. Details are given in the manual that comes with
Press Release the machine.
I I
.
Callbr8llon -SOltV'
y ~I
Signal
(Inpul) 0
~
I ~I- - - - - - Linearity
EEG
t : :I Linearity of the channels is assessed by repeating the
Chart I
(Oulpul) calibration procedure using a variety of different calibra-
tion voltages at the same gain setting. In each case the
maximum deflection on the chart is accurately measured.
Figure 6.1. The process of DC calibration; 50-~V input at a These deflections should be in proportion to the calibra-
deflection sensitivity of 7 ~V/mm. tion voltages. This means that if 50 Il V yields a deflection
of 7 mm, 20 IlV should give a 2.8-mm deflection; 10 IlV, a
1.4-mm deflection; 100 IlV, a 14-mm deflection; and so on.
speak of it as measuring 50 IlV peak-to-peak. For standard
Normally, the linearity is very reliable and does not change
gain, this signal should yield a pen defection of 7 mm
unless some component in the amplifier circuit fails.
between the peaks and troughs of the waves. Although only
the newer model machines provide AC as well as DC
calibration, many do have a jack to which an accurately Frequency Response
calibrated external oscillator may be connected for doing
an AC calibration. At first glance the most obvious way of checking the fre-
Direct current calibration uses rectangular-wave signals, quency response of an EEG machine would seem to
sometimes called DC "pips:' When the calibration button involve the use of a variable frequency oscillator. If the
on the machine console is pressed, the voltage present at machine has a jack for connecting an external oscillator to
the inputs of the channels changes instantaneously from 0 the inputs, this can, indeed, be done.l The EEG technician
IlV to, say, 50 IlV and remains at that level until the calibra- would simply run the oscillator through a number of differ-
tion button is released. The sequence of events is illus- ent frequencies from 0.1 Hz to say 90 Hz, making sure that
trated in Fig. 6.1 along with the output on the chart of the the amplitudes of all the calibration signals of different fre-
machine. The fact that the calibration signal as seen on the quency used were identical. Shelhe would then measure
chart is quite different from the signal applied to the input the peak-to-peak deflection on the chart for each calibra-
should come as no surprise to readers who have already tion frequency. These values would be plotted against fre-
studied the material in Chapter 2. quency to obtain the frequency-response curve, one curve
The tracing on the chart, of course, describes a decaying for each channel.
exponential; it is the result of the capacitor in the circuit of It is readily apparent that this procedure would be quite
the low-frequency filter. The reader will recall from Chap- time consuming and hardly possible to carry out prior to
ter 2 that a capacitor responds only to a change in voltage. taking an EEG. As it happens, it is not even necessary. A
Pressing the calibration button produces a change from 0 short-cut method for obtaining information about the fre-
IlV to 50 1lY. This results in a corresponding deflection of quency response of the EEG machine is available. This
the pen and a change in the position of the tracing; but as short-cut method is based on the fact that a precise mathe-
the voltage remains steady at 50 IlV, the tracing decays matical relationship exists between the frequency
back to zero. When the calibration button is released, the response of an electrical circuit and its transient response.2
steady voltage of 50 Il V is abruptly removed and the input
is returned to 0 1lY. Accompanying this change is a deflec- 1 The internal AC calibrator on the machine will not serve this
tion of the pen and a change in the position of the tracing, purpose as it provides only a sine wave of a single frequency,
which is equal and opposite to that observed when the usually 10 Hz.
calibration button was pressed. But, again, the tracing 2This mathematical relationship is embodied in the Laplace
decays back to zero as the voltage at the input remains transformation developed by Pascal Laplace, the late 18th cen-
steady. As the pen deflects upward when the calibration tury French mathematician. The Laplace transformation (LT)
provides a way of relating a function of time f (t), the response of
button is pressed, we infer, in agreement with EEG con-
a circuit to a step function, to a function of frequency, the fre-
vention, that the calibration signal is 50 IlV negative at Gl. quency response of the same circuit. This relationship is given by
Needless to say, there should be no perceptible differ- the equation
ence in the deflection sensitivities of all the channels on LT(f(t)) = Joof(f)E-Sfdt
the machine when their gain settings are identical. Small
where s is a complex variable related to 21tf, the reciprocal of the
differences that may be present are easily corrected by the time constant of the circuit. Note' the quantity E - Sf, which is
EEG technician by turning a screw-driver-adjusted con- called the kernel of the equation. This, of course, is the now
trol that is usually located on the front panel of each am- familiar expression for a decaying exponential.
44 6. Calibration and Calibration Methods

Briefly, all electrical circuits may be thought of as having Table 6.1. Relationship between time
a characteristic response in the time domain and a charac- constant (TC) and cutoff frequency in
teristic response in the frequency domain. In the time a series R-C circuit used as a low-
domain we have the circuit's transient response, while in frequency filter
the frequency domain we have the frequency response. For Cutoff frequency Time constant
simple series R-C filter circuits, the salient variable in the (Hz) (seconds)
time domain is the time constant, while in the frequency 0.1 1.59
domain the corresponding variable is the cutoff frequency. 0.15 1.00
These two variables are related according to the following 0.3 0.53
0.5 0.30
equation:
1.0 0.159
1 1.5 O.lOO
Cutoff frequency = 21tTC 5.0 0.032

where TC is the time constant in seconds. The formula

shows that as TC increases, cutoff frequency decreases and
vice versa. setting than for the IS-Hz setting. Note also that the termi-
This simple relationship tells you that if you know the nal point of the tracing is sharp for the 70-Hz setting but
value of the TC for a series R-C circuit, the cutoff frequency rounded in the case of the IS-Hz setting. The calibration
can be calculated from the formula. Knowing the cutoff with the high-frequency filter set to 35 Hz falls somewhere
frequency, you can readily plot the frequency-response in between. This aspect of the calibration comes under the
curve - that is, the asymptote plot - for the circuit. In prac- heading of rise time of the circuit.
tical terms, this means that the same information about the If the chart had been run through the machine at a
circuit may be derived by obtaining the transient response much higher speed, the difference in rise times between
and estimating the TC as by laboriously obtaining the cir- the settings would have been more apparent. Indeed, at
cuit's response to a wide range of frequencies and plotting the higher chart speed, it would be seen that the tracings
the frequency-response curve. If the reader will briefly do not rise instantaneously but describe what appears to
turn back to and review the section on transient response be an exponential function - even at the 70-Hz setting.
in Chapter 2, he/she will discover that the DC calibration This is indeed the case. These differences are of practical
technique provides a way of obtaining the transient value. Thus, the experienced EEG technician can readily
response of the circuits in the EEG machine to a step func- detect differences in the high-frequency response of the
tion. different channels by examining the tracings and visually
In Table 6.1 we have listed the values of the time cons- measuring the rise times.
tants corresponding to the commonly used low-frequency
filter cutoff frequencies. Figure 6.2 shows that there is a
profound change in the DC calibration as we go from a Biological Calibration
cutoff frequency of 0.1 Hz to a cutoff frequency of 5 Hz. In
fact, as Table 6.1 shows, there is a 50-fold increase in the We have discussed AC and DC calibration of the EEG
time constant as the cutoff frequency is changed from 5 to machine in considerable detail. A third calibration method
0.1 Hz. Although the time constant may readily be is also employed in EEG work. This is the so-called biologi-
checked by careful measurement of the tracings obtained cal calibration or bio cal. The bio cal is used extensively,
during the DC calibration, this is rarely necessary. It is and machines having a montage switch as described in
simpler to keep a template available that was made at a Chapter 1 frequently have a position included in the
time when the time constant was known to be correct. switch for the bio cal.
With this template in hand, it is an easy matter to match it Despite the formidable name, the bio cal is nothing
up to the routine calibrations to see if there is any deviation more than the simultaneous recording on all channels of
from the standard. the electrical activity from the same pair of electrodes. Its
Although not as obvious, the transient response or DC primary purpose is to obtain an additional, quick check of
calibration also provides some information regarding the the frequency response of all the channels. It is also useful
frequency response of the high-frequency filter circuit. for picking up gross differences in the time axis alignment
This will become apparent from a careful perusal of Fig. of the pens. To perform its function effectively, the pair of
6.2. As shown in this figure, the three rows of calibrations electrodes used in the bio cal should tap voltages from the
are for high-frequency filter settings of 70, 35, and 15 Hz, entire EEG frequency spectrum. This is the reason why
respectively, from top to bottom. Examination of the the frontal pole and occipital electrodes - usually Fp I and
upward deflections of the pens reveals that the tracing rises 02 - are selected for this purpose. In the awake and rela-
more rapidly in the case of the 70-Hz high-frequency filter tively alert patient, tracings from these leads normally
Postcalibration 45

LF = 0.1 Hz LF = 0.3 Hz LF = 1 Hz LF = 5 Hz

HF = 70 Hz

HF = 35 Hz

HF = 15 Hz

t-----i
1 sec
100I'VI
Figure 6.2. DC calibrations at different high-frequency filter settings (down), and different low-frequency filter settings (across).

include the alpha and beta rhythms, the central rhythms, the present discussion should be understood to be inter-
as well as the lower-frequency eye movement potentials. nally generated noise, or noise produced by the EEG
The biological calibration is used mainly to check the machine itself. Noise can, of course, be externally gener-
EEG machine for differences between the channels. By ated as well. To rule out the possibility that any noise seen
running his or her trained eye down the chart, the in the calibration is externally generated, the inputs of the
experienced EEG technician or the person interpreting machine should be short circuited and the tracing taken
the EEG record can pick up even small differences again. Details of the procedure are taken up in the chapter
between the various channels. It is essential, of course, for on troubleshooting.
all the channels on the EEG machine to be alike. This
point cannot be overemphasized as much of the value of
the clinical EEG rests upon the ability of the test to detect Postcalibration
differences - sometimes of a subtle nature - between the
two hemispheres of the brain. It is obvious that any such The calibration procedures that have been outlined and
differences could not reliably be detected unless the discussed refer to the precalibration, or calibration that is
recording channels themselves were identical. performed immediately prior to the time that a patient's
EEG is taken. Immediately upon completion of the EEG,
a postcalibration is done. The postcalibration is identical to
Noise Level the precalibration with the exception that it also includes
DC calibrations at any deflection sensitivities that were
At the standard deflection sensitivity of 7 Il V/mm, no noise used in addition to the standard of 7 IlV/mm.
should be perceptible during routine calibration. This If the postcalibration is no different from the precalibra-
means that the tracings taken during the DC calibration tion and both satisfy the standards set forth, we usually
should be smooth and regular. It is a good idea to record, conclude that the machine is both a reliable and a valid
in addition, a page or two with the controls in the calibra- instrument. The conclusion concerning reliability, how-
tion position but without generating the calibration signal. ever, is only an inference. The postcalibration only tells us
These tracings should show smooth, perfectly horizontal that the machine is functioning exactly like it did some 30
straight lines, with no evidence of any deviation above or minutes ago before the patient's EEG was begun. We can-
below the horizontal. All machines used in routine clinical not be certain that something did not change sometime
work should be capable of satisfying these standards. during the 30 minutes and then changed back again before
When the EEG machine is used at higher gain - as, for the postcalibration was started. This kind of thing has hap-
example, in brain death recordings-the requirements are pened and is not uncommon when the machine has some
more stringent, but some noise will become perceptible. kind of intermittent fault. On the other hand, if pre- and
The noise at routine calibration appears as a random postcalibrations are no different from each other over
wavering of the tracings and should be less than 2 IlV peak- weeks and months of routine use, the probability is high
to-peak with reference to the input. Noise in the context of that the machine is indeed reliable.
Chapter 7
Recording Electrodes

The role of recording electrodes in EEG technology and understand something about the way in which electrical
intepretation is a relatively simple one in practice but a currents pass across the metal-electrolyte interface, we
complex one in theory. In this chapter our attention is need to have some basic knowledge concerning the elec-
primarily directed to the practical issues involved. It is trical properties of electrolytes or conducting solutions. To
hardly possible to obtain a satisfactory EEG without hav- do this, it is essential to become familiar with the concept
ing good quality electrodes that have been properly con- of an ion.
nected to the patient. But what is a good electrode? What
constitutes proper electrode application technique? How
do departures from these standards affect the EEG Ions
record? The present chapter addresses all these questions.
At the same time, in order to understand what actually Everyone is familiar with what happens when you pour
takes place when you attach a pair of electrodes to a per- ordinary table salt into some water and stir the mixture.
son's scalp and connect the other ends of the wires to a Assuming that a large amount of salt is not used, the salt
channel of the EEG machine, it is necessary to consider crystals eventually disappear and what remains is a clear
some of the basic theory involved. liquid. We say that the salt has completely dissolved in the
water or has gone into solution. In purely physical terms,
the salt has changed state completely. For present pur-
Basic Concepts poses, however, some more important changes have taken
place.
In practical terms, the electrodes - or leads as they are also In chemical terms, what has happened is that the ele-
called - are simply the means whereby the electrical ments of which the table salt is composed have become
activity of the brain is communicated to the input circuits dissociated. In going through this process of dissociation,
of the amplifiers in the EEG machine. Although a remark- ions are formed. Ions are particles in solution that bear an
able variety of different types of electrodes have been used electrical charge. For our example of the table salt - which
for this purpose, there is a fundamental component or ele- is sodium chloride or NaCl- going into solution, we end
ment that is common to all of them. This component is the up with sodium ions designated by the symbol Na+ and
metal-electrolyte interface. The metal is the material of chloride ions designated by Cl-. The sodium ions have a
which the electrode is composed, while the electrolyte positive electrical charge while the chloride ions have a
may be a conducting solution, gel or paste, or it may be the negative electrical charge.
fluids of living tissue as when an electrode is inserted The ions in a solution have a number of interesting
below the skin. It is at the metal-electrolyte interface that properties. Of particular interest in the present context is
current flow within the brain becomes electron flow in the the fact that ions are free to move about in the solution. If
electrodes and electrode wires. By what mechanism is this a voltage is applied between two points in the solution, an
activity able to pass across the interface and be recorded? electric current can be made to flow in it. The current is
In Chapter 2 we discussed electric currents, electrons, carried by the ions in the solution in the same way that a
the electrical properties of conductors and insulators, and current is carried by the loosely bound electrons in a
the way in which electrical currents flowed in metals. To metallic conductor. Thus, a simple analogy is appropriate,
Electrode Potentials 47

namely, that ions are to electrolytes and conducting solu- nonpolarizable or reverSible, and the silver-silver chloride
tions as the loosely bound electrons are to metals. electrode is a common example. With this electrode
In the context of our discussion of recording electrodes, (designated by the symbol Ag-AgCI) in a solution of sodium
it will be apparent that the metal-electrolyte interface is chloride, there is a tendency for Ag to go into solution
the junction where a flow of ions is converted into a flow of forming Ag+, but also an opposite tendency for the Cl- ions
electrons. In other words, it is the place where an elec- in solution to combine with the Ag+ to form AgCI. The
trochemical phenomenon is converted into a purely elec- result is an electrical balance between the two opposing
trical phenomenon. This is why recording electrodes are processes.
sometimes referred to as transducers. The reader may find With other electrode materials, only a minimal transfer
it useful at this point to turn back to Chapter 1 where of charges occurs across the electrical double layer. Such
transducers were defined and discussed briefly. electrodes are termed polarizable electrodes. Polarizable
electrodes have an electrical charge on them. For this
reason they display the characteristics of a capacitor, which
The Electrical Double Layer means that they do not pass DC and act as a low-frequency
filter. Most recording electrodes available are of the polar-
Although almost any kind of metal may be used as an elec- izable type. Nonpolarizable electrodes are expensive and
trode, the electrolyte chosen for recording leads is usually technically more difficult to work with. Fortunately, a vari-
some kind of salt solution, principally sodium chloride. ety of polarizable electrodes are quite satisfactory for
Two major reasons dictate this choice. First, sodium chlo- recording clinical EEGs. They are discussed later in this
ride is very soluble in water. For this reason, a sodium chapter. Nonpolarizable electrodes are not essential in
chloride solution is able to contain a high concentration of EEG work since DC or very low-frequency voltages are not
ions, which means that the solution will be a really good recorded in routine clinical EEGs. For this reason, non-
conductor. Second, sodium and chloride ions are a major polarizable electrodes will not be dealt with any further
constituent of the body fluids and hence are compatible in this text.
with them.
Despite the fact that any metal that happens to be a good
conductor could serve as a recording electrode, some Electrode Potentials
metals are, at best, only poor materials for this purpose.
This state of affairs arises mainly from the fact that a metal We said earlier that when a metal electrode is placed in
electrode discharges positive ions into solution when it contact with an electrolyte, a voltage develops between the
comes in contact with an electrolyte. Some of these dis- metal and the electrolyte. This voltage was referred to as
charged ions may be tightly bound to the surface of the the electrode potential or half-cell potential. The term
electrode. Concomitantly, an adjacent layer of oppositely half-cell potential implies that the single electrode is act-
charged ions from the solution is formed, resulting in the ing as if it were half a battery, and this is indeed the case.
creation of the so-called electrical double layer at the Because it is like any other voltage connected to the input
metal-electrolyte interface. These two processes occur at of an amplifier, we can expect the electrode potential to be
different rates, depending on the species of metal used for amplified as any other voltage would be. Such being the
the electrode and the type of electrolyte. The difference in case, the electrode potential would appear as an artifact in
the rates of these two processes results in a voltage appear- the EEG tracing.
ing at the electrode. This voltage is termed the electrode But this does not normally happen for two reasons. First,
potential or half-cell potential. The latter term is appropri- we know that two electrodes are required to record an
ate since the potential of an electrode itself is always mea- EEG and that if the electrodes are identical, the same vol-
sured with respect to a reference electrode, it not being tage will be present on each of them. Therefore, the elec-
possible to measure the voltage of a single electrode with trode potential will appear as a common-mode signal at G,
respect to a solution. and G2 of the amplifier and be rejected by the CMRR.
Second, the electrode potential is a DC voltage. If this vol-
tage were relatively stable, the capacitor in the low-
Polarization and the Double Layer frequency filter of the EEG machine would block it out
before it had a chance to be amplified.
The characteristics of the double layer vary with different As it happens, different metals have different electrode
electrode materials. These characteristics determine potentials. For example, the base metal lead has an elec-
whether an electrode will be polarizable or nonpolarizable. trode potential of hardly more than 0.1 V, whereas alumi-
With some electrodes there is a free exchange of charges num has an electrode potential of about 1.7 V. The
(ions) across the double layer. Such electrodes are termed presence of a difference in voltage between dissimilar
48 7. Recording Electrodes

metals is the principle upon which the battery or voltaic Types of Electrodes
pile is based and is of some interest to the EEG technician.
Thus, if a pair of EEG leads attached to a patient happened By and large, most clinical EEGs currently are done using
to be made of different metals, there could be a substantial surface electrodes. The advantage of surface electrodes
voltage between them. This voltage would not necessarily over needle electrode is obvious, in terms of both con-
be objectionable if it were stable, since DC voltages are venience and comfort for the patient, as well as relative
blocked by the capacitor in the low-frequency filter. In freedom from infection. Less obvious but also a significant
practice, however, such voltages are rarely stable and for factor is the lower electrode impedances that are fre-
this reason they represent a source of artifact in the EEG quently possible with surface electrodes (see later section
recording. Such artifacts are sometimes referred to as a entitled "Factors Affecting Electrode Impedance"). For
"battery effect:' The upshot of this is simply that the two these reasons, this text deals only with surface electrodes.
recording electrodes of a pair should always be made of the By far the most popular surface electrode used in clini-
same material. cal EEG work is the metal-disk electrode. Disk electrodes
are circular pieces of thin metal that may be flat or slightly
cup-shaped to hold the electrolyte that forms the metal-
electrolyte interface. The diameter may vary from 4 to 10
Residual Potentials mm, the smaller disks being used mainly for recording in
infants. Some cupped-disk electrodes h:lVe a hole in the
Even though both electrodes are made of the same center through which the electrolyte can be introduced
material, in practice some voltage frequently can be meas- after the electrode has been attached to the scalp. Tin,
ured between them. In other words, the electrode poten- lead, solder, silver, and gold have been used in the con-
tials of the two leads may not be identical. A number of struction of disk electrodes. Gold electrodes, however, are
factors can be responsible for such residual potentials. Our not pure gold but are simply gold plated over high-fine sil-
discussion of them includes the following ways of alleviat- ver. The noble metals like gold, being less reactive than the
ing their effects: base metals, make the most stable, drift-free electrodes.
The disks are soldered to a flexible, insulated wire, and
1. There may be impurities in the metal, or the surface of this junction is carefully covered by a plastic material to
the electrodes may be contaminated by foreign metal prevent moisture or any of the electrolyte from reaching
ions. To avoid the former, only high-purity metals are the solder joint. Should a breakdown of the plastic material
used in recording electrodes. In the case of silver elec- cause penetration by water and electrolyte, an active bat-
trodes, for example, only silver designated as "high fine" tery would be created at the junction of the dissimilar
is used. Care in cleaning and storing is necessary to metals resulting in large, electrode-generated artifacts. For
prevent surface contamination. this reason, disk electrodes need to be handled carefully.
2. There may be foreign metal ions present in the electro- The EEG technician should never scratch the surface of an
lyte. To avoid this possibility, electrode pastes and gels electrode or bend or pull the electrode at the junction
should be carefully selected and protected from con- between wire and disk. The electrodes should be kept dry
tamination during use. Any tools used in lead applica- when not in use; avoid soaking them in water for long
tion should be kept scrupulously clean. periods of time. Appendix 7 takes up methods of disinfect-
3. There may be differences in the concentration of the ing metal-disk electrodes.
electrolyte at the two electrode sites through lack of
homogeneity in the electrode paste or gel used.
4. There may be a difference in temperature of the skin at Application of Surface Electrodes
the two electrode sites. This happens because some
metals used in electrodes have electrode potentials with The hair and surface of the scalp should be clean and free
temperature coefficients in excess of 100 11 VIa C. of hair oils, pomades, or other hair dressings before elec-
trodes are applied. For this purpose, it is desirable for the
Taken together, these factors could result in significant hair and scalp to be washed the night before the EEG is
differences in voltage between the two electrodes of a pair. taken. As an alternative, topical cleaning at the measured
But here, again, the presence of a voltage is not objection- locations using an alcohol prep swab may be tried. After
able in clinical electroencephalography if the voltage is the electrode sites have been measured off and marked,l an
stable. Problems arise only when the residual potentials
fluctuate. When this happens, the variations in voltage 1 Details concerning measuring and marking electrode sites are

constitute a source of artifact in the EEG tracings. found in Appendix 5.

Electrode Impedance 49

electrolyte is rubbed into them. Some EEG technicians example, some laboratories have used bentonite or low-
call this procedure "scrubbing," although, in practice, only melting-point wax. An entirely different approach makes
gentle rubbing is used. Preparations that contain free chlo- use of a cap or helmet that is tied to the patient's head and
ride ions and a mild abrasive for reducing the resistance of holds the electrodes in place. These methods are not dis-
the skin are available for this purpose. 2 These are best cussed in this text. Interested readers may consult the
applied using a cotton-tipped wood applicator stick. To literature on EEG technology for further information.
protect both patient and technician from possible infec-
tion, special care is necessary so as not to scratch or break
the skin. Care also needs to be taken to avoid spreading the Electrode Impedance
material over an area much wider than the diameter of the
Assuming that the electrodes have been applied to the
metal disk, as in doing so the effective area of the electrode
measured-offlocations on the patient's scalp following one
is increased beyond the limits of the metal disk. When this
of the procedures outlined above, the next step is to
happens, the localization capabilities of the electrode are
"check" the electrodes. This involves measuring their elec-
significantly reduced.
trical impedance.
An extreme case of spreading the electrolyte too far
Impedance is measured by applying a small, external
occurs when two adjacent electrode sites are involved. By
. voltage to the electrodes and then measuring the amount
carelessly spreading the electrolyte over too large an area,
of current flowing in the circuit formed by the leads. The
the two areas scrubbed may inadvertently overlap. This
reader will recall from Chapter 2 that Ohm's law states that
condition, known as a "salt bridge," creates a short circuit
between the two electrode sites. Leads attached to these 1= ~
sites would not function as two separate electrodes but as Z
a very large, single electrode. More about salt bridges later or, rearranging the terms in the equation
in this chapter.
Many different techniques have been used to secure the Z=~
metal disks to the scalp. The simplest and speediest 1
method is to use a conductive electrode cream or paste that This formula tells us that the impedance may be calculated
has adhesive properties sufficient to hold the disk in place. simply by dividing the applied voltage (V) by the current
In this case, a cupped disk is chosen. With the cup filled (1) flowing through the circuit. Impedance meters used to
with paste, the electrode is pressed firmly against the scalp check electrode impedance allow the EEG technician to
after the hair at the site has been separated. To keep long read the lead impedance directly so that no computation is
hair out of the way, some EEG technicians braid the hair or necessary. Details relating to the impedance meter are
tie sections of it together with rubber bands. A small taken up in a later section.
square of gauze is placed over the electrode to retard dry- Because impedance in the present application consists
ing of the paste. of a combination of resistance and capacitive reactance
Although paste is a satisfactory means of securing the (see Chapter 2), AC is used to measure impedance of the
electrodes when the patient is cooperative and relatively leads. Typically, the measurement is made by using a 10 to
quiet, the leads are easily pulled away by the movements of 30-Hz AC signal, which is well within the range of the
a convulsing patient or a very restless child. In these situa- EEG frequency spectrum. Since the patient forms part of
tions, the use of collodion is the best alternative. When col- the electrode circuit, the current also flows through the
lodion is employed, a cupped disk with a hole in the center patient. However, as current levels are very low-only a
is the appropriate choice. The electrode is held in place few microamperes - the current poses no danger what-
over the measured location and collodion is spread around soever and is rarely even perceived by the patient.
its edges. A stream of compressed air must be used to dry For optimal recording, it is generally agreed that the
the collodion quickly. Special care should be taken to avoid impedance of a surface electrode should be less than 5K
getting any collodion into the patient's eyes. With the elec- ohms. Recording problems usually arise when the
trode firmly in place, electrolyte is introduced through the impedance is either too high or too low. To understand
hole in the disk by means of a hypodermic syringe with a what happens when lead impedance is very high, it is help-
blunt, wide-gage needle. ful to look at the circuit that is formed with the patient by
Other materials and methods have been employed to the two electrodes and the amplifier. Such a circuit is seen
secure the recording electrodes on the scalp. Thus, for in Fig. 7 .lA, where VEEG is the voltage of the brain electri-
cal activity picked up by the electrodes, ZEI and ZE2 are
2 A preparation called "Omni-Prep~' which is commercially avail- the impedances of the electrodes, ZA is the input impe-
able, has been used with considerable success by the authors. dance of the amplifier, and V-\ is the voltage appearing at
50 7. Recording Electrodes

A. or the voltage present at the input of the amplifier is only

two thirds of the true EEG voltage. It should be clear from
this example that, to avoid excessive reduction of the
amplitude of the EEG voltages, electrode impedance must
be low by comparison with the input impedance of the
EEG amplifiers.
But the reduction in amplitude of the EEG voltages that
results from using high-impedance electrodes is not the
only reason why low-impedance leads are essential. A
more serious consequence is concerned with the recep-
B. tion (pick up) of 60-Hz artifact by the EEG amplifiers. It
happens that the amount of 60-Hz artifact that gets into
the amplifiers from the external environment is directly
proportional to the impedance of the circuits connected to
their inputs. This means that higher 60-Hz levels in the
tracings go along with leads of higher impedance and vice
versa. In the limiting case when impedance is equal to
zero, no externally generated 60-Hz activity would be
Figure 7.1. Equivalent circuits showing a pair of electrodes present in the tracings. This is the reason why the inputs of
attached to a patient's scalp and connected to the input of an the amplifiers are short-circuited to test for the presence of
EEG amplifier. (A) normal circuit; (B) circuit showing a salt 60-Hz activity in the external environment. If a 60-Hz
bridge. artifact disappears when the inputs are short-circuited, we
conclude that the 60 Hz is external to the EEG machine
since the short circuit is virtually the same as connecting
the input of the amplifier. This basic circuit was already zero ohms to the amplifier inputs.
analyzed in Chapter 2. Although in that instance only Based on the formula for VA that we have been dealing
resistance was present in the circuit, the same analysis is with, it would seem that the lower the electrode imped-
applicable when impedance is substituted for resistance. ance, the better the recording. In practice, however, this is
Referring back to Fig. 2.4 in Chapter 2, we find that the not the case. Recordings taken with leads of very low
EEG voltage divides across the three impedances so that impedance - measuring less than 500 ohms - usually indi-
the voltage at the amplifier is always some fraction of the cate that another phenomenon may be taking place. This
EEG voltage. For the circuit in Fig. 7.1A, this voltage (after phenomenon is the salt bridge that was mentioned earlier
rearranging the terms somewhat) is given by the formula in the chapter. A salt bridge acts as a short circuit or path-
way of very low impedance between the two electrodes.
ZA
VA = Z Z VEEG Figure 7.1 B shows the equivalent circuit for a pair of
A + ZEI + E2 recording electrodes that have been bridged by the appli-
Let us examine what happens in this formula when ZEI cation of too much electrolyte. With ZSB less than 500
and ZE2, the electrode impedances, are allowed to vary. ohms, it is easy to see that the brain electric currents will
Suppose ZA is equal to 2M ohms, and ZEI and ZE2 are be shunted away from the amplifier circuit. As a result, Vo\.
each 5K ohms. This means that will be very low amplitude and, in the limit, will be equal
to zero. Whenever a single channel on the EEG machine
V 2,000,000 V shows activity that is of markedly lower amplitude than
A = 2,000,000 + 10,000 EEC
the activity on the other channels, the person reading
VA = 0.995 V EEG
the record as well as the EEG technician should suspect a
salt bridge.
or the voltage present at the input of the amplifier is very
nearly identical to the EEG voltage. On the other hand, if
the electrodes were poorly applied to an unwashed scalp, Factors Affecting Electrode Impedance
the impedance of each might be as high as 500K ohms.
Under these conditions, Because electrode impedance is such a critical variable, it
is necessary to consider the factors that affect it and the
V - 2,000,000 V ways in which it may be reduced to acceptable levels. First,
A - 2,000,000 + 1,000,000 EEG
we have the factor of surface area. Large-diameter disks
VA = 0.666 VEEG have more surface area than smaller diameter disks and for
Electrode-Induced Artifacts 51

this reason have a lower impedance. This is why needle should not touch the patient's scalp but should be "floated"
electrodes, which have a small surface area by comparison, on the surface of the electrolyte. The method of applying
may show a relatively high impedance even though they leads that employs electrode cream or paste would seem to
penetrate the skin. Unfortunately, it is not practicable in satisfy this requirement admirably.
EEG work to reduce electrode impedance by increasing
the size of the electrode. When electrodes are larger than
10 mm in diameter, accurate localization becomes impos- Detection of Electrode Artifacts
sible. Moreover, with very large disks the interelectrode
distances become so small that the danger of having a salt Electrode artifacts are best detected and identified by
bridge is significantly increased. including the suspected electrode as a common electrode
Empirical studies have shown that the impedance of a in a bipolar montage (see Chapter 11). What happens is
pair of surface-recording electrodes on a patient is mainly best described by an example. Suppose that of five elec-
due to the skin on which the electrodes are placed. This trodes designated A, B, C, D, and E, electrode C is sus-
being the case, removal of the skin directly under the elec- pected of producing an artifact. To confirm this, the elec-
trodes would greatly reduce the impedance, but obviously trodes are connected to four EEG channels, as shown in
this is not possible in routine clinical electroencephalogra- Fig. 7.2.
phy. Nevertheless, the practical alternative of gently rub- As electrode C in Fig. 7.2 is common to two channels, an
bing a preparation containing an electrolyte and a mild electrode artifact like a "pop" will be present in both,
abrasive into the skin under the electrodes is usually quite namely, channels 2 and 3. Note that the deflections are of
successful. Additionally, it also helps to allow a little time equal size and of opposite phase in the two channels so that
for the skin to become hydrated and the electrolyte to soak one appears as the mirror image of the other. This happens
in before checking the electrodes. While waiting, the tech- because electrode C goes to opposite grids of channels 2
nician can spend the time filling in the clinical details in and 3. Note also that despite their large size, the deflec-
the worksheet. tions are present only in channels 2 and 3, suggesting that
the disturbance has no field. This confirms that the deflec-
tions observed are artifacts and do not originate in the
Electrode-Induced Artifacts patient. Indeed, an artifact should be suspected whenever
a deflection pattern like that shown in Fig. 7.2 is observed.
We already mentioned one major source of electrode- Had the deflections originated in the patient, there would
induced artifacts in our discussion of residual potentials. It be a field surrounding the focus at electrode C. Depending
was noted that for various reasons, a pair of electrodes may on the distances involved, this field could be picked up by
act as a battery. This phenomenon, which is known as the the electrodes connected to channels 1 and 4, which
battery effect, may constitute an important source of would then show deflections similar to but of smaller
artifact in the recording if the voltage generated by the amplitude than those in channels 2 and 3. This is taken
electrodes is not stable. up in Chapter 12 where the rules of localization are dis-
Let us assume that a pair of electrodes of high inherent cussed.
stability is correctly and carefully attached to a patient's
scalp. Will these leads yield a satisfactory recording? The
answer to this question is that it depends on the degree of Impedance-Measuring Devices
mechanical disturbance to which the electrodes are sub-
jected. In this case we are speaking of disturbance of the We have discussed electrode impedance and the theory of
metal disks themselves, not disturbance of the wires to measuring impedance in some detail. It remains yet to
which they are attached. Artifacts produced by displace- consider the actual methods that are employed in practice.
ment of the wires are termed movement artifacts and are Although it is easy to think of the impedance of a single
obviously avoided by preventing the lead wires from being electrode, it is no simple matter to measure it. A little
disturbed. thought will explain why. Impedance is measured by pass-
Mechanical disturbance of the disks produces an artifact ing a current through the element to be measured. But
usually referred to as an electrode "pop:' Such artifacts how do you pass a current through a single electrode? The
appear to result from a disturbance or instability of the answer is that you cannot. An electric circuit always has
electrical double layer. According to Geddes (Geddes LA, two connections, whereas a single electrode attached to
1972), electrodes that are relatively free of such artifacts the patient has only one. What is needed to make a circuit
are those in which the electrode-electrolyte or metal- is a pair of electrodes. But this means that the measuring
electrolyte interface is removed from direct contact with current passes through two electrodes connected in series
the patient. This would suggest that the metal disk itself so that the impedance measured will be the impedance of
52 7. Recording Electrodes

Figure 7.2. Appearance of an elec-

trode artifact in bipolar recording.
A The tracings show the occurrence of
a "pop" in electrode C. Note that the
artifact appears only in the two

v
B channels that are common to the
defective electrode and that the
deflection in one channel is the mir-
Electrodes c ror image of the deflection in the
----'~--- other. Electrode "pops" bear a strik-
ing resemblance to the deflections
o
traced out by DC calibration signals.

t
Electrode "Pop"

both electrodes combined. In estimating the impedance of approximately equal to each other in magnitude. Under
one of the electrodes, we have to assume that each elec- such conditions,
trode is one-half the total impedance.
Although the method just described for measuring the 1
Ztotal Zx + 20
impedance of recording electrodes is used extensively, it
has a serious problem. The problem is simply that we have Z,.
no assurance that the impedances of both leads in the pair
or
are the same. The same meter reading could be obtained
as well if one lead were high impedance and the other were Zn
very low, and vice versa. A better method is clearly neces-
Ztotal =
ZX + 20
sary.
By the ingenious application of Ohm's law and the rules If Zx Z,. 5K ohms, total impedance is
governing the combining of impedances, it becomes possi-
ble to solve this dilemma. To understand how this is ZtDtal = 5,000 + 250
accomplished, consider the circuit shown in Fig. 7.3. This = 5,250 ohms
circuit, which is a series-parallel circuit, consists of a single
impedance, Zx, connected in series with a total of 20 which means that the total impedance of the circuit differs
separate impedances that are hooked up in parallel. In but little from the impedance of Zx.
Chapter 2 we learned that the total impedance of a group The circuit just discussed embodies the principle upon
of impedances connected in parallel is equal to which modern impedance meters used to measure
impedance of a single recording electrode operate. Zx is
the electrode whose impedance we wish to measure, while
ZI-20 are the impedances of the remaining 20 leads used
or in taking a routine clinical EEG. Inside the impedance
meter box is a complex switching system. This switching
1 system alternately connects each of the electrodes at-
tached to the patient in series with all the other electrodes
that themselves have been hooked together in parallel.
Note that the impedance of any lead may be estimated to
The total impedance in the circuit, Ztotah is equal to within 5% of its actual value by means of this circuit.
1 The method of measuring impedance just described is
ZtDtal = Zx + 1 1 1 1 normally carried out before the patient is hooked up to the
Z. + Z2 + Z~ + ... Z20 EEG machine. Many EEG machines provide a means of
quickly measuring impedance of electrodes at any time
Suppose, now, that all of the 20 Zs in this equation were while the EEG is being run. This is a convenience since an
Impedance-Measuring Devices 53

Figure 7.3. Simplified circuit Current-Generating

cb1
of an up-to-date impedance / Source
/ (10-30 Hz)
meter showing the series- .----------c "v J------------,
parallel circuit used for meas-
uring the impedance of single
electrodes. Microammeter
(Calibrated
To Read
Directly In Ohms)

Zx Z, Z20

electrode suspected of having a high impedance can be the electrode pair connected to it; a peak-to-peak deflec-
checked without interrupting the test. tion of 1 mm = 2,000 ohms. By using a bipolar montage so
This feature is enabled by closing the electrode test that some electrodes are common to two channels, the
switch on the console of the machine and then pushing the EEG technician can figure out which electrode of a pair is
electrode test button. The electrode test switch automati- high impedance.
cally adjusts the sensitivity of all channels to a standard
value, say, 7 !lV/mm, and turns on a 30-Hz test oscillator.
Pushing the electrode test button feeds the 30-Hz signal to Reference
the electrode pair of each channel. This signal is recorded
on each channel of the machine, and the recorded ampli- Geddes LA: Electrodes and the Measurement of Bioelectric
tude of each tracing is proportional to the impedance of ElJents. New York, Wiley-Interscience, 1972.
Chapter 8
Electrical Safety

Everyone knows that it is potentially hazardous to be across the connections is 5K ohms will cause 24 rnA to
standing outdoors in the rain during an electrical storm. flow, which, by Fig. 8.1, is a dangerous shock. It should be
Most persons attribute the danger to the fact that the body obvious, therefore, that ordinary 120-V AC house current
provides a pathway for the flow of electric current to used to power the EEG machine can represent a potential
ground from a nearby discharge of lightning. In other danger to the EEG technician and the patient. Indeed,
words, there is a risk of being struck by lightning. Since the persons have been electrocuted by all kinds of appliances
current levels in a typical lightning stroke can exceed that use ordinary house current.
20,000 A, the danger is indeed a real one. Microshock is another electrical hazard that EEG tech-
Common knowledge tells us that it can be dangerous nologists and others dealing with EEGs need to be con-
for a person to touch an uninsulated live electric wire. Yet cerned about. Microshock is a term used to describe very
it is well known that birds often perch on such wires small currents that nevertheless may be lethal because of
without danger of electric shock. The difference lies in the where they are applied. Patients with indwelling elec-
fact that in the former case, the body provides a pathway trodes, catheters, or implanted transducers in the heart are
for the flow of current to ground if the person is directly or at considerable risk because these devices may provide a
indirectly in contact with the earth. Thus, it is the flow of pathway for the flow of electric current. Such currents may
current and not simply the presence of a voltage that con- be very small indeed-as small as 100 J.1A. However,
stitutes the danger, and it is the amount of current forced although 100 J.1A is harmless and not ordinarily percepti-
through the body that is the real measure of a shock's ble when applied to the external surface of the body, it may
intensity. How much current constitutes a danger? To be lethal when introduced directly to the heart. More will
answer that question, it is essential to consider where a vol- be said about this problem and how it is resolved later in
tage is applied and the pathway the electric current takes the chapter.
through the body. In taking EEGs, electrical safety is concerned chiefly
with protecting the patient and the EEG technical from
inadvertently becoming a pathway for the flow of electric
Macroshock and Microshock currents to ground. To understand how this can come
about and how it may be prevented from occurring, it is
The term macroshock applies to the type of hazardous essential to understand the way in which "ground" is
situations we have just described. Macroshock involves involved in electrical circuits. For this reason, we begin our
currents that pass from one external surface area of the discussion of electrical safety with a consideration of the
body to another and are perceptible to the person exposed topics of ground and grounding.
to them. Although the effects will depend partly on the
actual pathway of the current through the body, Fig. 8.1
shows, in general, the physiological effects of various cur- Ground and Grounding
rent densities. Recalling that the current flowing in a cir-
cuit is directly proportional to the applied voltage and In the domain of electrical phenomena, "ground" can take
inversely proportional to the impedance, it is readily on a variety of meanings. The term itself refers to the
apparent that 120 V applied to a person whose impedance ground of the earth; indeed, the British speak of "earthing
Ground and Grounding 55

1000 voltage transmission, this practice has been largely aban-

doned in modern power distributing circuits where an
insulated wire is used for the return path. Nevertheless,
the earth continues to be of importance as this return wire
itself is grounded. This connection to earth provides a
Severe Burns stable reference of zero volts for the circuit as well as a safe
pathway to earth for electrical currents produced by
lightning in a storm.
Inside the home as well as in the EEG laboratory, the
term ground takes on a more specific meaning. In this case,
ground refers to the third contact on the 120-V AC electri-
100 cal outlets found along the walls of any room. This is the
contact that mates with the third contact (the long prong)
Extreme Breathing on the plug of the power cord running to the EEG
til Difficulties
~ machine. If you trace where the long prong on the plug
Q) goes, you will find that it is connected to an insulated wire
Q. Breathing Upset &
E Labored (the green wire) in the power cord.2 Once inside the
.! Severe Shock machine, this wire is ultimately connected to a number of
Muscular Paralysis different points. Among them are the ground jack on the
:E electrode board of the machine, the ground connections of
Cannot Let Go
the differential amplifiers, and the console of the machine
Painful itself. Note that the console is made of metal, which is a
10 good conductor of electricity, and that the metal chassis
Mild Sensation
completely encloses the electrical and electronic circuits
contained in the machine.
Going now in the opposite direction, that is to say, from
the previously mentioned third contact in the wall socket
into the wall structure, you will find that this contact is
hooked up to a wire covered with green insulation. Note
that this wire matches the color of the wire inside the
Threshold Of
1.1 Sensation power cord to which it corresponds; green always indicates
a ground wire in modern electric power distributing sys-
1 L....-_ _ _ _- - '
tems. Following the wire to its source, you will discover
that it is connected to the earth. Connection to ground is
Figure 8.1. Physiological effects of electric currents. (From The
fatal current, Tektronix Service Scope, Dec 1965, #35,1-2, by per- usually made by way of a large-diameter cold water pipe or
mission of Tektronix, Inc., Beaverton, Oregon.) by a metal rod(s) or plate buried in the earth. As the
plumbing in most houses or structures is metal, and it
makes contact in one way or another with the earth, the
various pipes themselves become grounded. Electrically
a circuit" when they refer to "grounding:' Thus, ground can speaking, therefore, a person touches earth whenever he
refer to any point in the earth to which an electrical circuit or she comes in physical contact with any metal part of a
may be connected. house's permanent structure.
Why does the earth play such an important role in elec- Given these basic wiring facts, it can be deduced that (1)
trical matters? There are a number of reasons. In the first the console of an EEG machine is (or should be) grounded
place, the earth is an electrical conductor. This fact is of when the power cord is plugged into an appropriate 120-V
considerable practical importance. To save on the cost of AC socket, and (2) any metal fixtures in the EEG labora-
insulated wire, many early electrical generating systems tory that are a permanent part of the room (electrical
used the earth as a return path for the flow of electricity in switch plates, heating pipes and ducts, metal sinks, water
their power distributing circuits.l Except in cases of high- pipes, faucets, drain pipes) are (or should be) grounded.

I The reader will recall from Chapter 2 that two connections are 2The other two wires in the cable-one with black insulation
always needed to make an electrical circuit. In this example, the (the hot wire) and the other with white insulation (the return
earth serves as one of these connections. pathway)-provide the 120-V AC that runs the machine.
56 8. Electrical Safety

This is a well-thought-out plan for which there is good rea- Normally, the leakage currents generated in the EEG
son, which is embodied in the first rule of electrical safety machine pass harmless to ground. However, should the
for the EEG laboratory. Simply stated, this rule says that ground wire that connects the machine to earth be inter-
for safe operation all metal objects and exposed metal sur- rupted, these currents need to find alternative pathways.
faces in the EEG laboratory must be connected to ground. One pathway is via the chassis of the machine. Another is
Why is grounding an essential part of safe operation? We back through the input and the recording electrodes. This
can answer this question best by considering what could means that the EEG technician and the patient hooked up
happen if a fault developed inside the EEG machine. Sup- to the machine are both at risk from these currents - the
pose one of the many current-carrying wires that are inside patient because he or she is connected to the EEG elec-
the machine came loose and touched the inside wall of the trodes and may also be connected to some other equip-
machine's chassis. What would happen? With the chassis ment that is grounded, and the EEG technician because
of the machine properly grounded, the current would be he or she may be touching something connected to
carried away harmlessly to ground without offering any ground. Because of this risk, leakage current limits have
danger to the EEG technician operating the machine. On been specified for EEG machines. The maximum allow-
the other hand, if the EEG machine were ungrounded and able chassis leakage current with the ground wire of the
the EEG technician happened to be touching it while at power cord interrupted is 100 /lA. For the inputs of the
the same time making contact with a heating duct or pipe machine, a leakage current of up to 50 /lA between elec-
in the laboratory that was grounded, current would flow to trodes and ground is allowed. It should be obvious from
ground through the technician's body. In other words, our discussion thus far that protection against chassis leak-
being in contact with ground is dangerous if there are age currents is afforded by making sure that the EEG
sources of electric current nearby that can make connec- machine is connected to ground when the power cord is
tion with the body. This is analogous to what happens plugged in. How chassis leakage current is measured is
when a person stands on the ground outdoors during an taken up in Appendix 4.
electrical storm. The result in either case could be a seri-
ous injury, if not loss of life.
Because proper grounding of the EEG machine is so Patient Grounding
important, the EEG technician should periodically check
the installation to verify that the ground connection is Thus far we have been talking about the grounding of the
intact. How thi~ is done is taken up in Appendix 3. EEG machine. In routine clinical EEG recording, a
ground lead is usually attached to the patient. By means of
this electrode, the patients gets connected to earth via the
Leakage Currents ground wire of the EEG machine. But if being in contact
with ground is a potentially hazardous condition, does not
As we just mentioned, a potentially dangerous situation the deliberate use of a ground connection pose a serious
exists if the ground connection of the EEG machine is danger to the patient? And why is a ground lead attached
interrupted and a fault were at the same time to develop to the patient in the first place? We take up the latter ques-
within the machine. But now suppose that the machine tion first. But before doing this, some background informa-
became ungrounded, as in the previous example, but no tion is in order.
fault was present in the machine. Is there still a potential We all know that radio and ordinary television are
for harm? methods of communication that employ no wires between
To understand what happens in this case, it is important transmitter and receiver; they are wireless systems. In
to recognize that the power cord and parts of the power principle, their operation is relatively simple. A transmitter
supply of the EEG machine behave like a number of capa- beams out an alternating electrical voltage that produces a
citors connected together in parallel. The green ground widespread electrical field. At a distance from the trans-
wire acts as one side of the capacitors while the current- mitter is the receiver to which an antenna is connected.
carrying wires of the power cord act as the other. The The antenna is nothing more than an electrical
effect, which is known as stray capacitance, is distributed conductor-in its simplest form, a loop or coil of wire. In
along the entire length of the cord. With 60- Hz 120-V AC Chapter 5 we noted that an electric current could be
applied to the hot wire of the power cord, a current will induced in a conducting circuit that is placed within range
flow through the capacitive reactance formed by the stray of a changing magnetic (electrical) field. In the case of
capacitance. This current is called the leakage current. Its radio and television, such currents are induced in the
magnitude depends on the length and characteristics of antenna of the receiver. These currents are very feeble
the power cord and on the design and construction of the indeed. Nevertheless, when amplified and suitably
power supply. Leakage currents are not negligible; for a processed (demodulated), they emerge as radio and televi-
6-ft power cable they may range between 7 and 60 /lA. sion programs.
Effect of Patient Impedance 57

It happens that by attaching EEG leads to a patient's Indeed, patient safety may aptly be defined as protecting
head, we create what turns out to be a pretty good antenna. the patient against all unnecessary risks no matter how
In some cases this antenna has been known to pick up improbable their occurrence.
strong local radio and television stations. As might be One possible source of risk to the patient occurs if the
expected, such signals are capable of introducing artifacts patient's body happens to be touching the chassis of the
into the EEG tracing. In practice, however, interference EEG machine or some other metal fixture in the room that
from radio and television is generally not a problem in should be grounded, but through some fault is not. When
EEG work since the high-frequency filters largely elimi- this happens, the patient serves as the pathway to ground
nate these sources. What is a problem, however, is the for the leakage currents discussed in the last section.
60-Hz power lines. These power lines, which act like a Moreover, the patient would be at additional risk if an
transmitting antenna, are almost everywhere. The result is electrified device or current-carrying wire happened to
that a 60-Hz electrical field is almost impossible to avoid make electrical contact with the ungrounded chassis or
under ordinary circumstances.3 metal fixture.
When placed within range of a 60-Hz electrical field, Another way in which the patient's body could provide a
a patient with EEG leads attached serves as an excellent pathway for the flow of current to ground would occur if
receiving antenna. Because the body acts like a capacitor any of the 21 EEG electrodes attached to the patient's
with respect to the earth, 60-Hz AC will flow in this head were suddenly to acquire a voltage other than the vol-
antenna circuit. Although the current flowing in this tages derived from the patient. This might come about if
antenna circuit is normally too small to pose any danger to an internal failure occurred in a differential amplifier and
the patient, it frequently generates voltages that are large the power supply voltages of the EEG machine somehow
enough to be recorded by the EEG machine. In some became connected to the amplifier's input circuit. Need-
cases, 60 Hz artifact can obliterate the EEG tracings.4 By less to say, the probability of this happening is very, very
placing a ground electrode on the patient, we effectively low indeed. Nevertheless, to minimize this potential haz-
ground the antenna. As a result, these currents are signifi- ard, some EEG machines employ optical coupling devices
cantly reduced, especially if the ground electrode is in the input circuits to isolate the patient from inadvertent
located somewhere on the patient's head. This means that contact with dangerous power-supply voltages.
the differential amplifiers in the EEG machine have less The greatest possible risk to a patient who is having an
60-Hz activity (less common mode voltage) to discrimi- EEG taken occurs when other electrical devices besides
nate against. the EEG machine are connected up to the patient at the
So we see that the patient's ground connection is essen- same time. This is not an uncommon occurrence, espe-
tial for reducing 60 Hz artifact in the EEG tracings. cially when EEGs are done in hospital rooms or in the
Indeed, the presence of 60 Hz in a recording is frequently intensive care unit (ICU). As a general rule, the more
indicative of a poorly attached ground lead. But the advan- instruments and devices of various kinds one connects to a
tage gained by using a ground lead is not obtained without patient, the more chances there will be of encountering a
some cost. By deliberately grounding the patient, we sub- fault of some kind. Devices such as ECG machines, electri-
ject the patient to the risk of electrical shock should he or cally powered blood pressure monitors, instruments con-
she come into contact with a live voltage or with a current- nected to indwelling catheters, and electrically powered
carrying wire. When this happens, the patient serves as a implants may all have their own ground connection with
direct pathway for the flow of current to ground. How the patient. If any of these ground connections (or the
might such a situation come about in practice? EEG ground) developed a fault, leakage current from the
There are a number of possible ways in which a patient's device could flow through the patient on its way to ground
body might provide a pathway for the flow of current to via the remaining intact ground connections. Depending
ground in the EEG laboratory. In discussing the ways, the on the precise pathway followed by the current through the
reader will argue that they are all highly unlikely events. body, the result could be destructive if not actually life
This, of course, is true. Nevertheless, when talking about threatening.
safety, unlikely events need to be considered because they
are known to have occurred at one time or another.
Effect of Patient Impedance
By now it should be clear to the reader that the danger
3So-called electrically shielded rooms have been employed to
screen out 50-Hz fields. However, such rooms are rarelv used, if
from leakage currents and currents resulting from some
at all, in routine clinical EEC work. For this reason, th~v are not fault in any electrical device connected to the patient
discussed in this text. . comes from the possibility that these currents might flow
4 In some cases it is possible to measure as much as a volt or two to ground via the patient's own body. The actual amount of
of 50-Hz AC between a point on the body and the earth. current that could flow through the patient depends on his
58 8. Electrical Safety

or her impedance. As we know from Chapter 2, this rela- so-called bipotential isolator electrode board is strongly
tionship is given by Ohm's law, which states that current recommended. The bipotential isolator ensures that the
flow in a circuit is equal to the voltage divided by the cir- EEG lead connections are neither the source of hazardous
cuit's impedance. This means that the patient's impedance currents flowing through the patient, nor the means
is an important factor in electrical safety; if the patient's whereby dangerous currents can find their way to ground.
impedance is high, less current will flow through his or her
body than if impedance is low.
The impedance of an ordinary surface EEG electrode Isolated Ground and Biopotential Isolator
attached to the patient is attributable largely to the imped-
ance of the skin under the electrode. For this reason, elec- Recognizing the potential hazards associated with con-
trical contacts that bypass the skin and go directly inside necting a patient to ground, there is obvious need for some
the body may offer extremely low-impedance pathways for kind of fail-safe method or device to protect the patient.
the flow of electrical currents. For example, a catheter that The isolated ground, which is a product of modern tech-
carries fluids to or from the body presents a current path- nology, is just such a device. What exactly is the isolated
way having an impedance as low as 500 ohms. If such a low- ground, and how does it function to protect the patient?
impedance pathway were connected inadvertently to a Properly speaking, the isolated ground does not really
current source, injury or death could result. This is one of isolate the patient from the ground at all. If we wanted to
the reasons why taking EEGs in the ICU presents a greater "isolate" the patient from any connection with ground, the
potential risk of electrical shock to the patient than taking ground electrode could simply be left off the patient. But
them in the EEG laboratory. as we learned earlier in this chapter, a ground electrode is
important - it is needed to minimize the amount of 60 Hz
artifact in the EEG tracings. In reality, the isolated ground
The EEG Technician's Role is a sophisticated current-limiting device. One such device
employs a solid-state component that is connected in ser-
in Patient Safety ies with the ground electrode connected to the patient.
This component acts like a resistor in the circuit, like a
Aside from ensuring that the EEG equipment used is variable resistor. With little or no current flowing in the
designed, constructed, and maintained with a view to the ground circuit, the solid-state component has a relatively
operator's and patient's safety, what can the EEG tech- low resistance that ranges between 4K and 6K ohms. How-
nician do to minimize the risk of an electrical accident ever, should the current flowing in the circuit increase and
happening? approach hazardous levels, the resistance of the compo-
First of all, it is important to identify what electrical nent increases and quickly can become very high. Since by
equipment, if any, is already hooked up to a patient before Ohm's law current is inversely proportional to resistance,
attaching EEG leads. Remember that the more wires you this circuit prevents dangerous levels of electric current
connect to a patient, the more chances there are of faults from flowing through the patient's body on into ground.
being present or developing and the greater the risk of The isoground device can protect the patient only from
electric shock. When an electrical device already con- electrical currents finding their way to ground via the
nected has a ground of its own on the patient, do not attach ground lead. In routine clinical electroencephalography,
an EEG ground to the patient but use the already existing there are 21 other electrodes attached to the patient. If
ground instead. If this results in unacceptably high levels a fault developed in anyone of these input connections
of 60 Hz artifact, remove the existing ground lead and to the EEG machine, and if any other electrical device
replace with the standard EEG ground electrode place- besides the EEG machine happened to be hooked up to
ment - usually the center of the patient's forehead. A good the patient, the patient could serve as a pathway for the
general rule to follow is that there should be only one flow of hazardous currents between these points. To pro-
ground electrode attached to the patient at anyone time. tect the patient against this potential danger, the bio-
Second, an electrode board having an isolated ground or potential isolator may be used. This device is a special elec-
isoground can be employed instead of the commonly used trode board in which a current-limiting solid-state
unit. The isolated ground limits current flow to ground via component like that used in the isolated ground is con-
the EEG ground electrode to safe levels regardless of any nected in series with each of the 21 leads (as well as the
faults that might develop in other connections to the ground lead) that are attached to the patient's head. By
patient. How this device works is taken up in the next using the biopotential isolator, none of the electrodes con-
section of this chapter. Finally, if other electrical devices nected to the patient during EEG recording can serve as a
are connected to the patient in addition to the EEG pathway for the flow of dangerous electrical currents
machine-as frequently happens in the leu -the use of a through the patient.
Ground Loops 59

Although the safety provided the patient by the might be at different voltages, thereby causing a current to
isoground and the biopotential isolator is of prime con- flow through the patient's body. But although patient safety
cern, if should be recognized that the benefits are not is the most important reason for avoiding a ground loop, it
obtained without some cost. The solid-state component is not the only reason. Previously we mentioned that the
that is the heart of these devices has a resistance that is wires running to the EEG electrodes attached to the
considerably greater than zero even at very low current patient create an antenna that picks up 60 Hz artifact. The
levels. As one of these components is connected in series same is true of a ground loop. As the loop is surrounded by
with each EEG lead, the resistance of the component gets a 60-Hz field, Faraday's principle of electromagnetic
added to the electrode resistance. This being the case, the induction applies, and a 60-Hz current will be induced in
EEG technician should recognize the consequences of the loop. Depending on the strength of the field and the
using these devices. area enclosed by the loop, a 60 Hz artifact may be recorded
In the first place, when an electrode board having an in the EEG tracings.
isoground is used, the EEG technician will discover that A ground loop does not necessarily have to involve a
impedance measurements of the ground lead are always patient. If two separate pieces of electrical equipment
higher than the impedance measurements of the other each having a ground wire of its own happen to have their
electrodes. This obviously happens because the imped- metal chassis touching, a ground loop will be formed. This
ance-measuring device displays impedance of the elec- can happen in the EEG laboratory when the chassis of a
trode plus impedance of the current-limiting device that is photic stimulator grounded by its power cord is allowed to
connected in series with the electrode. Secondly, EEGs come in contact with the chassis of the EEG machine.
taken when using the biopotential isolator will generally Being surrounded by a 60-Hz field, the loop will have a
show higher levels of 60 Hz artifact than EEGs taken using current induced in it and thereupon a voltage will be
the standard type of electrode board. The reason is that the developed. By Ohm's law, this voltage is equal to lZ, the
impedance of the current-limiting device increases the product of the current and the impedance; iflarge enough,
total impedance of a pair of electrodes, and 60 Hz artifact it may be recorded as a 60 Hz artifact in the EEG tracings.
is always greater with higher electrode impedance. The Many seemingly mysterious 60 Hz artifacts observed in the
upshot is that the EEG technician needs to use special EEG laboratory are explained in this way. As Ralph Morri-
care in attaching EEG electrodes to ensure low son, author of a text on grounding techniques, rightly
impedances when using a biopotential isolator. stated, "Basic physics, when properly applied, explains all
known electrical phenomena ... Most ... grounding
problems are just Ohm's law" (Morrison R, 1967).
Ground Loops The general grounding rule to follow is that all electrical
devices, as well as the patient, should have their own single
A ground loop is a condition that occurs whenever more connection to ground, and the ground connection should
than one ground wire is attached to a patient. The loop, of be common to everything.
course, is produced by the patient making an electrical
connection between the two ground wires. Earlier in this
chapter we noted that placing more than a single ground
Reference
connection on the patient was potentially dangerous. This Morrison R: Grounding and Shielding Techniques in Instrumenta-
was to be avoided because the two ground connections tion. New York, John Wiley & Sons, 1967, p. viii.
Chapter 9
Elementary Practical Troubleshooting
Methods

In the early days of electroencephalography, a person as the montage switch, power supply, calibrator, and chart
wanting to take an EEG frequently had to play the role of drive are of modular construction as well and may easily be
an electrical engineer and electronic technician, as well as removed and replaced. From these facts the two main
an all-around mechanic. The EEG machines in the 1930s methods of troubleshooting emerge. These are, first, the
through early 1950s were often makeshift, home-made method of substitution for diagnosing malfunctions and
rigs that were unreliable and sometimes temperamental- breakdowns limited to a single channel of the machine,
or so it seemed. It was not uncommon to interrupt an EEG and second, the method of isolation or elimination in the
recording to correct some malfunction caused by a noisy case of malfunctions or breakdowns that are common to all
or microphonic vacuum tube or a discharged or leaky bat- channels of a machine.
tery, or to eliminate an artifact produced by the corroded
contacts on a switch or connector. Because 60-Hz notch
filters and amplifiers with high common-mode rejection Single-Channel Problems -The Principle
were not yet available, 60 Hz artifact was a constant source
of harassment. Such problems, it can be imagined, made of Substitution
the outcome of a recording session uncertain.
The availability of today's more sophisticated EEG The simplest kind of single-channel problem is when a
machines has ended all that. The EEG technician can now channel fails completely. You tum on the machine and
obtain a recording without having to minister to the needs despite your double checking and triple checking the
of a malfunctioning machine. Nevertheless, modern setup and connections, nothing happens. Although the
machines are not entirely free of malfunction, and the other channels are all operational, this channel will record
EEG technician or the person interpreting the record is neither an EEG or a calibration; it is completely dead. At
sometimes called upon to diagnose the cause of a fault or this point you could employ the method of substitution
breakdown. Any but minor repairs or adjustments that may that will shortly be discussed. But the most likely cause of
be necessary, however, typically are left to the manufac- this kind of breakdown is a burned-out fuse if the circuit
turer of the machine or to its representative. Additionally, that provides the power needed to run the amplifier is
the EEG technician or interpreter may sometimes have to fused. So it is worth checking the fuse(s) in the amplifier
discover the source of artifacts appearing in a record that first.
originate outside of the EEG machine. The instruction manual that comes with the machine
shows how to locate and replace amplifier fuses; spare
fuses are usually provided in a repair kit that also comes
Basic Principles with the machine. If a fuse needs to be replaced, it should
be recognized that a burned-out fuse is frequently only a
Despite its complexity, an EEG machine is relatively easy symptom - a symptom that there may be some malfunc-
to troubleshoot. This is occasioned by the fact that EEG tion present within the circuit protected by the fuse. If the
machines are composed of a number of identical channels, fuse you replace burns out repeatedly, the amplifier will
each usually consisting of several separate, interchangeable need to be returned to the manufacturer for repair. On the
modules. In many machines, moreover, components such other hand, if a burned-out fuse is not the problem, it will
Single-Channel Problems Observed During EEG Recording 61

be necessary to make use of the substitution method to same artifact that was seen on channel 5, you can be
locate the source of the problem. reasonably sure that the channel 5 amplifier is the culprit.
Despite its simplicity, the method of subsitution is a As a double check, it is good practice to return the ampli-
powerful technique for discovering the source of a mal- fiers to their original positions and verify that the artifact
function. Nevertheless, there are pitfalls associated with its moves from channel 3 back again to channel 5. In the event
use that need to recognized. These can best be that the malfunction was caused by a dirty contact in the
appreciated by looking at a simple example. connector, the problem may be corrected by cleaning the
Suppose that in calibrating your machine prior to taking contacts. The procedure to follow is detailed later in this
a patient's EEG, you suddenly discover that channel 5 is chapter under "Connector and Switch Contacts:'
behaving peculiarly. Although all the other channels of the Before going through the double-substitution proce-
machine display a horizontal, perfectly straight line, the dure, a few precautions should be observed. First, for
pen of channel 5 wanders about erratically. A short strip of safety's sake make sure that the main power switch on the
recording reveals that this channel is tracing out a voltage machine is off while you make the substitutions. Second,
in the theta and delta frequency range. Since the artifact consult the instruction manual that comes with the
has a magnitude of about 50 !lV, it can significantly con- machine before removing an amplifier or, for that matter,
taminate the EEGs recorded on this channel. any other modular component. Many manufacturers have
Where does the artifact come from? Before even special methods and some even have special tools that aid
addressing this question, the experienced EEG techni- in removing the modules. Third, all connectors should be
cian will quickly double check the machine and verify handled carefully and protected from dust, dirt, and espe-
that channel 5 is set up correctly and that all the switches cially from electrode paste or jelly. They should be plugged
are in their proper positions. Some technicians may even into their mating connectors firmly but never forcefully as
index all the switches on this channel back and forth the contacts are easily bent or damaged.
several times to assure that the switch contacts are free The method of substitution can be applied to check the
of any foreign material. (The role of switch contacts in power amplifiers, lead selector switches, filters or penmo-
producing artifacts is discussed later in this chapter.) tors, assuming, of course, that they are all of modular con-
Having done this, however, you discover that the artifact is struction. Once the fault has been localized to a particular
unchanged. Now the only recourse is to apply the method module, it is a relatively easy matter to correct the
of substitution. problem. Thus, most manufacturers of EEG machines will
After selecting one of the good channels for the substi- ship you a "loaner" module to replace a malfunctioning one
tution, say channel 3, you need to decide which of the if you telephone and describe the symptoms of the mal-
modules to substitute. You can, of course, routinely substi- function, explaining what tests you have carried out to
tute all of them, one at a time. But experience has shown localize the fault to a particular module. Use the packing
that the most likely source of a problem such as this will be material from the loaner to package the faulty module and
the amplifier, or preamplifier if the preamplifiers in your return it to the factory for repairs. To document the fault,
machine happen to be separate, modular components. So it is helpful to send a strip of record from the machine
you remove the amplifier in channel 5 (the bad channel) showing the nature of the malfunction as well as a brief
and replace it with the amplifier from channel 3 (the good explanation along with the defective module. The reason
channel). The malfunction disappears. Channel 5 is now for this is that rough handling that might occur during
O.K., and you conclude that the amplifier that was origi- shipping could cause an artifact produced by a poorly sol-
nally in channel 5 is faulty. But in doing so, you would be dered joint in a circuit to momentarily disappear. Should
making an inference and leaving yourself open for a pos- this happen and the factory had no record documenting
sible error. the malfunction, the credibility of the person returning the
The error we refer to derives from the fact that the mal- module might be questioned.
function could have been due to the connector that the
amplifier was hooked up to as well as the amplifier itself. It
is not unusual for the contacts in a connector to become Single-Channel Problems Observed
noisy spontaneously and for the problem to be cleared sim-
ply by breaking and remaking the connection, as happens During EEG Recording
when an amplifier is removed and replaced. To rule out
this possibility, it is essential to do a double substitution; in In the just-completed discussion, the artifact present in
other words, you need to observe the result of installing the channel .5 was observed during the calihration done prior
amplifier from channel 5 (the bad channel) in channel 3 to taking an EEG. Suppose, instead, that the same peculiar
(the good channel) as well. If after doing this the artifact signal was observed on a single channel of the chart while
moves with the amplifier, i.e., channel 3 now shows the an EEG was being taken. Now, thinking that this signal is
62 9. Elementary Practical Troubleshooting Methods

an artifact of the kind discussed in the last section, you electrode board and adjusting the appropriate lead selec-
quickly switch the machine over to calibration to observe tor switch to this new position. If the peculiar voltage dis-
it more closely. In doing so, the peculiar signal disappears appears, it is obvious that the voltage is an instrumental
and the channel calibrates properly. Could this voltage, artifact.
this peculiar signal, be an instrumental artifact? What can be done to correct this problem? Dried elec-
If the recording happened to be from a referential mon- trode paste or other material clogging a jack in the elec-
tage, it would be impossible to judge whether the voltage trode board can sometimes be removed by dipping a
in question was an instrumental artifact, an electrode wooden dowel the size of the pin plug on an electrode wire
artifact, or a voltage generated by the patient. To inves- into some alcohol and working it back and forth in the jack.
tigate, you switch to a bipolar montage. In so doing, you Great care must be taken that the dowel does not break off
find that the peculiar signal is present now on two chan- in the jack, or that the inside of the jack is not damaged. If
nels, both of which have a single electrode in common. the jack is already corroded, this procedure will probably
This finding rules out the possibility that the voltage is due be futile. In such a case, the only recourse is either to dis-
to an intermittent malfunction in the channel on which the continue using the defective jack and use a spare one on
artifact was first seen, or to a fault in the lead selector the board instead - remembering that the lead connected
switch or montage switch. However, it still could be an to it will need to be switched in separately if you use a
instrumental artifact that is associated with the electrode montage switch - or to ship the electrode board back to
board, an electrode artifact, or a voltage from the patient the factory for repair.
- the latter possibility depending on the presence and dis- A better way of dealing with this problem is simply to
tribution of the voltage in adjacent leads. Artifacts associ- prevent it from occurring. This is readily accomplished by
ated with the electrode board are taken up in the next sec- the technician ensuring that hislher hands are free of elec-
tion. The other possibilities are considered in Chapters 7, trode paste and other such materials before the plug ends
11, 12, and 13. of the lead wires are handled. Similarly, care in handling
the electrodes after they have been removed from a patient
also can help. Experienced technicians never let the plug
Electrode-Board Artifacts ends of their electrodes touch the disk ends if the latter are
covered with electrode paste.
While electrode-board artifacts are not common, they can Rarely, the hypothetical artifact we have been discussing
occur if the EEG technician is careless about using elec- may originate not from the electrode board itself but from
trode paste and prep materials like Omni-Prep®, allowing a faulty contact in the connector of the interconnecting
them to be smeared on the plug ends of the electrode cable (the cable that connects the electrode board to the
wires. When this happens, the electrode paste or other EEG console). What to do in this event is discussed later in
material may be transferred to the jacks on the electrode this chapter under "Connector and Switch Contacts:' Such
board where it dries and cakes up. Sometimes, the salt artifacts are particularly bothersome, frequently coming
present in these materials actually causes corrosion of the and going without apparent rhyme or reason.
jacks. The caking and/or corrosion produces a high resist-
ance contact between the plug of the electrode wire and
the electrode-board jack. The result of this condition may Problems Common to All Channels
be a variety of curious, frequently intermittent artifacts in
the tracing, or tracings if the lead is connected to more These include both the simplest and the most difficult
than one channel of the machine. problems to diagnose. They may have their origin either
Electrode-board artifacts are particularly troublesome inside or outside the EEG machine. Artifacts or break-
because they are often mistaken for electrode artifacts. downs common to all channels that originate inside the
When first observed, the EEG technician will invariably EEG machine arise from a variety of causes. Artifacts
reapply the electrode involved - sometimes several times originating outside the EEG machine may be caused by
-without any effect whatsoever. After doing this, most disturbances in the power line, noise in the earth or ground
technicians would suspect the problem to be a faulty elec- connection, and noise in the environment in which the
trode and would replace it with a new one, but again to no EEG laboratory is situated. We will consider externally
avail. At this point, the evidence clearly suggests that the generated artifacts first, but only very briefly because
voltage in question either is generated by the patient or these artifacts are not normally within the purview of the
arises from a fault in the electrode board and/or connector EEG technician. Dealing with them first does not imply
of the interconnecting cable. Whether the patient or the that externally generated artifacts take priority over
machine is to blame may readily be decided by plugging artifacts originating inside the machine in practical cases
the electrode under consideration into a spare jack on the of troubleshooting.
Problems Common to All Channels 63

Externally Generated Artifacts Morse code reference in the dictionary revealed that this
was indeed the case. We were able not only to decode the
These can be the most difficult to diagnose and eliminate. message being sent at the time, but also to get the transmit-
The suspicion that an artifact originates outside the EEG ter's call letters. The transmitter, we found, was owned by
machine can be arrived at in a number of ways. You might a ham operator-a student at the university. When he
already have searched for the source in the machine itself learned about our problem, he obliged us by going off the
and failed to find it. Or you may have tried another EEG air whenever we were taking EEGs.
machine in the identical location and experienced much If after short-circuiting the inputs of all the channels the
the same problem. Or the pattern and time of appearance artifact still remains, you need to consider whether the
of the artifact may suggest that its occurrence is coincident power line into the EEG machine is the source. When an
with some activity or event in the vicinity of the laboratory. EEG laboratory shares the same power line with electrical
If you suspect that a particular artifact does originate equipment having heavy start-up current loads like large
outside of the EEG machine, you need first to isolate the motors and x-ray machines, power line artifacts are not
problem to either the power line, the ground, or the uncommon. To identify the offending piece of equipment,
environment. Artifacts from the environment invariably it is necessary to check out the EEG machine when the
get into the EEG machine by way of the inputs. To identify equipment in question is not in operation. Sometimes, as
the environment as the source of the artifact, or to rule it in the case of elevator, pump, or fan motors, this may be
out, you need to find out what happens when you short- only on nights and holidays. Should you find that a particu-
circuit the inputs of all the channels. This is done for each lar piece of equipment using the line is responsible for the
channel by switching both Gl and G2 to the same position. artifact, it may help to plug the EEG machine into a differ-
To avoid interaction between the channels, choose a differ- ent electrical outlet if one is available in the laboratory. It
ent lead selector switch position for each channel. If after is not unusual for a single room to be served by two differ-
carrying out this test the artifact disappears, it can be con- ent branches of the power line and for an artifact to be
cluded that the artifact originates somewhere in the worse on one branch than on the other. If this fails to allevi-
environment. ate the problem, the only choices are to eliminate the
Artifacts originating in the environment can come from offending equipment, to move the EEG laboratory to
a variety of sources. The power lines and transformers in another location, or to install a surge suppressor or a spe-
the vicinity of an EEG machine, which operate at 60 Hz in cial isolation transformer on the power line feeding the
the United States and 50 Hz in Europe, are the most com- EEG machine. But this decision is best left to a specialist
mon points of origin. Note that although their origin may - an electrical engineer or biomedical technologist.
be the same, the place of entry of power line artifacts that Once you have eliminated the environment and the
we discuss next is different. Thus, while environmental power line as sources of an artifact and you are sure that it
artifacts are coupled through the inputs, power line does not originate within the EEG machine, the source
artifacts get into the machine directly via the power cable remaining is the ground. Noise originating in the ground
that runs to the machine. Another possible source of wire is most troublesome because it may be extremely
environmental artifacts is a winking fluorescent lamp in difficult to diagnose, costly and sometimes impossible to
the vicinity of the EEG machine. A less likely but possible eliminate. The first thing to do is to make sure that any
source is a radiotelegraphy station located close to the auxiliary electrical equipment used in the EEG laboratory
EEG laboratory. has a wire of its own going directly to ground, i.e., that
The latter is of particular interest because one of the other equipment does not get its connection to ground via
authors has had some experience with it. For months the the EEG machine. Be sure also that the chassis of the EEG
EEG laboratory was plagued by the occurrence of machine and any auxiliary equipment used are not in
medium-to-high amplitude spikes on the tracings of all actual contact with each other. This is important because
channels of the machine. These spikes, which occurred in with the two chassis touching, a ground loop is created. A
a variety of apparently random patterns, would appear ground loop provides an alternative pathway to ground for
suddenly at any time during the day; they continued for as the auxiliary equipment via the EEG machine and vice
much as a couple of hours, and then disappeared as versa. If the auxiliary equipment should happen to be
abruptly as they had started. They clearly originated from generating some kind of electrical noise and leading it onto
the environment because they disappeared when the the ground wire, the noise could find its way into the EEG
inputs were short-circuited. Where did the artifacts come machine. The topic of ground loops is taken up in some
from? Well, one day while recording and observing them detail in the chapter on electrical safety.
for at least the hundredth time, the thought occurred that If the artifact is not generated locally, you will need to
the spikes were not appearing entirely at random but fol- look outside the EEG laboratory for the source. This is
lowed some organized pattern. A quick reference to the done by disconnecting, one at a time, all other pieces of
64 9. Elementary Practical Troubleshooting Methods

electrical equipment that are hooked up to the same If new fuses are again installed and these too burn out, a
ground wire used by the EEG machine and then observ- malfunction is present in the power supply. Contact the
ing the result. In some cases, this test is impossible to manufacturer for a loaner unit and instructions so that the
carry out as the exact pathway taken by the EEG labora- defective power supply can be returned to the factory for
tory's ground wire on its way to earth may be unknown. repair. If, on the other hand, the fuses burn out only when
An alternative is to move the EEG machine temporarily to the power supply is connected up to the amplifiers and
another location where the ground wire is closer to the other components, there may be a short circuit in the
earth connection and is free of branch connections to any cables distributing power within the machine. A telephone
electrical equipment. If the artifact remains, the entire call to the manufacturer or hislher representative will
ground system may be noisy, and you will need to consult inform you how to proceed in this instance.
a specialist for help. Another breakdown that affects all channels happens
Sometimes, problems with ground noise can be cor- when there is a failure in the calibration circuit. The
rected by providing an entirely separate ground system machine seems able to record EEGs, but the record taken
for the EEG laboratory. This is accomplished by having during calibration no longer shows the proper deflection
several long, copper-clad steel rods driven into the earth sensitivities - or the calibration waves may be totally absent
nearby and connecting the ground wire of the EEG -when you press the calibration switch. To aid in trouble-
machine to these rods. Obviously, this is not a good solu- shooting such problems, some machines have a test jack on
tion if the building housing the EEG laboratory sits on the front panel for measuring the voltage feeding the
rock or on sandy, dry soil. Another possible solution is to calibration circuit. The instruction manual explains how
have a special circuit - a wave trap - designed and installed this voltage may be checked. If the measurement carried
in series with the ground wire to the EEG machine. By out shows that no voltage is present, a fuse protecting the
providing a high impedance pathway for the noise, the circuit may be burned out and should be replaced. If the
artifact is kept from entering the EEG machine. But these voltage is too low, the calibration circuit may have devel-
are matters for the specialist and obviously outside the oped a fault. In this event, the module containing it should
realm of the EEG technician's responsibilities. be returned to the factory for repairs. Another possibility,
if the machine is of older vintage, is that the battery provid-
ing the calibration voltage is run down and needs to be
Internally Generated Problems - Breakdowns
replaced. Here, again, a few moments spent with the
Breakdowns affecting all channels of an EEG machine are instruction manual or a telephone call to the manufacturer
the easiest to diagnose. Following is an example that may will tell you how to proceed.
be familiar to some EEG technicians. Machines that have malfunctioning all-channel controls
Upon turning it on, you discover that the EEG machine will display breakdowns that affect all the channels. To
is dead. Something has gone wrong with the machine. But determine whether a problem is attributable to the all-
wait! Before looking inside for the source of the problem, channel control circuit, set all the amplifiers for indepen-
it is good practice to verify that the fuse or circuit breaker dent channel control. If in so doing normal operation is
in the power line to the machine has not burned out or restored, the malfunction resides in the all-channel control
been tripped. The simplest way of doing this is to plug a unit. Check the fuses in this module to determine whether
lamp or other electrical device that is handy into the same or not they are burned out. If fuses check out, the only
outlet used by the EEG machine to see if it works. While choice is to return the module to the factory for repair.
this test is so obvious that it hardly seems worth mention-
ing, it is frequently overlooked. The result of the oversight
Internally Generated Problems - Artifacts
can be a fruitless seach for a nonexistent problem inside
the machine. Artifacts that are present on all channels and originate
If the electrical outlet checks out all right, but the within the machine can arise in two different ways. They
machine is dead - i.e., no pilot lights on, no pen deflections are caused either by malfunctions in components common
regardless of what you may do - the problem very likely is to all channels, or by a malfunction present in a single
the power supply. A fuse may have burned out. Spare fuses channel that is spread to the others by connections or path-
for the power supply usually come with the machine and ways and components that are common to all the channels.
replacement instructions are found in the instruction Assuming the power supply adequately isolates the EEG
manual. For safety's sake, disconnect the power cord machine from the power line, the ground circuit is the only
to the machine before removing and replacing any fuses. pathwa!l that is common to all the chanl1f·ls. MachinE" ('om-
Should the newly installed fuse or fuses burn out, locate ponents having a common relationship to all the channels
and disconnect the cable that carries power from the are the power supply, the calibrator, and the all-channel
power supply to the amplifiers and other components. control circuit if the machine has one.
Problems Common to All Channels 65

Artifacts caused by a malfunction in a single channel supply is accessible, the two power supplies can be
and spread to the others by pathways and/or components exchanged and the result observed. Otherwise, about all
common to all the channels are the easiest of the group that the EEG technician can do if a power supply malfunc-
to diagnose. For this reason, you should test for them tion is suspected is to measure the voltages produced.
first.l If the machine has an all-channel control feature, These voltages ought to be correct to within about ± 2 % of
begin by setting the switches on all the channels for their stated values (see the instruction manual) and should
independent channel control. Should this cause the arti- be very stable. An accurate digital voltmeter or voltmeter
fact to disappear, we would conclude that the all-channel with a scale sensitive enough to detect a 1% shift in voltage
control module was involved-either causing the artifact should be used. These measurements need to be made
or spreading it from another source to all the channels. while the machine is in actual operation or while a calibra-
On the other hand, if the artifact remains after all the tion is being run. Low or unstable voltages are indicative of
amplifiers are set to independent channel control, the power supply malfunction, and your findings should be
all-channel control module is not involved. In the latter communicated to the manufacturer, who will instruct
case, continue the troubleshooting by removing and re- you further.
placing each amplifier, one at a time, and carefully observ- It is important to keep in mind that the validity of such
ing, in each case, the effects on the remaining channels. measurements is determined to a large degree by the
If the artifact in question disappears after one of the ampli- characteristics of the particular voltmeter used. Thus,
fiers is removed, that amplifier is clearly suspect. Next, although the power supply voltages you measure appear
you need to find out whether the connector hooked up to stable, they may, in reality, be unstable. This could hap-
the amplifier is involved. To do this, remove another ampli- pen if any fluctuations occurring in the power supply
fier from its bin and put the suspected amplifier in its voltage were too rapid for the voltmeter to follow. Of
place. If now the previously observed artifact returns, the course, more sophisticated measurements may be carried
suspected amplifier is clearly at fault and should not be out using a cathode-ray oscilloscope. But these methods
used until replaced. of measurement are not ordinarily available to the EEG
The situation in which the artifact disappears when technician.
the controls of all the amplifiers are set for independent Artifacts due to the calibrator usually originate in the
channel control needs yet to be considered. This prob- switch that produces the calibration pulses or in the poten-
lem may be caused either by a malfunction in the all- tiometer that adjusts their amplitude. When they occur,
channel control or by a malfunction in a single channel such artifacts show themselves as intermittent, randomly
that is spread to the others by the all-channel control. To occurring spikes or sharp waves having the same pattern in
decide which it is, you need to discover whether one of the all the channels. Sometimes they may disappear briefly or
amplifiers is faulty. Amplifiers in particular are focussed even for long periods of time if you repeatedly close and
on because of all the components in a channel, they are open the calibration switch many times. The artifacts are
the most likely to malfunction. The necessary trouble- due mainly to a high-resistance contact in the switch. If the
shooting procedure is tedious but simple. With the con- artifacts persist, the switch wiIl need to be replaced.
trols for all the channels set to all-channel control, remove Artifacts originating in the potentiometer that adjusts
and replace each amplifier, one at a time, observing the the calibration-pulse amplitude have similar characteris-
effects of this procedure. If the artifact disappears after tics, although the amplitude of the calibration pulse may
removal of any single amplifier, the amplifier in question is also show some erratic, spontaneous variations. If an
responsible for the artifact. On the other hand, if the accurate digital voltmeter is available for resetting the
artifact remains unchanged despite the removal of any of calibration voltage, the EEG technician can attempt to
the amplifiers, the problem most probably lies with the all- correct the problem his or herself. First, locate the poten-
channel control. tiometer and the test point for measuring the calibration-
Artifacts originating with the power supply of the EEG circuit voltage inside the calibrator circuit. Next, using a
machine are difficult to localize. If another EEG machine screwdriver that fits the slot in the control shaft of this
of the same type and using exactly the same model power potentiometer, rotate the control shaft back and forth
several dozen times and return it to its original position.
Connect the digital voltmeter to the test point and adjust
1 This test may be carried out with a practice patient connected the potentiometer carefully until the voltmeter reads the
up to the machine using a bipolar montage. A more convenient exact voltage specified in the instruction manual. Replace
arrangement is to connect a separate 5K ohm resistor (a dummy any cover that may have been removed from the unit con-
patient) to Gl and G2 of each channel of the machine. This is
most readily accomplished by soldering pin plugs to the lead taining the calibrator circuit. Having done all this, now run
ends of the resistors and then plugging these devices into the a calibration in the usual way. If the artifacts were due to a
electrode board. high-resistance contact in the potentiometer, the simple
66 9. Elementary Practical Troubleshooting Methods

procedure of cleaning the contacts by rotating the control ping a suspected connector with the handle of a light
shaft back and forth will frequently correct the problem. 2 screwdriver.
Artifacts of this kind are quite common in some of the
older EEG machines. This is because the connector con-
Connector and Switch Contacts tacts in the vintage machines were usually silver plated. As
anyone using silver or silver-plated flatware knows, silver
The role of connector and switch contacts in the genera- tarnishes quite readily in the atmosphere of our industrial
tion of artifacts has already been mentioned several times society. The silver-plated contacts in a connector are no
in this chapter. The extensive use of modular construction exception. Any tarnish occurring at the junction between
in many EEG machines means that a lot of connectors are two contacts can raise the contact resistance appreciably.
needed to hook the various modules together. Compared The use of gold-plated contacts has greatly reduced if not
with a hard-wired connection like a solder joint, connec- eliminated this problem. Nevertheless, even gold contacts
tions made by connectors can become very noisy. So we can become noisy because of the presence of foreign
find that the convenience afforded by modular construc- material on their surfaces. For this reason, the EEG tech-
tion is not obtained without some cost to the user of the nician needs to have some ready method of cleaning con-
machine. Nevertheless, given that connector noise can nector contacts.
readily be identified and easily corrected, the convenience The plug ends of some connectors can be cleaned rather
far outweighs the costs. easily by using the rubber eraser on the tip of an ordinary
Artifacts produced by noisy connector connections arise lead pencil. Rub the eraser in an even stroke across each of
mainly in two different ways. In the first place, some con- the contacts in the direction of the tips. Make sure first that
tacts in the mating connectors may not fit together prop- the tip of the eraser has been rounded off and that it is
erly because they are defective or have been damaged. scrupulously clean. If the contacts are flat, one or two
Connector contacts are readily liable to mechanical strokes with the eraser are sufficient; round contacts will
damage-they are easily bent, scored, or pitted. For this require several strokes. Carefully remove all eraser crumbs
reason, they need to be handled carefully. It is essential not from the cleaned contacts before the plug is inserted again
to use excessive force when plugging a module or cable into the socket. Contacts on multiple-pin connectors are
into its mating connector. frequently not accessible with a pencil eraser. In these
A second way in which connector connections can cases a thin sheet of rubber can sometimes be used
become noisy results from the inherent tendency of metal instead. Draw a narrow strip of the material across the pins
to corrode or to become coated with foreign material. at several different angles. If the contacts are inaccessible
Metals, of course, are very good conductors. They offer a even by this method, about all the EEG technician can do
low resistance to the flow of electric current, which is why is to work the plug end of the connector back and forth
they are used in connectors. But if the junction between about a dozen times in its mating socket. Files, emery
the contacts in two mating connectors becomes coated cloth, or other abrasive materials must never be used on
with corrosion or foreign material, the contact resistance connector contacts.
may increase sufficiently to significantly resist the flow of The contacts in switches can present many of the same
current across the junction. What is important as far as the problems. As with connectors, the artifacts generated by
production of artifacts is concerned is that contact switches are the result of intermittent, high-resistance
resistance under such conditions not only is elevated but contacts. Unfortunately, the methods used for cleaning
also may become unstable - it may change rapidly and connector contacts cannot be applied to switch contacts.
spontaneously from a low to a high value within seconds. Switch contacts are not readily accessible to a pencil
This is what produces the characteristic noisy-contact arti- eraser; indeed, some switches are completely enclosed in
fact; electronic technicians and engineers sometimes a container so that the contacts are not even visible. As
check for the presence of such artifacts by sharply tap- mentioned here earlier, switch-contact artifacts can some-
times be eliminated by repeatedly indexing the switch
back and forth about the suspected contact. A variety of
2 The EEG technician should be aware that this simple procedure
cannot be carried out on all machines. Thus, some manufacturers contact cleaners are available commercially. These can be
put special seals on the chassis of their modules. If these seals are sprayed directly on the contacts of the troublesome switch
broken by the user to get to a circuit for troubleshooting and if the contacts are accessible. In the authors' experience,
repair, the manufacturer's warranty is voided. Other manufac- however, they have not proved particularly useful. If simply
turer's sometimes put sealing wax on the shafts of potentiome- indexing the switch does not correct the problem, the
ters. If any adjustments are attempted, the wax will be broken
and the warranty may be voided. Therefore, before attempting switch will have to be replaced in all probability.
any such troubleshooting or adjustments, consult the instruction The types of switches considered thus far in this chapter
manual that comes with the machine. are the conventional mechanical types - rotary, toggle, and
Chart-Drive Malfunctions 67

lever switches. As a result of recent technological develop- deserves special mention. This switch, sometimes called
ments, the switches on some of the very newest-model the master writer switch, has three positions and controls
EEG machines have changed greatly. The use of so-called the actual operation of the machine. In the first or off posi-
"soft-touch" switches, the display of machine parameters tion, the electronic portions of the machine are on (assum-
by means of a cathode-ray tube, and touch-screen switch- ing, of course, that the main power switch is turned on),
ing have noticeably modified the physical appearance of but the chart drive is not operating. In the next or chart
the EEG console. Also, rotary switches that control multi- position, the chart paper runs through the machine as well.
ple-switching operations are being replaced by solid-state, This position is used to check tracking of the chart through
electrical switches. These changes, in turn, have made the machine. Finally, in the last or run position, the ampli-
menu-driven machines possible. While these switching fier outputs are connected to the penmotors so that the
devices show promise of being more reliable than their EEGs are traced out on the moving chart.
conventional equivalents, only time will tell whether they Because the switch we are discussing gets a great deal of
and the other recent modifications in the EEG machine use, it occasionally breaks down. Usually, the breakdown is
will enhance overall machine reliability, reduce downtime, such that only one channel of the machine is affected. The
and decrease the amount of time expended in trouble- symptoms of the breakdown are classic. The channel is
shooting. completely dead and nothing you do will make the pen
deflect from its baseline position. Yet, the amplifier, pen-
motor, lead selector, filter-all the modules in the channel
Chart-Drive Malfunctions -test out O.K. A check with a voltmeter, however, shows
that the operating voltage never reaches the penmotor
Some of the problems that beset the chart drive have been because it is blocked by a faulty master writer switch.
taken up already in the chapter on the writer unit. A few Replacement of the switch, of course, is necessary. In some
yet remain to be considered. Although the troubleshooting machines, this is facilitated by the fact that the switch is
that the EEG technician can do on the chart drive is incorporated in a separate module - the writer control
limited, a few simple diagnostic tests are possible. The module.
methods employed follow the same logic that is used for In feeding paper through the machine, the chart drive
troubleshooting the rest of the machine. provides the time base for the EEGs traced out on the
The heart of the chart drive is, of course, the motor that chart. Measurements of frequency of the waveforms of the
powers it. In many machines the current needed to run the tracings, therefore, depend on the accuracy with which the
motor is derived from the power supply for the machine, chart paper moves through the machine. The actual drive
and in some cases this current is separately fused. Thus, mechanism used is quite simple; it consists usually of a
the first thing to do if the chart drive fails to operate is to rubber pressure roller in direct contact with a knurled
locate and check the fuses. Remember, however, that metal roller. The chart paper rides between the two rollers.
before touching these fuses you should make sure that the Through use, the rubber may deteriorate or develop a flat
power cord to the machine has been disconnected from spot on its surface. For this reason, the rubber pressure
the wall socket. If the fuses check out, the problem is roller should be inspected occasionally and replaced when
either the power supply or the motor. To help you decide necessary as a worn out roller can degrade the accuracy of
between the two alternatives, many power supplies have the chart speed. See also "Chart Drive" in Chapter 5.
test points on their chassis that permit easy measurement The standard chart speed of30 mmls should be checked
of the power-supply voltages. Check the instruction occasionally. This is done most readily by recording 60 Hz
manual. If the voltage that runs the chart drive checks out artifact on all channels of the machine and then finding out
O.K., the malfunction is in the motor; otherwise, the power how long a segment of chart in millimeters is occupied by
supply is at fault. In some machines, modular construction exactly 60 of these waves. Separate measurements should
extends even to the chart drive. This, of course, greatly be made at different positions on a page of the chart to
simplifies servicing once a malfunction has been localized determine whether the paper is feeding accurately over
to the chart drive. the folds as well as over the smooth portions of the chart.
The chart drive contains an important switch that The chart speed should be accurate to ± 2 % .
Chapter 10
Neurophysiology

Scientists have diligently pursued the goal of unraveling neurons. The axon is often covered by a layer of myelin,
the mystery of brain electric activity from the days of Hans which shows points of interruption known as nodes of
Berger, but like many other natural phenomena, less is Ranvier. The myelin sheath, which acts as an insulation for
known about the exact genesis of the EEG than about its the axon, helps in the rapid conduction of electrical sig-
physiological and pathological variations. A number of nals. The primary function of the axon is the conduction of
techniques, including surface, depth, and intracellular, as signals from a neuron to one or more other neurons. It also
well as in vitro recording methods, have been used to study transports materials like neurotransmitters synthesized by
this phenomenon, and a wealth of data has been accumu- the cell body through the axoplasm onto the synpatic
lated. Before considering these data and entering into a terminals (axoplasmic transport).
discussion of the current ideas concerning the origin of the Although all neurons are essentially similar in possess-
EEG, it is essential that we look at the neurons - the cellu- ing cell body and processes, there are considerable differ-
lar units of the nervous system. We will examine them from ences in their morphology. They may be unipolar, in which
the points of view of anatomical structure and generation case there is only one process emerging from the cell- and
of bioelectric activity. dividing into branches that serve as dendrites and axon;
hipolar wherein one process acts as a dendrite and the
other as the axon; or multipolar, in which case there is one
Structure of the Neuron axon and several dendrites. Most cells in the human ner-
vous system are multipolar. The advantage of such a neu-
There are two distinct varieties of cells in the nervous ron is that it can make contact with a very large number of
system: the nerve cells or the neurons and the support cells other neurons; for example, the Purkinje cell, which is a
or the glia. Although glial cells are important in providing large cell in the cerebellar cortext is known to receive as
the appropriate environment for neuronal function and for many as 150,000 contacts from other neurons.
myelination of the axons, it is the neuron that forms the The length of an axon can show considerable variation.
ultimate unit of brain function. A typical neuron has three As already mentioned, an axon can, in some cases, extend
easily identifiable parts, namely, the cell body (soma, for very long distances before making contact with another
perikaryon), the dendrite, and the axon (Fig. 10.1). The cell cell. Neurons having such long axons are often referred to
body, which contains organelles such as the nucleus, as relay neurons. They serve to relay information from one
endoplasmic reticulum, and Golgi apparatus, is the meta- area of the nervous system to another, as, for example, from
bolic center of the neuron. It is covered by the neuronal the motor cortex to the anterior horn cells in t\1e spinal
membrane, which separates the cell contents from the cord. Neurons with shorter axons make contact with cells
extracellular fluid. in different layers in the same vicinity and are called inter-
The dendrites, which are small multiple arborizations of neurons.
the cell body (like the branches of a tree), serve as the
points of input of signals to the neuron. The axon is like a
tube extending from the cell body for long distances (as Membrane Potential
much as 1 m in the human); its distal end divides into many
fine branches forming the synaptic terminals. These termi- The neural membrane displays some interesting and
nals are found near the cell bodies or dendrites of other important properties. Of particular importance is that the
Membrane Potential 69

potassium ions within the cell, whereas sodium and chlo-

- Dendrite
ride ions show higher concentrations outside the cell
(see Table 10.l). Such a difference in the ionic concen-
Soma tration is maintained by selective permeability of the
P-'t""""- -ir5--- Nucleus
membrane to specific ions and by active transport mecha-
nisms that selectively pump certain types of ions in or out
. - - - -- - Axon hillock
across the cell membrane. Let us examine each of these
...,1111-- - -- - Myelin sheath
mechanisms .
The cell membrane at rest is highly permeable to potas-
Axon sium ions but poorly permeable to sodium ions. Since the
:1111,- - - -- Node of Ranvier concentration of potassium ions is 35 times greater inside
the cell than outside, a concentration gradient exists across
AIIk- ---- Neurofibrils the membrane. This concentration gradient tends to drive
potassium ions from the intracellular space into the
1:.1..-- ---- Axon terminal extracellular fluid along the passive potassium channels.
The outward diffusion of potassium ions, which are posi-
Synapse tively charged, leads to an excess of negatively charged
ions inside the cell. This is because certain negative ions
Figure 10.1. Schematic diagram of a neuron showing the major within the cell (the organic anions) are unable to pass
structural features. through the cell membrane; instead, they tend to line up
along the inner surface of the membrane. The excess of
negative charge on the inside and positive charge outside
the cell membrane soon prevents further escape of more
resting membrane is electrically polarized; Le., a differ- potassium ions, although the actual concentration of potas-
ence in potential or voltage exists between the two sides. sium ions stays higher within the cell. Indeed, the loss of
To understand the origin of this membrane potential, an potassium ions from inside the cell is relatively insignifi-
understanding of the structure of the neuronal membrane cant because of the large number of potassium ions in the
and its ionic channels is essential. The following discussion whole of the cytoplasm.
takes up the bare essentials. Details are found in more By the time the potassium ions stop diffusing out and
advanced texts. there is an excess of negative ions on the inside and posi-
The neuronal membrane is made up of proteins and tive ions on the outside of the cell membrane, the posi-
lipids and is about 10 nm (0.011l) thick. The lipid forms a tively charged ions - of which the most abundant are
double layer that, being immiscible with water, does not sodium ions - tend to line up along the outer surface of the
allow water-soluble ions to move in and out of the cell. cell membrane. But because the cell membrane is poorly
However, the cell membrane contains areas in which there permeable to sodium ions, these ions cannot enter the cell
are protein "pores" through which ions can pass. These are in sufficient numbers to neutralize the excess of negative
called ionic channels and are of two varieties: passive and charge inside the cell. Because of this selective permeabil-
active. The passive channels are always open and allow ity of the membrane and also because of an active pumping
diffusion of selected ions, depending on the concentration mechanism described later in this chapter, there is an
gradient across the membrane. accumulation of negative charges on the inner surface and
The active channels may be kept open or closed through positive charges on the outer surface of the neuronal mem-
gates strategically placed at one or both ends of the chan- brane. As the membrane separates opposite charges on its
nels. When the membrane is at rest, most of the active two sides, it is said to be "polarized:'
channels remain closed. These channels open abruptly The cell membrane with its associated ions on either
when there is a specific change in the membrane poten- side resembles a charged capacitor since the lipid lining
tial and hence are called voltage-regulated channels. acts as a dielectric separating positive and negative
The channels are selective, acting like filters, and often charges. If we were to measure the charge across the mem-
allow only one species of ion to pass through. Thus there brane, we would find that in the resting state the inside of
are specific channels for sodium, potassium, and calcium the cell is - 40 to - 90 mY compared with the outside.
ions. This is called the resting membrane potential (RMP). All
The neuronal membrane separates the cytoplasm of signaling and transmission of information in the nervous
the neuron (neuroplasm) from the extracellular fluid. If system is based upon the induction of fluctuations in the
we analyze the composition of the intracellular and extra- RMP, which lead to the synaptic and the action potentials.
cellular fluids, certain specific differences become evi- For this reason, it is important to gain some insight into the
dent at once. Thus, there is a higher concentration of ways in which such fluctuations take place.
70 lO. Neurophysiology

Nernst Equation tively, of the particular ion. By substituting the constants

and converting the natural logarithms to base 10 loga-
Diffusion of potassium ions from the inside to the outside rithms, the equation may be simplified to
of a cell (efflux) occurs only for a brief period of time.
1 [Tlo
Equilibrium is quickly established, and the potassium ions ~ = n 61.5 loglo [Tli
cease to move outward owing to the excess negative charge
that accumulates inside and also because of the repelling which gives ~ in millivolts at 37°C (310° Kelvin). For a cell
force of the positive charge outside. The potential differ- membrane that allows only one type of ion to diffuse, this
ence between the inside and the outside of the cell mem- formula can predict the membrane equilibrium potential
brane due to potassium ions, when there is no net move- accurately. Table 10.1 gives the Nernst potentials for
ment of potassium ions into or out of the cell, is called the sodium, potassium, and chloride ions on the basis of the
potassium equilibrium potential or Nernst potential. The above formula.
equilibrium potential for any ion may be defined as the
electrical force required to balance the ionic movements
caused by diffusion; it is proportional to the logarithm of Goldman Equation
the ratio of the concentrations of the ion to which the
membrane is selectively permeable. Equilibrium potential The Nernst equation applies only if the membrane is
can be calculated using an equation propounded by the permeable to a single ion and the concentration of this ion
German scientist Walther Nernst in 1888 on the basis of is greater on one side of the mem brane than the other. The
thermodynamic principles. In other words, the Nernst glial cells are known to be selectively permeable to potas-
equation provides us with a method of calculating the sium ions, and their membrane potential is close to the
potential at which the concentration gradient causing value estimated from the Nernst equation. However, the
efflux of an ion is exactly balanced by the electrical gra- situation is more complex in the neuron as the neuronal
dient that opposes such efflux. membrane is permeable to several different ions. Thus, it is
The Nernst potential for any ion is defined by the equa- not only permeable to potassium but also to chloride and,
tion: to some extent, to sodium ions.
A number of factors seem to influence the membrane
potential under these circumstances. The concentration
gradient of each ion across the membrane, the polarity of
each ion, and the degree of permeability of the membrane
where R = the gas constant (8.316 joules per degree), T = to each different ion are perhaps the most important fac-
temperature in degrees Kelvin, F = the Faraday (96,500 tors. The Goldman equation, which is an extension of the
coulombs per mole), n = valence of the ion with its Nernst equation, attempts to integrate the contributions
appropriate sign, and [Tlo and [T\; are the extracellular of each different ion into a single equation by taking the
(outside) and intracellular (inside) concentrations, respec- permeabilities of the ions into account. When only
sodium, potassium, and chloride ions are taken into con-
sideration, the Goldman equation for the membrane
Table 10.1. Concentration of Major Ions in the Intracellular and potential is given by the expression
Extracellular Fluids of Vertebrates and the Nernst Potentials
Intracellular Extracellular Nernst
Concentration Concentration Potential a
Ion (mmoIlL) (mmoI/L) (mV at 37°C)
where the constants R, T, and F are as previously defined,
Sodium (Na+) 14 142 +62
-9.5
[K+lo, [Na+lo, [CI-Io are the extracellular concentrations of
Potassium (K +) 140 4
Chloride (CI-) 4 11.5 -90 the ions, [K+li, [Na +\;, [CI-\; the intracellular concentra-
tions, and PK, PNa , and PC! represent the resting permea-
a These values are computed using the formula
bilities of these ions when there is no net flow of ionic
~ = (lin) 61..5 loglO OTlo/ITli). current.
For the chloride ion we have It is clear from the above equation that the permeability
~ = (11-1) 61..5log 1o (11.5/4) of the membrane to each different ion is a crucial factor in
the actual contribution of each ion to the membrane
- 61..5 loglO (28.7.5)
potential. Since the membrane is highly permeable to
- 61..5 x 1.4.587 potassium in the resting state, the RMP is close to the
- 90 mY. potassium equilibrium potential.
Synaptic Potentials 71

The Sodium-Potassium Pump the cell. The accompanying increase in the number of
positive charges within the cell closes the inactivation
The membrane is highly permeable to potassium, but it gates of the sodium channels so that no more sodium ions
also allows some amount of sodium diffusion. Sodium ions can enter the cell.
tend to diffuse slowly from outside the cell to the inside, At this point in the sequence of events, the gates of the
and if this were allowed to proceed unhampered, the potassium channels open and allow potassium ions to
charges eventually would become equal on either side of escape outside the cell; this leads to a decrease in the posi-
the membrane. The cell uses an ingenious active pumping tive charge within the cell and reestablishes the original
mechanism (electrogenic ion pump) to prevent this from negative RMP. In other words, the membrane is repolar-
happening. Using active ion channels and energy from ized. Once this happens, the active potassium channels
adenosine triphosphate (ATP), the cell pumps out sodium close and in so doing prevent further escape of potassium
ions while taking in potassium ions. Three sodium ions are ions. Although the concentration of sodium ions inside the
expelled for every two potassium ions taken in. This tends cell membrane increases during the generation of an
to reestablish the intracellular concentration of potassium action potential, the increase is small when compared with
and sodium continuously so that appropriate ionic concen- the concentration of sodium ions in the extracellular fluid.
trations are maintained to ensure a constant RMP. It will Nevertheless, with repeated passage of action potentials,
be seen later that during the generation of an action poten- intracellular depletion of potassium and accumulation of
tial, the membrane becomes highly permeable to sodium sodium ions may occur. However, this is circumvented by
for a brief period of time. This leads to sodium ion accumu- the action of the sodium-potassium pump that was dis-
lation within the cell with a corresponding increase in cussed earlier.
positive charge. Thereupon, the electrogenic pump helps What initiates the action potential? Any condition that
to reestablish the negative RMP by pumping out the leads to a sufficient decrease in the negative charge inside
sodium ions. The rate of pumping is increased when the the cell membrane can initate an action potential. The
sodium ion concentration increases within the cell. decrease in negativity may be produced chemically as, for
As mentioned earlier, the RMP in nerve cells ranges example, by neurotransmitters, or mechanically or electri-
from - 40 to - 90 mY, the inside being negative with cally. The most familiar circumstance is electrical stimula-
respect to the outside. When there is an increase in the tion of a peripheral nerve, as in the study of somatosensory-
negative charge inside the cell membrane, the membrane evoked potentials. In such studies the cathode of the
is said to be hyperpolarized. When there is an increase in stimulating electrode produces an excess of negative
the positive charge inside the cell membrane, it is said to charge outside the nerve membrane. This is equivalent to
be depolarized. reducing the negative RMP by an amount sufficient to
result in the opening of the voltage-dependent sodium
channels and the generation of the action potential. Simi-
Action Potential larly, potentials are induced at the synaptic terminals by
chemicals like acetylcholine, which can open pores in the
Neurons communicate with each other through genera- membrane and thereby result in sodium ion influx. Once
tion of action potentials, which are changes in mem- an action potential is initiated, it is propagated along the
brane potential that are propagated along the axons. If axon by the opening of sodium channels in the adjacent
we were to record an action potential from an axon, we areas of the axonal membrane, which leads to a wave of
would discover that the negative RMP suddenly becomes depolarization and subsequent repolarization.
positive for a very brief period of time and then rapidly
returns back to its original negative level. The initial stage
of this rapid change, known as depolarization, is accom- Synaptic Potentials
panied by an abrupt and massive change in the sodium
permeability of the neuronal membrane. This occurs as a As mentioned earlier, the most important function of
result of the opening of voltage-dependent sodium chan- neurons is communication. Neurons communicate with
nels. These channels, which are protein-lined pores in each other and also with effector organs such as muscles
the membrane, have activation gates situated toward the and glands. Such communication is accomplished by the
outer layer of the cell membrane and inactivation gates process of synaptic transmission. A synapse is the junction
situated toward the inside of the membrane. A decrease in between two neurons or between a neuron and an effector
negativity of the membrane potential of 20 to 30 mV organ. In the former case, the junction is between a synap-
causes the abrupt opening of the activation gates, leading tic knob (see Fig. 10.1) of one neuron and a dendrite of
to an increase in sodium permeability by a factor of about another. Let us briefly look at the mechanism involved in
5,000 and resulting in a massive influx of sodium ions into synaptic transmission in the central nervous system.
72 10. Neurophysiology

The transmission of signals from one neuron to another

across a synapse is achieved mainly through chemical Extracellular Space
transmitters. Chemical transmitters can either excite ~
(depolarize) or inhibit (hyperpolarize) the neuronal mem-
GI
brane. For example, neurotransmitters like acetylcholine c:
I!
are excitatory whereas y-aminobutyric acid (GABA) is .a
E
inhibitory. Excitatory neurotransmitters evoke an electri- GI
:::E
cal change in the postsynaptic membrane called the excita- Ii
o
tory postsynaptic potential (EPSP). The transmitter first
binds itself to a receptor in the postsynaptic membrane,
which results in the opening of the sodium channels. This ....s
Intracellular Space
depolarizes the postsynaptic membrane, thereby inducing
the EPSP.
The EPSPs are sometimes called miniature potentials. Figure 10.2. Equivalent circuit for a cell membrane. E K, ECl, and
Unlike action potentials, they do not propagate but spread ENa are potassium, chloride, and sodium batteries respectively.
passively along the membrane, diminishing in amplitude The potentials of these batteries depend on the concentration
as the distance increases. The usual size of the EPSP is gradients of the respective ions. RK , RCI> and RNa represent the
around 5 mv' Normally, this value is not sufficient to trigger leakage resistances, respectively, of the different ionic channels.
an action potential. However, when a number of synapses em is the membrane capacitance; Vm is the membrane potential.
making contact with a dendrite or a cell body develop
EPSPs, these potentials can summate and cause sufficient
depolarization of the axon hillock (Fig. 10.1) through set- parameters (in actual practice, these parameters are dis-
ting up of ionic currents in the extracellular and intracellu- tributed along the length of a membrane). The circuit dia-
lar fluid to evoke an action potential. Summation may be of gram shows three separate conducting channels corre-
two different kinds, namely, spatial summation and tem- sponding to the major ions. Each channel has a battery that
poral summation. Spatial summation is the summation of represents the equilibrium potential produced by the con-
several EPSPs produced simultaneously or nearly simul- centration gradient for the particular ion and a leakage
taneously at different sites on the postsynaptic membrane. resistance that stands for the membrane's permeability for
Temporal summation refers to the summation of successive that ion. Note that the polarity of the sodium battery is
potential changes at a single site on the postsynaptic mem- opposite to that of the potassium and chloride batteries.
brane such that one EPSP is superimposed onto another. The circuit also includes a capacitor that can store electric
Inhibitory neurotransmitters act in a different way. They charge. As mentioned earlier in this chapter, this is
seem to open the chloride channels, leading to an influx of because the lipid bilayer acts as a dielectric, separating
chloride ions that, in turn, results in an increased negative positive and negative charges. The capacitor serves as the
charge inside the cell membrane. The potential produced second main route whereby current may flow across the
in this way is known as an inhibitory postsynaptic potential membrane. The equivalent circuit is useful in analyzing
or IPSP. It hyperpolarizes the cell membrane, thereby various details of neuronal functioning, but such particu-
inhibiting depolarization and preventing the generation of lars are beyond the scope of this text.
an action potential.
Except for the fact that EPSPs are depolarizing and
IPSPs are hyperpolarizing, both share the same properties. Membrane Potential Fluctuations
Thus, IPSPs show temporal and spatial summation, as do and the EEG
EPSPs. Inhibitory synapses are often strategically located
so that they can prevent generation of action potentials It is not absolutely essential to know exactly how the EEG
from the axon hillock. is generated for the limited purpose of its clinical interpre-
tation. Nevertheless, an insight into the mechanisms of
generation of the EEG is certainly helpful for a clearer
Membrane Equivalent Circuit understanding of the pathogenesis of the different EEG
abnormalities seen in various disorders of the central ner-
From what we know about the permeability of the neural vous system.
membrane and the ionic composition of intracellular and Based on current knowledge, it is clear that the EEG as
extracellular fluids, it is possible to represent the mem- recorded over scalp represents fluctuations in the mem-
brane by an equivalent electrical circuit. Figure 10.2 is a brane potentials of a large number of neurons in the
simplified version that lumps together the membrane cerebral cortex. In earlier sections we saw that there are
Rhythmicity of the EEG Patterns 73

two major types of fluctuations in the membrane poten- intracellular electrode, which generates an out-going cur-
tials, namely, the action potential and the synaptic poten- rent across the synaptic membrane. This site, therefore, is
tial. Since the EEG is an extracellular recording, the elec- a source rather than a sink, and it produces a positive field
trical potentials recorded would be expected to represent potential in the region of the synapse and a negative field
voltage changes in the extracellular space - field potentials potential at the membrane sinks at a distance.
secondary to changes in the membrane potentials of the On the basis oflarge amounts of data accumulated from
neurons. Let us briefly explore the possible mechanisms such microelectrode studies and from similar studies
involved. employing simultaneous surface recordings, it is now
When an EPSP is generated, there is a sudden influx of generally accepted that the EEG waveforms seen in scalp
cations through the subsynaptic membrane. Such an influx recordings or in recordings taken directly from the brain's
would attract cations from the surrounding extracellular surface represent summated field potentials set up by
space and cause them to move toward that area. This EPSPs and IPSPs from a large number of cortical neurons.
phenomenon is similar to the flow pattern when the drain
of a sink filled with water is suddenly opened; the extracel-
lular space may be compared to the water in the sink and The Role of Different Types of Neurons in
subsynaptic membrane to the outlet. The ionic movement the Generation of the EEG
sets up a field potential that would be negative in the
region of the subsynaptic membrane and positive in the There are basically three types of neurons in the cerebral
surrounding extracellular fluid. In the case of an inhibitory cortex. These are the pyramidal neurons, the stellate neu-
synapse, a different but related phenomenon occurs. rons, and the spindle neurons (see Appendix 2). To pick up
When an IPSP is generated, there is an influx of anions like electrical activity from such cells by means of electrodes
chloride through the subsynaptic membrane into the cell. placed on the surface of the scalp, sufficiently large field
Such an influx would result in an excess of cations in the potentials need to be set up in the extracellular space sur-
extracellular space close to the synapse. This, in turn, leads rounding the neurons. In other words, a relatively large
to a flow of cations away from the synaptic area, thus set- area on the surface of the brain has to become either nega-
ting up a field potential that would be positive in the region tive or positive for a measurable voltage to be recorded
of the subsynaptic membrane and negative in the sur- over the scalp. Taking into consideration the orientation of
rounding extracellular fluid. a scalp electrode in relation to the cortical surface, large
It is true, of course, that action potentials in the axons numbers of vertically oriented dipoles are necessary. (Ver-
could also set up ionic fluxes and field potentials similar to tically oriented refers to the axis of the dipole being per-
those just described. But because of its very brief duration pendicular to the outside surface of the cortex. See Chap-
(about 1 ms), the action potential is an unlikely source of ter 12 for a discussion of dipoles.)
EEG waveforms like the alpha rhythm. The longer dura- If one looks at the anatomical arrangement of the corti-
tion (10 ms and greater) of the synaptic potentials and cal neurons (see Appendix 2), it becomes obvious that the
their graded nature make them a more likely source of the pyramidal cells are the most probable source of such elec-
EEG waveforms. This is clearly brought out in Fig. 10.3, trical fields. They are oriented perpendicularly to the cor-
which compares the waveforms of the action potential and tical surface, with apical dendrites ending superficially in
the EPSP. layer I of the cortex, with cell bodies situated in layers II
The probable sequence of events just described has and III and to some extent in layer V. The current flow
been verified by simultaneous recording from microelec- owing to the EPSP and IPSP could produce a field poten-
trodes placed within the cell and in the extracellular space tial with negativity or positivity in the dendritic zone and
(Fig. 10.4). During an EPSP there is a positive deflection opposite polarity at a distance from the surface, thus con-
recorded from the intracellular electrode placed near the stituting a vertical dipole. Afferent input from the large
synaptic knob of the stimulating axon. At the same time, number of neurons that make contact with the dendrites of
there is a large current flowing inward at the subsynaptic the pyramidal cells in layer I might therefore result in the
membrane and an equally large current flowing outward at production of waveforms like those that characterize the
numerous places some distance from the synaptic mem- EEG recordings.
brane, as shown in Fig. 10.4. The extracellular electrode
situated near the synapse records a negative potential with
respect to a distant reference point since it is near the sink Rhythmicity of the EEG Patterns
that has been created. On the other hand, the extracellular
electrode also placed near the membrane, but at a distance We have seen that cortical neurons can produce extracel-
from the synapse, records a positive potential. Conversely, lular field potentials. But what leads to the rhythmic varia-
during an IPSP there is a negative deflection from the tions in voltage that are an intrinsic characteristic of the
74 10. Neurophysiology

Axon terminal Dendrite

Resting
potential

Time (milliseconds)

.
(a)
jij 0
c:
.!!
...
~8.
't:Icu
c: c:
~~
.a
E
cu
E
Resting
potential

I I
I I
~ Time (milliseconds)
Synaptic (b)
delay

Figure 10.3. Schematic depicting (a) recording of membrane the much longer duration of the EPSP. (From Stevens CF: Neuro-
potential in an axon terminal showing an action potential and (b) physiology: A Primer. New York, John Wiley & Sons, 1968, p. 35,
recording of membrane potential in a dendrite showing an EPSP. by permission of the author and holder of the copyright.)
Notice the difference in the amplitude of the two waveforms and

EEG? This important question brings in the concept of a Andersen and Andersson (1968) explained the role of
pacemaker that "drives" the cortical neurons. Various the thalamus in the etiology of the EEG by their facultative
experiments have been conducted for the purpose of dis- pacemaker theory. Briefly, the theory assumes that rhyth-
covering the region of the brain and the mechanism mic activity is an inherent property of groups of cells in the
responsible for producing such rhythmic activity of the thalamic nuclei. The rhythmicity is produced by a simple
cortical neurons. We know that if EEGs are recorded from mechanism in which the discharge of one thalamic neuron
animals subjected to brainstem sections at different levels causes (via an inhibitory neuron) inhibition of many adja-
such as the medulla, pons, or the midbrain, the rhythmic- cent neurons. During the postinhibitory rebound that fol-
ity seems to persist. However, when the thalamocortical lows, many of the adjacent neurons discharge and the cycle
connections are disrupted, the rhythmicity disappears. thereupon repeats itself. This rhythmic activity is believed
The thalamic nuclei have extensive connections with all to be imposed upon the cortex by diffusely projecting
parts of the cortex and, therefore, seem to be the most thalamocortical fibers. In so dOing, it could result in rhyth-
likely site for a cortical pacemaker. mic activity in large numbers of cortical neurons. Figure
Rhythmicity of the EEG Patterns 75

Figure 10.4. Diagram showing the fields generated Intracellular Recording Extracellular Recording
by EPSPs and IPSPs in excitatory and inhibitory
synapses of the central ne rvous system neurons.
For simplicity's sake, the neurons are shown as hav-
ing only a single dendrite: the synaptic knob from
the connecting neuron is seen at the top and to the
right of the dendrite. In all cases, positive is up. In
A, an EPSP in the dendrite generates a negative
field in its immediate vici nit)', and a positive field at
a dis tance along the dendrite and cdl body of the A
neuro n. In B, an IPSP in the dendrite generates a
posith'e field in its immediate \'ici nity, and a nega-
tive field at a distance. (From Hubbard JI, LLinas
R. Quastel OMS: Electrophysiological Analysis of

•
5ynal,tic Transmission. London, Edward Arnold,
1969. p. 289: courtesy or the authors and holders
of the copyright.)

EXCITATORY SYNAPSE

Intracellular Recording Extracellular Recording

INHI8ITORY SYNAPSE
76 10. Neurophysiology

ey inhibitory
--t. interneuron
I sec I

~ distributor neuron

Figure 10.5. Diagram illustrating Andersen and Andersson's lows, many of these neurons discharge and the cycle repeats
model for the generation of EEG rhythmicity by means of a tha- itself. The different groups of thalamic cells have different fre-
lamic pacemaker. A, B, and C are three groups of thalamic cells quencies of discharge, as illustrated in the right-hand column,
that send their axons via thalamocortical fibers to the cerebral rows A, B, and C. The corresponding cortical spindles, whose fre-
cortex and activate columns of cortical cells designated a, b, and quencies match the thalamic discharges, are shown in rows a, b,
c. Collaterals of the axons of the thalamic cells excite inhibitory and c. (From Andersen P, and Andersson SA: Physiological Basis
neurons (black) that can simultaneously inhibit a large number of of the Alpha Rhythm. New York, Appleton-Century-Crofts, 1968,
thalamic neurons. During the postinhibitory rebound that fol- p. 59; courtesy of the authors and publisher.)

10.5 illustrates the way in which the thalamocortical affer- To summarize, the EEG appears to be the result of syn-
ent fibers are believed to impose rhythmicity upon the chronized variations in the membrane potentials (synaptic
cerebral cortex. potentials) oflarge numbers of neurons in the cerebral cor-
Rhythmic activity such as the alpha rhythm and barbit- tex. Summated EPSPs and IPSPs in the dendrites of the
urate spindles could conceivably be produced in the man- vertically oriented cortical pyramidal neurons, which are
ner described. Because the ascending reticular activating caused by afferent activity coming from the thalamus, are
system has a profound influence on the thalamus, it could the most likely causes of the rhythmic variations in voltage
synchronize or desynchronize the EEG pattern. However, that characterize the scalp EEG.
while the thalamic pacemaker concept explains some of
the phenomena in EEG rhythmicity, there are many unex-
Reference
plained areas. According to some scientists, rhythmicity
may be associated with corticocortical connections. But Andersen P, Andersson SA: Physiological Basis of the Alpha
this is a topic for more advanced texts. Rhythm. New York, Appleton-Century-Crofts, 1968, pp. 3-83.
Chapter 11
Recording Systems

Previous chapters dealt with the instrumental aspects of both sides, over a prolonged period of time. This is essen-
the EEG recording system. Separate chapters were tial not only to adequately describe the features of the nor-
devoted to the topics of recording electrodes, the differen- mal EEG, but also to localize abnormalities. To use another
tial amplifier, filters, and the writer unit. This chapter will analogy, the localization of abnormalities may be com-
look at the principles and techniques of electrode arrange- pared with the practice of taking several samples from
ment used to obtain a maximally useful EEG recording. different areas of a polluted lake in order to find the source
or sources of contamination. To accomplish this, it is
apparent that some kind of standardized, logically based
Electrodes as Field Samplers recording system is needed.

Brain electrical activity as seen in the scalp EEG is gener-

ated by the neurons of the cerebral cortex. There are bil-
lions of neurons in the cerebral cortex and any number of
Historical Background
them may be active at a particular moment of time. Unlike
the ECG where there are only five waves that normally Historically speaking, the sophistication of EEG recording
repeat at regular intervals to reckon with, the EEG is a systems has closely followed technological developments
continuum of electrical discharges that may vary from in electronics. In the 1940s when technology was limited,
moment to moment. The electrical activity is different in EEG recordings were made on machines having only two
frequency and amplitude over different areas of the brain. or four channels. This limited the EEG to the simultane-
Since the brain is suspended in the spinal fluid, which acts ous recording of samples from one or two pairs of elec-
as a volume conductor, the electrical activity recorded on trodes on each side. Such limited sampling, of course, is
the scalp turns out to be extremely complex. totally inadequate for describing the electrical activity of
A simple analogy may be useful. Imagine dropping a the entire brain. Nevertheless, many of the features of
stone in a pond of water and observing the ripples that are the EEG that we know today were first recorded and
formed on the surface. These ripples travel outward in ever- described by researchers and clinicians using such primi-
widening, regular concentric circles. Now, drop several tive equipment.
stones in different spots at the same time. Each stone will When multichannel machines became available, the
produce its own series of concentric ripples. In places question of where to place the many electrodes that it was
where the ripples come together, a complex, seemingly possible to use, and how to hook them up, became a major
chaotic pattern of ripples will appear on the surface of the issue. Different EEG laboratories began to use totally dif-
water. The multiple generators of electrical activity in the ferent placements. To bring some harmony into the result-
brain present a similar picture. In this context, the EEG ing chaos, the First International Congress of EEG held in
electrodes attached to the scalp become "samplers" of the London in 1947 recommended that an attempt be made to
electrical fields set up by the multiple generators of elec- standardize the electrode systems used. Herbert Jasper
trical activity. studied the different systems used at the time and, in 1958,
To obtain a complete and valid picture of the brain's suggested adopting what is called the 10-20 International
electrical activity, it is necessary to simultaneously record System of electrode placement. This systems is used by the
samples of activity from different areas of the scalp, on vast majority of EEG laboratories around the world.
78 11. Recording Systems

The 10-20 International System NASION

The placement of electrodes in this system depends upon

measurements made from standard landmarks on the skull.
The system affords adequate coverage of all parts of the
head, with electrode positions designated in terms of the
underlying brain areas (i.e., frontal pole, frontal, central,
parietal, occipital, and temporal) to which they cor-
respond. These areas are abbreviated using capital letters,
with F corresponding to frontal, C corresponding to cen-
tral, and so on. A single-digit number goes along with the
letter. Odd numbers designate left-sided and even num-
bers right-sided locations. Thus, for example, C3 corre-
sponds to the central region on the left side.
The term "10-20" is used because the electrodes are
placed either 10% or 20% of the total distance between
a given pair of skull landmarks. The use of percentages
to ascertain the distances between electrodes rather than
absolute values allows for the normal differences in size
and shape of the head between different persons. This
means that the 10-20 International System is appropriate
4
INION
for use with small infants as well as adults having very
large heads. Figure 11.1. The 10-20 International System of electrode place-
Measurements are carried out using a narrow measuring ment.
tape with markings preferably in centimeters and milli-
meters. For anteroposterior measurements, the distance
between the nasion and inion over the vertex in the mid- Derivations
line is taken. Five points are located along this line and
designated frontal pole (Fp), frontal (F), central (C), parie- With a total of 21 electrodes to work with, how should the
tal (P), and occipital (0). The point Fp is 10% of the electrodes be hooked up to best display the brain's electri-
nasion-to-inion distance above the nasion. F is located cal activity? In other words, what combinations of elec-
behind Fp at a distance of 20% of the nasion-to-inion dis- trodes should be connected to the variolls channels of the
tance; C is behind F at a distance of 20%, and so on. The EEG machine, and at what times?
points located are marked off directly on the scalp with a Because two connections are needed to complete an
colored china-marker pencil. electrical circuit (see Chapter 2), two electrodes have to be
The lateral measurements are made in the central connected to each channel (amplifier) of the machine. As
coronal plane on the basis of the distance between the was mentioned earlier in Chapter 1, a particular pair of
left and right preauricular points. Ten percent of the electrodes connected to a single amplifier is referred to as
distance above the preauricular points marks the loca- a deriuatioll. Experience has shown that a machine that
tion of the T3 and T4 electrodes, C3 is at a distance of displays at least eight derivations simultaneously is neces-
20% above T3, and C4 is 20% above T4 (see Fig. 11.1). sary to adequately study the spatial characteristics of the
Details concerning the measuring techniques and of lo- brain's electrical activity. However, a 16-channel machine
cating the positions of the various other electrodes are is preferable; an IS-channel machine is even better. The
given in Appendix .5. Using these directions, a total of larger machines are capable of gathering more data in
19 electrode placements are marked off on the scalp. the same amount of time as well as providing better resolu-
Together with the earlobe placements (designated Al tion of the spatial characteristics of the brain's electrical
and A2), this comprises the 21 standard electrodes in activity.
the 10-20 International System. Figure 11.2 shows the With the use of21 electrodes, one can have a total of21O
approximate locations of the electrodes in relation to areas different derivations. 1 But in actual practice, all possible
of the cerebral cortex. A recent study (Homan RW, Her-
man J, Purdy P, 1987) employing CT scanning to visualize
1 The number of possible combinations of n things taken two at a
brain structure suggests that the 10-20 System provides time is equal to II2[n(n - 1)]. For example, if n = 3, we have
scalp locations that correlate well with the expected cere- 112[3(3 - 1)] = 3, which is readily verified by trial and error.
bral structures. When n = 21, the formula becomes 1/2[21(21 - 1)] = 210.
Montages - Rationale 79

Referential Montages

The principle of this technique involves measuring the

electrical activity at different electrodes simultaneously, in
comparison with a common reference electrode. Ideally,
the common reference electrode should be unaffected by
cerebral electrical activity. Each electrode is connected to
grid 1 of a different amplifier, and the single reference
®
TempOral
electrode is connected to the grid 2 inputs of all the ampli-
fiers. The terms monopolar and unipolar have sometimes
Lobe
been used to refer to referential recording, but the use of
these terms is discouraged.
The major advantage of referential montages is that the
common reference allows valid comparisons to be made
Figure 11.2. Topographic relationship between 10-20 System between amplitude measurements in different derivations.
electrodes and areas of the cerebral cortex.
This is in contrast to the case of bipolar montages where
amplitude measurements may be unreliable so that ampli-
tude comparisons between derivations are invalid. As we
combinations of electrodes are seldom used. There is an
will see in Chapter 12, localization of a discharge in refer-
important reason for this. Since interpretation of the EEG
ential montages is based on the presence of amplitude dif-
ultimately involves comparison of different derivations, it
ferences between channels. If we assume that the common
is essential to use derivations having comparable interelec-
reference electrode is unaffected by a particular discharge,
trode distances. This requirement eliminates a large num-
then the discharge will appear with the same polarity in all
ber of possible derivations. Indeed, most routine EEG
the nearby electrodes and will show a higher amplitude in
work employs only 48 or even fewer derivations.
the electrode adjacent to the source in comparison with
the surrounding electrodes.
Montages - Rationale The major disadvantage of referential montages lies in
the fact that there is no ideal reference electrode. The
The particular arrangement whereby a number of differ- commonly used sites of reference, namely the earlobes, are
ent derivations is displayed simultaneously in an EEG close to the temporal lobes and hence pick up a consider-
record is termed a montage. With even only 48 derivations, able amount of cerebral electrical activity from those
a large number of different montages can be designed. The areas. As will be detailed later in Chapter 12, this can lead
main reason for using different montages is to make EEG to confusion in localization. Briefly, if there is an active
interpretation as easy and accurate as possible. For this spike focus at T3, the midtemporal electrode, then the left
purpose, certain guidelines have to be followed, and the ear reference (AI) will also be "active:' Under such condi-
American EEG Society has given some recommendations tions, the voltage between T3 and Al may be less than the
in this regard. voltage between F7 and Al or between T5 and AI. The
First of all, a montage should be simple and easy to com- result is a spike in the T3 derivation that is smaller in
prehend. Montages should follow some kind of anatomical amplitude than the spikes in the F7 or T5 derivations;
order or pattern. For example, channels representing the therefore, the spike focus is falsely localized to F7 or T5
more anterior electrodes should be arranged on the instead of to T3 which is correct.
recording chart above those from the more posterior Another disadvantage of using the earlobes as a refer-
regions. Derivations from the left side should be located on ence is that problems with ECG artifacts are more com-
the chart above derivations from the right side. This may mon. Why this happens is readily understood if the reader
be accomplished either by alternating the derivations, i.e., will recall our discussion of common mode rejection in the
left, right, left, right, and so, or by placing derivations from chapter on differential amplifiers. The ECG is a common-
the different sides in blocks, e.g., left, left, left, left; right, mode or in-phase signal, and common-mode signals are
right, right, right. It is advantageous for a laboratory to use rejected by a differential amplifier. The degree to which
a few common or standard montages so that records from the ECG will be rejected depends on the common-mode
different laboratories can be compared with ease. rejection ratio of the amplifier and on the extent to which
There are two basic types of EEG montage: referential the ECG voltages present at grids 1 and 2 of the amplifier
and bipolar. It is advantageous in routine EEG work to use are the same. Now, the ECG voltages appearing at the vari-
both. A brief discussion of each type follows, after which ous EEG electrodes are rarely identical; their magnitudes
examples of some commonly used montages are given. depend on a number offactors, one of which is the distance
80 11. Recording Systems

G l - -__
is adjusted to mJl1lmlze ECG artifacts (see Fig. 1l.3).
Although such an arrangement can reduce ECG artifacts,
it is somewhat complex for routine EEG work, as rebalanc-
ing may become necessary when electrode impedances
change or the position of the head vis a vis the heart is
altered.

___ -- Cl Vertebra Average Potential Reference

Sometimes referred to as the Goldman-Offner reference,
__ - Suprasternal this system of obtaining a common reference was derived
Notch from a similar technique used in electrocardiography by
N.F. Wilson and colleagues in 1934. The principle upon
which the method is based is statistical. Assume that the
voltages present at the EEG electrodes occur at random
and are therefore independent of each other. In other
words, when the voltage at some electrodes is positive, it is
Balance Control
negative or zero at the others, and vice versa. Now, if all
Figure 11.3. Noncephalic reference electrode. The halance con- these voltages are summed and the mean is taken, it is easy
trol is a 50K-ohm potentiometer. To avoid unbalancing the ampli- to see that the mean will tend toward an absolute voltage of
fier inputs, the electrodes may be connected to the potentiome- zero as long as none of the electrodes show any excessively
ter via a buffer rather than directly as shown in the diagram. large values that fall outside the distribution of the others.
This average potential, thereupon, serves as a common
reference and is connected to the grid 2 inputs of all the
of the electrodes from the heart. In the case of closely amplifiers. As is the case with the ear reference, each of the
spaced electrodes, the differences in voltage may be quite grid 1 inputs is connected to a different electrode. The
small, but they can become large if the electrodes are practical circuits used to derive the average potential are
widely spaced, as when one electrode of a pair is con- somewhat complex and need not concern us here. The
nected to an earlobe. These voltage differences are treated interested reader may consult a more advanced text for
as out-of-phase signals by the amplifier; they are ampli- such detail.
fied along with the EEGs and appear as artifacts in the The major disadvantage or shortcoming of the average
recording. potential reference is that the basic assumptions upon
It is sometimes possible to reduce ECG artifacts in refer- which the method is based are not entirely satisfied. In
ential recording by connecting both earlobes together. particular, the voltages present at the various EEG elec-
This is referred to as a linked-ear or (AI + A2) reference. trodes do not occur at random; nor do these voltages fit a
Needless to say, it is essential for impedances of the Al and normal distribution. Thus, for example, excessively large
A2 electrodes to be low (3K to 5K ohms) when the voltages associated with eye movements are commonly
earlobes are employed in referential recording. picked up by Fpl and Fpz, and the high-amplitude vertex
waves that accompany stage II sleep are of maximum
Extracerebral Reference Electrodes amplitude in Cz. If these electrodes are included in the
average potential reference, eye-movement potentials and
In order to reduce the contamination of the common refer- vertex waves may appear as artifacts in the tracings from
ence electrode by cerebral electrical activity, many other many of the electrodes. What happens is that these large,
sites besides the earlobes have been proposed. Thus, for distinctive voltages contaminate the average and, in so
example, electrodes located on the angle of the jaw, on the doing, get into the amplifiers via the grid 2 inputs. To avoid
chin, the tip of the nose, and the neck have been tried as such contamination, FpI, Fpz, and Cz are never included
references. These attempts have not been notably success- in the average. F7, FS, Fz, and pz are often excluded for
ful. The major problem is the contamination of all chan- the same reasons, leaving a total of 14 electrodes in the
nels by ECG and electromyographic (EMG) artifacts. average.
Noncephalic electrodes have also been tried as com- Average potential reference systems have a provision
mon references. One noncephalic reference electrode that easily permits the technician to exclude any of the
described uses an electrode over the patient's C-7 verte- electrodes actually contained in the average. This is an
bra, which is connected to another electrode over the essential feature of such systems because any electrode
suprasternal notch through a balancing potentiometer that containing a high-amplitude discharge like a spike or sharp
Commonly Used Montages 81

wave can contaminate the average in the same way that was Table 11.1. Some Commonly Used EEG Montages
already described. However, there is a limit to the number (A) (B) (C)
of electrodes that mav be taken out of the average, as aver- Longitudinal Transverse Referential
ages based on a small number of cases are unreliable. As a Bipolar Bipolar w/earlobes
rule of thumb, averages containing fewer than 10 elec- Fp, - F7 F7 - Fp, JFp F7 - Al

]L
trodes should be avoided. An example of average reference F7 - T3 Fp, - F8 T3 - Al
JL
contamination by high-amplitude focal spike discharge is T3 - T5 F7 - F3 To') - Al
given in Chapter 12 (Fig. 12.13).
Despite these problems, recordings obtained with the
T5 - 01
Fp, - F8
F8 - T4
F3
Fz
F4
-
-
-
Fz
F4
F8
]. F8 - A2
T4 - A2
T6 - A2
JR
]R
} l
average potential reference are often superior to those T4 - T6 T3 - (;3 Fp, - Al
using an ear reference. Nevertheless, there are instances T6 - 02 C3 - Cz F3 - Al

l
where the average potential reference can be grossly mis- Fp, - F.'3 Cz - (;4 (;3 - Al
leading. One interesting example is the case of a patient F.'3 - (;3 C4 - T4 P3 - Al

}
l"
(:,'3 - P.'3 T.'5 - P3 OJ - Al
whose EEG shows an alpha rhythm of high amplitude, P3 - pz
P3 - OJ Fp, - A2
with the activity spreading into the midtemporal and cen- Fp, - F4 pz - P4 F4 - A2
tral regions. When the average potential reference is used F4 - C4 P4 - T6 C4 - A2
in such a case, a remarkable thing occurs. The alpha C4 - P-t ]R To') - 01
Jo P4 - A2
rhvthm is seen in widespread distribution over the entire P4 - 02 02 - T6 02 - A2

sc~lp, including the Fpl and Fp2 electrodes. The finding is

obviouslv an artifact; the alpha rhythm gets into the
anterior 'channels via the grid 2 inputs from the contami-
nated average reference. This is readily verified by noting Commonly Used Montages
that the alpha waves appearing in the frontal derivations
are opposite in phase to the same waves present in the As mentioned earlier, it is good practice to use routinely a
occipital derivations (see Fig. 14.3). few montages that are common to different laboratories so
that EEG records from them can easily be compared. It is
advantageous to use both bipolar and referential montages;
Bipolar Montages in the case of bipolar montages, both longitudinal and
transverse montages should be included.
In bipolar recording, the potential difference between two Table 11.1 shows some commonly used montages. This
electrodes placed on the scalp is displayed. Unlike the case table should be studied in conjunction with Fig. 11.1. In
of referential recording, both electrodes are considered to column A of Table 11.1 we have longitudinal bipolar arrays,
be active, and the varying difference in voltage between namely, the temporal and the parasagittal bipolar chains
the two is recorded. Electrodes in a bipolar montage are on both sides. Note that the derivations from right and left
connected in a sequential manner: the electrode going to sides are combined in blocks and that the temporal and
grid 2 of the first derivation is also connected to grid 1 of parasagittal chains are joined together into a 16-channel
the next derivation. These sequences can be arranged in montage. This montage is referred to colloquially as the
chains, either in a longitudinal or a transverse array. With "double banana:'2 If a machine with only eight channels is
such montages, an electrical discharge originating in the available, the temporal and parasagittal derivations can be
common electrode of two adjacent channels will show the recorded in separate runs.
phenomenon of phase reversal in both longitudinal and Column B of Table 11.1 shows a standard transverse
transverse sequences. bipolar montage on a 16-channel machine. Note that the
As we will see in Chapter 12, the advantage of bipolar more anterior electrodes are located at the top of the page,
sequential montages is the ease with which localization while the more posterior electrodes are located at the bot-
can be made. Thus, phase reversals are very easily detected tom. Note, also, that the electrodes on the left side appear
bv eve in the tracings. On the negative side, bipolar mon-
before those on the right. This configuration is commonly
t~ge~ do not provide an accurate or valid measure of the referred to as a coronal montage. As a careful perusal of
amplitude of the waveform of a particular event. Depend- column B will show, this montage is not readily convertible
ing on the magnitude and phase of the voltages at the two for use on an eight-channel machine.
electrodes, the signals are subject to cancellation or sum-
mation (see Chapter 12) in the amplifier. For this reason,
bipolar recording merely provides a comparison of the vol- 2 When viewed in the context of Fig. ILl. the temporal and
tage at one electrode of a pair with respect to the voltage parasagittal chains combined take the shape of a banana. There
at the other. is one of them on each side; hence the term "double banana."
82 11. Recording Systems

Finally, column C in Table 11.1 shows a commonly used are actually located over the inferior frontal area (see Fig.
referential montage that employs the ipsilateral earlobes as 11.2). Tl and T2 may be included as part of a bipolar chain
common references. This same montage is also appropri- or in a referential montage.
ate for the average potential reference, in which case the Additional electrodes may also be applied between the
average reference is substituted for Al and A2 in the table. standard electrodes in the coronal rows. Thus, we have
Fpz between Fpl and Fp2, Fl between Fz and F3, F5
between F3 and F7 on the left, F2 between Fz and F4, F6
Reformatting of Montages between F 4 and F8 on the right, and so on for central,
parietal, and occipital rows. Together with the 21 standard
Recent advances in technology have afforded a means derivations and the Tl and T2 electrodes, this yields a total
whereby the pattern of activity observed in one montage of37 derivations. Finally, additional electrodes may also be
may be used to derive or predict the pattern of activity that placed between the rows defined by the frontal pole and
would be seen in another. Although the method involves frontal electrodes, by the frontal and central electrodes, by
some extensive computational operations that are carried the central and parietal electrodes, and by the parietal and
out by computer, it is simple in theory. An example will occipital electrodes. In this way, more than 60 diITerent
best serve to explain the process of reformatting. derivations become available. 3 When electrodes are
A patient's EEC is recorded using a referential montage placed so closely to each other, smaller-diameter disks are
in which tracings from the 19 scalp electrodes are taken advisable, and special care needs to be taken when apply-
with respect to a common electrode. Each tracing, of ing them to avoid a salt bridge between electrodes.
course, shows the variation in voltage that occurs with time
at a particular derivation. If, now, the voltages from two of
these derivations - say T3 and T5 - are combined algebra- Special Electrodes
ically over time, the result would be a time-varying voltage
like that observed ifT3 and T.5 were connected in bipolar The electrical activity of certain portions of the cerebral
fashion to a diITerential amplifier. The same operation can cortex, notably the basomedial parts of the temporal lobe
be carried out for any two electrodes, and in this way a and the orbital and medial parts of the frontal lobe, is not
wide variety of montages can be created. In practical accessible to the electrodes taken up thus far. This some-
terms, the method permits the technician to take the EEC times leads to problems in accurately locating seizure foci,
using but a single montage. Later, when the record is read, particularly in patients who are being considered for tem-
the electroencephalographer can reformat into any num- porallobectomy. To overcome such problems, a number of
bers of diITerent montages, selecting those that provide the special electrodes may be used. These are described
most accurate localization information. below. Refer to Fig. 11.4 for the approximate location of
these electrodes.

Extension of the 10-20 System Zygomatic Electrodes

Although sufficient for most routine EEC work, the stan- Ordinary disk electrodes are used, and they are located
dard 19 scalp and 2 ear electrodes do not adequately evalu- over the easily palpated zygomatic arch, below and
ate the electrical activity of the cerebral cortex in all cir- anterior to the Tl and T2 electrodes. Zygomatic electrodes
cumstances. This is especially true in the case of are useful for picking up activity from the tips of the tem-
topographic mapping of brain electrical activity, as the poral lobes.
accuracy of information contained in a map is directly
related to the total number of electrode locations from Nasopharyngeal (NPC) Electrodes
which the map is derived. To remedy this situation, a num- The tips of these electrodes are placed in contact with the
ber of electrodes may be added to the standard 21 deriva- roof of the nasopharynx, so that activity from the uncus,
tions. hippocampus, and orbitofrontal cortex may be picked up.
The most commonly used additions to the 21 standard An NPC electrode consists of a piece of insulated flexible
derivations are the Tl and T2 electrodes. These are
located by first finding the point that is one third of the way
from the external auditory meatus to the outer canthus of JThese extensions of the 10-20 System have been organized into
the eye, and then locating a point 1 cm directly above. FaIl- an expanded system of electrode placement - the 10% system-
by a number of electroencephalographers. For details and sug-
ing between and somewhat below F7 and T3 on the left, gested electrode-site nomenclature, refer to Nuwer MR: Record-
and F8 and T4 on the right, Tl and T2 are closer to the ing electrode site nomenclature. ] C/ill Neurophysio/ 1987;
anterior part of the temporal lobes than F7 and F8, which 4:121-133.
Special Electrodes 83

Nasopharyngeal Ethmoidal owing to the tips being close to the midline. If the activity
observed in nasopharyngeal electrodes is totally confined
to them without any reflection in other derivations, dis-
tinction from an artifact may be impossible.

T1
Sphenoidal Electrodes
Sphenoidal +--~:y Thin, flexible insulated platinum wire is introduced along
a spinal needle, under local anesthesia so that the tip of the
wire lies in close proximity to the foramen ovale. After x-ray
verification of the position of the electrode, the spinal
needle is withdrawn. The wire can stay for several days for
prolonged recording. Activity from the basal and mesial
temporal cortex can be recorded without too much
artifact. The procedure is usually well-tolerated but needs
to be done by a physician familiar with the technique.
Figure 11.4. Basal view of the brain showing the approximate
locations of special electrodes. Ethmoidal Electrodes
The electrode is a flexible insulated silver wire with a bul-
bous tip. Under topical anesthesia it is introduced into the
silver wire with a 3-mm silver or gold-plated silver ball at nostril and gently passed up so that the tip lies in contact
the tip. The silver wire varies in length from 5 to 15 cm (to with the cribriform plate of the ethmoid bone. Activity
accommodate pediatric and adult patients) and can be from the orbitofrontal cortex may be recorded using this
bent to suit the dimensions of the nasal cavity. A trained technique.
technician can place these electrodes easily and with only
minimal discomfort to the patient, although in patients
Surgically Placed Electrodes
with deviated nasal septum insertion may be difficult and
there may be some discomfort. Local anesthesia is seldom Patients undergoing evaluation for seizure surgery may
required. need long-term recording by electrodes situated close to
The electrode should be autoclaved before use and may the cerebral cortex. The electrodes may be placed
be lubricated with sterile conductive gel. Holding the epidurally, subdurally, or within the brain substance
electrode between the fingers, the ball at the tip is guided (depth electrodes). For subdural recordings, a flexible
along the floor of the nasal cavity beneath the inferior tur- plastic plate with up to 64 electrodes is used. During sei-
binate until it has passed through the nasal cavity and is in zure surgery, specially designed electrodes may be placed
contact with the pharyngeal mucosa (verify this placement over the exposed cortex to localize the sites of epileptiform
by asking the patient whether the ball is touching the back activity accurately (electrocorticography). Details are
ofhislher throat). At this point, rotate the electrode so that found in more advanced, specialized texts.
it is pointing upward and outward. The electrode can be
retained in that position by securing the connecting wire
under mild tension to the chin or jaw with a piece of tape.
Reference
To remove the electrode, retrace the same steps. Homan RW, Herman J, Purdy P: Cerebral location of Interna-
Nasopharyngeal electrodes are notorious for artifacts tional 10-20 System electrode placement. Electroencephalogr
from respiration and pulse and may give false lateralization Clin Neurophysiol 1987; 66:376-382.
Chapter 12
Localization and Polarity

In plain and simple terms, the EEG is the recording of the meninges, skull bone, and scalp (which in turn interfaces
difference in electrical potential or voltage between vari- with the surrounding atmosphere) - before reaching an
ous pairs of sampling electrodes attached to the surface of electrode. One result of this is a fourfold decrease in ampli-
the scalp. Seen in this limited context, there are three tude of EEG signals and a marked attenuation of the
major questions that need to be answered in clinical elec- higher frequencies. The magnitude of the attenuation is
troencephalography, namely, (1) what is the magnitude of rather dramatically illustrated by the phenomenon some-
a particular voltage observed at a particular instant in times referred to as the "breach effect;' or focal enhance-
time?, (2) what is its polarity, that is to say, is the particular ment of the amplitude of beta activity resulting from a
voltage positive or negative?, and (3) from where does it skull defect.
originate? Whereas the answers to these questions can be
relatively simple for a linear conductor, they are consider-
ably more complex in the case of a volume conductor like Concept of a Dipole: Fields and
the brain. The magnitude of the complexity already was Equipotential Contours
recognized in 1853 by Hermann Helmholtz who noted
that a given "electromotive surface" may reflect an infinite How are voltages distributed in a volume conductor? And
variety of internal electrical fields (Helmholtz H, 1853). what is the relationship between the voltages within and
those observed on the surface of a volume conductor? To
facilitate discussion of this topic, the various voltage
Volume Conductors sources within a volume conductor are looked upon as
simple dipoles. A dipole is an electrical unit composed of
What is volume conductor? We can best define this by first equal but opposite electrical poles or charges separated in
reviewing what is meant by a linear conductor. All the elec- space. It is analogous to a bar magnet where one end is
trical circuits we have heretofore dealt with that are part of north and the other end is south. Just as there is a magnetic
an EEG machine are linear conductors. The electrical cur- field encircling a magnet, so there is an electrical field sur-
rents involved flow along limited pathways in wires and var- rounding a dipole. Let us examine the nature of that field.
ious elements like resistors and condensers. In a volume The electrical field around a vertically oriented dipole in
conductor, additional pathways have been added. The con- a vessel containing a conducting medium is shown in Fig.
ducting medium occupies three-dimensional space so that 12.1. The horizontal line that is perpendicular to the axis
current flow can take many pathways. These pathways may of the dipole represents the interface between the con-
display characteristics that are quite complex, as when ducting medium or volume conductor below and the air
conducting media having different electrical characteris- above. The curved lines represent equipotential contours;
tics are involved. this means that the voltages (referred to a distant reference
Such is the case with the brain and brain electrical electrode) measured at all points along a given contour are
activity where the recording electrodes are placed not the same. Note that the voltagt>s art> smaller as the contours
directly 011 the brain but on the scalp. The brain itself is a move farther away from the electrical poles. Note also that
volume conductor. But, in addition, the EEG signals must the equipotential contours appear distorted and show a
pass through volume conductors - cerebral spinal fluid, different configuration on the surface than they do within
Theory of Localization 85

:x:
l-
t!)
2
~ .02
I-
III

o 2 3 4 5 6 7 8 9 10

IX) 10 ¢ N
_000 o 6
AIR 0000 o C>

Figure 12.1. The electrical field around a vertically oriented volume conductor interface. Field-strength values are relative to
dipole. The figure shows the surface and depth distributions of the strength of the dipole, which is equal to 1. Remote reference
electrical potential for a dipole located 1 cm below the air- electrode.

the volume conductor. The absolute voltages are seen which voltages are recorded simultaneously from different
to be larger, and the field is more extended on the sur- derivations. For this purpose, the differential amplifier is
face. essential. As mentioned in an earlier chapter, a differential
The upper portion of Fig. 12.l shows a plot of strength amplifier records the difference in voltage between two
of the field at various locations on the surface relative to electrodes or derivations. By convention, EEG machines
the strength of the dipole, the voltage of which is taken to are designed so that the pens deflect upward when grid 1
be 1.000. As will be seen, the field is strongest at the axis of the differential amplifier is negative with respect to grid
of the dipole, which is the line connecting the points of 2. Although this may suggest to the reader that the deriva-
maximum negative and positive charge. In Fig. 12.2 we tion connected to grid 1 is electrically negative if the pen
show the surface and depth distributions of potential when of that channel deflects upward, a little thought will show
the dipole is oriented horiwntally with respect to the that this is not necessarily so.
interface between conducting medium and air. Note that
when the dipole is oriented in this manner, a phase reversal
is perceived in the voltage measured at the surface. The Problems of Polarity
topic of phase reversals is taken up later in this chapter.
Consider some simple examples. Suppose that grid 1 is
connected to - 50 IlV while grid 2 is connected to + 10 IlV
Theory of Localization The voltage difference under such conditions is 60 IlV, and
since grid 1 is more negative than grid 2, the pen deflects
Localization in electroencephalography is based on the upward. But now, suppose instead that grid 1 is connected
premise that brain electrical activity is generated by to + 10 IlV while grid 2 is connected to + 70 IlV In this
dipoles as described in the previous section. The location case the voltage difference is again 60 IlV, and since grid 1
of the dipoles is inferred from the distribution and polarity is less positive (more negative) than grid 2, the pen again
of voltages observed on the surface of the scalp. This is deflects upward. We find, therefore, that in both instances
accomplished by the use of multiple-channel recording in the pen deflects upward; but in the former case grid 1 is
86 12. Localization and Polarity

:r
~
z
~.Ol
l-
(/)

o
~ Or--9~~8--~7~~6~~--~-L--~-L--+-~--~--~~---~~6--~7--~8--~9~~
iL
w
~Ol
I-
.q
...J
W
a:

Figure 12.2. Surface and depth distributions of electrical potential as in Fig. 12.l, except that the dipole is horizontally oriented.

connected to a negative voltage, whereas in the latter it is Concerning polarity, we are able only to deal with relative
connected to a positive voltage. The obvious conclusion is polarity- the polarity at a particular electrode relative to
that we cannot infer the absolute polarity at a particular other regions on the scalp or body. The localization of the
electrode simply by connecting it up to a differential electrical event occurring within the brain from activity
amplifier and observing the output. recorded by electrodes placed on the scalp is determined
How then do we discover the polarity of an electrical by five principles. These principles are discussed in the
event occurring within the brain from surface recordings following section.
of electrical activity? And how do we discover its location?

The Five Principles of Localization

A F These prinCiples or rules are illustrated in the diagrams of
Figs. 12.3 through 12.9. In these diagrams, F is the point
of intersection with the scalp of the axis of a radially
oriented dipole that is perpendicular to the scalp. F, then,
2 represents a focus or the center of a limited region on the
scalp displaying the electrical activity generated by the
dipole. Following EEG convention, the differential ampli-
Figure 12.3. Principles oflocalization, rule 1. A, B, and F are scalp fier is represented by a triangle with the apex pointing to
electrodes connected to the differential amplifiers of two EEG the right. The solid line is the input to grid 1 and the
channels. The radial dipole is oriented so that the axis of the broken line the input to grid 2. The voltage picked up from
dipole is perpendicular to the scalp at F. Note that interelectrode the dipole and amplified is represented as a triangular
distance FB is twice the distance in FA. waveform. Polarity of the waveform is negative because the
The Five Principles of Localization 87

negative pole of the dipole is adjacent to the surface while A F

the positive pole is buried deeper in the cerebral cortex.

Rule 1. If one of a pair of electrodes is at F, the focus, the

amplitude of the recorded potential will increase as the 2
distance between this electrode and the second electrode
of the pair increases. Thus, in Fig. 12.3, the distance
FB is greater than FA; therefore, the amplitude of the
Figure 12.4. Principles of location, rule 2. Legend as in Fig. 12.3
voltage recorded between F and B is greater than the
except that interelectrode distances FA and AB are equal.
amplitude recorded between F and A. In short, widely
spaced electrodes record larger voltages than closely
spaced electrodes.

Rule 2. Given two pairs of electrodes having equal

interelectrode distances, the potential recorded from the
pair having one electrode at F will be greater than the
potential recorded from the pair having neither electrode
F
at F. In Fig. 12.4, the interelectrode distances FA and AB
are equal. The voltage recorded is greater in channel 1
than channel 2 because one of the channell inputs is con- CASE
nected to F, the focus of the activity. 1

Rule 3. The farther away the dipole is from the surface of

the scalp, the smaller will be the potential observed at the
surface and the smaller the voltage recorded between pairs F
of electrodes, interelectrode distances being constant.
This rule is illustrated by two examples in Fig. 12.5. Note
that the dipole in case 1 is nearer the surface than it is in CASE
2
case 2 so that the voltage recorded by electrodes at F and
A is greater in case 1 than in case 2. Because the actual
dipole generators from which we are able to record using
surface electrodes are near the surface of the cerebral cor-
Figure 12.5. Principles of localization, rule 3. Cases 1 and 2 both
tex, the rule has more theoretical than practical sig-
have the axis of the dipole perpendicular to the scalp at F. But in
nificance. It is possible, of course, for a dipole generator in
case 1, the negative pole is close below the surface, whereas in
a sulcus or on the mesial or inferior surface of the case 2 it lies deep in the cerehral cortex.
hemisphere to be a deep generator; but, in such a case, the
dipole axis probably would not be perpendicular to the
surface. This condition cannot be analyzed by current
methods herein described as they assume that the dipole is
perpendicular to the scalp. Generators located in the sub-
cortical gray matter are of little practical interest because
they are too far away from the scalp to be recorded by con-
ventional EEG methods.

Rule 4. If three electrodes are connected so that one is at 1

F and is common to two recording channels, being the grid
2 input of the first channel and the grid 1 of the second, the 2
pen deflections in the two channels will be in opposite
directions. Figure 12.6 shows this set of conditions. The
outputs of the two channels illustrate what is meant by the
term "phase reversal;' or what is really an instrumental Figure 12.6. Principles of\ocalization, rule 4. The radial dipole is
phase reversal not a true phase reversal. Note that the rever- oriented so that its axis is perpendicular to the scalp at F. The
sal results from the fact that the shared electrode goes to foclls of activity, F, lies equidistant from the electrodes A and B.
opposing inputs and hence causes the opposing deflections Channels 1 and 2 show an instrumental phase reversal.
88 12. Localization and Polarity

the inputs of the channel 1 amplifier. The deflection ob-

served in channel 2 is larger than that in channel 3 because
1
Q is closer to the focus than R- a corollary of rule 2.
When an earlobe electrode is used as a common elec-
o trode in referential recording, an "active ear" can become
'>----- 2 a serious source of contamination in the derivations for
which this electrode serves as a reference. Ear contamina-
3 tion is taken up in a later section of this chapter.
Figure 12.8(a) shows a special case of rule 5. In this
instance the focus F is not on the line joining electrodes A,
Ib) B, C, and D but instead is to one side. Nevertheless, F is
equidistant from Band C so that the rule still holds.
However, the exact position of F along the perpendicular
from the midpoint of the line joining Band C cannot be
determined using the configuration of electrodes shown in
2 Fig. 12.8(a). To locate the focus in this dimension, a chain
of electrodes perpendicular to the ABCD chain at the mid-
point between Band C is applied. This configuration is
3 shown in Fig. 12.8(b), where the electrode at R happens to
be directly over the focus F. Note that there is an
instrumental phase reversal at electrode R, which, by rule
4, localizes the focus to this electrode.

Figure 12.7. Principles of localization, rule 5. (a) The radial

dipole is oriented so that its axis is perpendicular to the scalp at
F. The focus, F, is equidistant from electrodes Band C, thereby
forming an equipotential zone at these electrodes. Channel 2,
therefore, records no difference in potential between them. 1
Channels 1 and 3 show an instrumental phase reversal. (b) Rule
5 in the case of an "active ear:' In this instance, the focus F is situ-
o
>----2
ated in the temporal area adjacent to the ear and is equidistant
from electrodes P and Q. Channel 1 documents the presence of
the equipotential zone at these electrodes. 3

to occur. A phase reversal identifies the electrode that is Ib)

nearest to the point of maximum voltage, or the focus.

Rule 5. If two electrodes are equidistant from F the focus,

no voltage will be recorded between them. In Fig. 12.7(a),
Band C are equidistant from F and no voltage is recorded 2
from the "equipotential zone" surrounding these two elec-
trodes, which are the inputs to channel 2. This outcome is 3
an example of cancellation, a phenomenon that will be
taken up in a later section. Figure 12.7(a) also shows a
phase reversal between channels 1 and 3.
An interesting, practical application of rule 5 occurs in
the case of the so-called "active ear;' in which a focus is situ- F
ated in the temporal area adjacent to the ear. This is illus-
Figure 12.8. Special case of rule 5. (a) The focus, F, is equidistant
trated in Fig. 12.7(b), where electrodes are placed in a
from electrodes Band C, but is not on a line joining them. As in
coronal chain across the top of the head, from left to right, Fig. 12.7(a), channel 2 records no difference in potential between
starting with the electrode on the left earlobe. With the these electrodes. (b) Use of a horizontal line of electrodes to
focus located midway between the earlobe and the mid- document the location of the focus in the horizontal dimension.
temporal electrode, an equipotential zone is created about The phase reversal in channels 2 and 3 indicates that electrode R
electrodes P and Q so that no voltage is recorded between is at the focus.
Cancellation, Summation, and the Determination of Polarity 89

EEGs. The importance of these phemonena cannot be

overemphasized, as a thorough understanding of their
effects is essential in order to correctly interpret an EEG
record.
2 Cancellation occurs when input voltages of the same
polarity are connected to grids 1 and 2 of a differential
amplifier. Cancellation may be either complete or partial.
We already encountered a case of complete cancellation in
Figure 12.9. Another special case of rule 5. The focus, F, is
the last section. When a focus of electrical activity is
between electrodes Band C, but is closer to one than the other.
Channels 1 and 2 show an instrumental phase reversal of unequal equidistant from the electrodes connected to the inputs of
amplitude, which indicates that the focus is between electrodes a differential amplifier, the voltages at grid 1 and grid 2 are
Band C, and nearer to B than C. What happens when F is closer identical, and the channel records an output of zero volts.
to C than B? We explain this outcome by saying that the voltages at the
two inputs, being identical, have cancelled each other out.
The reader should recognize that any number of different
Another special case of rule 5 occurs when F is between positive and negative voltages as well as zero volts at both
two electrodes, but nearer to one than the other. In such a inputs can yield the same result, namely, an output equal
case a voltage will be recorded between these two elec- to zero volts. This observation highlights the fact that a
trodes, but the voltage will be less than it is when one of the differential amplifier measures voltage differences not
electrodes is directly over F. The rule is illustrated by the absolute voltages.
comparative amplitudes in channels 1 and 2 of Fig. 12.9. Partial cancellation occurs when the voltages connected
In this figure an instrumental phase reversal is observed to both grids have the same polarity but are of different
between channels 1 and 2. This happens because grid 2 of magnitude. A few examples will show what happens when
channell and grid 1 of channel 2 are connected together different combinations of voltages of the same polarity are
at B, a common lead. The phase reversal indicates that connected to the two inputs of a differential amplifier. The
electrode B is nearest to the focus. Since the voltage effects are summarized in Table 12.1.
between Band C is less than the voltage between A and B, Table 12.1 illustrates three important points that readers
F must be between Band C but closer to B than C. should verify for themselves by reference to the various
entries. In the first place, note that the magnitude and
All these rules are derived from the fact that around the polarity of the output voltages are determined by algebrai-
point of maximum potential that is the focus, there are con- cally subtracting the input voltage on grid 2 from the input
centric isopotentiallines (equipotential contours in three- voltage on grid 1. Secondly, the output voltage is always
dimensional space). Each successive line represents a uni- smaller than either input voltage, an outcome that is
form decrement in potential, and every point on a line has predicted by the term cancellation. Lastly, it is impossible
the same potential as every other point on the same line. to work backward and deduce either the magnitude or
The distance between successive concentric circles polarity of the input voltages from the magnitude and
becomes greater as the distance from the focus increases, polarity of the output voltage. This will be apparent by not-
which indicates that the rate at which field strength is ing in Table 12.1 that an output of - 5 ~ V can be generated
decreasing diminishes as one moves farther away from the
focus. The magnitude of the potential recorded between
any pair of electrodes in the field surrounding a focus will
Table 12.1. Some Examples of Cancellation in a Differential
depend on the strength of the field at one electrode rela-
Ampliflera
tive to the strength of the field at the other. The more
isopotentiallines between two electrodes, the greater the Input Voltages (ll V) Output
potential difference between them; two electrodes any- Grid I Grid 2 Voltage (ll V) Polarity
where on the same isopotentialline will have no potential - 1.5 - 10 .5
difference between them. - 20 -30 10 +
+ 10 + 6 ..j +
+ .50 +80 30
Cancellation, Summation, and the -2.5
+20
-20
+ 16
.5
..j +
Determination of Polarity +2.'5 +30 .'5
a l() Simplify the tahle. output values shown assume that the amplifier
Cancellation and summation are phenomena that occur as has a gain or amplification factor of exactly I. This makes the amplifier
the result of using differential amplifiers for recording a buffer amplifier.
90 12. Localization and Polarity

Table 12.2. Some Examples of Summation in a Differential nized that the voltage displayed at any point in time in an
Amplifier" EEG tracing represents the difference between the vol-
Input Voltages (IlV) Output tages present at the two electrodes to which the differen-
Grid 1 Grid 2 Voltage (11 V) Polarity
tial amplifier is connected. Furthermore, it is important to
understand that any polarities assigned to various electri-
- 20 + 30 50
cal events observed in an EEG tracing are not absolute
+ 100 - 75 175 +
- 30 + 20 50 polarities but are only relative polarities. Thus, we cannot
+ 25 -150 175 + say that a particular deflection in the tracing results from
- 3 + 2 5 the voltage at a particular electrode being negative; we can
- 2 + 3 5 only say that it is negative with respect to the voltage at the
a To simplify the table, output values shown assume that the amplifier other electrode in the circuit - that the voltage is relatively
has a gain or amplification factor of exactly 1. This makes the amplifier negative. Fortunately, it happens that from the neu-
a buffer amplifier. rophysiological standpoint, most focal activity such as
spikes is likely to be negative. So when a spike is seen in a
clinical EEG, the best guess is that it is electrically nega-
by grid 1 and grid 2 voltages of - 15 and - 10 ~ V, - 25 and tive. But the EEG tracing does not tell us that, even though
- 20 ~ V, and + 25 and + 30 ~ V. These, of course, are only the tracing happens to be compatible with this conclusion.
three of an infinite number of different combinations of It only tells us that the focus is negative with respect to the
grid 1 and 2 voltages that can produce an output of - 5 ~ V. area surrounding it. Information concerning absolute
Summation occurs when input voltages of opposite polarity can be gained only from other types of recordings
polarities are connected to grids 1 and 2 of a differential using different kinds of methods.
amplifier. The examples in Table 12.2 show what happens
when different combinations of voltages having different
polarities are connected to the two inputs of a differential
amplifier. Note that, as was the case with cancellation, the
Phase Reversal
magnitude and polarity of the output voltages are deter-
mined by algebraically subtracting the input voltage on A phase reversal can be either of two different types,
grid 2 from the input voltage on grid 1. Also, observe that instrumental phase reversal or true phase reversal. Instru-
the output voltage is always larger than either input mental phase reversal is by far the most common type
voltage - an effect suggested by and in harmony with the encountered in clinical EEG. As mentioned earlier in this
term summation. Table 12.2 also shows that it is impossible chapter, it occurs when grid 2 of one channel and grid 1 of
to infer magnitude of input voltages from magnitude of the a second channel are both connected to a single electrode
output voltage. Thus, for example, note in Table 12.2 that a situated over a focus of activity. As seen in Fig. 12.6, oppos-
50-~V output arises from grid 1 and 2 inputs of - 20 and ing deflections occur in these two channels because the
+ 30 ~v or - 30 and + 20 ~v, and an output of 175 ~v identical voltage goes to opposing inputs. The term
from + 100 and - 75 ~V or + 25 and - 150 ~V. instrumental, therefore, simply reflects the fact that the
Because the polarity of every output voltage shown in phenomenon is the result of the particular way in which
Table 12.2 is the same as polarity of the corresponding electrodes are connected to the EEG machine. Instrumen-
input voltage to grid 1, it appears that output polarity tal phase reversals are the key to localization when employ-
might serve as a clue to the absolute polarity of the input ing a bipolar recording system - a recording system in
voltages. Unfortunately, this does not happen in practice, which adjacent channels are connected in a chain.
the reason being that we can never be absolutely certain Recording-system details have already been discussed in
that a particular event in an EEG tracing is the result of the previous chapter.
summation. For example, although in Table 12.2 an output A true phase reversal occurs when the axis of a dipole
voltage of - 5 ~ V is present only when there is a negative that is the source of electrical activity recorded from elec-
voltage on grid 1 and grids 1 and 2 have voltages that sum trodes on the scalp is not perpendicular to the scalp. This
to 5 ~V, this outcome is not unique to summation. Thus, as would happen if, for example, the dipole were located in a
Table 12.2 shows, an output of - 5 ~ V can be produced by sulcus of the cerebral cortex, which could place its axis
a variety of different positive as well as negative voltages almost parallel to the scalp. The result of such a condition
connected to grid 1. is analogous to the situation and outcome shown in Fig.
In concluding this section, the reader should be clearly 12.2. Note that a phase reversal occurs in the plot of the
aware of two essential facts concerning EEG recordings. voltage measured at the surface. This is a true phase rever-
We reiterate them here at the risk of seeming repetitious sal since the voltages are all measured with respect to the
because they are so important. Firstly, it should be recog- same distant electrode.
Phase Reversal 91

Thus far in this chapter, we have discussed phase rever- s

sals as if they occurred only in response to the presence of
a brief electrical event like a spike generated in a limited

J>-
cortical region. This is clearly not the case. A phase rever-
sal is not synonymous with the presence of a spike; nor is
it necessarily indicative of an abnormality in the EEG. An (
I
instrumental phase reversal may occur whenever the same 2
electrode is connected to opposing inputs of two adjacent
channels. Thus, for example, the alpha rhythm recorded
in T5-0 1 can show some phase reversals with the alpha 3
rhythm recorded in 01-02, but this has no clinical sig-
nificance.

Localization in Referential Recording

In the last section we mentioned the case in which the Figure 12.10. Contamination of a referential recording em-
voltages present at various points along a surface are all ploying an ear reference electrode by an "active ear:' F, the
measured with respect or reference to a single electrode. focus, is equidistant from electrodes P and Q. Channels 2 and 3
are contaminated with activity picked up from F by P, the refer-
This condition is referred to as referential recording, and
ence electrode.
the method has already been discussed in some detail in
the previous chapter. Our purpose here is simply to show
how referential recording is used in localization.
In referential recording, a different scalp electrode is located in an equipotential zone. On the other hand, chan-
connected to grid 1 of each differential amplifier, while a nel 2 shows a deflection, there being a potential difference
common electrode goes to grid 2 of each amplifier. This present between Rand P and likewise in the case of chan-
common or reference electrode may be either a single nel 3. The deflection is of larger amplitude in channel 3
electrode, as in the case of an ear reference, or a composite than in channel 2 because the distance between Sand P is
of numerous electrodes, as in the case of an average refer- greater than the distance between Rand P (an application
ence. The basic convention discussed earlier still holds, of rule 1). Note that these are downward rather than
namely, that a channel will deflect upward when grid 1 is upward deflections as in the previous examples. This is the
negative with respect to grid 2, and downward when grid result of the fact that grid 2 is negative with respect to grid
1 is positive with respect to grid 2. This means that a phase 1, whereas grid 1 was negative with respect to grid 2 in the
reversal observed in a line of referentially connected elec- earlier examples.
trodes is a true phase reversal. Indeed, a true phase rever- The phenomenon just discussed is referred to as active
sal is best detected and localized using referential record- ear contamination of the scalp electrodes because the out-
ing. The other clue to localization in referential recording puts of channels 1, 2, and 3 show activity that suggests that
is amplitude. In referential recording, the larger the deflec- a surface positive focus is present at electrode S. The fact
tion associated with a particular focus of activity, the closer that in EEG work foci are usually surface negative and only
the electrode is to the focus. As interelectrode distances rarely surface positive argues against the latter possibility.
are the same for homologous left and right derivations in That we, indeed, are dealing with a surface negative focus
referential recording, this is the optimal system to use between electrodes P and Q is readily confirmed by con-
when making amplitude comparisons between the two necting P, Q, R, and S in a bipolar chain as in Fig. 12.7(b)
hemispheres. and observing the outputs as shown. If the focus were sur-
When an ear electrode is employed as a reference, ear face positive and located at S instead of surface negative
contamination can present a major problem. This happens and located at F, as in Fig. 12.7(b), the channell, 2, and 3
when a so-called "active ear" is present. As mentioned outputs would be different. We leave it to the reader to
briefly in Chapter 11, the contamination results from sig- determine what these outputs would be like.
nificant activity occurring in the adjacent temporal region
being picked up by the ear reference electrode. An exam-
ple best describes what happens. Commonly Seen Localizing Patterns
In Fig. 12.10, the focus F is midway between electrode
P, the electrode on the earlobe, and electrode Q. Following Some of the most commonly occurring localizing patterns
rule 5, channell shows no deflection because P and Q are are shown in Fig. 12.11. The five examples given illustrate
92 12. Localization and Polarity

Bipolar Chain
~
-V- -V-
A-B

B-C ~ ~ -~

C-O

Referential
~ ~
----v-
A-R ~. ~
-V-
~

~
B-R ~ ~
~
----v-
C-R .~ ~- -y-- ~

-V-
O-R -.~ ~
I
-V-
~

Interpretation Focus Of Focus Of Focus Of Focus Of Negativity At R

Maximum Maximum Maximum Maximum ("Contaminated"
Negativity At B Negativity Positivity At C Negativity At A Reference)
Between
BAnd C

Figure 12.11. Some commonly seen localizing patterns. Simultaneous bipolar and referential recordings. A, B, C, and 0 represent
electrodes placed over F7, T3, T5, and 01. R in referential recording is on the contralateral ear.

the configurations seen in referential as well as in bipolar

recording. In each case the interpretation or location of
the focus is given at the right. With machines having 18 or
more channels, such simultaneous referential and bipolar
recording has become practicable and localization of foci
of spike activity can be made more quickly and accurately.
Note that in confirming by referential recording the loca- Negativity At R./ Negativity At R /
tion of a focus observed in bipolar recording, or vice versa, Contralateral Ear IpSilateral Ear
we are able to verify its existence. Bipolar Chain
The last example in Fig. 12.11 shows the localizing pat-
terns when the contralateral ear, which serves as the refer-
A-B - - - - - - ---y--
ence, is contaminated. A different localizing pattern will B-C ~
be seen when the ipsilateral ear is contaminated instead C-D ~
and serves as reference. The localizing patterns for these
two different conditions are shown side by side in Fig. Referential
12.12 for comparison. Following conventional EEG prac- A-R ---y--
tice, the reference electrode is connected to G2. This ~
B-R -v--
means that contamination (negativity) at R results in a ~
downward deflection of the tracings, which is a valuable C-R
localizing sign. ~ ~
D-R
It is interesting to note that the bipolar localizing pat-
terns for negativity at the ipsilateral ear and for negativity
~ -V-
at B (Fig. 12.11) are identical. The difference between the Figure 12.12. Contamination (negativity) at contralateral and
conditions, however, is picked up by the referential record- ipsilateral ears and the localiZing patterns seen in simultaneous
ing, a fact that highlights the importance of using both bipolar and referential recording. A, B, C, and 0 represent elec-
bipolar and referential recording. trodes placed over F7, T3, T.'), and 01.
Commonly Seen Localizing Patterns 93

Contaminated Average Potential

Reference FP1 FP2
F7 T3 - 20~V
As explained in Chapter 11, the average potential refer- T5 - 200~V
ence (also referred to as averaged common reference) is an 01 - 20~V
attempt to obtain a truly indifferent electrode, that is, a
point of zero potential against which the voltages at other @
electrodes may be compared. In this technique, G2 of each @)
channel is connected to a common point whose voltage is
an average of the voltages from all the electrodes. We noted
T. Included In Average T. Excluded From Average
earlier in Chapter 11 that the Fp" Fp2, and Cz electrodes
are excluded from the average, and that F7, FS, Fz, and pz
are often also excluded. F 7 -Av V
The main difficulty with this montage is that a high T3- Av ,

~
amplitude potential, as for example a large spike in one
electrode, can cause a surge in voltage at G2, which leads
to a confusing localizing pattern in many channels. Figure T5- AV ~
12.13 shows the effect of having a large spike - 200 /lV in 01-Av 1\
amplitude present at T5 with spikes of - 20 /l V at T3 and
01. As there are ten electrodes in the averaged common
Fa-Av
reference, 'lio[( - 200) + ( - 20) + ( - 20)] or - 24 /lV may v
be expected at G2 of each channel. This leads to a deflec- T 4-Av V
tion of - 176 /l Vat T5, and virtually no deflection ( + 4 IN)
Ta- Av
at T3 and 01. The other channels show a spurious down- V
ward deflection due to G2 being 24 /lV negative compared 02-Av
V
with G1. To remedy this situation, the technician has to
identify the electrode picking up the high amplitude Figure 12.13. Contamination of average potential reference (Av)
potential (easily identified because it shows the largest by spike focus at T5. Circled derivations designate electrodes in
deflection) and remove it from the average. In the present the average. Tracings show recordings from electrodes in the tem-
example, once T5 is excluded from the average, the nega- poral chains; all referred to the average potential. The spurious
tivity in G2 is reduced to virtually zero so that the down- downward deflections disappear when the T5 electrode is
ward deflections disappear and T3, T5, and 01 show their removed from the average.
actual voltage levels of - 20 /lV, - 200 /lV, - 20 /lV, respec-
tively.

Reference
Helmholtz H: Dher einige Gesetze der Vertheilung elektrischer
Strome in korperlichen Leitern mit Anwendung auf die
thierischelektrischen Versuche. Annalen der Physik 1853;
89:211-233.
Chapter 13
Introduction to EEG Reading

The first encounter with an EEG tracing is somewhat per- learning is accomplished through observing an experi-
plexing to the physician and the technician alike as they are enced electroencephalographer read EEGs. The next step
likely to be awestruck by the complexity of the record. involves reading under supervision; having seen how an
Often, the initial impression is that the task is too complex experienced electroencephalographer interprets a record,
to learn. The physician fa.miliar with reading ECGs soon and having gathered essential information regarding nor-
realizes that there is little in common between the analysis mal and abnormal patterns, the trainee interprets records
of the repetitive complexes of the ECG and the ever in the presence of his or her instructor. Ideally, the instruc-
changing waveforms of the EEG. At this stage, the prospec- tor should regularly quiz the trainee on the various wave-
tive electroencephalographer is tempted to exclaim: "This forms and artifacts in the tracings, and the trainee should
is all Greek and Latin to me:' Indeed, learning to read complement this by seeking answers to the questions.
EEGs is not unlike learning to read a foreign language. Without at least an elementary knowledge of the basic
principles of electricity, neurophysiology, and the tech-
nique of recording, it is impossible to learn to read EEGs
Reading EEGs - An Analogy properly. One needs to know what calibration means, how
the various frequency filters work, how various artifacts are
To read a new language, needless to say, one needs first to identified, and how neurologic disorders produce altera-
learn the alphabet. The alphabet of the EEG consists of tions in electrical activity of the brain. The prospective
the various frequencies and waveforms that comprise the electroencephalographer also needs to have a thorough
tracing. Just as the letters of the alphabet are combined in working knowledge of the various montages used. All these
different permutations and combinations to form words topics are taken up in considerable detail in this text.
and then sentences, so the EEG tracings are made up of Numerous EEGs need to be seen before one becomes
combinations of waveforms of different frequencies and familiar with the wide range of normal variations in differ-
morphology. To carry the analogy further, it is not enough ent age groups and physiological states. The task becomes
to be able just to read the words and sentences; one needs even more difficult when tracings of neonates and prema-
to understand quickly the meaning of what is written. In ture infants have to be interpreted. It may take two or three
the same way, EEG reading involves analyzing the wave- years of experience in reading before one has acquired
forms and deducing their significance. With experience, reasonable expertise.
one uses a speed reading technique in which a whole page
is rapidly scanned for evidences of normal and abnormal
phenomena. How successfully this is done depends to a
large extent on developing pattern-recognition skills.
Terminology

It is essential to use standard terminology in describing the

Learning to Read EEG. The International Federation of Societies for Elec-
troencephalography and Clinical Neurophysiology has
How does one learn to read EEGs? Like any other branch proposed definitions for the various terms used in EEG to
of medicine this involves a continuous process of learning facilitate communication between different electroen-
for many months or sometimes even years. Often the initial cephalographers. In this section, we list the definitions of
Terminology 95

some of the terms that are most commonly used in EEG intervals; usually the intervals vary from one to several
reading.1 seconds.

Background Activity Amplitude

This term denotes the general setting in which changes in This is expressed in terms of voltage in microvolts based on
frequency, amplitude, or morphology appear. Although the a peak-to-peak measurement. One needs to know the sen-
alpha rhythm may be the background activity in the trac- sitivity at which a recording was made to determine this.
ings from the posterior regions, it is important to note that For this purpose, the reader consults the routine calibra-
the term background activity is not synonymous with tion at the beginning or end of the record. The amplitude
alpha rhythm; thus, over the frontal area, the activity may will vary depending on the technique of recording, the
be mostly in the beta frequency band. The background bipolar montages with short interelectrode distances giv-
activity may not always be a normal pattern; the term can ing a smaller amplitude than the referential montages with
also refer to abnormal patterns. larger interelectrode distances. Ideally, amplitude should
Both the background activity and the changes that be described in terms of the actual voltage; however, the
appear in the features of the tracing are described in terms terms low, medium, and high amplitude are often used.
of frequency, amplitude, wave shape, symmetry, synchrony, The term low is used when the amplitude is under 20 IlV,
location, continuity, and reactivity. It is important to under- medium when it falls in the range of 20-50 Il V, and high for
stand the meaning of each of these terms to give a proper more than 50 1lV. The use of these terms is discouraged
description of the EEG. owing to lack of uniform criteria.
Attenuation and blocking are terms used when there is a
reduction in the amplitude of EEG activity, usually in
Frequency response to some stimulus. The classic example is attenua-
This term refers to the rate at which a particular waveform tion of the alpha rhythm in response to eye opening. The
repeats; it is usually used in the context of rhythmic term suppression is used when little or no electrocerebral
activity (repeating with regularity). Depending on the fre- activity can be discerned in a tracing. Paroxysmal activity
quency, the activity is classified as delta (less than 4 Hz), is a term denoting activity of much higher amplitude than
theta (4 to 8 Hz), alpha (8 to 13 Hz), or beta (more than 13 the background that occurs with sudden onset and offset.
Hz) activity. Although these terms are ideally restricted to It need not necessarily denote an abnormal activity.
rhythmic activity, they are also often used to describe non-
rhythmic or random activity; in this case the frequency of Wave Shape or Morphology
a particular wave will be ascertained by taking the inverse
of its duration. Electroencephalographic activity is essentially a mixture
The frequency bands are used to describe the activity of waves of multiple frequencies. The appearance of the
irrespective of where it occurs. But the term alpha rhythm waveforms depends on the component frequencies, their
is more specifically used to denote the 8 to 13 Hz rhythm relative voltages and phase relationships, and, of course,
occurring during wakefulness over the posterior region of upon the frequency filters used. The waveforms are also
the head; it occurs generally with maximum voltage over continuously fluctuating in response to stimuli and depend
the occipital area, is best seen with the patient's eyes on the state of the patient. Several descriptive terms may
closed and under conditions of physical relaxation and be used in this context.
relative mental inactivity, and is blocked or attenuated by A transient is an isolated wave that stands out from the
attention, especially visual attention and mental effort. background activity; if it has a sharply pointed peak and
Sometimes the terms fast and slow activity are used to the duration is less than 70 ms (less than 2 mm at the paper
denote a dominant frequency above or below the alpha speed of 30 mm/s) it is called a spike; when the duration is
band. The term monorhythmic is often used when the par- between 70 to 200 ms, it is called a sharp wave. The term
ticular activity shows rhythmic components of a single fre- complex is used when two or more waves occur together
quency. When there are multiple frequencies the term and repeat at consistent intervals; examples are spike and
polyrhythmic is used. The term periodic applies to EEG wave complexes and sharp and slow-wave complexes. An
waves or complexes recurring at approximately regular activity is described as monomorphic when the morphol-
ogy of subsequent waveforms is similar whereas the term
polymorphic is used when they are of dissimilar morphol-
I For a listing of commonly used terms and their definitions, see
ogy. The description should also include the number of
the glossary in Appendix l. The reader may also refer to Chatrian
GE, Bergamini L, Dondey M, et al: A glossary of terms most com- phases. Thus, a wave may be monophasic (positive or
monly lIsed by clinical e1ectroencephalographers. Electroen- negative) or diphasic (positive and negative), triphasic or
cephalogr Clin Neurophysiol1974; 37:538-553. polyphasic.
96 13. Introduction to EEG Reading

Symmetry sible, it is important to break down the complex tracing in

terms of frequency, voltage, reactivity, synchrony, and
In general, symmetry refers to the occurrence of approxi- distribution.
mately equal amplitude, frequency, and form of EEG The various activities occurring in different states of
activities over homologous areas on opposite sides of the consciousness, namely, wakefulness, drowsiness, and sleep,
head. should be described clearly. One may start with a descrip-
tion of the background activity, which often tends to be the
alpha rhythm in the awake subject. Mention should be
Synchrony
made about its frequency, amplitude, location, symmetry,
This term refers to the simultaneous appearance of mor- and reactivity to eye opening. Next, the features of other
phologically identical waveforms in areas on the same side rhythmic activities present should be described in similar
or opposite sides of the head. terms; for example, beta activity in the frontal or central
areas.
Intermittent activity should be described in similar
Location terms, including the location and synchrony. The presence
of various phenomena such as V (vertex) waves and sleep
Several different terms are used. Focal or localized are
spindles should be clearly described. If sharp waves,
terms used when a particular activity is confined to one
spikes, or other intermittent activity is present, it should
particular region of the head. For example, an activity may
be described in terms of location, polarity, and amplitude;
be localized to frontal, temporal, parietal, or occipital
how the activity is affected by changes in state should also
areas. The term generalized is used when activity is not be noted.
limited to one region but occurs over a wide area. An
The effect of activation procedures such as hyperventila-
activity is said to be lateralized when it is present on one
tion and photic stimulation should be described. In the
side only.
case of hyperventilation, the way in which this procedure
influences the background activity and whether it induces
Continuity other changes should be mentioned. For photic stimula-
tion, the reader should mention whether there is a driving
An activity may be described as continuous or intemlittent, response and, if so, whether it is symmetrical and at what
depending on the percentage of time it is present. Thus, an frequency or frequencies it occurs. If there are any specific
activity is called continuous when it occurs without inter- responses like photoparoxysmal or photomyogenic
ruption for prolonged periods of time and discontinuous or responses, they should all be called attention to in the
intermittent when it appears only from time to time. description.

Reactivity Interpreting the EEG

The term refers to alterations in the amplitude and wave-
form of activity in response to a stimulus. An example is the The basic question to ask after completing a visual analysis
attenuation of alpha activity on eye opening. of the EEG is whether the findings are consistent with
the accepted norms for the age and state of the patient.
This means that the reader should have a thorough knowl-
There are other terms that are used in various special
edge of the normal variations of EEG patterns in relation
circumstances. These will be taken up in relevant chapters.
to age and state of the patient. Such a judgment is possible
only after the reader has seen numerous EEGs and has
formed an impression in his or her own mind about normal
Describing the EEG patterns.
If the EEG is normal, the interpretation ends with a
An adequate and accurate description of the EEG record statement to that effect. If an abnormality is present, the
is important for several reasons. When a clinician would next phase of interpretation involves categorization of the
like to compare the EEGs from different laboratories, or abnormality in more specific terms. Categorization should
when a recent EEG needs to be compared with the find- be precise. Some examples are: focal epileptiform abnor-
ings of an old record that is no longer available, the written mality, generalized epileptiform abnormality, foeal slow-
description of the records is essential. It may be said that ing, generalized slowing, intermittent rhythmic delta
if the description is good, the electroencephalographer activity, polymorphic delta activity, asymmetric alpha
can picture the actual EEG record in his mind's eye. To rhythm, asymmetric photic driving, asymmetry of sleep
make the description as objective and as accurate as pos- spindles or vertex waves. If an abnormality is found to be
More on Artifacts - Physiological Artifacts 97

localized, one needs to specify what area of the brain Table 13.1. EEG Reading-A Synopsis
underlies the abnormality. Steps in EEG Reading Skill/Knowledge Required
The next step in the interpretation is to suggest what
kind of changes may be happening in the brain that could Visually scan the EEG and Familiarity with various EEG
account for, or be compatible with, the abnormal EEG pat- describe the waveforms in waveforms, artifacts, altera-
terms of frequency, amplitude, tions in waveforms at different
tern. This entails a clear knowledge of the relationship
morphology, polarity, sym- filter settings, montages, sensi-
between the various EEG abnormalities and the various metry, synchrony, and reac- tivities and paper speeds.
disorders that affect the brain. One of the major problems tivity.
in this aspect of interpretation is that many different types
Determine whether the EEG Thorough knowledge of the nor-
of disorders affecting the brain can give rise to the same patterns are compatible with mal features of the EEG in
type of EEG abnormality so that very often only general normal patterns for the age various age groups and physio-
comments can be made. These comments may be like the and state of the patient. logic states; familiarity with
following: "This pattern is suggestive of a diffuse the variations that are
accepted to be within the nor-
encephalopathy;' or "the finding is compatible with a focal
mal range.
structural lesion;' or "this finding is suggestive of a focal
If the EEG is abnormal, deter- Knowledge of the various EEG
seizure disorder;' or "the abnormality is compatible with a
mine the most likely cause patterns that accompany
seizure disorder of the generalized type;' etc. Following the using the type of abnormality, different neurological dis-
technical interpretation, it is always useful to provide a its distribution, and other orders. Familiarity with the
clinical correlation on the basis of the patient's clinical his- characteristics as a basis. Look diagnostic and prognostic sig-
tory. Often it may be of value to say whether the EEG at the available clinical data nificances of various abnormal
and decide whether the EEG patterns.
abnormality seen is consistent with the clinical diagnosis.
pattern is or is not consistent
Table 13.1 gives a brief synopsis of EEG reading. with the suspected condition.

More on Artifacts - Physiological

Artifacts ings. Any uncertainty about whether or not an artifact is an
ECG is easily resolved by actually recording an ECG on
In general, four different varieties of artifacts are encoun- one channel along with the EEGs. This, of course, needs to
tered in EEG work: environmental, instrumental, elec- be done at the time that the routine EEG is taken. Obvi-
trode, and physiological. The EEG technician and the ously, a close, harmonious working relationship between
physican reading EEGs both need to be familiar with all of the EEG technician and the physician reading the EEGs is
them. Needless to say, artifacts in the EEG should be essential in resolving such problems.
eliminated whenever possible or kept to a minimum. To
achieve this goal requires close collaboration between the
EMG Artifacts
technician and the physician reading the EEGs.
Environmental, instrumental, and electrode artifacts These are the most common artifacts seen in EEG record-
have been discussed in various earlier chapters, principally ings. Muscle spikes originate mostly from the muscles of
the chapters on recording electrodes (Chapter 7) and the head: the frontalis muscle, the masseters, ster-
troubleshooting (Chapter 9). In this section we consider nomastoids, and temporal muscles are common sources.
the topic of physiological artifacts. Electromyographic artifacts are recognized mainly by
There are four major sources of physiological artifacts, their distinctive morphology; the spikes themselves are
namely, the heart, the muscles of the head and neck, the very sharp and of short duration. In this regard, however,
eyes, and the skin. The person reading the EEG must be particular attention needs to be given to the settings of the
able to recognize these artifacts if they occur in the record- high-frequency filters on the EEG machine. Settings lower
ing. He or she needs to learn to "read through" the artifacts than 70 Hz will result in the spikes being rounded off so
whenever possible. In this respect, the reader acts like a that they may easily be confused with brain electrical
filter in much the same way as the frequency filters func- activity in the beta band.
tion on the EEG machine. We will take up each of these As is the case with ECG artifacts, the EEG technician
artifacts in turn. Appendix 6 shows some EEG tracings plays an essential role in the detection of EMG artifacts.
containing these artifacts. While taking the EEG, he/she closely observes the patient,
notes various movements, and records their occurrence
directly on the EEG record. These notations are especially
ECG Artifacts
helpful in recognizing EMG artifacts when the tracings are
Because of their regularity and distinctive morphology, read and interpreted. Moreover, the technician's efforts in
ECG artifacts are the easiest to recognize in the EEG trac- establishing rapport with the patient, and in helping him
98 13. Introduction to EEG Reading

or her to relax, go a long way toward reducing many EMG Writing the EEG Report
artifacts.
A major complaint sometimes made about the EEG report
by some referring physicians (other than neurologists) is
Eye-Movement Artifacts that it makes little sense and often does not help in the
diagnosis or management of their patients. To some, the
Electrically, the eyes behave very much like batteries rotat- report may even seem misleading. For this reason it is
ing in their sockets. This means that electrodes located in important that the report be constructed in two parts: one
the anterior regions of the head can very readily pick up part deals with the actual description of the EEG findings
changes in voltage that are correlated with eye movements. and their interpretation; the other part contains a clinical
The artifacts are quite distinctive and are easily recognized correlation that renders the report meaningful to the refer-
after some experience. To assist recognition, it is helpful in ring physician.
the course of training to record samples of eye movements It is important to begin the report with a brief history
-up, down, right, and left-using some of the common and the clinical findings to date (usually available from the
montages. In this way, technician and reader alike can physician requesting the EEG and/or from the technolo-
become more familiar with the spatial distribution of these gist's worksheet). It is also helpful to mention what the
artifacts. referring physician hopes to find out from the EEG, if it is
If there is any question concerning whether or not explicit. The next paragraph should provide descriptive
activity recorded in the EEG is due to eye movement, an details regarding the testing situation. These should
electrode should be attached to the patient's cheek include whether the test was done at the bedside or in the
directly below the eye. This electrode is connected to grid intensive care unit and whether any modifications were
1 of one channel; grid 2 of the same channel is connected made in the electrode connections, as, for example, using
to the ipsilateral earlobe. The recording from this deriva- a reduced array in a neonate. The use of special electrodes
tion is compared with the recording from an anteriorly like nasopharyngeal or sphenoidal leads should be noted
placed derivation in a longitudinal bipolar chain, e.g., here. Also mention whether the patient was sleep
Fpl-F7 or Fp2-F8. Since the eye falls between these two deprived, and whether any medication was given before or
derivations, eye movements will appear in the two chan- during the test and, if so, what kind and how much.
nels as out-of-phase deflections or mirror-image signals. If Next comes the section that describes the EEG and the
the deflections in the two channels are in phase, they are state of the patient. This portion of the report should be
not eye movements but may be of cerebral origin. purely descriptive and should not contain any interpretive
statements such as normal or abnormal. Following this is
the paragraph setting forth the impression. Is the EEG
Galvanic-Skin Artifacts normal or abnormal, and if abnormal, what kind of abnor-
mality was seen?
Like all living tissue, the skin is electrically active. Changes The last paragraph should attempt to correlate the EEG
in electrical activity of the skin are usually associated with findings with the clinical picture. Thus, for example, in the
sweating, although some changes in voltage may be ob- case of a seizure disorder in which the EEG is normal, it
served between two points on the skin in response to stim- should be mentioned that the EEG does not support the
ulation (the so-called Tarchanoff effect). Generally speak- diagnosis of seizure disorder. But it also may be pointed out
ing, changes in skin potential associated with sweating or that a normal EEG does not necessarily rule out a seizure
stimulation are very slow changes. They occur mostly at disorder. In this context, one may suggest further studies
the very low end of the delta frequency band, making them such as a sleep-deprived EEG or a repeat EEG using
easy to recognize in the EEG tracings. Sometimes these special electrodes. If the EEG in a patient suspected of
artifacts can become quite large. When this happens, they having a metabolic encephalopathy shows diffuse slowing
usually can be reduced considerably by adjusting the low- or frontal intermittent rhythmic delta activity (FIRDA),
frequency filters from the standard l.O-Hz setting to the one may state that this finding is consistent with the clini-
5.0-Hz cutoff point. cal diagnosis.
Chapter 14
The Normal EEG

Since the late 1920s when Hans Berger first recorded the electrical activity that was first described in 1929 by
EEG in humans, an enormous amount of knowledge con- Berger, who named it alpha.
cerning the normal EEG has been accumulated. During
these years, the EEGs of normal persons have been
Alpha Rhythm
recorded in numerous situations and under a wide variety
of conditions. Tracings have been taken during perfor- This is 8- to 13-Hz rhythmic activity that occurs most
mance of a virtually endless list of different tasks and prominently in the posterior regions and is a conspicuous
activities, as well as during different states of conscious- feature of the EEG in the awake, relaxed adult. In some
ness, from persons over the entire life span. Much of the persons it is so rhythmic-and the waves are so regular-
data concerning the normal EEG need not concern us that it looks like the output of a sine wave generator. The
here. Thus, the clinical application of EEG is concerned alpha rhythm of most adults ranges between 9.5 to 10.5
mainly with the features of the tracing as they are seen in Hz. In the main, amplitudes are 50 IN or less, and ampli-
wakefulness under resting conditions l and in sleep. The tude tends to wax and wane over periods of one to several
EEG during specific, clinically significant activation seconds.
procedures is discussed in Chapter 16. As will be apparent from Fig. 14.1, which is an EEG of
We begin this chapter with a consideration of the major an awake, resting adult, the alpha rhythm is best seen when
features of the EEG seen during resting wakefulness. After the person's eyes are closed. Opening the eyes results in an
this, the normal EEG in sleep is taken up. As there are age- attenuation of the alpha rhythm. Reactivity to eye opening
related differences present in some features of the normal is typically used as evidence that the activity is indeed the
EEG, separate sections dealing with the normal EEG dur- alpha or posterior dominant rhythm. Mental effort or
ing maturation and in old age are also included. The reader focusing one's attention can also attenuate the alpha
should understand that a thorough and comprehensive rhythm. An EEG tracing may contain 8- to 13-Hz activity
coverage of these topics would require an entire text. For that does not attenuate with eye opening. Although such
this reason this chapter should be recognized as strictly an activity is classified as "alpha" by virtue of its frequency, it
elementary introduction to the normal EEG. is not alpha rhythm and should be distinguished from it.
Occasionally, an increase in amplitude and abundance
of alpha activity occurs with attention or eye opening
Features of the Awake EEG in Adults instead of a decrease. This reversal is referred to as a "para-
doxical effect" or "paradoxical alpha:' It is seen mostly with
The most prominent feature of the normal waking EEG is eye opening in response to stimulation following a brief
the posterior dominant rhythm. It was the feature of brain period of drowsiness (see Fig. 14.2).
The alpha rhythm is commonly of somewhat higher
amplitude on the right than the left side. By contrast, fre-
I The resting condition also stipulates that the person has not
quency normally differs by less than 1 Hz between the two
been fasting and that he/she has not consumed stimulants like
coffee, tea, or soft drinks before the time the EEG is taken. It is sides. In a small minority of normal individuals (less than
the responsibility of the technician to inform the patient of this at 10%), no alpha rhythm is perceptible using conventional
the time the appointment is made for the EEG. recording methods. The significance of this is unknown.
100 14. The Normal EEG

Fp1 F7
'(C·It!~'~r'~l~\\r".1/'~r\
\ I ' \
F7 T3 ~~W'o.t, "'~J-'{''''~
T3 T5 -...,'-'I'I'/'J\fWoN<MMiV'lotoNVW'IVWN'I.I/WVIIr.wv-'\AJ'"

T5 01 ~PNN!fNfNN'M!fl[lJMV\rwvv\fVIJ'VIf-., .r-~.......---~~"--""'-~--"""'MJIA../JiNlJ\fWMr-INW\J\MMf.JlIJo.!.MMf.~

Fp2 Fa ~'11 ~Jj"~,~r~/\~I'Y".,.,v"''''··''"'' I ',1 V I IJ

Fa T4 .-..-..,...-""""foNVv\.f'Vvvv,/INWV'~vWVVVW'" ~

T4 T6 ~wJINo/'Iu"N</JfJ'JVWWWf\lW'.Iv'WVlII~lA-"-'""v~"'"
---.;....;:..---
T6 02 ~~\~\VvW#f'h..'~1IIM~
Fp1 F3

F3 C3 ....,.,,--.r""'vvvw...-vvvw""""'wwo;"""""''vV'IV''V''\~
r~~I'{l'\"",'I'rv'!, r-..""""'_""""""""""-..,-_",""","..-JII"""""VoMA.,...,.,.,_ _""",,

1_-

Figure 14.1. Alpha rhythm in an awake, relaxed, and resting artifacts associated with eye opening and closing. Frequency of
young adult. The eyes are closed at the start of the tracing, are the alpha rhythm is approximately 11 Hz; little variation is seen
opened on command at OE, and closed again at CE. Note that from second to second. Filters: low frequency = 1 Hz, high fre-
the alpha rhythm is posteriorly dominant; it is markedly attenu- quency = 70 Hz. Calibrations: horizontal = 1 second, vertical =
ated during eye opening but quickly returns to its original level 50 1lV.
once the eyes are closed. Note also the muscle and movement
Features of the Awake EEG in Adults 101

F7 Fp1 ~~~""I'I"'i"""""""'"'""""""""""" ""'",'", ,,11,'11

Fp1 Fp2 ",--,'-'"""'-'--vv_""--,U'---,~"",,,,/"V',r-

Fp2 Fa

F7 F3 ~~~~~,/'vIN~~
F3 Fz
Fz F4 ~~~'"""W\f"'/\.N'v'\.1\
F4 Fa 4~V'r"N./.v~·I':~Vi

T3 C3 ~JV~{I/\NJ~V"vvJ~
C3Cz 'f"'V~!'

Cz C4 ~v/'v't""t\~/~o....,,.f~,,w~~~
C4 T4 rvv'~~V"\f.'\.NV\'j

T5 P3 ~~\..JW'\J'-J~~~
P3 pz
pz P4
P4 T6
T5 01
01 02
02 T6
c
----------------~·~~r----~----------------------------------------------~====~-----

Figure 14.2. Paradoxical alpha, or alpha rhythm occurring in tory. Shortly thereafter (arrow at "c"), an alpha rhythm of about
association with eye opening following drowsiness. The two 10 Hz is seen in the posterior regions. Filters: low frequency =
arrows near the start of the tracing at ";i' point to POSTS, which 1 Hz, high frequency = 70 Hz. Calibrations: horizontal = 1
are a feature of light sleep. The arrow at "b" indicates artifacts second, vertical = 50 IlV.
associated with eye opening in response to a noise in the labora-
102 14. The Normal EEG

T3

T5

F8

T4

T6

Fp1

F3

C3

01

Fp2

F4

C4 ,'.

P4

02

Fz
1--

Figure 14.3. Alpha rhythm in widespread distribution as seen in which is apparent from the fact that the waveforms in the anterior
a referential montage using an average potential reference. The leads are 180 0 out of phase with respect to the waveforms in the
person's eyes were closed. The tracing shows persistent, rhythmic posterior regions. Arrows point to some of these waves. This
activity at 10 to 10.5 Hz that appears to be present even in the should not be confused with alpha coma (see Chapter 15).
anterior regions. This peculiar distribution of the alpha rhythm is Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibra-
spurious. It is due to contamination of the average reference, tions: horizontal = 1 second, vertical = 50 J.lV

Occasionally, the alpha rhythm occurs in widespread anterior regions of the head. Such is illustrated in Fig.
distribution, extending to the central and temporal 14.3. Note, particularly, that the alpha activity appearing
regions. When this happens and an average potential in the anterior regions is of opposite phase to that in the
reference is being used, it is important to recognize that posterior areas. This readily identifies it as spurious and
the reference, which is common to all channels, may resulting from contamination of the average reference.
become significantly contaminated with alpha activity. The lesson gained is a general rule that the EEG tech-
The result is a record that gives a false impression con- nician should know and follow: avoid the average reference
cerning the distribution of the activity. Indeed, the record when a feature of the EEG is widespread in distribution
may show an alpha rhythm in all derivations, even in the and of high amplitude.
Features of the Awake EEG in Adults 103

+ +

1_-

~_~~~~~~~-----' L-~~_~_~_ _-'' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' _' ' ',II,,,,,,,,,,,""""'' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' IM"''MMMM.

Figure 14.4. Slow alpha variant rhythm at 6 Hz. The person's eyes the 6-Hz alpha variant alone; it disappears with eye opening and
closed at the first vertical arrow and opened again at the second. the commencement of photic stimulation at 24 flashes per
A mixture of 6-Hz and 12-Hz rhythmic activity is seen in the second. Filters: low frequency = 1 Hz, high frequency = 70 Hz.
posterior region on either side at Y' Rhythmic activity at "b" is Calibrations: horizontal = 1 second, vertical = 50 ~v.

Alpha Variant alpha rhythm present. Fast alpha variant rhythms have a
frequency range of 14 to 20 Hz; as in the case of the slow
In some persons the posterior dominant rhythm shows variants, the fast activity alternates or is intermixed with
some interesting variations. These features of the waking the ordinary alpha rhythm.
EEC, which are termed alpha variants, consist of rhythmic Alpha variant rhythms react to stimulation in the
activity like the alpha rhythm but of frequencies that are same way as the ordinary alpha rhythm. Thus, they are
faster or slower. They occur mostly when the person's eyes attenuated or blocked by eye opening and by mental
are closed. Slow alpha variant rhythms range between 3.5 effort. Figure 14.4 shows an alpha variant at 6 Hz that
and 6 Hz, and generally alternate or are intermixed with is intermixed, at times, with an alpha rhythm of 12 Hz.
the ordinary alpha rhythm. Often, the frequency of the The significance of alpha variant rhythms, if any, is un-
slow variant is harmonically related to the frequency of the known.
104 14. The Normal EEG

Fp1 F7

F7 T3

Fp2 Fa

Fa T4

T4 T6 ~1ty.,}'lN-.r--"""""..n ...~.....,.,...,t-"I"""".......,..,..,...,,,,,-~.Ao.~""""W"'-~_""""""""'~""""'"

Fp1 F3
+b +
F3 C3

P3 01

Fp2 F4

P402

Fz Cz
1_-
Cz pz

Figure 14.5. A mu rhythm at about 11 Hz. Between the arrows at tent on the right. The eyes were closed throughout the recording.
"a:' the mu activity is present almost solely in the centroparietal Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibra-
region on the right side. At "b" it occurs on both sides but is asym- tions: horizontal = 1 second, vertical = 50 11Y.
metrical, being of somewhat higher amplitude and more persis-

Mu Rhythm seen in Fig. 14.5. Because the mu and alpha rhythms fre-
quently occur at the same time in a tracing, the two may be
Although the mu rhythm resembles the alpha rhythm in confused. As shown in Fig. 14.6, however, they are easily
both frequency and amplitude, the similarity ends there. separated. Thus, whereas the alpha rhythm is attenuated
Ranging in frequency from 7 to 11 Hz, the mu rhythm is by eye opening, the mu rhythm is unchanged by this
composed of arch-like or comb-shaped waves that occur maneuver. The fact that the two rhythms are independent
over the central or centroparietal regions of the head on of each other is further documented in Fig. 14.7, where an
either side. The activity may be bilaterally symmetrical alpha rhythm is observed both in the absence and
and synchronous, or asymmetrical and asynchronous, as presence of mu activity.
Features of the Awake EEG in Adults 105

'"""_ /\ 9iB i\
Fp1 F7 "'-..,;~ "'I...r-J-I ~/~.:~tl; i~_""."-"Y;\'''''\

F7 T3 '~\\\\~rw-..i"<"'~~"J<'",.r-+,~.....r---"~----"",·;',//'v~~_~''''' ~~
....

T5 01 ·t/~"""J,VIIW'lVIj~W\f'fv'wf>N'''''''~-'~~~~W~
1\ ~ ,\
Fp2 Fa .....~~ \ .... _ .......... I".~",,(,r': \... _.~_.JIo_
.~ ~ J/ . .~ ....\ /
J ~J
Fa T4 ~~~r"V'JV'/"~Vv"/V·A._""...J'-"J'~"'-"'" .N""VWVo"""""",,,-_

T4 T6 ,i}.tVIt',<Wf\'i"\~\~W"W,,\\I,'VI..\;vv'.·.~\.'''V~....,J'IV..~·J''~_'N'--~~,\.~vrvPAWNHWI[1N~{\v..r\I.J'AN'I'''~,~

T6 02 ~"'~'f\YI~W>-.,.vvvv--'---'---.-..,......,---~.-----."...--""--"""~f/-NII'~~~~WIW'

Fp1 F3 ~;J~~,~"'(I!i
v 'I V"
F3 C3 ~~/lJ\!~'i'"""-N'.r1'v-.

C3 P3 ~~f'JV'"'--"""'~""f"-M",-"",",M,.-..,"""","V"'-o'\~~"",,",v--.-.~""""""""""'W"'v..

F4 C4 ~~~~~~~~~.~~~~- ..
~:~~~
~
o()o

Fz Cz
1_-

Figure 14.6. Mu rhythm during attenuation of the alpha rhythm ated, but the mu rhythm is conspicuously present on the right
in response to eye opening. The eyes were opened at the first side (open arrows). Note the sharp, comb-like character of these
solid arrow from the left, and closed again at the second solid waves. Filters: low frequency = 1 Hz, high frequency = 70 Hz.
arrow. During eye closure the alpha rhythm was greatly attenu- Calibrations: horizontal = 1 second, vertical = 50 1lY.
106 14. The Normal EEG

213 21.
F7 Fp1 .... Mor-.....,.....--..

Fp1~2~~~~~~~w-~~--~~--~~~~--~~--~~~~~~--~~--~~

~F8

Fz F4

F4 F8 N1

T3 C3 ~'JvJ'''''''''..... M~11I

C3Cz~\fV"W'o<o'VV"'iJ"o'

Cz C4

C4 T4
12

13

pz P4
.
P4 T6

T5 01

01 02

02 T6

Figure 14.7. A mu rhythm in the central region on either side comitantly witb the mu rhythm and also when it is absent (solid
(open arrows). The mu activity seen here is neither bilaterally arrow). Filters: low frequency = 1 Hz, high frequency = 70 Hz.
synchronous nor symmetrical. The subject's eyes were closed Calibrations: horizontal = 1 second, vertical = 50 1lV.
throughout the recording; note that an alpha rhythm is seen con-
Features of the Awake EEC in Adults 107

517

T501

Fa T4

Fp1 F3

F3 C3~~~~-w~~~~~~~~~~~~~~~~~~~~~~~~
+
+
P3 01

1_-
P402

Figure 14.8. Blocking of the mu rhythm resulting from muscular activity, which is seen on both sides but occurs more frequently
contraction on the contralateral side. The tracing shows a very and is of considerably greater amplitude on the right, is not nor-
marked reduction in amplitude of the mu rhythm in the left cen- mal. Filters: low frequency = 1 Hz, high frequency = 70 Hz.
tral region in response to the subject clenching the right fist Calibrations: horizontal = 1 second, vertical = 50 !lV.
beginning at the arrows. This is a normal response. The slow

Although mu rhythms are not reactive to eye opening, attenuation or blocking of a mu rhythm present on the con-
they are responsive to activity of the motor system. Move- tralateral side. Figure 14.8 shows how a prominent left-
ment of the extremities or muscle contraction, such as sided mu rhythm is blocked by having the person clench
clenching the fist, on one side of the body results in the the right fist.
108 14. The Normal EEG

176 177
Fp1 F7

F7 T3 :z

T3 T5

T501

Fp2 Fa
I
Fa T4

T4 T6

T6 02

Fp1 F3

F3 C3

C3 P3

P3 01
13 I
Fp2 F4

F4 C4
15
C4 P4
I
P402

II
Cz PZ
Figure 14.9. Beta activity with eyes open and then closed starting are closed, the alpha rhythm masks the beta activity so that beta
at "x:' Arrows point to low amplitude (less than 20 I1V) beta is best seen in tracings from the anterior regions. Filters: low fre-
activity at about 22 to 24 Hz. Note that with the eyes opened, the quency = 1 Hz, high frequency = 70 Hz. Calibrations: horizon-
beta activity is present in most derivations, being visible in the tal = 1 second, vertical = 50 11V.
posterior regions as well an anteriorly. However, when the eyes

Beta Activity Although beta activity is best seen in tracings from the
anterior regions, it is commonly present in the posterior
regions as well, albeit masked by the alpha rhythm.
Although activity with frequencies higher than 13 Hz is Because of this, it is easier to appreciate the distribution of
common in the waking EEG of adults (and children as beta activity when the person's eyes are opened. Figure
well), amplitudes are normally only 20 ~V or less in more 14.9 shows beta activity in a tracing with the eyes open
than 90% of the cases. For this reason, beta activity, which and closed.
usually consists of frequencies greater than 13 Hz and up The frequency of beta activity should be the same on
to 35 Hz, is not a prominent feature of the waking EEG. both sides. Amplitude, however, may display an asymmetry,
Features of the Awake EEG in Adults 109

1"111111111"'11111"'11111111"'1111111,""11111'"1'111 IIIltll""I,I'II'I II,ill,II"I""""",',"I""'II111"'I,I"""'Iilllli""III'II"'tll)J

Fp1 F7 ..~~w ........,~,~••, M~I_"""f~':-_ _ _<>:::"""'_~-V'fV'-_""""'_""""_-.A~~______-v-."""""-",,tv-.r""'""'_ _ _--'-,-.,.NI

F7 T3~'~M-~--~~~~~------~~.~~~'~~~~--~~~~~~~~~~~
T3 T5 -_-.,flt"'__"'N~N"'NV.J'W,'vvv'_'~___J""'''_~'~~I'''rv-....wv'''-'''-~''VNIN"</'-.MN'.-A~N'''-ti'~'""''''V\!
T5 01 __'-"'-"~__~~~~~~~~~~~~~~~~~~~~~~~~kN~~~_ _~~~
Fp2 Fa ~\~ '" \~~-I'~~~!,~,4------'""'-~------...-..V'V".,.,...'"'"'V""""'...,............Mo-.......,.........--"'~"""'Y'W'v-.t'IMv........,......_..-.'\""
Fa T4
T4 T6 ~\~~~.\,\~ ~-~~'v'Wv"Y-~~''''''''-JV'v~J'../V''''IfV'-oJVArV\tJ\J'~N--'''''-JV''''''''''","/V'-
70 Hz HF filter ~ 15 Hz HF filter
T6 02 ~~'~~--~~~~~~~~~~~~-----NWv~

P3 01 ~",MfV'~",~\ :~\1JrV'Jwyvv.J,~J\[J'NWv~~\1'

FP2F4 ...t,\/,~I~~'~~'~~~~
F4 C4 :
C4 P4"'-"'~--~~~~~~~~~~~~~~~~~~"""-~~~--~~~~~~~~~

P402~y.~I~W';i\'i~V~~
: 1---
Fz Cz :

--------------------------------~--------~~-------------------------------------------

Figure 14.10. The effect of high-frequency filtering on muscle low-amplitude fast activity were left. This activity looks like beta
artifacts. Prominent muscle spikes were recorded in the anterior (open arrows), but is really muscle activity with the spikes
leads with the high-frequency filter at the standard 70-Hz setting. rounded offby filtering. Calibrations: horizontal = I second, ver-
Switching to the IS-Hz setting removed the spikes, but traces of tical = 50 1.1. V.

with minor asymmetries being attributable to differences 15 Hz. When this is done, any muscle spikes that remain in
in skull thickness on the two sides. Consistent, major dif- the recording will show a rather marked change in charac-
ferences in amplitude between the two sides - differences ter. Figure 14.10, in which the filter setting was abruptly
in excess of 35% -are considered to be abnormal. changed from 70 to 15 Hz, illustrates this. Note that with
When examining a tracing for evidences of beta activity, the filter set at 15 Hz, the sharply pointed muscle spikes
the electroencephalographer needs to be especially aware are no longer seen. Instead, there is rhythmic, 20- to 30-Hz
of the high-frequency filtering that was used in taking the activity present in the anterior leads that looks a great deal
EEG. The reason for this will be apparent from a perusal like beta activity. In reality, however, this activity consists
of Fig. 14.10. As noted elsewhere in the text, the recom- oflow-amplitude muscle spikes that have been rounded off
mended high-frequency-filter setting for routine EEG by the action of the filtering. To avoid mistaking filtered
work is 70 Hz. Occasionally, however, muscle artifacts may muscle spikes for beta activity, it is essential to keep a close
be so numerous and persistent that the technician's only watch on the high-frequency-filter settings used in taking
recourse is to drop the setting to 35 Hz or, rarely, even to the EEG.
110 14. The Normal EEG

Fp1 F7

T3 T5 ~~~~.I\f'JV"'~.,..!"""i'~~~"'~'''''''/V'''''''_''''''''
A 1 • ,~ ,

T5 01 J-Jv.1~\ ~..~iI''\rA...NJ ,~VVvv'vV"","~"v\\\/'''-I',MfJ tJJV~~\\/NV",",~...J"\-r'

Fp2 Fa vl\l'~F~~/'''\~~f~r~~
Fa T4 1....A~~~~'~~~~~~~·, ......·~'-'tMJ

T4 T6 ~""-VJlfv~~'~"'I"V'r'v'"._..\-...~~
. ( f

T6 02 ~,~v,"'''\,~'''iWlI,'\Jv~\\~~,v''''/YW'uv~~vV\\~L~vWl\.,''Jv\.,;c-..'\I~
Fp1 F3 ~~~~~V''''-j''\rJ~0.,Io~~~~~""'II~''''''''''''''''''..JW'"'"n'''
F3 C3 ~'v-"Jv~.~~If,\"""~~,V""",,,,,,

C3 P3~~l"~~~~~~~

P3 01 ~".,vJll~""',v""W~\'''''NiIM\WI'.r
Fp2 F4 ~~~1~1f;.J~lr'J""w'IJ""V-"'"
F4 C4 ~~
C4 P4

P402~\~V~
Fz Cz

Cz pz

Figure 14.11. Lambda waves. The subject's eyes were closed and arrows point to lambda waves. Filters: low frequency = 1 Hz,
the tracing shows a prominent alpha rhythm at 8 to 9 Hz, which high frequency = 70 Hz. Calibrations: horizontal = 1 second,
is blocked when the eyes were opened at the vertical arrows. The vertical = 50 IlV.
eyes remained open throughout the rest of the record. Curved

Theta Activity Theta activity of drowsiness is discussed and illustrated in

the next major section of the present chapter.
This includes activity having frequencies of 4 Hz to less
than 8 Hz. Although a small amount of6- to 7-Hz random
Lambda Waves
activity is present in the background of the waking EEG of
most young adults, theta activity in any but trace amounts These are sharp transients that occur in the occipital
is not considered to be normal. As theta activity is a normal regions when the eyes are open and the person is engaged
accompaniment of drowsiness, it is important to avoid mis- in visual exploration. Durations of the transients vary con-
taking theta activity of drowsiness for waking theta activity. siderably and are reported to range from 100 to 250 ms;
In this regard, the technician's observations and notations amplitudes are usually under 100 ~v. Lambda waves are
concerning the subject's behavior while the EEG was predominantly positive at the occipital electrodes with
taken are important in helping to make the distinction; respect to other areas. They may be fairly symmetrical on
they are essential in cases where the posterior dominant the two sides, as in Fig. 14.11, or quite asymmetrical; or
rhythm is absent or not readily discernible in the tracing. they may be present only on one side.
Features of the EEG During Drowsiness and Sleep in Adults III

~1~2------------~~~----------~----~~~------------~~--~~--­

~Fa~------~~~----~------~~~~~~--~~~~~~~

F3 Fz

Fz F4
F4 Fa

Cz C4

C4 T4

T5 01
01 02
1_-
02 T6 ~~~--~--~.~~~.~.--~~~~~~--~----~--~--~~--~--~---~

Figure 14.12. Rhythmic theta and delta activity during drowsi- rhythm appears. Note the low-amplitude ECG artifacts. Filters:
ness. The slow activity (open arrows) is mainly in the central low frequency = 1 Hz, high frequency = 70 Hz. Calibrations:
regions. The episode of drowsiness is followed after about 10 horizontal = 1 second, vertical = 50 ~v.
seconds by partial awakening during which time the alpha

Lambda waves should not be confused with positive ground activity of the EEG. The transition may be grad-
occipital sharp transients of sleep (POSTS), which occur ual or it may be very abrupt. The most prominent change
during sleep, nor mistakenly interpreted as a focus of is the disappearance of the posterior dominant (alpha)
abnormal activity. Lambda is easily distinguished from rhythm. In some persons this is preceded first by a per-
these other EEG features by the fact that the waves ceptible slowing in the frequency of alpha. With the alpha
promptly disappear when the eyes are closed. This, again, rhythm gone, the background becomes dominated by
highlights how important it is for the EEG technician to be theta activity, which occurs in generalized distribution
a careful observer; for if he/she should fail to note that the but is commonly most prominent in central or fronto-
activity occurred only with the eyes open, the interpreta- central regions. The theta activity varies in amplitude
tion could become uncertain. from 10 to about 50 11 V; it may be rhythmic as in Fig.
14.12, or semirhythmic and/or irregular as in Fig. 14.13.
Features of the EEG During Drowsiness At times, some slower activity may also be intermixed. It is
not unusual for periods of drowsiness to alternate back
and Sleep in Adults and forth with periods of wakefulness, at which time
The transition from the awake to the drowsy state, or stage I the alpha rhythm returns. Two such cycles are seen in
sleep, is marked by some profound changes in the back- Fig. 14.13.
112 14. The Normal EEG

F7 Av r~'{"~'-.~J'/V'\J\~~-~~~~---'o.//"--...J'-~-~~~","",~~

T3
t ; ~:
· "
~1{If'I,jVAA"V'.~-~""-'---------"""".../'_~~-""""""""""'---"""""----~"""""-""""---"""'-~~f\.!.vV"~~..-

awake 1 drowsy : awake 1 drowsy

T5 ~~-*~'-~-""_~~~~rV'-~~~~~
· . :
F8 · ____ . ... .
· ' .
.J'J~I\",~",.,:V'.\,~v--.\., . ./\-...I\..r-~-, ...-."-_---.."'"\";-~ ,---....-..--"tA--.-,,--,,,,,--.~-_-"-,",~,/'-~~,~-,,, .....,..,~ ........ -..;..~~~---.....J'\...~
. .
T4 · :

' . : I

···:
~~y.A".,~~----------"""'"-----~-~
' .
"
. "
T6

,, , ,:
~-----~-----~~.~~~~~~--~----------------~
: :
Fp1
···
"-I~~""\.oA/'J\f""~~----"-"-~---~_./~~~"'--"'-""V',~~,,",,,'~~
·
.
.. .
F3 f\J~AJI.."""",...A/.rI"'''foJ'~-.;''I''..r--~'''-..~'''-_~._/ --v-...r~''''''''....-....r~''V'\.~~~
·: ::
. '
_____

C3 : : :
/V.Jo{.,....A'J~/v"Jv~~~-~~~-~--~--~---~~,-J~~~

P3

01 ~~~~~~~ ............'--"--........._"""-':..,...,___"'"""___"'-."-~-.r,___-

Fp2
; ft' ,
~~'\./"~"v.r-~~~"-"~""""~~
,i i
: . :
F4 ............,.~~~~ :
C4 ~~~-~'V"~-~~~-~-~~~~~
: :
: I :
P4 ~ ~~~'~"""""-VW""""'-V-~--:--~~---~--
.I

02 ~rw~~~~~~~~~~--~~--~~~--~----

Fz ~~~~~~~~v-~-v.~

1-

Figure 14.13. Tracing showing rapid shifts between an awake and activity is present. There is a return to wakefulness that lasts
a drowsy EEG. The record begins with an alpha rhythm at about 2 seconds before the tracings again revert back to drowsi-
approximately 11 Hz. which abruptly disappears after about 2.5 ness. Filters: low frequency = 1 Hz. high frequency = iO Hz.
seconds. A i-second interval of drowsiness follows during which Calibrations: horizontal = 1 second. vertical = 50 ~V.
time 15- to 35-,N theta (arrows on left) and delta (arrows on right)
Features of the EEG During Drowsiness and Sleep in Adults 113

Fz F4

C3Cz

Cz C4

C4 T4

T5 P3

pz P4

P4 T6

T5 01

01 02
1_-
02 T6
Figure 14.14. Diffuse beta activity during drowsiness following where it sometimes has an amplitude of 40 J.1V Filters: low fre-
administration of chloral hydrate to promote sleep. The 20- to quency = 1 Hz, high frequency = 70 Hz. Calibrations: horizon-
24-Hz rhythmic activity is most prominent in the frontal regions tal = 1 second, vertical = 50 J.1V

Another change in the background activity that occurs test, beta activity may become widespread and quite
in the transition from the awake to the drowsy state con- prominent, sometimes attaining amplitudes in excess of 50
cerns the beta activity. Beta activity in the range of 18 to 25 Il V. Figure 14.14 shows diffuse, persistent beta activity dur-
Hz usually, but not always, increases in amplitude with ing drowsiness following administration of chloral hydrate.
drowsiness; this has been termed sub vigil beta. At times, the As a person goes from the drowsy state, or stage I sleep,
beta activity appears in bursts of short duration; these are into stage II sleep, we find that the EEG displays a number
referred to as beta spindles (see Fig. 14.15). When chloral of distinctive, easily recognized features. These are taken
hydrate is administered to promote sleep during the EEG up in turn.
114 14. The Normal EEG

F7 Fp1

Fp1Fp2

Fp2 Fa

F7 F3

F3 Fz

Fz F4

F4 Fa

T3 C3

C3 Cz

Cz C4

C4 T4

T5 P3

pz P4

P4 T6

T5 01

01 02
1_-
02 T6
Figure 14.15. Early stage II sleep showing the initial appearance waves. Note the phase reversal in channels 9 and 10, which indi-
of V waves. In the first 2 seconds, the tracing shows central and cates that the focus of the wave is at Cz. The diagonal arrow
frontocentral theta activity that is characteristic of drowsiness. points to one of several beta spindles present in the tracing.
Directly thereafter an incompletely formed V wave (marked by Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibra-
the triangle) is seen. About 8 seconds later, a typical V wave tions: horizontal = 1 second, vertical = 50 flY.
occurs (horizontal arrow), closely followed by several other V

Vertex Waves Figure 14.15 shows the emergence of V waves in the early
phase of stage II sleep.
Also referred to as V waves or vertex sharp transients, this V waves are bilaterally synchronous and essentially sym-
feature of the EEG is most prominent in stage II sleep. The metrical on the two sides, although some shifting asym-
waves are aptly named, as their focus lies at Cz, the vertex. metries are not uncommon. Thus, the amplitude may be
When the waves are oflarge amplitude -100 IlV and larger somewhat higher on one side at one time, and then higher
is not uncommon - they also are picked up in the C3 and on the other side at another time. The waves can assume a
C4 electrodes. Their fields frequently spread to the fron- variety of different forms, as will be seen in Fig. 14.16.
tocentral regions and sometimes even extend to the parie- Sometimes they appear as sharp waves, and at other times
tal areas. V waves usually are diphasic, but occasionally they fit the definition of spikes. The particular morphology
may be triphasic as well; the initial deflection is negative, has no clinical significance. As mentioned later in this sec-
and this is followed by a lower-amplitude, positive phase. tion, a V wave may be followed by a sleep spindle.
Features of the EEG During Drowsiness and Sleep in Adults 115

F7 Fp1

Fp1 Fp2 ~~-,.....".,......--..-~"""

Fp2 Fa

F7 F3

F3 Fz

Fz F4

F4 Fa

T3 C3

C3 Cz

Cz C4

C4 T4

T5 P3

P3 pz

pz P4

P4T6~

T5 01

01 02
1_-
Figure 14.16. Three different forms of V waves. At the left, the triphasic wave, the initial negative deflection of which fits the
thick arrow indicates a diphasic sharp wave of moderate ampli- definition of a spike. Filters: low frequency = 1 Hz, high fre-
tude; in the center, a high-amplitude diphasic sharp wave is quency = 70 Hz. Calibrations: horizontal = 1 second, vertical =
shown; at the right, the thin arrow points to a high amplitude 50 ~v.
116 14. The Normal EEG

591
F7 FpI

Fp1Fp2

Fp2 Fa

F7 F3

F3 Fz

Fz F4
-----
F4 Fa

T3 C3

C3 Cz

Cz C4

C4 T4

T5 P3

P3 pz

pz P4

P4 T6

T5 01

01 02
1-
02 T6

Figure 14.17. Stage II sleep showing an F wave (opposing arrows) have their focus at Cz. Filters: low frequency = 1 Hz, high fre-
and several V waves (single arrows). Note that the focus of the F quency = 70 Hz. Calibrations: horizontal = 1 second, vertical =
wave is in the frontal region at the midline, while the V waves 100 ~v.

F Waves or Frontal Waves ilar to the V wave. The K complex is a slow-wave trans-
ient, it is commonly diphasic, and amplitude is gener-
Occasionally, a sharp transient not unlike a V wave appears
ally a maximum at the vertex. This is a large-ampli-
in the frontal regions at the midline without a correspond-
tude wave, with amplitudes running as high as several
ing wave present at the vertex (Fig. 14.17). Such transients
hundred microvolts. A sleep spindle (see below) may
are sometimes referred to as F waves. Their amplitude is
immediately follow or be associated with the K com-
usually less than 100 IN. V waves and F waves have the
plex. As seen in Fig. 14.18, a K complex may last for
same significance; they are normal features of the EEG
nearly a second; but at times, the duration can be some-
during stage II sleep.
what longer. K complexes can occur apparently spon-
taneously. They also can occur in response to sudden
K Complex sensory stimulation such as an unexpected, loud noise in
This is yet another feature of stage II sleep that is sim- the EEG laboratory.
Features of the EEG During Drowsiness and Sleep in Adults lli

F7 Fp1

Fp1Fp2

Fp2 FB

F7 F3

F3 Fz

Fz F4

F4 FB

T3 C3

C3 Cz

Cz C4

C4 T4
11
T5 P3
13 13
P3 pz
.. ..
pz P4

P4 T6 "
16

T5 01
11

01 02
.. 1_-
02 T6
Figure 14.18. Stage II sleep showing a K complex between the ous POSTS also seen in the tracing. Filters: low frequency =
solid arrows. Amplitude of the wave appears to be larger in the Hz, high frequency = 70 Hz. Calibrations: horizontal =
frontal than in the central region; duration is markedly longer second, vertical = .'50 11 V.
than a typical \' wave. Open arrows point to some of the numer-
118 14. The Normal EEG

~1~2--~----~~----~~----~~~~~~~~--~~~~~~----~~~­

~F8 --~~----~--~--------~~~~~--~~~~~~~~~~~~~__~~

F7 F3

F3 Fz

Fz F4

F4 F8

T3 C3

C3Cz

Cz C4

C4 T4

13
P3 pz

I~

P4 T6

T5 01

11 1_-
02 T6

Figure 14.19. Stage II sleep in which a sleep spindle (vertical spindle also accompanies the V wave. The sleep spindles are
closed arrow), a V wave (horizontal arrow), and POSTS (vertical widely distributed, but appear to be of higher amplitude in the
open arrow points to one of the POSTS) are all present in the frontocentral regions. Filters: low frequency = 1 Hz, high fre-
same recording. The sleep spindle has a frequency of about 14 quency = 70 Hz. Calibrations: horizontal = 1 second, vertical =
Hz and an amplitude of approximately 50 IlV. Note that a sleep 50 1lY.

Sleep Spindles amplitude in the central regions, as is seen in Fig. 14.19,

but sometimes an anterior dominance is noted instead
(Fig. 14.20). Sleep spindles in adults should be bilaterally
These are bursts of very rhythmic activity at 11 to 15 Hz synchronous and essentially symmetrical. However, it is
that are seen in stage II and in the early phase of stage III not unusual to observe some shifting asymmetries in
sleep. Duration and amplitude are both variable; ampli- which amplitude is alternately somewhat higher on one
tude is generally less than 50 J.1V but occasionally may side, and then higher on the other during the course of the
exceed 100 J.1 V. Sleep spindles generally occur in recording. Sleep spindles are sometimes preceded by a V
widespread distribution. Commonly, they are of higher wave, as may be observed in Fig. 14.20.
Features of the EEG During Drowsiness and Sleep in Adults 119

T5 01

1_-

Figure 14.20. Sleep spindles and V waves in stage II sleep. The wave that is directly followed by a sleep spindle. Filters: low fre-
sleep spindles in the tracing appear to have their highest ampli- quency = 1 Hz. high frequency = 70 Hz. Calibrations: horizon-
tudes in the frontal region (thick arrows). sometimes attaining tal = 1 second. vertical = 50 11V.
amplitudes greater than 100 11V. The thin arrow points to a V
120 14. The Normal EEG

F3 Fz

Fz F4

F4 Fa

T3 C3

C3 Cz

Cz C4

C4 T4

T5 P3
13 13
P3 pz
14
pz P4

P4 T6 '"
16

T5 01
17

01 02
I. I. 1_-
02 T6
Figure 14.21. Stage II sleep showing POSTS, a number of which tive relative to the voltages at other areas. Filters: low frequency
are indicated by the arrows. These sharp transients commonly = 1 Hz, high frequency = 70 Hz. Calibrations: horizontal = 1
occur in runs as seen in the figure. The phase reversals apparent second, vertical = 50 11V.
in the bottom three channels indicate that the POSTS are posi-

POSTS Amplitude differences as large as 60% may be seen and

are considered to be normal. This, also, can sometimes
This very descriptive acronym stands for positive occipital
make their distinction from a focus of abnormal, sharp-
sharp transients of sleep. These transients, which do look
wave activity difficult.
somewhat like the posts of a fence, are seen in stage II
sleep. They occur over the occipital regions on either side,
being positive relative to other areas. POSTS occur singly The EEG in Deeper Stages of Sleep
or, more commonly, in runs; sometimes as many as four or
five may be seen in a single second. Figure 14.21 is typical In a routine clinical EEG, the sleep recording is normally
of their appearance. Whereas amplitudes are usually 50 limited to tracings of stages I and II sleep only. When
~V or less, POSTS may attain amplitudes in excess of 100 deeper stages of sleep are observed, the person is usually
~V, as seen in Fig. 14.22. Note in this figure that the aroused. In most cases, recordings from the deeper stages
POSTS are very sharp indeed and in some instances would of sleep are oflittle diagnostic value. Nevertheless, it is use-
fit the definition of a spike. For this reason it is important ful in a general text to mention briefly the other stages of
that they not be mistaken for a focus of abnormal activity. sleep so that the reader will be able to recognize them and
POSTS are often bilaterally synchronous. At the same distinguish them from stages I and II. The term slow-wave
time they are commonly asymmetrical on the two sides. sleep is used to denote stages III and IV.
The EEG in Deeper Stages of Sleep 121

Fp1 F7

T3 T5 -Ay-'J'VV'w_/--0~'~~ .,,-,,-,'.J-~i,'N\/'.·'.v .";'~..: ...-- ,",'.' '~"'INVv\'i"'-f''''"'''''~'r~'""''t''/-fv~~~

, ,
T5 01 ~\,.JlJV'J'1fVV\;1rJvV\n/1\/IAYv~/~~

Fp2 F8

T4 T6 ~,jIM",-",~J"'./ij\~~t'~""/'\"A~/'''N~V~}~!~iv/~~
" , ,,
T6 02~!/F~r//frJrVVl!~~}~~
Fp1 F3 ~,~~~~~.~~~~-v~~

F3 C3

C3P3~~~'f.,
,"
P3 01 ~ /lNl/lrJ\l'wrJ\J'/\rl /r/VV'"'V"l/\t,Mr,J'{"",~'c~
if ll

C4 P4 ,, ,
~r'#""';--'~./v'ww..,,"·r-A~"v-v~'"""r-J".""_""ItJ"'

P4 02 ~(~rfl~v0N)ltJ'r'r/tj;wJM~~
Fz Cz
1_-

Figure 14.22. Stage II sleep in which numerous, high-amplitude sleep spindles, another feature of stage II sleep. The channel at
POSTS are present. A number of these sharp transients are indi- the bottom shows the ECG. Filters: low frequency = 1 Hz, high
cated by arrowheads. Note that some of the POSTS are very frequency = 70 Hz. Calibrations: horizontal = 1 second, vertical
sharp, indeed, and look like spikes. The double arrows point to = .50 ~v.
122 14. The Normal EEG

F7 Av
t
~
T3

T5

F8

T4

T6

Fp1

F3

C3

P3

01
Fp2

F4

C4

P4

02

Fz

Figure 14.23. Stage III sleep. The solid arrows point to some of dIes. The channel at the bottom shows an ECG. Filters: low fre-
the rhythmic delta waves, which in stage III sleep constitute quency = 1 Hz, high frequency = 70 Hz. Calibrations: horizon-
more than 20% of the record. Open arrows indicate sleep spin- tal = 1 second, vertical = 100!1V.

Stage III the deeper stages of sleep, has amplitudes in excess of 100
J.1 V. In stage III sleep, delta activity comprises more than
This stage is characterized by a background that consists of 20% of the record. Occasionally, a few sleep spindles are
irregular and semirhythmic theta activity mixed with mixed in with this activity. These tend to disappear as the
mostly rhythmic delta activity, i.e., activity of frequencies amount of time spent in stage III sleep increases. Figure
less than 4 Hz. The delta activity, which is the hallmark of 14.23 shows a segment of stage III sleep.
The EEG in Deeper Stages of Sleep 123

F7 Av
t
T3

T5 ~

Fa
T4

T6

Fp1

F3

C3

P3

01

Fp2

F4

C4

P4

02

Figure 14.24. Stage IV sleep. The arrows point to rhythmic, high excess of 300 Il V. Filters: low frequency = 1 Hz, high frequency
amplitude delta waves, which in stage IV sleep constitute more = 70 Hz. Calibrations: horizontal = 1 second, vertical = 150
than 50% of the record. Some of the waves have amplitudes in 1lV.

Stage IV activity, which may show amplitudes of 300 Il V or greater,

comprises more than 50% of the recording during stage IV
This is a deeper stage of sleep. The EEG consists of high- sleep. Sleep spindles disappear during this stage. Figure
amplitude, rhythmic theta and delta activity. The delta 14.24 is a short recording of stage IV sleep.
124 14. The Normal EEG

FS-T4

~-~ ---~~--------~~.--------------~-----~--~~~~~-------,-'-------------­
~-~ ----------------~--~~~~~
F~~----------------~--~~~~~~~~--~~~~~~~--~~~--~~~~~--

~-~----------------------~------~----~~----~---------~.--------~

~-~~------~----~--~~~~~~

C3-~ ~ ~ ___
, ~~
____
F3-C3 --.-------~--_.r.....,..."""" ~,.,..r"""""';V"''"'"\o.__-~..........._____..-'''-....._../'''''.........
__ __ ______ __
~,....-.---~ ___ ~-
--------''_'I'''''-..--
_________--.______
~~~

~~ ~HFro~_--~.~.~__________--~_~~------____•___~._._~~~_~--___________•__._~~.________
LF 1Hz
F7-T3 ___-.-----:r--_ _ _~_~,..,.,,"_".,.......,.,,----"'-wJ"'\
T3-T5 _~_IOO_II_Y_I_~_~~_~~~______........ ,.,.--,,-v-__"'-~_~_ _""""~_'-"~~_ _ _ __

Oz-O! ..... - ...... ... •• .......,......."" .......... "'.041, .... ..,. ..... '

Figure 14.25. The EEG in REM sleep. The tracing includes absence of chin muscle activity in channel 3. The EEG consists
recordings of vertical (channell) and horizontal (channel 2) eye mostly oflow-amplitude beta activity in diffuse distribution. Note
movements and muscle activity from the chin (channel 3). The the compressed time scale. (Reprinted from Matsuo F, Gaskin JA:
frontal pole to frontal derivations on both sides (Fp2-F4 and Unexpected REM sleep episodes in standard EEG laboratory
Fpl-F3) show a cluster of saw tooth waves (underlined) that initi- recording. Am] EEG Technol 1986; 26:33-40, by permission of
ate an episode of REMs seen in channels 1 and 2. Note the authors and publisher.)

REM Sleep weeks, and months of life. From the standpoint of technol-
ogy, special montages are needed in taking a neonate's
The EEG during rapid eye movement (REM) sleep is strik- EEG. In dealing with the EEG in neonates and young
ingly different from the tracings seen in the other stages of infants, therefore, the reader should consult the special-
sleep. The background is paradoxically similar to that ized texts that are available for guidance in these matters.
observed during wakefulness with the eyes open. Figure Nevertheless, in the routine practice of clinical electro-
14.25 shows a segment of recording obtained while the encephalography, children often need to be tested. This
subject was in REM sleep. It documents the presence of section, therefore, is meant to serve as an introduction to
REMs that are the distinguishing feature of this interesting the EEG in children. The material, however, is limited to a
stage of sleep. Such recordings are of special importance in sampling of the major differences that are seen between
polysomnography, particularly for the diagnosis of condi- the EEGs of children and adults.
tions like narcolepsy. The interested reader should consult
the specialized texts that are available as well as the period-
icalliterature for more information about REM sleep and Waking Activity
its clinical significance. The most striking difference that meets the eye in EEGs
from awake children is the character of the posterior dom-
inant rhythm. Generally speaking, the posterior dominant
Age-Related Differences: The EEG in rhythm is slower and of higher amplitude in children than
Relation to Maturation in adults. Insofar as frequency is concerned, the posterior
dominant rhythm in many young children does not even
It is impossible in an elementary, general text of this kind qualify as an alpha rhythm. Thus, frequency may be less
to cover the wide range of differences that the EEG dis- than the 8-Hz lower limit that defines the alpha rhythm.
plays during the course of growth and development. Partic- This will be apparent from a glance of Fig. 14.26, where
ularly extensive are the differences evident in the first days, the posterior dominant rhythm is only 6 to 7 Hz in the
 Age-Related Differences: The EEG in Relation to Maturation 125

100924 103854 020

Fp1 F7

F7 T3 V"'''-'~"","''''V\I'' ~_""'f'J"""\ ......~ , ......

T3 T5

Fp2 Fa .........~........_I'-J"'v--..,.......,.--_____-'"

Fa T4

T4 T6 ___V~_"'I\I

T602~~

Fp1 F3 ........___ ..-..,..,....,('<0.../'_-..-....-..................

F3 C3 """-.--v"'v/'.jV-'V"If"v"'-v-..-'\../'-/"......--v-.-.,rv'\,

C3 P3 ",,",-r-vl.J'v-

P3 01

Fp2 F4 '--"'-V'o~

P402

4yrs 6-7Hz 1_- 10yrs a-9Hz 1_- 13yrs 11Hz 1_-

Figure 14.26. Changes in frequency of the posterior dominant of the waves in the 4-year-old child. Filters: low frequency =
rhythm with age during growth and development. Subjects' eyes Hz, high frequency = 70 Hz. Calibrations: horizontal = 1
were closed. Note that between the ages of 4 and 13 years, fre- second, vertical = 50 ltv.
quency increases by about 5 Hz. Note also the higher amplitude

4-year-old child. In younger children, it is even slower (Fig. posterior dominant rhythm fit the definition of alpha
14,30). Nevertheless, such activity is, indeed, the posterior rhythm? At what age should it have a frequency of at least
dominant rhythm as it occurs most prominently in the 8 Hz? Unfortunately, the question cannot be answered
posterior regions and attenuates with eye opening. with absolute certainty because the posterior dominant
The tracing from the lO-year-old child in Fig. 14.26 rhythm shows a great deal of variability in normal chil-
shows a posterior dominant rhythm of 8 to 9 Hz. The fre- dren. However, a convenient rule of thumb is that it should
quency of the waves in this child's tracing satisfies the defi- be at least 8 Hz by 8 years of age. This conservative rule
nition of alpha. Note in the case of the 13-year-old child, is based on the finding that more than 95% of normal
the posterior dominant rhythm has reached 11 Hz. In 8-year-old children have a posterior dominant rhythm of
other words, age and the frequency of this feature of the 8 Hz or more.
EEG are directly related. But at what age should a child's
 12E Age-Related Differences: The EEG in Relation to Maturation

019018 019019
Fp1 F7

T3 T5 ~NJ~~V/'<l""""f\rf-.r.~"v~/W\[v'-'".fIJiI,,,,,/,,\;J"'-I.J.f""'r-Irfd{'JN""'f~AfJ'J\~NV"'J\flr~~

T5 01 ~A~MV~N~NvWf!/V\i~:"td!Av\,~~VJ\jj\\~}SJ'V\I~\Mt:i"if''iVI{Y:tl:NI!V'-~'-vj\:!!W~Y;'f'NJv'N::,~,\~!{.IJ\"'~I\W!I'I~illd~jM!NJIf\!~~W~Wtt1N~
Fp2 Fa

T4 T6 t''''Jv.'''fJ\~N.;J~'t''f..wtt~~'-rIN''''I[/.Jf';WJ:;N'i~·'''''!~I/V\I/lrI'll''IVtN~'ft'.,f""~f'Vy.f"'thl\~t'-'A",)"""'.~~'~

T6 02 f~mNtW~:N~rfNf.~!JNir,Jlrt'ttv~rJif!!f[NtNd~rMJJtli['U[Nir!t;'!IWi r~fI~fr~N}frrtflr;fl'ff~1N\NN~1NJ~~
Fp1 F3 VV'~~,,~

C3 P3 ~WNJv~~.~~\fI~~'MvVWv"'4.,r'!\\""";.rv'--rw--.~Vv~

P3 01 1Mm~wt~~~~~JN~~~~\w~~:j~'MVi'¥I'~\h,~\~\~~\\V:"l\\r:\~~V:\~\~~v\i~\V\VJlf·VjV\''''V''~~\\~V\A\<W·''''u\~~\;rtf~vM~~~~~

C4 P4 ~\rv.fW'f'V'-./'~'i/VNVI.~,~~

P4 02 ,~tw~~!\{\fvMi\[~[\!rf~¥;}~~~t~{(I~\r\v1~rt~~~Vl\}Jv\~~~~~~~~~NN~~
Figure 14.27. Posterior slow waves of youth in a lO-year-old child. dominant rhythm of about 10.5 Hz. Filters: low frequency = 1
The subject's eyes were closed. Arrowheads mark some of the Hz, high frequency = 70 Hz. Calibrations: horizontal =
more prominent waves that are seen to fuse with the posterior second, vertical = 50 IlV.

Tracings taken from the posterior derivations show asymmetrical as well. Posterior slow waves of youth attenu-
other differences in normal children. The most notable ate or block with eye opening and disappear during drowsi-
are the slow transients that have been termed posterior ness, along with the alpha rhythm. They frequently are
slow waves of youth. They are recorded with the person's accentuated and/or become more numerous during hyper-
eyes closed. Figure 14.27 illustrates these interesting ventilation.
waves, which are shaped like the sails of a schooner. Note Although only traces of theta activity are seen in the
that these waves are fused with the waves of the posterior waking EEGs of normal young adults, frontocentral and
dominant rhythm with which they are intermixed; their central theta activity is quite common in normal children.
amplitude is similar to the amplitude .of the alpha rhythm. Figure 14.28 shows evidence of significant amounts of
Although Fig. 14.27 shows them to be present only in the frontocentral theta activity in a normal 5 year old. At times,
occipital region, at times they also are seen in the post- paroxysmal bursts of rhythmic theta activity-mostly in
temporal and parietal regions. frontal and frontocentral regions-are also seen in chil-
Posterior slow waves of youth occur most commonly in dren. Such activity, which may have amplitudes in excess
the EEGs of children 8 to 14 years of age. They may be of 100 IlV, should not be confused with similar activity-
present in younger children and in older adolescents, but termed hypnagogic hypersynchrony- that occurs during
they are rare in normal adults over 21 years of age. drowsiness. The significance of the high-amplitude, rhyth-
Although these waves are frequently bilaterally synchron- mic theta activity sometimes present in wakefulness is
ous and symmetrical. they may be asynchronous and/or unknown; however, it is not considered to be abnormal.
Age-Related Differences: The EEG in Relation to Maturation 127

FP1F7~

T5 01 ~~fNtfV'f'JMf~~l'4~~~AW~WVv\J~
Fp2 Fa

Fa T4

T4 T6 ~A·"V''\Jrvfr,.r~''v~~Vv''''~

T6 02 ~~J-JyN,rl,v'-/VVV.M

Fp1 F3

P301~~~AJV\~~~~~
Fp2 F4
+

Fz

Figure 14.28. Frontocentral theta activity (solid arrows) in a rhythm is variable and has a range of about 7.5 to 10 Hz. Such
5-year-old child. The subject's eyes were closed. The tracing also variability is not uncommon in children. Filters: low frequency =
contains a number of posterior slow waves of youth, some of 1 Hz, high frequency = 70 Hz. Calibrations: horizontal = 1
which are marked by open arrows. The posterior dominant second, vertical = 100 1lV.
128 14. The Normal EEG

F7 FpI

FplFp2

Fp2 Fa

F7 F3

F3 Fz

Fz F4

C4 T4

PzP4

P4 T6
10
T5 01
11
01 02 ""-J'~-""'""--"'-"-,,,\fv.......""-'---v''-.N vv'-""· ....... ,.........,......,.~...--v"-"o.rv-''"'''-'...,-.--''''''''-..f\-.''-''''I\

02T6

Figure 14.29. Hypnagogic hypersynchrony in a 4-year-old child. throughout. This is a normal finding. Filters: low frequency = 1
The arrows indicate three bursts of paroxysmal, high-amplitude Hz, high frequency = 70 Hz. Calibrations: horizontal = 1
rhythmic activity at about 4 Hz. The subject's eyes were closed second, vertical = 100 ).LV.

Activity During Drowsiness and Sleep widespread distribution but is more commonly centrally
or frontocentrally dominant (see Fig. 14.29). When inter-
Although drowsiness in normal children, like drowsiness mixed with fast activity that may be present at the same
in adults, is often signaled by an overall reduction in time, these paroxysmal bursts may falsely give the impres-
amplitude of the background, the EEG in the majority of sion of spike and wave discharges. Despite their ominous
infants 3 to 11 months old and a significant percentage appearance, these waves are a normal feature of the EEG
of children 1 to 6 years of age displays a unique, high- in childhood.
amplitude phenomenon during drowsiness. This phe- As already mentioned, hypnagogic hypersynchrony can
nomenon is known as hypnagogic hypersynchrony. It con- occur in the very young. Figure 14.30 shows hypnagogic
sists of paroxysmal, high-amplitude bursts of slow (3 to hypersynchrony alternating with a wakeful pattern in a
6 Hz), very rhythmic activity. Having amplitudes some- 14-month-old baby. The phenomenon is a normal feature
times in excess of 300 ~ Y, this activity may occur in up to age 15 years, but is rarely seen after 11 years.
Age-Related Differences: The EEG in Relation to Maturation 129

Fp1 F7

F7 T3

T3 T5

T5 01

Fp2 Fa Vl,.J"'v<' vv<c..r--~""-,,, - ,--~~

Fa T4 JJ\~Vv\NJV\NfJ\j~\;VV\~F\~\JvN~j\j~WVVV~
T4 T6 ~\~,!INJ~~~'I(\~~
T6 02 ~vV\~J;rvVV"hJ::~j\A'J:fVvtfJy~~
Fp1 F3 , n,:'
~
F3
VV\AAJv
C3 P3
II

P3 01 ~iV"V'-,\}J:~I'~f)/'" :J 1JVVJ\J
Fp2 F4 ~\j
F4 C4 ~VVlNvJlrV'lf\4Mi1~~V'lI(-+~
C4 P4 ~vJ\~~\ :
P4 02 fVIj\}/\.fvAVvVJ'I.JvJW\",~.AjJv0J ;
Figure 14.30. Alternating wakeful and drowsy states in a slower activity (hypnagogic hypersynchrony). Following the brief
14-month-old child. The child's eyes were closed throughout the drowsy episode, the posterior dominant rhythm returns (under-
recording. At the left, a posterior dominant rhythm of about 4 to lined and marked by arrows). Filters: low frequency = 1 liz, high
·L5 Hz (underlined and marked by arrows) is present. This is frequency = 70 Hz. Calibrations: horizontal = 1 second, vertical
replaced by a burst of generalized, high-amplitude, somewhat = ,50 1lV.
130 14. The Normal EEG

F7 T3

,
T5 01 ~~~~~~--~~~~~~-·~~~~~~~~~,v~~~~~~~~~. "
Fp2 Fa

Fa T4 ~.~~~\~~~~,~~~~~--~~~~~~~~~~~~~~--~~~~~~

Fp1 F3
a
~~~~~~~~~~lwN~~~~~~~~~~~~~~~--~~~w~~~/V~v-~~~~

, bJ
F3 C3~~~~t~~~~~~~~~~~~~~~~~~~~~NM~~.~~~~~~

C3 P3 '"V'~"\,I\V----''yIo/''tIII\I~~'''-'\/V~''''''~--'''''''VJ"'y-.r-.l'''v-lvrw'''fY\,~rJ''v'-~.-.;v..rv'IJ.,J"''V------V-V,¥\

P3 01

Fp2 F4

F4 C4

C4 P4
I. 16

P402

Fz Cz ~
1-
Cz pz

Figure 14.31. Asynchronous sleep spindles in a l-year-old child. several POSTS that are also features of stage II sleep. Filters: low
The arrows at "a" mark sleep spindles on left and right sides that frequency = 1 Hz, high frequency = 70 Hz. Calibrations:
are asynchronous. At "b" the spindles are partly synchronous. The horizontal = 1 second, vertical = 100 1lV.
arrows at "c" point to vertex waves, and the arrowheads note

The principal features of stage II sleep taken up earlier features of sleep in young children may be found by con-
in our discussion of the adult EEG are generally applicable sulting the more advanced, specialized texts that are
to children as well. Some of these features emerge and available.
acquire adult characteristics very early in life; others Arousal from sleep in children may show a phenomenon
acquire adult characteristics somewhat later. The sleep that is akin to hypnagogic hypersynchrony that was dis-
spindle is an example of the latter. Thus, sleep spindles, cussed earlier. This phenomenon or feature of the EEG in
which first appear at 6 to 8 weeks postterm, are bilaterally childhood is termed hypnopompic hypersynchrony, and a
asynchronous and continue to show some asynchrony dur- sample is shown in the tracing of Fig. 14.32. This figure
ing the first year of life (Fig. 14.31). Some degree of asyn- nicely illustrates the rapid shifts that may occur from sleep
chrony may continue and is not considered to be abnormal to drowsiness, and back again to sleep.
until age 2 to 2.5 years. Details concerning the other EEG
Age-Related Differences: The EEG in Relation to Maturation 131

-..... 1TTTTTT'...I1TTrTTf"'.....T'Tl T1 H' .....·TnlTlTl _ nn,.,11" ;1111TtTr-... ' 11 TnT f'_',nTTlrL'TTT1TTTT-.....- -.......T~JTTTTTTTTUTIT1

Fp1 F7 ~--.,.,-.rw~'VV~~v""'..r-'\i+.JVvvf\~~
F7 T3 f"I},"'J\vJ--~~~~r1\ :,J\
T3 T5 ~~-/'---v-V~v/A-v-f.rA.-J~-vv\~y~JV~
T5 01 ~~~~FVvJV\/~~
Fp2 Fa ~-fIf'.~~~,~~..;vJ\jV\.J"\Jv~
: Aro~al :
Fa T4 r\V\,jw,..v-/'\V'....;vv,..vvv.f"Vv"~,~"'~\J"r"J\..,0'V' :
• '\ 1 •

T4 T6 ~~~'~-~~/It\)~JV\cJ~~
T6 02 ~~-~~"r\~"--J~~/~~

Figure 14,32. Arousal from sleep in an 8-year-old child. The stage nopompic hypersynchrony. Filters: low frequency = 1 Hz, high
II sleep - note the sleep spindles at arrows - is interrupted by a frequency = 70 Hz. Calibrations: horizontal = 1 second, vertical
paroxysmal burst of high-amplitude, rhythmic slow activity last- = 150 1lY.
ing about 4 seconds. The paroxysmal activity is known as hyp-
132 14. The Normal EEG

1'1' 1'1 r I 11111111" 1111111" I 1'1111111' 11111111" 11'11' 'I" I r 111111 r 11111' III' 111111111' 11'111111' 1111' 1111' 111111111' 11111' II r 111111' II'
I I

Fp1 F7. ... 'w' "~ ... . . . . . . . "". w....

F7 T3
T3 T5
T5 01
Fp2 Fa
Fa T4
T4 T6

Fp1 F3"'_1I ~ ....... i'~ "" I'" ~ .."W" • .......... ~w..••• or • .,,'J', ..... _~JoAL,___~""_,,,,.OI'V"''''''_'''

F3 C3~~~~__~~~~~~~~~~~~~MW~~~~~MW~_ _~_ _~M

C3 P3~~~~~~~~~~~~~__~~~~~~MM~~~~~~~__~_

P3 01~~~~~~~~~~~~ ____~~______~~~~~~~__~__~_
Fp2 F4 ~·~.~____~__.~~~w~~.~_~~~-.~~~~__
·~,~~.__~'__~~·~.~~~~~~w~~~_.~~~~ _____.~.·__~~.~~
F4 C4 ____~__~__~__~~~~~~~~~--~~~~~~~__~~~__~
C4 P4~~~~~~~~~~~MM~~ __~~~~MW~~~~____~~~__~_
P4 02~~~~~~~~~~N#~~~~~~~~~~~~~~~__~~~~~v#
Fz CZ~~~~~~~~~~~~~~WM~~~~~~~~~~~MM~~W-~~~__

Cz Pz MN~~~~~~MM~~~MM~~~~~~~~ww~~~~~~I~-----w-~~~~

Figure 14.33. Awake, eyes-closed EEG in a 60-year-old person. temporal slOWing on the left side. Filters: low frequency = 1 Hz,
The open arrows indicate the posterior dominant rhythm at high frequency = 70 Hz. Calibrations: horizontal = 1 second,
about 10Hz. The two solid arrows point to a single episode of vertical = 50 ~ V.

Age-Related Differences: The EEG consist of one to three or four waves. Figure 14.33 shows a
single episode of very mild temporal slowing in a 60 year
in Old Age old. Such rare instances of temporal slowing at this age are
considered to be normal.
In older individuals the episodes become more frequent
There is some evidence that suggests that the frequency of and may be of higher amplitude. Figures 14.34 and 14.35,
the posterior dominant rhythm declines with advancing which are tracings from apparently asymptomatic 78 and
age. The clinical value of this finding is somewhat dubious, 80 year olds, respectively, illustrate this. Considering the
however, since thoroughly healthy individuals in advanced patient's advanced age, the EEG in Fig. 14.34 may be con-
years may not show such a change. Moreover, since EEG sidered normal, assuming of course that such episodes of
slowing is commonly associated with dementia, it is not temporal slowing occur only occasionally throughout the
clear whether the reported slowing is an accompaniment record. The EEG in Fig. 14.35, however, illustrates a bor-
of normal aging or an early sign of pathology. derline case. Interpretation in such cases is difficult, and,
The same problem obtains in the case of temporal slow at best, the final judgment concerning normality or abnor-
activity, which is undoubtedly the feature most commonly mality is tenuous. Obviously, more research into the EEG
observed in the EEGs of older persons. This activity is of old age is needed before such clinical judgments can be
most often seen in the temporal region on the left side, but sharpened.
it also may occur intermittently or simultaneously on both The normal EEG in hyperventilation and in photic
sides. 1emporal slow activity is episodic, irregular, and stimulation is dis(,lIssPc\ in thp chapter on activation proce-
mostly of low amplitude (20 to 30 ~V). The episodes may dures.
Age-Related Differences: The EEG in Old Age 133

Fp1 F7--____~~__~~__~____~__~~~~--~---
F7 T3~~--~--------~~--~~~--~~-----

T3 T5 --~~~.~.~.~.~~----~.M.~---V--~~~~~~.~.vv~--~~

T5 01 ~--~~~~----~~------~~~~~~~----~
Fp2 Fa ~~~""-J'-~~-----"""""'~---""""""~"""-v.r-"v-""'--'~~_~

Fa T4
T4 T6 ~~~~~~~.~.~.~.~~~~--~

T6 02 ~_~"""",~~~~~_~v'-..~~_________" - -

Fp1 F3 ~~'-.y""'""''''''''''''''''''''''-'""","""",,,,-ri''N>~
F3 C3"""'-",.......,......."""""''''"'''''''''''''.......--~........"........'--''''''''I~v~
C3 P3 __~~~'-~____~_~~~~~~~~~~__~_
P3 01 ~-M~~~~~_ _ _ _~_ _~~~~~~~~_ _~~

Awake
Fp2 F4 ~--..-"""" ____~~___-v-~""'"'""'.........- __.-A-J"""""~"'VW.......--.,.........,..,..

F4 C4 ~.....vv.r-v-JI"""""""""'_"""""-""\,...,...."""""-.,-.p.""""''-I.A.,f~..,.,..-.......".''"'''--_

C4 P4 ~~~~~~~~~~~~~~~~~~~__~~_

P4 02~ __~~~~~__~~~~~~~~~~~~~~_
1-

~~----------------------~~---------------------

Figure 14.34. Temporal slowing on both sides in a 78-year-old Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibra-
person. The arrowheads indicate three episodes of slowing, tions: horizontal = 1 second, vertical = 50 ~v.
which consist of irregular, low-amplitude theta and delta activity.
134 14. The Normal EEG

T3 T5

T5 01

Fa T4

T4 T6 ~.,...,.,.vVV'oV'.A'"

T6 02 ~...-..-"'I'yJ'W'-t-..
Awake

C3 P3~~~~~__~~~~~~~__~~~~~~__~~_~~_

P3 01 12

13

F4 C4 """'"....-...I~r.I\I'l\n!UI
..
C4 P4
16
1_-

Figure 14.3.5. Temporal slowing in an 80-year-old person. The frequency = 70 Hz. Calibrations: horizontal = 1 second, vertical
slowing (arrows) is more severe and more extensive on the left = SO ~v.
side, where it extends to F7. Filters: low frequency = 1 Hz, high
Chapter 15
Abnormal EEG Patterns

A perusal of Chapter 13, Introduction to EEG Reading, information, EEG interpretation and judgments of nor-
should convince the reader that a thorough knowledge of mality or abnormality may be of doubtful clinical value.
the different normal and abnormal EEG patterns is essen- The abnormal EEG patterns may be broadly divided
tial to gain proficiency in EEG interpretation. This into five categories: abnormalities of the background
knowledge can be gained only by going over a large num- rhythms, abnormal sleep patterns, focal or generalized
ber of EEG tracings and becoming familiar with the vari- abnormal slow activity, paroxysmal epileptogenic abnor-
ous physiological and pathological alterations commonly malities, and abnormal periodic paroxysmal patterns. It
and uncommonly seen in the EEG. This chapter, there- should be obvious, of course, that there is some overlap
fore, takes up the descriptive features of individual abnor- between some of the categories; thus, for example, there
mal EEG patterns and briefly mentions their significance. are times when slow activity may appear in paroxysms.
Later, in a chapter on clinical correlations (Chapter 21),
the specific disorders of the central nervous system (CNS)
that lead to the abnormal EEG patterns are highlighted, Abnormalities of the Background
and the EEG is discussed from the standpoint of its diag- Rhythms
nostic and prognostic implications. The reader will note
some amount of repetition and overlap between the two Alternations in rate, rhythm, distribution, symmetry,
chapters; but this, hopefully, will serve to reinforce the amplitude, or reactivity of the background activity may
important aspects of the topic. occur during various CNS disorders. The alterations may
involve one or more of the physiological rhythms, namely,
the alpha, beta, or mu rhythms.
General Considerations
Alpha Rhythm
The term abnormal EEG patterns refers to patterns of
activity that are judged to be outside the normal range. In the awake adult an alpha rhythm ofless than 8 Hz is ab-
These judgments are based on current knowledge accum- normal. Since a number of clinical conditions can produce
ulated through the evaluation of EEGs oflarge numbers of slowing of the alpha rhythm, the slowing is considered a
neurologically normal individuals of different ages by nonspecific abnormality. Thus, bilateral slowing of the
many electroencephalographers. In the chapter on the alpha rhythm may be seen in metabolic, toxic, and infec-
normal EEG (Chapter 14), we saw that one needs to take tious encephalopathies of diverse etiology. It is also a con-
into account the age and state of the patient to correctly sistent finding in patients with dementia irrespective of
interpret a particular EEG pattern. Thus, for example, a the underlying cause. The degree of slowing often parallels
pattern that is normal for a drowsy patient may be consi- alteration in the mental status of the patient. It should also
dered abnormal if the patient is fully awake. Similarly, a be noted that the alpha rhythm slows down in patients with
pattern that is normal for a neonate may be quite abnormal hypothyroidism and can become normal when a euthyroid
for an older child. These examples underscore the impor- state results from adequate treatment. Figure 15.1 shows
tance of the technologist's notations regarding age and an "alpha rhythm" of 7 Hz in an adult patient who was
state of the patient on the EEG tracing. Without such found to have toxic serum levels of phenytoin.
136 15. Abnormal EEG Patterns
.
,
522
Fp1F7~~~,",~

F7 T3 _____''''""-

T5 01

Fp2 Fa

Fa T4

Awake
T6 02~ __~~~~______M-~~~·~~~~~VN~~~~__~~~~~~~~~

P3 01

Fp2 F4

C4 P4 ~~~~WN~~~~~~~~~~--~~~--~~~~~~~~~~~~~~~~--

P4 02 ~N'v'''~t''VV\f~.I{v''V'/J'~~j'tvvtrfWvvvJ'Jvv~.f'rN'-''~~

1_-

Figure 15.1. Posterior dominant rhythm of i Hz in a 30-year-old high frequency = iO Hz. Calibrations: horizontal 1 second,
epileptic with a serum phenytoin level of 24 Ilg/mL. The arrows vertical = 50 Il V.
point to lateral eye movements. Filters: low frequency = 1 Hz,

Asymmetrical slowing of the alpha rhythm with a consis- bral cortex - especially in the posterior regions - or that
tent difference of greater than 1.5 Hz between the two cause accumulation of fluid between the brain and the
sides is abnormal and should suggest the possibility of a recording electrode, as in the case of subdural or epidural
lesion on the slower side. However, such a finding does not hematoma and scalp edema, may lead to attenuation of
necessarily indicate the presence of a lesion in the occipi- alpha rhythm ipsilaterally.
tal lobe itself; asymmetrical slowing of the alpha rhythm is Abnormalities may also occur in the distribution of the
known to occur even with lesions that are more anteriorly alpha rhythm. Normally, it is distributed in the occipital,
located. parietal, and, to some extent, posterior temporal areas;
A difference in amplitude of the alpha rhythm between however, activity may occur over widespread areas, includ-
the two sides is considered significant if it exceeds 50 %. ing the frontal regions. Such an alpha pattern is abnormal
Since the alpha rhythm in most normal persons is of higher and is seen in alpha coma, which may result from a number
amplitude on the right side, even a 35% decrease on the of conditions such as brain stem infarct or cerebral anoxia,
right side may be significant. Figure 15.2 shows a marked or it may be a drug effect. In this context, it is worth reiter-
amplitude asymmetry of the alpha rhythm, which is of ating that an alpha rhythm may appear spuriously in the
much lower amplitude on the right side compared with the frontal areas when using an average potential reference
left. The computed tomography (Cf) scan showed a right- (see Fig. 14.3, Chapter 14), and this should not be mis-
sided subdural hematoma. Lesions that involve the cere- taken for an alpha coma pattern.
Abnormalities of the Background Rhythms 137

Fp1 F7

F7 T3

T3 T5

T501

Fa T4

1_-
Figure 15.2. Asymmetrical and slow (7-7.5 Hz) alpha rhythm in a 14-year-old adolescent having a right-sided subdural hematoma.
Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibrations: horizontal = 1 second, vertical = 50 !lV.

Fp1 F3
..
,
860

F3 C3

C3 P3

P3 01
Unresponsive
Fp2 F4

F4 C4

C4 P4

P4 02

Fz Cz

Cz pz
1_-

Figure 15.3. Alpha coma pattern in a 60-year-old patient suffer- tion did not evoke any change in the alpha rhythm. Filters: low
ing from a lower brain stem infarct. The patient was unresponsive frequency = 1 Hz, high frequency = 70 Hz. Calibrations:
to verbal commands and external stimuli. Note the diffusely dis- horizontal = 1 second, vertical = 50!lV.
tributed alpha rhythm. Passive eye opening and external stimula-

Lack of reactivity to eye opening is a Significant finding, The reader will find further discussion on the alpha coma
particularly if consistently demonstrated on one side. This pattern in Chapter 21.
may be an early finding in occipital lobe lesions. A total A focal increase in amplitude and/or frequency of the
lack of reactivity of the alpha rhythm is a feature that may alpha rhythm is known to occur in patients with structural
be seen in alpha coma, particularly in cases of diffuse lesions, particularly tumors; but this is quite an uncommon
cerebral anoxia due to cardiac arrest. In the case of alpha finding. Remember that a localized increase in amplitude
coma resulting from lower brain stem lesions, there may be may also be seen over a skull defect.
some degree of reactivity. This contrasts with findings in Asymmetrical photic driving in the alpha frequency
psychogenic unresponsiveness where reactivity to eye band, if quite consistent, may be abnormal. Rarely, the
opening is normal. Figure 15.3 shows an alpha coma pat- driving may be more pronounced on the side of the lesion.
tern in a 60-year-old patient with a low brain stem infarct. See Chapter 16 for further details on photic stimulation.
138 15. Abnormal EEG Patterns

""'" """'" '"'''''' """'" """'" """'" """",'m""" "",,,~~a,,,,,,,,, "'"''''

------------------------------------------~wr---------------------------------------

Figure 1.5.4. Asymmetry of beta activity in a 30-year-old patient thin arrows point to rhythmic beta activity, which has a higher
with a subdural hematoma on the left side. The tracing also shows amplitude on the right side (double arrows). Filters: low fre-
a marked attenuation of slow background activity on the left ljlIency = I Hz, high frequency = 70 Hz. Calibrations: horizon-
(open arrows) as compared with the right side (solid arrows). The tal = 1 second, \'ertical = .50 11V.

Beta Activity An excessive amount of beta activity, especially in

diffuse distribution, is usually a drug effect. Many drugs
Both attenuation and accentuation of beta activity may be can produce an increase in beta activity; barbiturates are
abnormal. Beta attenuation is often seen in patients with the most common. Figure 15.5 shows a marked increase in
destructive cortical lesions or when there is an abnormal beta activity in a patient who is on barbiturates for epil-
collection of fluid between the cortex and the recording epsy. A focal increase in beta activity is most often seen
electrodes. Figure 15.4, which is from a patient with a left over a skull defect. The skull bones act as high-frequency
subdural hematoma, shows attenuation of alpha as well as filters; in the presence of a bone defect, therefore, beta
beta activity on that side. activity may become quite prominent.
Abnormalities of the Background Rhythms 139

Fp2 F8 Ar'M~~I",,\~'fIJ/~lIiIrV'I/~lv1IfII/'~~~"'I/I~, ~1"'V'I\~1IMI/o. ...J//'f'WIfI"".I""..A.Jt/

F7 F3 ~~JvJ~_,!4'11~H·.AI~itlll/H~IIIIII~l#lk¥I~ft..¥/"~~~

F3 Fz ,Jj~".'1J'\~""'I'/'Wi'';\;.'/M'IIHI~V''1:\\~r\\I/I-'';IW.I''I",I,......ri'flh·~~''''\!i~;'V,'1'~'I,~'.\W~)'\\\W'''\'INM~\~~..",,Jt~'r>o/tvIl\\~(rt.~~
Fz F4 Y:~~"WI'/II~}""""~~J;!,'i.'J¥,~11ir\III~:<ii~::,':i!...,Jr:,'1II,~.,,V!,',~tN~::'~!i~'I/II'~'~'.~'!"'/:I~I')t\':~'\:"!'Ifo\"'II,.rt\Jr~J,~I"'.'f,;kl!'I\WI.iI~IrJiw);nJIMI~I~
\'~I.JI II~'\'N'~(:JlIIt,\~ "'\,JI'1"I~\J.~', 111~,'\',,11,,1:,
"f ~ 11111!~A'ri\·~}./1 . . )1 .,'" "I ;,. L"""-,
.._ ............. "),.......11 L~"'.J........-"......
lll...~ ,1 r.~'" t;;"l/~,'r+J.'it~.\,.,~. ':'J......\\~,~:.~;,~;I;'I(Wia:.},II....lt}.\.~~· ·.V.yt·,I;\~lj~W W"'i~;fNNtrl· ....-I'·V·.. · - ¥"r'N \f"'~ r ....... 'f'.,...-v'
fl."
F4 F8 ~!r;"II~.Vli'~1
I,ll 'II I ' ,;1 ',I', I', 'Ii il I : \' I 1

T3 C3 1~~iff~".,..\·\\\"V"'\/\,.~lt'"""~~,?o.J/,.,.,~,~,\.;.\\~,~ICIl,~,\!,\,;',\v..",\·''''~rI',~,,,~~:;,,,,,,,,\\\:;\\\''''.w-.,,~JV~f'''4~~~

T5 P3

P3 PZ
pz P4

P4 T6 ~~~fIIo,"fN."\\~\~'i"~iII{I\~-IW.~~"""J-"vI,-",\'I,.IJ.,~~~IJt..."/'.'M.,,,,,~~~{l

T501 ~11~·fU.""""'''

01 02

02 T6

Figure 15.5. Excessive beta activity in a 5-year-old child who is times forms obvious spindles. Filters: low frequency = 1 Hz, high
on phenobarbital for control of generalized seizures. Note the frequency = 70 Hz. Calibrations: horizontal = 1 second, vertical
diffusely distributed, high-amplitude beta activity that some- = 50 IlV
140 15. Abnormal EEG Patterns

F7 F3

F3 Fz

Fz F4

C3 Cz ~I../'Wt"'r~r \v("f.f\'~.r--v'l\.r-rV'<-/~~\/"''''/~·/lt,('vf'''''l.i\''
I
CzC4 ,j,~~

T5

P3 pz

pz P4

P4 T6

T5 01 ~-""~~~~v~~~,,,,~

01 02
1_-
02 T6
Figure 15.6. Focal increase in beta activity over the left midtem- in the homologous area on the right. Note the vertex wave.
poral and central areas in a patient with an underlying skull Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibra-
defect. The arrow at "a" points to prominent beta activity on the tions: horizontal = 1 second, vertical = 50 1lV.
left side, and the arrow at "b" indicates the lower amplitude beta

Figure 15.6 shows a focal increase in beta activity in lar increase in beta activity over the right frontal, central,
the left midtemporal and central areas in a patient with a and temporal areas in a patient who had previous cranial
skull defect from a craniotomy. Figure 15.7 shows a simi- surgery.
Abnormalities of the Background Rhythms 141

T5

Fa
T4 ~"'/'''''W'''I'"~,.JYI'\V'·JA::tv\••i,'I'tI.~N'''''·f'.'''·A:r'i.'.·,J.\jV'''W''''''·:t';\~Jr.'-tI'-··'I;'\'j\j:·"':"t'o.ti'lVitNJi.,V.JM8'r,}"t.,~';~A./f'~
T6
~~IJ~III"""'J*".rN<J',,-.j\/'''/''f/''~fv-.. '<i"~I./I.(.P~'N·/i}H'./'r~
Fp1 ~'vI\)~"'JV"'\./Vv"',/vv<'V~-\ "'\ 'J'--' \"~,/It)~I'0'V\f''1/''V !\.~\.~f\v;J\fl/'N\.A
F3 .A.~~'-.rvv~r,J'wv'-~~~~~~

01

Fp2 ~~'--I~""""""~·f"'<··,v.j'·'V"·/'-1·t"\/~--JO../V'~,Jl''''~~
F4 ~-<f:I"'~"-.Jw-Wfl(/'rN"'~~'-'vI'JI~;1J~\¥~~~~
+ + ~
C4
~~JI~~w/{"Wo\'''~r'~;J~NJWwJ\wrl' -r/VVI%..~~tJ
P4
~~
02

Fz I ~\r~YA{'I,~~
Cz Av

Figure 15.7. Increased amplitude of beta activity in the right old patient had a history of craniotomy. Filters: low frequency =
frontal, central (solid arrows) and temporal areas compared with I Hz, high frequency = 70 Hz. Calibrations: horizontal = I
the homologous areas on the left side (open arrows). The 40-year- second. vertical = 50 IlV.
142 IS. Abnormal EEG Patterns

Fp1 F7 .- 201 202

F7 T3

T5 01

Fp2 Fa

Fa T4

T6 02

Fp1 F3

P3 01

Fp2 F4

P402

Fz Cz

Cz pz
~~~~~--------....-.~~~~-------I-
, , . __ s - ; ' ':_ s _: ' , ~
Figure 15.8. Burst-suppression pattern in a patient who had indicate low-voltage theta activity that occurs during the bursts.
suffered from cerebral hypoxia following cardiopulmonary arrest. Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibra-
Areas marked "S" indicate epochs of suppression. Arrowheads tions: horizontal = 1 second, vertical = 50 1lV.

Mu Rhythm normal individuals the alpha rhythm is absent and the wak-
ing EEG may show mostly low amplitude, fast activity.
Asymmetry of the mu rhythm may not always be abnormal When the background activity in a tracing appears
as some degree of shifting asynchrony and asymmetry is greatly attenuated, the technician has to double-check a
well-known to occur in normal persons. However, if it is number of points. These include checking the impedance
consistently absent on one side but present on the other, of the electrodes, making sure that the amplifier sensitivity
the finding might suggest an abnormality on the side that settings are correct, and verifying that the cable from the
mu activity is absent. A consistent difference in the fre- jack box is indeed connected to the EEG machine. It
quency of mu activity between the two sides is also consi- should be recognized that when this cable is disconnected,
dered abnormal. Higher amplitude mu rhythm on one side the tracing may show some artifacts resulting from the
has been known to occur over skull defects. amplifier inputs being open; these artifacts could be mis-
taken for brain activity. When background activity is of
Other Abnormalities of Background Activity very low amplitude, it is necessary to record at a higher
sensitivity like 5, 3, or even 2 ~Vlmm. If no activity greater
Marked attenuation of background rhythms is abnormal, than 2 ~Vlmm is present in the tracing, the possibility of
whether it is generalized or localized. As mentioned in brain death (cerebral cortical death) may be considered if
Chapter 14, however, in a small percentage of otherwise the clinical picture warrants it; under such circumstances,
Abnormal Sleep Patterns 143

Fp1 F7 /'--

F7T3~

T3T5~~
T501""",-,~,--

Fp2 F8 ~--..r---...r--.....r---"'~/'--.f"--~~~-",---~_____--"-,-,-",,,,.../'-''-'-vr'V '-/'-.r_______....r-....-_~'Vv'~~_____...__.J""'__ _____...__""~

F8 T4

T4 T6 -----------...........
T602 __ ~~ ________ ~~~~ ____ ~- __ ~~~~ __ ~~~~~~~~ __ ~~~

Fp1 F3

F3 C3
C3 P3
P3 01
Fp2 F4
F4 C4 ~____Ar~_ _ _ _~~_ _ _ _-/--~~~~~r-~J'~~~~~~v'r---_~~~
____~____~~-r--

C4 P4 ~----,-

P4 02 __~~~----~~~~~~~~----~~~------/~~~r---~--~--~--~,~--~~
1-
______________________ --Jn~ _ _ _ _ _ __

Figure 15.9. Asymmetry of sleep spindles in an 8-year-old child in the homologous area. There is also a decrease in amplitude of
with left hemiplegia accompanying Sturge-Weber syndrome. A the background activity on the right side. Filters: low frequency
CT scan showed atrophy and gyml calcification involving the = 1 Hz, high frequency = 70 Hz. Calibrations: horizontal = 1
right side. The closed arrows point to a sleep spindle in the left second, vertical = 100 11V.
frontocentral area, and the open arrows show attenuated spindles

the EEG has to be taken according to specific guidelines asymmetry of sleep spindles in a patient with left hemiple-
stipulated by the American EEG Society (1986) for estab- gia accompanying Sturge-Weber syndrome. By contrast,
lishing electrocerebral silence. These include, among sleep spindles may appear with higher amplitude over a
other things, using double-distance electrode placements, skull defect.
documenting the effects of external stimulation, and The V waves may also be asymmetrical in amplitude.
recording at a sensitivity of 2 llV/mm. Figure 15.8 is an The presence of consistently asymmetrical V waves indi-
example of extreme suppression of electrical activity fol- cates a structural lesion, a subdural hematoma or effusion
lowing cerebral hypoxia. The only activity seen is very on the side with the lower amplitude. Sometimes the V
low amplitude theta, which occurs between the areas of waves may appear larger on the side of a skull defect.
suppression. Figure 15.10 shows asymmetrically large V waves on the
right side due to a skull defect.
Another group of sleep-pattern abnormalities includes
Abnormal Sleep Patterns disorders of sleep architecture. A person normally goes
through stages I and II sleep before the first phase of REM
Amplitude asymmetry of sleep spindles is suggestive of a sleep occurs, usually 90 minutes after the onset of sleep.
lesion on the side with the lower amplitude. This may hap- But the REM phase can occur at the onset of sleep, and
pen both in structural lesions and also when there is abnor- this abnormality is a feature of narcolepsy. Polysomno-
mal collection offluid between the brain and the recording graphic studies are needed to evaluate such sleep dis-
electrode, as in subdural hematoma. Figure 15.9 shows orders.
144 15. Abnormal EEG Patterns

636 631
Fp1 F7

F7 T3

T3 T5

T501~
•
F8T4~........"....................,....r

T4 T6

T6 02

Fp1 F3
left
F3 C3
L_
C3 P3

P3 01
I)
Fp2 F4
I)

F4 C4

C4 P4

P402

Fz Cz

Cz pz

Figure 15.10. Asymmetrical V wave and beta activity in a double arrows mark an epoch of breach rhythm. Small vertical
40-year-old patient with a skull defect on the right side. Note the arrows point to POSTS. Filters: low frequency = 1 Hz, high fre-
higher amplitude of the V wave on the right (R) as compared with quency = 70 Hz. Calibrations: horizontal = 1 second, vertical =
the left (L). The open arrows indicate the asymmetrical beta 50 !Lv.
activity, which is of higher amplitude on the right. The horizontal

Abnormal Slow Activity tude and/or frequency of such activity between the two
sides is considered abnormal.
The distinction between normality and abnormality is
less precise in the case of theta than delta activity. With
theta activity, asymmetries in amplitude and frequency
One of the commonest abnormalities in EEG is the occur- may be more Significant than the mere presence of the
rence of abnormal slow activity. It must be understood activity. This is due to the variable occurrence of theta
that certain forms of slow activity are entirely normal. activity in drowsiness and in the waking state of normal
These include the delta activity that occurs in stages III young and very old persons.
and IV sleep, the theta activity that is present in the back- Abnormal slow activity may occur either intermittently
ground activity of children during wakefulness, and also or more or less continuously, in which case it is termed
the delta activity that may be seen during hypervent- persistent. It can be generalized, focal, or lateralized. We
ilation. The presence of a consistent asymmetry in ampli- take these up in turn.
Abnormal Slow Activity 145

F7 Av ~~rv~,"'--'"'V""-J"-f\J/"'~"~~~
t
T3 ~A/'\.~~~~~'\

T5

Fa
T4 ~~ /',-,__-,/.._,-./V"\__A~\rv~~-->/",__-pr"",_~r\/~

T6 ~~"f'V~J\...,~~/~

Fp1 iv\Fv~~\~/'\j\~~~\~"~0'~~
F3 f\JV~~jv/\J\/~~"~-~./'-y~
C3 ~~~f\./J\.~J'-~'V~

P3~~~~~~

01

Fp2 ;;;\f~~\~~\~
F4 \r .
C4

P4

02

Fz A7\F~~J)

Figure 15.11. Frontal intermittent rhythmic delta activity the delta waves, thus confirming that the waves represent corti-
(FIRDA) in a 40-year-old patient with chronic renal failure. Note cal activity and not eye activity. The patient appeared to be con-
the 1.5- to 2-Hz frontally dominant rhythmic, high-amplitude fused during the recording. Filters: low frequency = 1 Hz, high
delta activity occurring in approximately 2-second epochs (dot- frequency = 70 Hz. Calibrations: horizontal = 1 second, vertical
ted lines). The bottom channel, which is an eye electrode = 50 ltv.
referred to the ipsilateral ear, shows activity that is in phase with

Generalized Intermittent Slow Activity Intermittent rhythmic delta activity is usually of high
amplitude; it stands out from the background and often
This is a common and easily identified abnormal EEG pat- has a frequency of 2 to 3 Hz. The component waves are
tern. It consists of intermittent rhythmic, usually mono- often sinusoidal or saw-toothed, and have a rapid up-
morphic, slow activity most commonly occurring in the stroke and slower downstroke. Each epoch of delta activity
delta frequency band. The acronym IRDA (intermittent may last from 1 to 3 seconds and may repeat every few
rhythmic delta activity) is often used for this pattern. The seconds. Both the frequency of occurrence of the epochs
activity is characteristically bilateral and synchronous, and their amplitude may increase during hyperventila-
showing frontal (FIRDA, see Fig. 15.11) or occipital domi- tion or drowsiness. Intermittent rhythmic delta activity
nance (OIRDA, see Fig. 15.12); rarely, it may be most is often attenuated by eye opening and other alerting
prominent over the temporal areas. The dominance seems stimuli. It may disappear during deeper stages of sleep,
to be age related, OIRDA being more common in children. but reappear during the REM stage. Since eye-movement
146 15. Abnormal EEG Patterns

Fp1 F7

Fp2 Fa ~~~~'''oA,/''''V'N'V'VV\

FaT4~~..!'~~v~
T4 T6 ~~J"~~~~~J\j;~ .......... ..
T6 02 ~"-vvrvvv~~~JV'V~\}V

C3 P3

Fp2 F4

F4

C4 P4

P402

Fz CZ ~/VV'~~M ~rl\ rJ 4'\.r--",jlMrAjVA /llVV"".Jif'f'\ ~. . .,. .'-~~

CZ pz ,nit'",," _ AA II Ii". "- J\__ .Md.f"/\v.., Mf\A (\ n"",rAJi./\ A AII J\ IWI..~A~ 0 ~~A"..rwv'IAI'\I\~~':::::::""""'..r'\JV\...

Figure 15.12. Occipital intermittent rhythmic delta activity epochs (dotted lines). Filters: low frequency = 1 Hz, high fre-
(OIRDA) in an 8-year-old child with aqueduct stenosis and ven- quency = 70 Hz. Calibrations: horizontal = 1 second, vertical =
tricular dilatation. Note the high-amplitude, posteriorly 50 ~v.
dominant 3- to 4-Hz delta activity occurring in 1- to 2-second

artifacts may resemble FIRDA, the technician should underlying cause rather than the increased pressure per
record the patient's eye movements by placing an elec- se. Further studies showed that it can occur in a large vari-
trode in the infraorbital area and connecting it together ety of conditions that affect the eNS, ranging from meta-
with the ipsilateral ear electrode to one channel of the bolic encephalopathy to localized mass lesions. At the
EEG machine. If the waveform recorded on this channel is present time, IRDA is considered to be a totally non-
in phase with the waveforms on the other channels, eye- specific abnormality reflecting disturbance in cerebral
movement artifacts are excluded. function as a result of diffuse encephalopathies of meta-
Although IRDA is easily identified, some difficulty bolic, toxic, infectious, or traumatic origin, or focal
arises with regard to its precise clinical correlation. It was encephalopathies such as cerebrovascular accidents, and
once believed that IRDA resulted from increased intra- intracranial tumors. In focal encephalopathies, FIRDA
cranial pressure. However, the observation that IRDA is may occur with higher amplitude on the side of the lesion,
not seen as a feature of benign increased intracranial ten- but this is not always a reliable finding. For this reason,
sion changed this concept; the IRDA may be related to the IRDA is considered to be of little localiZing value.
Abnormal Slow Activity 147

: • (! ~3
Fp1F7~~~~~~

F7T3~~~~~~~
:
: :
: :
:
"
T3T5~~~~...;.-~--~~~~~
'
' .
:
.
I
.
' :
.
--
T5 01 ~~...-v~-;~./'-V-~~~~~~~~

C4 P4~

P402
1_-
Fz Cz
----------------~~l_~~----------------.----------------------------~~~

Figure 15.13. Intermittent, left-sided delta activity (between the the right than the left side. Filters: low frequency = 1 Hz, high
dotted lines) and focal spike discharge at T3 (solid arrows) in a frequency = 70 Hz. Calibrations: horizontal = 1 second, vertical
50-year-old patient with a left temporal lobe glioma. The open = .50 I1V.
arrows point to sleep spindles that occur at higher amplitude on

Since IRDA was initially associated with the presence of Focal and Lateralized Intermittent
mass lesions is deep midline regions like the third ventri- Slow Activity
cle, the subfrontal regions, or the posterior cranial fossa,
the terms "distant rhythm" or "projected rhythm" have These abnormalities have the same features as generalized
been used. But this is no longer favored because there is intermittent delta activity except that they are limited to
little difference between the intermittent delta activity of one area or to one side of the brain. When consistently
such mass lesions and that resulting from diffuse encepha- present, such activity should arouse the suspicion of an
lopathies. underlying structural lesion (Fig. 15.13), although the
Intermittent rhythmic delta activity often accompanies correlation is not as consistent as in the case of persistent
decrements in mental status of the patient such as lack of polymorphic delta activity. The underlying cause may be a
attention, confusion, and obtundation. In focal lesions the mass lesion, trauma, or ischemia; or the activity may even
presence of IRDA also is often accompanied by such be a postictal phenomenon. Figure 15.14 is an example of
changes in mental status, suggesting that a diffuse cerebral lateralized intermittent rhythmic slow activity in a patient
dysfunction may be accompanying the focal lesion. with a subcortical infarct.
148 15. Abnormal EEG Patterns

"I
Fp1 F7

F7 T3
T3 T5

T5 01

Fp2 F8
F8 T4
; Arousal
T4 T6

T6 02
Fp1 F3

F3 C3
C3 P3

P3 01

Fp2 F4

F4 C4

C4 P4

P402
Fz Cz
Cz pz • •
......-
Figure 15.14. Lateralized intermittent rhythmic delta activity right side. Vertical arrows point to POSTS. Horizontal arrows
occurring during both sleep and wakefulness in a 50-year-old point to V waves. Filters: low frequency = 1 Hz, high frequency
patient with a right subcortical infarct. Note the 2- to 3-Hz rhyth- = 70 Hz. Calibrations: horizontal = 1 second, vertical = 501lY.
mic delta activity occurring intermittently (dotted lines) on the

Persistent Slow Activity polymorphic delta activity (PDA) usually has a frequency
of 0.5 to 3 Hz, and the waveforms change in frequency,
Persistent slow activity is usually in the delta frequency amplitude, and morphology (shape) in a continuous
band. It may occur as monomorphic, rhythmic waves or as fashion. In other words, no two succeeding waves appear to
polymorphic, arrhythmic waves. It may be generalized, be quite alike. Polymorphic delta activity tends to show no
lateralized, or focal. In the case of the rhythmic delta reactivity to stimulation and persists both during wakeful-
activity, the waveforms resemble each other and maintain ness and sleep. Even hyperventilation may not have much
a somewhat constant frequency. On the other hand, the effect on PDA.
Abnormal Slow Activity 149

" , " """'" '"'''''' """'" """'" """'" """" 88." " '" ""'"'' ""'"'' """'" """'" ""'"'' """'" """'" "'"'''' ,II ,

Fp1F7~~

F7 T3
T3 T5
T501
Fp2 FB

T602
Fp1 F3
F3 C3
C3 P3 /Y'-..~-..r.r~_

P301
Fp2 F4
F4 C4
C4 P4
P402
Fz Cz
Cz pz

Figure 15.15. Diffuse slow activity in a 20-year-old patient diagnosis of viral encephalitis was made. Note the muscle
presenting with fever, headache and vomiting. Although the artifacts in most of the channels. Filters: low frequency = 1 Hz,
patient appeared awake at the time of recording, he was confused high frequency = 70 Hz. Calibrations: horizontal = 1 second,
and disoriented. Cerebrospinal fluid showed normal glucose, vertical = 50 IlV.
with 48 lymphocytes and 6 polymorphs per cubic millimeter. A

Figure 15.15 is an example of generalized, persistent there are certain situations where the cr may be negative
slow activity consisting of a mixture of theta and delta as, for example, in recent infarct or contusion. For the exact
activity that is both rhythmic and arrhythmic. The patient localization of the lesion, the frequency of the waveform is
was diagnosed to have viral encephalitis. Figure 15.16 a better indicator than the amplitude; thus, the area show-
shows the occurrence of polymorphic delta activity on the ing the slowest activity is the most likely site of the lesion.
right side in a patient with an underlying glioma. When The amplitude is often higher in the immediately sur-
the delta activity is of very low amplitude and of very low rounding areas. Sometimes the tracing from the area over-
frequency, it may easily be overlooked. The technician lying a destructive lesion may be of such low amplitude
should be vigilant about such patterns as he/she can carry that it appears to be flat, whereas the surrounding areas
out certain maneuvers - such as changing the low- show large amplitude PDA.
frequency-filter setting to 0.3 to 0.1 Hz, and/or using a slow It is now believed that deafferentation of the cortex by a
paper speed - to make the slow activity more prominent. lesion that interrupts the thalamocortical afferents is the
Continuous PDA, especially when it is focal, is indica- underlying mechanism in the genesis of PDA. Polymor-
tive of an underlying structural lesion unless proved other- phic delta activity is most likely to be associated with acute
wise. The finding often correlates well with other tests like destructive lesions, but it gives no clues as to the specific
the CT scan and Magnetic resonance imaging (MRI), but etiology of the lesion.
150 15. Abnormal EEG Patterns

•~1 704
Fp1 F7

F7 T3

T501~.

Fp2 Fa

Fa T4 ~.~~~.~

I I
T4 T6

T6 02

Fp1 F3

F3 C3

C3 P3

P3 01

Fp2 F4

F4 C4

C4 P4

P402

1_-
Cz pz

Figure 15.16. Polymorphic delta activity on the right side in a where none is present. The slanted arrows point to some of the
patient with a large glioma. The open arrows indicate an intact delta transients. Filters: low frequency = 1 Hz, high frequency
alpha rhythm on the left side, which contrasts with the right side = 70 Hz. Calibrations: horizontal = 1 second, vertical = 501lV.
Paroxysmal Epileptogenic Abnormalities 151

P3 01

Fp2 F4 •• ••
F4 C4

Fz Cz

Cz
1_-

Figure 15.17. A lateralized mixture of rhythmic and polymorphic arrows point to some of the delta waves. Filters: low frequency =
delta activity in a 50-year-old patient with a right frontal infarct 1 Hz, high frequency = 70 Hz. Calibrations: horizontal = 1
involving both the cortex and the subcortical areas. The vertical second, vertical = 50 J.lV

Sometimes PDA and rhythmic delta activity may coexist patterns, on the other hand, include a number of patterns
in the same tracing as in Fig. 15.17. This may conceivably that are known to accompany clinical seizures.
depend on different degrees of involvement of the cortical
and subcortical areas by the lesion.
Epileptiform Discharges
Spike Discharges
Paroxysmal Epileptogenic Abnormalities A spike discharge is defined as a transient that is clearly
distinguished from the background activity, has a pointed
The term paroxysmal refers to activity that shows changes
peak at a paper speed of 30 mm/s, and has a duration of 20
in amplitude or frequency, which occur with sudden onset
to 70 ms; it usually is surface negative and is of variable
and offset, and that stands out distinctly from the ongoing
amplitude (Chatrian CE, Bergamini L, Dondey M et aI,
background activity. While certain patterns of activity
1974). Ordinarily, a spike stands out from the background
such as V waves, lambda activity, and hypnagogic hyper-
activity because of its distinct appearance and/or size; but
synchrony are also paroxysmal by this definition, the term
when the amplitude is small, it may be difficult to identify,
is usually reserved for abnormal activity. Broadly speaking,
especially when there is a considerable amount of beta
paroxysmal abnormalities may be classified into epilepto-
activity in the background. This is one reason why it is bet-
genic abnormalities and periodic patterns. Abnormal peri-
ter to avoid using medications for promoting sleep when
odic paroxysmal patterns are taken up later in the chapter.
taking an EEC, as most such drugs cause diffuse beta
There has been considerable debate about the correct
activity. As mentioned earlier in Chapter 14, use of the
terminology to use in describing patterns of activity that
IS-Hz high-frequency filter should also be avoided
are associated with seizure disorders. The term epilepto-
because the sharp-pointed character of a spike is lost and
genic abnormalities is usually used to indicate those tran-
its amplitude becomes markedly attenuated. When this
sients or patterns of activity that are known to have a
happens, a spike may be indistinguishable from beta
definite correlation with seizure disorders. These abnor-
activity or muscle artifacts.
malities may be further classified into interictal (in
between seizures) phenomena and ictal (during a seizure)
phenomena. The interictal phenomena, which are termed
Sharp-wave Discharges
epileptiform patterns or discharges, include spike dis- A sharp wave is defined as a transient that clearly stands
charges and sharp waves with or without accompanying out from the background activity, has a pointed peak at a
slow waves. The ictal discharges or e1ectrographic seizure paper speed of30 mm/s, and has a duration of70 to 200 ms;
152 15. Abnormal EEG Patterns

amplitude is variable, and like spikes, sharp waves usually occur in the waking EEG, one is dealing with midline
are surface negative (Chatrian GE, Bergamini L, Dondey spikes. Sometimes ECG artifacts may look like spikes;
M, et ai, 1974). Since there is little distinction between when this happens, it is essential to record the ECG simul-
spikes and sharp waves from the standpoint of their poten- taneously on the same chart with the EEG. It is important
tial for epileptogenicity, the terms are used interchangea- to keep in mind that genuine spike discharges are often fol-
bly in the ensuing discussion. lowed by slow waves, whereas ECG and other artifacts are
not. The role of activation procedures in enhancing epilep-
Polyspikes or Multispikes tiform activity is discussed in Chapter 16.
Spike discharges are usually monophasic or biphasic. The
term multispike is used when several spikes comprise a Parameters of Epileptiform Discharges
single waveform. As with spike discharges, multispike dis-
The size of the spike is only rarely a reliable criterion for
charges may also be accompanied by slow waves.
the assessment of its epileptogenicity. There are but few
such examples. Thus, it may be noted that small sharp
Spike and Wave Complexes spikes (see later in this chapter) which are of low ampli-
Another epileptiform pattern is the spike-wave complex or tude and of very short duration do not usually have any
sharp and slow-wave complex. Each spike or sharp wave is correlation with seizure disorders. Similarly, the very small
accompanied by a slow wave, usually of the same polarity. spikes present in 6-Hz spike and wave discharges (phan-
Spike-wave complexes may take different forms, the classi- tom spike and wave) are also known to have little relevance
cal example being the three per second spike-wave com- from the point of view of epileptogenicity. It is important in
plex of absence seizures. this context to remember that amplitude is not a reliable
measure in bipolar chains (Chapter 11).
Polarity of a spike may provide clues as to its potential
Detection of Epileptiform Discharges for epileptogenicity. Thus, negative spikes are more com-
When a spike or sharp-wave discharge is noted in an EEG, mon by far than positive spikes and are more significant
the following questions should go through the minds of from the point of view of epileptogenicity. Positive spikes
both technician and electoencepalographer. Is it indeed a like the 14- and 6-Hz bursts that are taken up later are con-
spike, or is it an artifact? Where is it coming from? Is it a sidered to be of little clinical significance. On the other
physiological phenomenon that looks like a spike such as a hand, positive Rolandic spikes, which are seen in prema-
V wave, a POSTS, or lambda wave? ture infants and are known to occur in association with
To ensure that a particular transient is a true spike, and intraventricular or periventricular hemorrhage, are an
to establish its exact location, the technician may have to exception.
carry out certain maneuvers. Figure 15.18 shows what Location of a spike is also relevant from the standpoint of
looks like a spike discharge that is confined to a single elec- correlation with seizure disorders. Thus, Rolandic spikes
trode, namely, F4. It does not appear to have an electrical and spikes arising from the occipital areas are said to be
field, as it is not seen in C4 or F8. Such being the case, one less well correlated with seizure disorders than anterior
needs to prove that it is not simply an electrode artifact. To temporal or frontal spikes.
do this, an additional electrode is placed between the
incriminated one and its neighbor so that any electrical
Pathophysiology of Spike Generation
field associated with the transient can be documented. In
this instance, the electrode at F4' showed a similar tran- Epileptiform activity is believed to be the result of paroxys-
sient, thereby confirming that the transient observed in F4 mal discharges occurring synchronously in a large aggre-
is not an electrode artifact. gate of neurons. Such discharges could conceivably give
When a spike is noted in an electrode at the end of a rise to spikes or sharp waves in the scalp EEG, particularly
bipolar chain, the localization can be made easier if the if the neuronal aggregate happened to be in an area
montage is revised and the electrode is placed in the mid- covered by the field of the electrode and the dipole hap-
dle of the chain. As explained in the chapter on localiza- pened to be in the appropriate orientation. At the cellular
tion, it is sometimes useful to combine bipolar and referen- level the corresponding abnormality consists of bursts of
tial recording on the same page to show the exact spontaneous depolarization of the neuronal membrane,
localization of a spike more accurately (see Fig. 12.l1). If which are termed paroxysmal depolarization shifts.
there is a question as to whether a particular discharge is Although a paroxysmal depularizatiun shift is considered
an abnormal spike or a normal transient, other measures to be the cellular hallmark of a hyperexcitable neuron, the
are necessary. For example, midline spikes may be con- hypersynchrony (several neurons discharging simultane-
fused with V waves, so a waking record is essential ously) probably results from abnormalities occurring at
whenever midline spikes are suspected. If the spikes do the synaptic level. In other words, abnormalities of the
Paroxysmal Epileptogenic Abnormalities 153

T3 T5

Fp2F8~~~~

II
F8T4~~~~ I I

T4 T6 \!V'\_rvJ'V'~~~~/\fvV\I~1"\"'0"'J'-,

T602~A~"v~

I I
I j

Fp2F4~~~

F4C4~~~ F4' F4

C4 P4 F4 C4

P402~

FzCz~~~
CZPz~~
~---,--~
--,------------
Figure 1.5.18. Focal spike discharges from the midfrontal area trical field and, hence, is not an electrode artifact. The horizontal
on the right side. In the left half of the tracing, a standard bi- arrows show a phase reversal that places the focus between F4'
polar montage was used. Horizontal arrows denote spike dis- and F4, but closer to F4. Use of the additional electrode should
charges with a phase reversal at F4. As there was no definite be a standard procedure when spikes or sharp waves appear
electrical field for the spike, the technician added another elec- restricted to a single electrode. Filters: low frequency ~ 1 Hz,
trode (F4) between Fp2 and F4. The revised montage in the high frequency = 70 Hz. Calibrations: horizontal = 1 second,
right half of the tracing shows that the spike has a definite elec- vertical = 50 Il V.

neuronal membrane, as well as abnormalities at the syn- Focal Epileptiform Abnormalities

apses that lead to hypersynchronization, are necessary for
the production of interictal as well as ictal discharges. Interictal focal epileptiform abnormalities manifest them-
Let us now consider some of the commonly seen interic- selves as focal spikes or sharp waves, or focal spike and
tal epileptiform abnormalities. Broadly speaking, two wave discharges. Their presence helps to confirm the clini-
types of interictal patterns are noted, namely, focal abnor- cal suspicion of a focal or partial seizure. In the following,
malities and generalized abnormalities. we consider some of the common focal spike patterns.
154 15. Abnormal EEG Patterns

~1~2 ____ ~ ______ ~~~~~~ ________ ~~ ________________ ~~ __ ~ __________

~Fa ____~~__~~~~~~~--~--~~~----~--~~--~~~--~~--~--~~

F3 Fz

Fz F4

F4 Fa

T3 C3 ~""..r-Y"I

C3 Cz

Cz C4

C4 T4

T5 P3 -....,,-...,-....-,/

pz P4

P4 T6

T5 01
1_-
01 02 ~~~r~~~~_~~~v~~~~~~v-~~~·~~/~~~/~

Figure 1.5.19. Focal spikes arising independently from C3 and The open arrow points to a V wave. Filters: low frequency =
C4 during sleep in a lO-year-old girl with benign Rolandic Hz, high frequency = 70 Hz. Calibrations: horizontal =
epilepsy. The closed arrows point to phase reversals at C3 and C4. second, vertical = 50 !Lv.

Rolandic spikes, which are distinguished by their oc- patients with cerebral palsy and other central motor dys-
currence over C3 and/or C4, may be unilateral, bilateral, function, their presence does not always indicate a seizure
or may shift from side to side. They may be seen simul- disorder. Central and midtemporal spikes are correlated
taneously over the parietal area (centroparietal spikes) with benign Rolandic epilepsy of childhood in about two
or in the midtemporal area (centromidtemporal or Syl- out of three cases. The reader will find more detail about
vian spikes) as well. Rolandic spikes are easily distin- this in Chapter 21 on clinical correlations. Again, it must
guished by their location and by their tendency to be be pointed out that such spikes may be seen occasionally
greatly accentuated during drowsiness and sleep. They in asymptomatic children. Figures 15.19 and 15.20 are ex-
are usually abundant in number. A slow wave usually amples of Rolandic spikes occurring in patients with be-
comes after the spike. Rolandic spikes should be distin- nign Rolandic epilepsy of childhood, each showing slightly
guished from asymmetrical V waves and from isolated different spike morphology. Figure 15.21 shows spikes
components of the mu rhythm. from the left central area in a patient with focal seizures
Since centroparietal spikes occur in a number of occurring several months following a left cerebral infarct.
Paroxysmal Epileptogenic Abnormalities 155

661
F7F~~~~~~~~~ __~~~~~~~~~~~~~~~~~~~

Fp2 Fa

F3 Fz

Fz F4

F4 Fa

T3 C3
.
C3 Cz

Cz C4

C4 T4

P3 pz

pz P4

P4 T6

T5 01

01 02
1-
02 T6

Figure 15.20. Rolandic spikes occurring in clusters during sleep. old child with nocturnal seizures characterized by facial twitch-
Open arrows point to spikes arising from C4, and closed arrows ing and salivation. Filters: low frequency = 1 Hz, high frequency
point to independent spikes from C3. The patient was a 12-year- = 70 Hz. Calibrations: horizontal = 1 second, vertical = 150 Jly.
156 15. Abnormal EEG Patterns

.. "............................. ~ ......n3........................... ,............................ .

Fp1 F7 "------------
F7 T3
T3 T5 ~'V'--~~~~"-V"'-or-..---~"V"'J'-"-~~___

T5 01 -V~~~~--_ _~~~~~~~.~~~.~~~~~~~_ _~~~_~

Fp2 F8

F8 T4
T4 T6
T6 02~~~~~~~~~~~~~~~~~~~~~ __~~
Fp1 Fa
F3 C3~~~~~~~~-~~~~~~.~AM,~\~~~~~~~~~
•
C3 P3 -"-~...---'
P3 01 ~~~,A .~--.J....v.~-..A..-----\, ~~ .--"-'-~ ~
Fp2 F4 ______~____~~~~~..__"-~-~~.r__'~ ____ ~~'_"_ _ _.../

F4 C4 ~--"---~-- ~~
C4 P4 ~·~.r--.A~_
P402
Fz Cz~----~~~~~~~~--~~~--~~ __~~~~~

-------------------------------------------~w-------------

Figure 15.21. Left-sided Rolandic spikes in a 60-year-old woman occurring at C3. The CT scan showed an old infarct in the left
with recent onset of focal motor seizures involving the right upper frontoparietal area. Filters: low frequency = 1 Hz, high frequency
extremity and face. The horizontal arrows point to phase reversals '" 70 Hz. Calibrations: horizontal = 1 second, vertical = 50IlV.
Paroxysmal Epileptogenic Abnormalities 157
119
F7 ~1~'~W~~~v~'~~_~~iO~~

~1 A1

~2 A2~~~~~--~~~~~~~~~~--~~~~~~~~~~~~~~--~--

F7 T3

T3 T5 ~\}fv1/'V\~~1vM~"V\WN\fIJV\

T5 01 ~Nf\MAV'~vWNv~~
Fa T4

T4 T6

T6 02 IWIJWIJI,fV'v-'I!WVlf\f\

C3 P3

1-

Figure 15,22. Mesiotemporal spikes arising from the left side sphenoidal wing meningioma. Note that the spikes are hardly
(horizontal arrows) picked up by nasopharyngeal lead Pg] in a visible in the scalp recordings. Filters: low frequency = 1 Hz,
40-year-old man with a history of recurrent episodes of confusion high frequency = 70 Hz. Calibrations: horizontal = 1 second,
lasting for about five minutes - preceded, each time, by an appar- vertical = 50 Jl V.
ent smell of gasoline. The CT scan was suggestive of a medial

Spikes that are localized to the inferior frontal (F7, F8) Detection of spikes arising from the inferior and medial
and/or anterior temporal electrodes (T1, T2) are also aspects of the temporal lobe is facilitated by the use of
potentiated by drowsiness and sleep. These discharges are nasopharyngeal or sphenoidal electrodes. Figure 15.22
highly correlated with complex partial epilepsy. They shows an example of spike discharges appearing in the
should not be confused with small sharp spikes, wicket nasopharyngeal electrodes almost exclusively.
spikes, or sharply pointed theta activity of drowsiness.
158 15. Abnormal EEG Patterns

Fp1 Fp2

Fp2 Fa .
F7 F3

F3 Fz

Fz F4

F4F8

T3 C3

C3 Cz

Cz C4

C4 T4

T5 P3

P3 pz

pz P4

P4 T6

T5 01

01 02

02T6

Figure 15.23. Focal spike and wave discharge arising from the patient was asleep, as shown by the vertex waves and sleep spin-
left frontopolar area in a I O-year-old boy who developed general- dles. A cr scan showed bilateral contusion in the frontal pole.
ized tonic-clonic seizures 3 months following a head injury. The Filters: low frequency = 1 Hz. high frequency = 70 Hz. Calibra-
arrow points to the slow-wave component of the discharge. The tions: horizontal = I second. vertical = 50 ltv.

Spikes originating in the frontal lobe (Figs. 15.18, 15.23) plex partial or secondarily generalized seizures. These
are also considered to have high epileptogenicity. Such discharges should be distinguished from asynchronous
patients may present with adversive, focal motor, com- F waves, small sharp spikes, and frontalis muscle spikes.
Paroxysmal Epileptogenic Abnormalities 159

F7 Fp1

Fp1 Fp2

Fp2 Fa

F7 F3

F3 Fz ~

Fz F4

F4 Fa

T3 C3

C3 Cz

Cz C4

C4 T4
~
T5 P3
13
P3 pz

pz P4

P4 T6

T5 01

01 02

02 T6

Figure 15.24. Focal spikes from left occipital area in a 5-year-old low frequency = 1 Hz, high frequency = 70 Hz. Calibrations:
girl with a history of a single generalized seizure. The horizontal horizontal = 1 second, vertical = 50 J.1y.
arrows point to phase reversals occurring at 01 and P3. Filters:

Occiptai spikes (Fig. 15.24), which are most often seen duration and have a "needle-like" appearance are known
in young children, may be unilateral or bilateral; they to occur in children with early-onset blindness. When
are not generally considered to be highly epileptogenic. occipital spikes occur in later age groups, they are often
Since they are seen at the end of the chain of electrodes epileptogenic and may be associated with an underlying
in the longitudinal bipolar montage, a coronal chain in- structural disorder. They are also known to occur in
cluding 01 and 02 may bring them out better. They have children with a form of benign focal epilepsy similar to
to be distinguished from lambda waves, lambdoid activity, Rolandic epilepsy.
and "spiky" alpha. Occipital spikes that are of very short
160 15. Abnormal EEG Patterns

700
Fp1 F7

F7 T3 ~~~~____~,rv,

T3 T5 ~.Iv#,,·""'/~!I\II.,Ny.('V'"!I'J.,.,.N>.\.#.;\,'"...,J\w""'f"'.IJ'I/'~~·"'M"w0v"...t.f'.N\,.('I"'VM~.ytA~-{y...('~

T501 ~~rfNNI:
Fp2 Fa

Fa T4

T4 T6

T6 02

Fp1 F3

F3 C3

C3 P3

P3 01

Fp2 F4

F4 C4

C4 P4
<0>

Figure 15.25. Midline spikes in an awake 6-year-old child with the oCcipital area, which indicates that the patient was awake.
recent onset of tonic-clonic seizures. The horizontal arrows point Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibra-
to two of the spikes, which show phase reversals at Cz. The verti- tions: horizontal = 1 second, vertical = 50 ~v.
cal open arrow marks the start of a continuing alpha rhythm over

Midline spikes (Figs. 15.25, 15.26) may easily be missed have a more restricted electrical field than V waves, which
unless coronal montages, including the midline elec- have fields that extend into the parasagittal areas. These
trodes (Fz, Cz, and pz) are used. They should be distin- discharges may occur in patients with seizures character-
guished from V waves, but the distinction may be difficult ized by posturing of the arms, adversive movements,
unless they are also seen in a waking record. Midline spikes speech arrest, and sometimes bladder dysfunction.
Paroxysmal Epileptogenic Abnormalities 161

J8l III
F7 Fp1

Fp1 Fp2

Fp2 Fa

F7 F3 'Vv,~-",

F3 Fz

Fz F4

F4 Fa

T3 C3

C3 Cz

Cz C4

C4 T4

T5 P3

pz P4

P4 T6

T5 01

0102

02 T6

Figure 15.26. Midline spikes arising during sleep from pz (thin 1 Hz, high frequency = 70 Hz. Calibrations: horizontal
arrows) in a 9-year-old child with generalized tonic-clonic sei- second, vertical = 200 Jl V.
zures. The thick arrow points to a V wave. Filters: low frequency
162 15. Abnormal EEG Patterns

Fp1F7~vJ\

F7 T3 ~~'~W,,J'~\,r~\,..,,I'''''-ltyf'./'J~.~~~~\-A'-1N~~~
:....
T3 T5 -vw"~N:rN"'~tWIJ"--J\~rvvr,rJ jJ~JI';''''J~vjJ·(r>J/JAfV'.f~
T5 01 ~~~'v~j

FP2F8~~~
F8T4 ~'vi~

T4

T6

Fp1 F3 ~vf\f'/\~
Asleep
F3C3~~~~VV"V~
C3 P3 ~~.~~~.J\
P3 01

Fp2F4~

F4 C4

C4 P4~~'\v~~"'-
!
P402 !~~

Figure lS.2i. Multifocal spike discharges in an 8-year-old, men- multifocally from either side. Filters: low frequency = 1 Hz, high
tally subnormal girl with a history of tonic-clonic as well as frequency = 70 Hz. Calibrations: horizontal = 1 second, vertical
myoclonic seizures that were poorly controlled with anticonvul- = lOOI1V.
sants. The arrows point to some of the spike discharges that arise

Spike or sharp-wave discharges may arise independently times accompanied by mental subnormality. Figure 15.27
from multiple sites in the same hemisphere or from both is an example of multifocal spikes.
sides. The terms multifocal spikes or "multiple indepen-
dent spike foci pattern" are used when there are spikes Generalized Epileptiform Abnormalities
originating from three or more noncontiguous electrode Unlike the focal epileptiform patterns, these are dis-
placements, with a minimum of one focus in each charges that appear simultaneously on both sides. There
hemisphere. Such a pattern correlates very highly with a are a number of patterns that show a significant degree of
seizure disorder, usually of the generalized type and some- clinical correlation.
Paroxysmal Epileptogenic Abnormalities 163

F3 Fz

Fz F4

F4 Fa
~~~~~~rft!i
~tV'VW~~~tlNVi!~~~f
C3 Cz

P3 pz

pz P4 I.

P4 T6

T5 01

01 02
I~
02 T6

Figure 15.28. Three per second spike and wave discharges typi- was unresponsive during this period. Filters: low frequency = 1
cal of absence in a lO-year-old boy with staring spells. The gener- Hz, high frequency = 70 Hz. Calibrations: horizontal =
alized bisynchronous, frontally dominant spike and slow-wave second, vertical = 1.50 ~V.
complexes occur at a frequency of about 3 ..5 to 4 Hz. The patient

3-Hz Spike and Wave Discharges The 3-Hz spike and wave pattern is one of the easiest
EEG patterns to recognize. Certain physiological patterns
This pattern is classically seen in absence seizures. It con- that may resemble it are hyperventilation-induced delta
sists of bilaterally synchronous and symmetrical com- activity-especially when the waves appear sharp or are
plexes, each made up of a high-amplitude, surface-negative "notched'~ and paroxysmal hypnagogic hypersynchrony.
spike and wave. The complexes repeat at a rate of about Certain artifacts like hiccup, and artifacts associated with
3 Hz and appear in a generalized distribution (Fig. 15.28); rhythmic rocking of a baby by its mother while the EEG is
maximum amplitude is usually in the frontal and rarely in taken, may also resemble this discharge. The 3-Hz spike
the occipital areas. At the onset of the discharges, repeti- and wave pattern is readily distinguishable from the 6-Hz
tion rate may be faster (4 Hz), whereas toward the end it spike and wave discharge, the latter having very small
may become slower (2.5 Hz). The discharges usually last spikes and short-duration discharges. When the onset of
for 3 to 4 seconds and are often precipitated by hyperventi- the 3-Hz pattern is asynchronous, or when the frequency
lation (see Fig. 16.4). When prolonged, they are consi- is less than 2.5 Hz, the possibility of secondary bilateral
dered to be ictal phenomena. During sleep the discharges synchrony (see later) or slow spike and wave should be con-
may get fragmented and appear as spikes or multi spikes. sidered.
164 15. Abnormal EEG Patterns

Fp1 F7

F7 T3

Fp2 Fa

Fa T4

T4 T6

T6

Fp1 F3

F3 C3

C3 P3

P3 01

Fp2 F4

F4 C4

C4 P4

P402

Fz Cz

Cz pz

Figure 15.29. Generalized. atypical fast spike and wave pattern. clonic jerks from the 10th year of life. The patient's mother had
The frontally dominant. 4- to 5-Hz spike and wave paroxysms experienced similar seizures up to age 25 years. Filters: low fre-
occurred during wakefulness in a 26-year-old patient with a his- quency = 1 liz. high frequency = 70 Hz. Calibrations: horizon-
tory of generalized tonic-clonic seizures and occasional myo- tal = 1 second. vertical = 50 ~v.

Generalized Atypical Fast Spike and Wave Discharges mixture of spike and wave complexes and muItispike and
wave complexes. Figure 15.29 shows an example of this
This pattern lacks the typical appearance and repetition pattern. Note the variation in the appearance of the dis-
rate of 3-Hz spike and wave discharges. It consists of 3- to charges. with some of them showing biphasic spikes and
5-Hz spike and wave discharges that show variations both others muItispikes.
in repetition rate and morphology. The waveform may be a
Paroxysmal Epileptogenic Abnormalities 165

Zli
F7 Av '\
t
T3 ~

T5 'V~~~~rvv~~''vJ~~~~
F8~~~

T4

T6~~~

Fp1 ~/'-I'-AJ'1~AjJ'\/\-vV'-Jv'.J\

F3

C3

P3

01

Fp2

F4

C4

P4

02 ~t-'r-vr'\r~/")I\-,'J~~J\{\/\(\/\(\
Fz ~

CzAv

Figure 15.30. Generalized sharp- and slow-wave complexes to anticonvulsants. The seizures were tonic or myoclonic and led
(sharp waves indicated by arrows) at l.5 to 2 Hz in a 5-year-old to frequent falls. Filters: low frequency = 1 Hz, high frequency
hoy with Lennox-Gastaut syndrome. The patient was mentally = 70 Hz. Calibrations: horizontal = 1 second, vertical = 150
subnormal and hyperactive and had seizures that were resistant 1lY.

Generalized Slow Spike and Wave Discharges for several seconds, usually without clinically obvious
seizures. The background activity is abnormally slow.
This pattern consists of sharp and slow-wave complexes Unlike the case of classic 3-Hz spike and wave, there is
occurring at a rate of less than 2.5 Hz (Fig. 15.30). It also little evidence of activation during hyperventilation. The
has been called "petit mal variant:' The discharges are pattern is often correlated with intractable seizures and
bilaterally synchronous and generalized, although fluctu- mental subnormality (see Lennox-Gastaut syndrome,
ating asymmetry is not uncommon. Each epoch may last Chapter 21).
166 15. Abnormal EEG Patterns

F7 T3

T3

T5 01

Fp2 Fa

F3
C3 P3

P3 01

Fp2 F4

F4 C4

C4

P402
17
Fz
1_-
Cz pz "

Figure 15.31. Generalized multi spike and wave complexes in a period. The arrows point to the multispikes. Myoclonic jerks are
3-year-old child with recurrent tonic-clonic as well as myoclonic indicated by the "X's:' Filters: low frequency = 1 Hz, high fre-
seizures involving mostly the upper extremities. The patient had quency = 70 Hz. Calibrations: horizontal = 1 second, vertical =
a documented history of cerebral hypoxia during the perinatal .50 ~v.

Generalized Multispike and Wave Discharges but more often in sleep recordings. Sometimes the dis-
charges are accompanied by myoclonic jerks. Generalized
Generalized multispikes or multispike and wave complex- or lateralized multi spikes may also occur in diffuse enceph-
es may occur as an interictal phenomenon in patients with alopathies of different etiology. Figures 15.31 and 15.32
primary generalized epilepsy (often with myoclonus) and show generalized and lateralized multispike discharges.
in Lennox-Gastaut syndrome. They may be seen in awake
Paroxysmal Epileptogenic Abnormalities 167

F7 T3

T3 T5

T5 01

Fp2 F8

T4 T6

Fp1 F3

C3 P3

P3 01

Fp2 F4

Figure 15.32. Generalized (solid arrow) as well as lateralized illness diagnosed as viral encephalitis. The horizontal arrows
(arrow with dotted tail) multispike discharges in a 12-year-old point to a focal spike showing a phase reversal at P4. Filters: low
patient with tonic-clonic, myoclonic, and left focal motor (upper frequency = 1 liz, high frequency = 70 Hz. Calibrations:
extremity and face) seizures from age 3 years following a febrile horizontal = 1 second, vertical = 50 11V.
168 15. Abnormal EEG Patterns

Fp1 F7 '\~J"----vJ'-o..~~~'f'~/'\>'~~V--J\\~\~

F7 T3 ~_I~V,v'j;/-~\'JV\j'--aJV~",j"V
T3 T5

T5 01 ~~~~r0~"JV'lf~/"'-
Fp2 Fa "'",j'~./v_c'vI\~~-H0A;'\J.JV\ ~(Iv
~.....: '-

Fa T4 ~~~~rr'~AJ\rlif'/~Jj_
T4 T6 ~~Vt\/W~--JJ\r-./\\/V\'J:-'-vJ( Vii""'')\' IV .JrV~.J\\
-- .' V'v +
T6 02 ~~\/,v-~~~",~v-,.~
Fp1 F3 ~~vv~~/\,)'~
F3 C3 ~~~,I;~JV'\
f::
M / \ '1~
0+'-' \j
C3P3~~ I

f'J 01 ~rNV~~~~\r":.'r~\r.~
Fp2 F4 ~~~J;\J\l'\/'v---J~/\;\
F4C4~~~4
C4 P4 ~~
. .
P402

Fz Cz

Cz pz

Figure 15.33. Hypsarrhythmic pattern in an 8-month-old baby between the dotted lines. The patient made a jerky movement
with infantile spasms. Note the chaotic background activity con- that involved the trunk and upper extremities at the beginning of
taining higb-amplitude, irregular delta transients (vertical this interval. Filters: low frequency = 1 Hz, high frequency = 70
arrows) and multifocal spike discharges indicated by horizontal Hz. Calibrations: horizontal = 1 second, vertical = 100 ~V.
arrows. A brief interval of electro-decrement can be seen

Hypsarrhythmia infantile spasms. During sleep, the activity may become

discontinuous. The pattern as described is the interictal
This pattern consists of continuous, high-amplitude 1- to pattern; when spasms occur, there is an abrupt attenuation
3-Hz irregular, disorganized background activity and shift- of the background activity (electro-decrement) and rhyth-
ing spike foci (Fig. 15.33). It occurs in most patients with mic, low-amplitude fast activity follows.
Paroxysmal Epileptogenic Abnormalities 169

Fp1 F7 ~!~Vr~vrvf\,rv~Vr\/\~~~'\r0nf¥0~
F7 T3 ¥M,l\(~(\>1l\/\ffvj{'y\' fhrP\;fVpf\I\~\rvwf\
T3 T5 ~~f'~pj~~

T5 01 ~~\,;~Y'
.111 r"O!lnrlt!!i~A).(\
~,;nvN:Ftv0i:/r!!1 ~:.,(0iJI\('\\If((r~i\/\0)\n\\rvV'Arl{(ir,rfl:rv ~vv l I' ~ .v V'
, , " A I I I
Fp2 Fa v"

Fa T4 f\)\;{\rrvr\r{\JtW\rJ\tN"vr"vJ\J'-f\f\~
T4 T6

C4 P4

P4 02 fIvJ,

Figure 15.34. Generalized 1.5- to 2.5-Hz continuous spike and discontinued anticonvulsants seven days before the recording
wave discharges (absence status/spike-wave stupor) in a 32-year- was taken. Filters: low frequency = 1 Hz, high frequency =
old patient who appeared confused. The patient had a history of 70 Hz. Calibrations: horizontal = 1 second, vertical = 100 ~v.
staring spells and tonic-clonic seizures from age 6 years and had

Ictal Patterns owing to the difficulty in establishing that the patient has
indeed had a clinical seizure within the short time that the
discharges last.
The ictal patterns often consist of either a change in the A progressive ictal pattern may be seen in both general-
frequency and amplitude of the interictal patterns, or a ized and focal seizures. There is usually an attenuation of
totally different pattern that may be activity in the alpha, the preceding interictal activity and even of the back-
beta, or slower frequency bands. The characteristic fea- ground activity, followed by a rhythmic discharge that may
tures of an ictal pattern are abrupt onset and an evolution take several forms. In the case of generalized seizures,
characterized by changes in frequency, morphology, and there initially is diffuse fast activity (10 to 25 Hz) that
amplitude. However, a nonevolving ictal pattern is also progressively slows down and increases in amplitude. At
known to occur in generalized seizures, the most common the onset, the spike component of this activity may not
example being that seen in absence. Here the ictal and quite be obvious and may look like rhythmic alpha or beta
interictal patterns are quite similar, the difference being activity. Different terms such as fast paroxysmal rhythms,
that the ictal pattern lasts longer and may be of higher generalized paroxysmal fast activity, and rhythmic spikes
amplitude. The onset and offset are abrupt, with a quick have been used to denote this activity. Since it is a common
return of normal background activity. In the case of feature at the beginning of a grand mal seizure, the term
absence status, there is continuous spike and wave activity "grand mal pattern" was originally used. Such discharges
at 2 to 4 Hz (Fig. 1.5.34). As pointed out in Chapter 21, the are particularly common in Lennox-Gastaut syndrome
distinction between interictal and ictal pattern in a non- when the child is experiencing a generalized tonic or aki-
convulsive generalized seizure is sometimes nebulous netic seizure.
170 15. Abnormal EEG Patterns

Fp1 F7

F7 T3

T3 T5

T5 01

Fp2 Fa ~ ____ -r-~

Fa T4

T4 T6

T6 02~ ~__~~~~~~~____~__~~~~~--~__~~

Fp1 F3

F3 C3

C3 P3

P3 01

Fp2 F4

F4 C4

C4 P4

P402

Fz Cz

Cz pz

Figure 15.35. Generalized delta activity in the postictal phase of low frequency = 1 Hz, high frequency = 70 Hz. Calibrations:
a grand mal seizure in a 20-year-old patient with primary general- horizontal = 1 second, vertical = 100 flY.
ized epilepsy. The patient was unresponsive at this time. Filters:

In the case of a generalized tonic-clonic or grand mal attenuation or slowing of the background activity (Fig.
seizure, the fast-frequency activity correlates with the 15.35). In the case of convulsive status, the same sequence
tonic phase; this is followed by progressive slowing and the of events may repeat at short intervals, or there may be
appearance of rhythmic generalized spikes that are bilater- continuous rhythmic generalized spiking (Fig. 15.36).
ally synchronous. These discharges correspond to the Generalized multispike and wave discharges may be ictal
clonic jerks. Soon the spike discharges become less and phenomena and are often accompanied by myoclonic
less frequent and cease. This is followed by generalized jerks. Figure 15.37 is an example of such a tracing.
Paroxysmal Epileptogenic Abnormalities 171

C4 P4

Figure 1.5.36. Generalized spike discharges occurring continu- during an interval hetween two convulsions. Intravenous diaze-
ously at about 2- to 3- Hz in a 30-year-old patient who was pam suppressed the spikes. Filters: low frequency = 1 Hz, high
unresponsive, had frequent grand mal seizures, and was diag- frequency = 70 Hz. Calibrations: horizontal = 1 second, vertical
nosed as convulsive status epilepticus. This tracing was taken = 100 1lV.
172 15. Abnormal EEG Patterns

Figure 15.37. Bursts of hilaterally synchronous spikes. mul- The "X's" mark the occurrence of myoclonic jerks. Filters: low
tispikes. and spike and wave discharges in a 60-year-old patient frequency = 1 Hz. high frequency = 70 Hz. Calibrations:
following cardiopulmonary arrest and resuscitation. Note the horizontal = 1 second. vertical = 50 1lV.
periods of suppression of the hackground between the hursts.
Paroxysmal Epileptogenic Abnormalities 173

T5 -~~~V''''-vV~/'~~---\/'I''''.V",~~/."",.~~------'''.vI'vI''''',''';-M_;"V'''''':'~~,,M.""}~-f"M,v""/,,,~~~
• al bl Cl' , ,
F8 ~~~vi'I/jY;"~~~~Jf'Ii~~""~~
T4 ~~~~~~'\~Jw""Ni'W,.,tl'~w.r""'~'''''''\\IM'''IW;,.J~!i'~,\'M''{I~,rv,~",\~,

T6 ~~'v~-....../-v""'-r~~-..K~~'~~f""J-"',-r'l'/-Y-~

Fp1 ~~V/"--J'~"'-.,/"'-../f\..;;/\J'A/"~V"'./'~·\,f"~~
F3

C3

P3

01

Fp2

F4

C4

P4

02

Fz
CzAv~~
Figure 15.38. Focal subclinical electrographic seizure arising arrow "a" over F8 and T4. A run of similar rapidly occurring,
from the right inferior frontal and temporal areas in a 45-year-old medium amplitude spikes is seen over F8, T4 and F4, beginning
patient with brain metastasis from melanoma. The patient at arrow "b" and ending at arrow "c:' The triangles point to sharply
presented with recurrent episodes of speech arrest, confusion, contoured delta transients that occur in the same area. No
and clonic movements of the right side of the face and upper behavioral changes could be detected during the rapid spiking.
extremities. Short vertical arrows point to focal spikes at F4 and Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibra-
F8. A brief cluster of rapidly occurring spikes can be seen at tions: horizontal = 1 second, vertical = 50 ~v.

In the case of focal seizures, there usually is a fast- lobe, particularly the medial part, surface recordings may
frequency discharge over the site of origin of the epilepti- show only the cessation of the previously occurring focal
form activity. This is followed by a slower rhythmic dis- discharges followed by the rhythmic, slow postictal activity.
charge that may take the form of spikes or sharp waves fol- It has been suggested that the fast-frequency activity
lowed, in turn, by postictal slowing (see Figs. 15.38- occurring at the onset may be picked up if sphenoidal elec-
15.40). In seizure discharges originating in the temporal trodes are used.
174 15. Abnormal EEG Patterns

F7 Av
t
T3

T5

F8
~,,-~~.....J~--~.~~-,,~~-.J~~
, , '
~~f\J-/J\~~~,-~
.
,t,
T4 ~~L.~~~'\JV '",/--'\---J~v-~"v~
T6 ~~,.JV"~~~~~~~
Fp1

F3

C3

P3

01

Fp2

F4

C4

P4

02

Fz
CzAv

Figure 15.39. Rhythmic focal delta activity occurring as a postic- activity. Long vertical arrows point to focal spikes occurring on
tal phenomenon in the right inferior frontal and frontopolar the same side. The rhythmic delta activity disappeared after 10
areas. Tracings are from the same patient as in Fig. 15.38. The seconds. Filters: low frequency = 1 Hz, high frequency = 70 Hz.
arrows with dotted tail point to some of the high-amplitude delta Calibrations: horizontal = 1 second, vertical = .50 1lY.
wa\·es. Brief clusters of spikes (arrowheads) preceded the delta
Paroxysmal Epileptogenic Abnormalities 175

T5 01
t t t t
Fp2 Fa

Fa T4

T4 T6
(a)

1_ _

Fp1 F7

T5 01

Fp2 F8

F8 T4

( b)

1_-
Figure 1.5.40. Focal eiectrographic seizure arising from the left seconds and was followed by a period of postictal focal slowing.
temporal area in a 38-year-old patient with an underlying glioma. During the ictus the patient appeared very confused, sat up in
In (a) the vertical arrows point to sharp-wave discharges that show bed, and showed some bizarre movements of the right upper
an equipotential zone het-.yeen F7 and T3. Immediately follow- extremity. Filters: low frequency = 1 Hz, high frequency = 70
ing, in (b) there is a rapid buildup of activity involving the whole Hz. Calibrations: horizontal = 1 second, vertical = 50 1lV.
left temporal area. This activity lasted for approximately 60
li6 15. Abnormal EEG Patterns

Fp1 F7

F7 T3

T3 T5

T5 01

Fp2 Fa

Fa T4

T4 T6

T6 02

Fp1 F3
~~~~~~~~~~rt(y1n"~~~\
F3 C3 ~~~~~~. ~f1~MJiN'J10)~M
C3 P3 ~~~~~~~~w~~N

P3 01

Fp2 F4

F4 C4

C4 P4
1--
P402

Figure 15.41. Secondary bilateral synchrony in a 40-year-old ing at the dotted line. The open arrow shows a spike on the right
patient with new onset tonic-clonic seizures. The patient had a side, with negativity at F4, preceding the bilaterally synchronous
history of head trauma 2 years prior to the first seizure. Note the discharge. Filters: low frequency = 1 Hz, high frequency = 70
bilaterally synchronous discharge of spike-wave complexes start- Hz. Calibrations: horizontal = 1 second, vertical = 50 !Lv.

Secondary Bilateral Synchrony nous discharges, often holds clues to the focal onset. This
may be in the form of a focal spike (as in Fig. 15.41) or
Seizure discharges that originate focally may spread fast activity preceding the bisynchronous discharge.
rapidly and involve both sides, so that the resulting sei- Amplitude or frequency differences in the discharge or
zure may be of the generalized type. The EEG pat- in the postictal slowing between the two sides are a less
tern, which consists of generalized bilaterally synchro- reliable clue.
Paroxysmal Epileptogenic Abnormalities 177

F7 T3

T3 T5

T501

F8T4~--

P3 01

Fp2 F4

C4 P4
1_-
P402
Figure 15.42. Small sharp spikes (SSS). also known as benign temporal areas on left and right sides; some of them show a more
epileptiform transients of sleep (BETS). in a 30-year-old patient widespread distribution, involving the inferior and midfrontal
with headaches and depression. The arrows indicate the low- areas as well. Filters: low frequency = 1 Hz. high frequency =
amplitude. short-duration spikes that occur independently in the 70 Hz. Calibrations: horizontal = 1 second. vertical = 50 11Y.

Epileptiform Patterns of Doubtful Significance Because of their duration and size, they may look like m us-
cle spikes; but they often are followed by a.slow wave. The
These patterns have been denoted "pseudoepileptiform"
slow wave is usually of smaller amplitude than the spike.
abnormalities, since they are of doubtful or no clinical sig-
Small sharp spikes may be monophasic, biphasic, or even
nificance. Nevertheless, they do resemble epileptiform
multiphasic. They are often seen over temporal and frontal
patterns. It is important, therefore, to differentiate them
areas, but may be more widespread. They are usually
from patterns that do show significant clinical correlation
bilateral, showing a shifting laterality from time to time;
with epilepsy.
occasionally they are synchronous. Small sharp spikes are
seen during drowsiness but disappear as the person goes
Small Sharp Spikes
into deeper sleep. These discharges are also referred to as
Small sharp spikes (SSS) are usually less than 50 ~V in benign epileptiform transients of sleep (BETS). They occur
amplitude and less than 50 ms in duration (Fig. 15.42). mainly in adulthood and are not usually seen in children.
178 15. Abnormal EEG Patterns

F7 Av 07.

t
T3

T5 awake drowsy

F8

T4

T6

Fp1 • b •
F3

C3

P3

01

Fp2

F4

C4

P4
1-
02

Figure 1.5.43. Tracing showing 14- and 6-Hz positive spikes in a F4 and to a lesser extent at Fpz. The small vertical arrows point
16-year-old patient with behavior problems. Arrows at "b" mark to ECG artifacts. Filters: low frequency = 1 Hz, high frequency
oil an interval of 14-Hz spikes showing positivity at To and T4, = 70 Hz. Calibrations: horizontal = 1 second, vertical = 50 J.1V
and to a lesser extent at F8. Arrows at "a" point to o-Hz spikes at

14- and 6-Hz Positive Spikes no definite correlation to epilepsy. It is worth mentioning
that 14- and 6-Hz positive spikes have also been reported
Positive spikes occurring at a frequency of 14 and 6 Hz in patients with Reye's syndrome, particularly when the
have been a source of controversy for many years. The pat- patients are comatose. The significance of this finding
tern consists of bursts of comb-shaped waves (Fig. 15.43) is unclear.
having a frequency of 13 to 17 Hz and/or 5 to 7 Hz. The
pattern is seen generally over the posterior temporal Wicket Spikes
region and adjacent areas on one or both sides of the head
during light sleep. The sharp peaks of the waves are surface The term is derived from the waveform's appearance,
positive. The pattern is best demonstrated by using con- which is similar to an arch. Wicket spikes occur either in
tralateral ear-reference recording. Due to the comb-like brief runs or as isolated transients. They are not accompa-
shape of the waves, the term ctenoids has also been used. nied by a slow wave. They occur over the temporal areas
Although the pattern is best seen during light sleep, it and may be unilateral or bilateral. Wicket spikes are seen
sometimes may occur during wakefulness. best during stages I and II sleep, although rarely they may
Fourteen- and 6-Hz positive spikes have been reported occur during wakefulness. They are seen mostly in older
in a number of disorders like headache, dizziness, abdomi- persons, with a reported incidence of about 1 %. No clini-
nal pain, and behavioral problems, but there seems to be cal correlation with epilepsy has been documented.
Paroxysmal Epileptogenic Abnormalities 179
,
..:
916
Fp1 F7 ~~-,~A/\fr

F7 T3 ~'~~~/o,!~i'0~~~~

Fp2 Fa "''IV'!.!
Fa T4 ~~~-".t"fi/'\/\~"
•
,J
T4 T6 l'""r-l\..t,,/w"/YVJif'l/irv"\-JVv"''''''''I\/'vvwvw,,_.t''V\·l\/\/,vv,.f.~

T6 02 ~YV'vvv.J\.Nvwv,"~.NVV"N1Wv--'J\/V\.J'J'0'/\t--·""v"'v"ri'''1\Jvv'J'--.j\J

Fp1 F3

P301

Fp2F4~~

F4 C4 ,~""';""~,....,JNVY/'\j~"f'--~'-'v'J\-'WV--'V'-"'-fl'or~N'.

IS
C4 P4 ~,~~~~~~~)

P402
•••
J ~
Fz CZ ~~VV'I '.t...(~r""-vv-,.r-v-~--"-"""""~",",--"{'-V'J",,"-,
J 1_ _ _

Cz pz

Figure 15.44. Six Hz (phantom) spike and wave discharge in a frequency = 70 Hz. Calibrations: horizontal = 1 second, vertical
2.'5-year-old patient with recurrent headaches. Arrows point to = .50 ~v.
the small-amplitude spikes. Filters: low frequency = 1 Hz, high

Breach Rhythm this pattern consists of brief (1/2 to 1 second) bursts of 5- to

7-Hz spike and wave complexes. As seen in Fig. 15.44, the
This consists of 6- to 12-Hz sharply pointed waves that spikes are of very low amplitude and are much smaller
appear in clusters, at higher amplitude than background, than the waves. The discharge, which is usually bilateral
in the proximity of a skull defect (see Fig. 15.10). The with frontal or occipital dominance, may occur during
waveforms are often intermixed with beta activity, and wakefulness or sleep, but it is seen mostly during drowsi-
their morphology may resemble a mu rhythm. They may ness. The reported incidence varies from 0.5% to 2.5%.
show a variable response to motor activity of the con- The pattern occurs in children as well as adults.
tralaterallimb. This pattern is not considered to be epilep- There has been some controversy as to the significance
tiform. of this pattern. The occipitally dominant discharges are
said to be very poorly correlated with epilepsy, whereas
6-Hz Spike and Wave the frontally dominant discharges, according to some
authors, may carry some degree of potential for epilepto-
Otherwise known as phantom spike and wave discharges, genicity.
180 15. Abnormal EEG Patterns

T501

F3C3~

16

Figure 15.45. Rhythmic mid temporal theta activity in a 35-year- (horizontal arrows) during stage II sleep. The open arrows indi-
old patient with recurrent headaches and one episode of syn- cate V waves. Filters: low frequency = 1 Hz, high frequency
cope. Note the sharply contoured 5- to 5.5-Hz waves occurring = 70 Hz. Calibrations: horizontal = 1 second, vertical = 50 IlV.
independently over the left and right midtemporal areas

Rhythmic. Temporal Bursts of Drowsiness Subclinical Rhythmic Electroencephalographic

Discharge of Moults (SREDA)
Otherwise known as rhythmic midtemporal theta of
drowsiness (RMTD) or psychomotor variant, this pat- This pattern is reported to occur mostly during drowsiness
tern consists of runs of sharply contoured theta activity in older adults. Often the discharge starts with a sharp or
that is often notched at the top (Fig. 15.45). Rhythmic slow wave of high amplitude and is followed by a build up
midtemporal theta of drowsiness may last for several of sharp waves to a sustained frequency of 4 to 7 Hz. The
seconds without a significant change in the frequency activity may last for several seconds to minutes and may
of the waves. The waves occur most commonly in the end abruptly. The most common areas involved include
midtemporal area, although the activity may spread to the temporal and parietal regions, but the activity may
the more anterior and posterior temporal areas and to become more widespread. Distinction from an ictal dis-
the parietal regions. The RMTD pattern is usually bilateral charge may be difficult, but the lack of a progressive
and may show some shifting laterality. It is seen in both change in discharge frequency is considered to be a
children and adults. No correlation has been found with differentiating feature. No definite correlation has been
seizure disorders. reported with seizure phenomena.
Abnormal Periodic Paroxysmal Patterns 181

Other Related Phenomena seen in acute destructive lesions involving one hemis-
phere. These particular patterns are taken up in turn.
There are a number of other waveforms that may resemble
epileptiform activity but that should be distinguished from
it. These include, to mention a few, paroxysmal forms of Generalized Periodic Paroxysmal Patterns
hypnagogic hypersynchrony; asynchronous "spiky" sleep SSPE
spindles of early childhood; and lambda, lambdoid, and
mu rhythms. Transients that resemble spikes or sharp The EEG in SSPE may be sufficiently specific to suggest
waves occur in the first few weeks after birth. These pat- the diagnosis. The periodic discharges consist of high-
terns pose interpretive problems that are beyond the scope amplitude (100 to 1,000 IlV) complexes - each consisting
of this text. of one or two slow waves - that recur at intervals of several
seconds. The interval between the complexes may have a
range of 4 to 14 seconds. Sharp waves may occur along with
Abnormal Periodic Paroxysmal Patterns these large delta transients, and each complex may last
from 0.5 to 3 seconds. The activity is often frontocentrally
dominant, and for this reason it may be confused with eye-
These are defined as stereotyped recurrences of paroxys-
movement artifacts. Myoclonic jerks may accompany the
mal complexes at relatively fixed intervals (Kuroiwa Y and
discharges, and when present, they are time locked to the
Celesia G, 1980). They should be present throughout the
periodic discharges. Initially, the background activity
entire tracing or a major portion of it. The discharges
between the complexes may be normal; but as the disease
should stand out from the background. They may be com-
progresses, the background shows slowing, disorganiza-
posed of slow waves, sharp waves, or sharp and slow-wave
tion, and epileptiform abnormalities.
complexes. Although they may appear to be epileptiform,
they are not necessarily associated with a chronic seizure
Jakob-Creutzfeldt Disease
disorder. They often indicate severe encephalopathy and
mayor may not be associated with clinical seizures. Some The periodic complexes consist of sharp waves of 100- to
of these patterns may suggest a specific diagnosis when 300-ms duration that occur at intervals of 0.5 to 2 seconds
taken in conjunction with the clinical picture, and for this (Fig. 15.46). Note that these complexes occur at a much
reason it is important to recognize them. faster rate than those in SSPE. The interval between them
The discharges may be generalized, lateralized, or even remains relatively constant in a given patient, although it
focal. Generalized periodic paroxysmal patterns are seen may vary from patient to patient. Sometimes the com-
classically in subacute sclerosing pan encephalitis (SSPE), plexes have a triphasic configuration. The background
Jakob-Creutzfeldt disease (JCD), and herpes simplex activity is severely disorganized in advanced cases of the
encephalitis (HSE). Electroencephalographic tracings disease. The periodic discharges may show a temporal rela-
with a burst-suppression pattern may also appear periodic, tionship to the myoclonic jerks that occur. This interesting
especially when the bursts occur at regular intervals. pattern is said to be present in as high as 90% of patients
Lateralized and focal periodic paroxysmal patterns are with moderately advanced JCD.
182 1.5. Abnormal EEG Patterns

ISO III
Fp1 F7

F7 T3

T3 T5

T5 01

Fp2 Fa

Fa T4

Fp1 F3

F3 C3

C3 P3 -----"'-""-"

P3 01

Fp2 F4

F4 C4

Figure 15.46. Generalized periodic complexes in a patient with upper extremities. Filters: low frequency = 1 Hz. high frequency
Jakob-Creutzfeldt disease. At the time of the recording, the = 70 Hz. Calibrations: horizontal = 1 second. vertical = 50 J.lv,
patient was demented and had myoclonic jerks involving the
Abnormal Periodic Paroxysmal Patterns 183

F7 T3

T3 T5

T5 01

Fp2 Fa

Fa T4

tt tt tt tt tt
C3 P3 ~-~~~-~.

P301~~

P402
Fz Cz --~~~~~--~--~~~~~~--------~~--~--~------~~----~~--~~----
1_-
l~~~~~~~~~~~~~~~~

Figure 15.47. Localized periodic complexes (vertical double ing 2 weeks. Filters: low frequency = 1 Hz, bigb frequt'ncy = 70
arrows) in the early pbase of herpes simplt'x t'llct'phalitis. The Hz. Calibrations: horizontal = 1 second, vt'rtical = 50 1lV.
complexes became lateralized and then generalized in the follow-

Herpes Simplex Encephalitis Other Related Conditions

The periodic complexes may be focal, as in Fig. 15.47, or There are a number of other conditions in which periodic
lateralized to start with; but later they become generalized. or quasiperidic patterns may be seen. In patients who have
The usual site is temporal or temperofrontal. The dis- suffered from cerebral hypoxia, generalized bisynchronous
charges consist oflarge sharp waves, 100 to 500 j.lV in am- sharp discharges may occur periodically against the back-
plitude, having a duration of up to 1 second and occurring ground of a flat EEG. These periodic discharges are often
at variable intervals of 2 to 4 seconds. The background ac- accompanied by myoclonus. Rarely, such discharges may
tivity may show focal and, later, diffuse slowing. The com- be drug induced. Thus, for example, generalized periodic
plexes usually appear between 2 days and 2 weeks after the complexes have been reported in association with phency-
onset of the illness, and their presence in a patient with the clidine intoxication.
clinical picture of encephalitis strongly suggests HSE.
184 15. Abnormal EEG Patterns
~ ~ ., ~
Fp1 F7 W'vV"""'------~ ~~~

F7 T3
!
fv,jvJ"'---------Jtr-------/'Vv~~~~~~
~ !
T3 T5 vJ'v'\r.r~-~..--/"J~ ________ ~~~~r~~~

T5 01 ~~-~-~------~~~~~~~~v...r____~

Fp2 F8 ~--~~~1I/-'-..r--v---­

F8 T4 f'V"\J\;J"----~~-----~~~..r'.r---------v-~~

T4T6~"'----~~~~~~~

T6 02 ~~----v--~~

Fp1 F3 /l-------~-~~
F3C3~---~~~~~

16
P402~

Fz Cz A}'f"J"--~--~~~
Figure 15.48. Pattern of burst suppression in a 60-year-old of any obvious convulsions at this time. Filters: low frequency =
patient following cardiopulmonary arrest. The bursts (vertical 1 Hz, high frequency = 70 Hz. Calibrations: horizontal = 1
arrows) contain activity of mixed frequency combined with second, vertical = 150 1lV.
generalized sharp waves. The patient was unresponsive but free

Suppression Burst Pattern trauma, and severe drug intoxication, as well as deep
anesthesia. The bursts consist of mixed frequency (theta
This may be considered as a periodic pattern, since it con- and delta) polymorphous activity lasting about 1 second.
sists of periodic bursts of activity with intervals between in Figures 15.8, 15.48, and 15.49 are typical of this abnor-
which the background activity is markedly attenuated to mality. When found in postanoxic tracings, the pattern sug-
less than 10 1lY. The pattern is indicative of a severe gests a grave prognosis.
encephalopathy and may result from cerebral anoxia, head
Abnormal Periodic Paroxysmal Patterns 185

, '1
Fp1 F7

F7 T3

T3 T5

T5 01
.
------~:~-----------
,

--------:~-------

Fp1 F3

F3 C3----- ~--~--~------------------------------~~------------~--~~---
C3 P3 -------"'.......--- II

.-- b -. -- S ~_ b _ :
P3 01 --------~:~ ____
~-----------------------------~1~3----------------------~~--------

Fp2 F4
F4 C4 --______ ~·~ ______ ~ __________________________----M"----__________ ------~~

Ii
C4 P4

P402 --------~:~~~----------------------------------_I~.------------------------.~~
Figure 15.49. Marked attenuation of background activity in a Muscle artifacts during the bursts correspond to myoclonic jerks.
50-year-old patient following cerebral hypoxia from cardiopul- Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibra-
monary arrest. Area marked "s" shows an epoch of suppression, tions: horizontal = 1 second, vertical = SOllY.
and areas marked "b" show bursts of low-amplitude slow activity.
186 15. Abnormal EEG Patterns

Fp1 F7

F7 T3

T3 T5

T5 01

Fp2 Fa

Fa T4

T4 T6

T6 02

Fp1 F3

F3 C3

C3 P3

P3 01

Fp2 F4

F4 C4

C4 P4
••• •••
16 1_-
P4 02

Figure 15.50. Triphasic waves in a patient with renal failure. The nent. The patient was obtunded. Filters: low frequency = 1 Hz,
large arrows point to clusters of triphasic waves with the highest high frequency = 70 Hz. Calibrations: horizontal = 1 second,
amplitude in the frontal areas. Small arrows point to the three dis- vertical = 50 !tv'
tinct phases of a triphasic wave having a large positive compo-

Triphasic Waves between their appearance in the frontal and occipital area;
the delay is shown in Fig. 15.51. The waves are usually
frontally dominant, bilaterally synchronous and general-
Triphasic waves may sometimes occur in a periodic fashion ized. Although originally described in hepatic
(Kuroiwa Y and Celesia C, 1980)and hence are included in encephalopathy, this abnormality may occur in other forms
this section. Each waveform shows a prominent positive of metabolic encephalopathies such as uremia and follow-
phase (Figs. 15.50, 15.51) preceded and followed by nega- ing cerebral hypoxia. The abnormality accompanies symp-
tive phases. Classic triphasic waves show a time delay toms of impaired consciousness.
 Abnormal Periodic Paroxysmal Patterns 187

1 )

Fp1 F7

F7 T3

T3 T5

T501
, '
Fp2 Fa

Fa T4

T4T6~

T6 02

Fp1 F3

F3 C3

C3 P3

P3 01

Fp2 F4

F4 C4

C4 P4
1-

Figure 15.51. Triphasic waves in a patient with hepatic nent of a triphasic wave that shows a fronto-occipital delay.
encephalopathy. Vertical arrows point to the three phases of the Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibra-
waveform. The slanted arrows point to the main positive compo- tions: horizontal = 1 second, vertical = 50 1lV.
188 15. Abnormal EEG Patterns

h.2
Fp1 F7 ~ V~"--'""VV\"'-----'V-~""'-""""
F7T3 ___ ~~~~~~~

T3T5~ ""~_
T5 01 ~/"\~~/""'.~/'··_~~~~
Fp2F8 ~~~-J~
F8T4""\·~~0
T4T6~~r~ ~
T602~~~~~~~
Fp1F3~~~'~~~~

F3C3~\)-

C3 P3

P3 01

C4

P4

1_-

Figure 15.52. Periodic lateralized epileptiform discharges had jerky movements involving the left upper extremity. Filters:
(PLEDS) in a 60-year-old patient with recent onset. massive low frequency = 1 Hz. high frequency = 70 Hz. Calibrations:
infarction of the right hemisphere. The patient was comatose and horizontal = 1 second. vertical = 50 1lY.

Lateralized Periodic Paroxysmal Patterns phenomenon that lasts for a few days and is followed by the
appearance of PDA in that area.
Periodic Lateralized Epileptifonn Discharges (PLEDS)
The term is used for periodic complexes that are lateral-
ized to one side and repeat at 1- to 2- second intervals. BIPLEDS
Each complex consists of spikes or sharp waves that are
often followed by slow waves (Chatrian CE. Shaw CM, and Sometimes PLEDS may occur independently on both
Leffman H, 1964). They are seen in acute, often destruc- sides; in this case, the term BIPLEDS is used. In one study
tive lesions involving one hemisphere. The classic exam- (de la Paz D and Bremer RP, 1981) the most common
ples are infarcts (Fig. 15.52), rapidly growing tumors (Fig. causes of BIPLEDS were anoxic encephalopathy and CNS
15.53), and infectious encephalopathies like HSE. Some- infection. It was reported that patients with BIPLEDS
times they may be accompanied by focal seizures that may were often comatose and had a higher mortality rate than
be difficult to control. The pattern is usually a self-limiting patients with PLEDS.
Abnormal Periodic Paroxysmal Patterns 189

I! r I' r II" r'j" r IIII f' r, IIIII ii' r I r 111111' r IIII i II ,I r r IIII i I~'f r 11'11' ,'" II ii' I'" 11'11'1'! IIIIII1 ".111 iii I t Ii' Iii 11 ii' I! 11111' r 1"'11' III i'" , IIII1 ,,'1111 Ttl I

Fp1 F 7 '- __ ~-----.,

F7 T3
T3 T5 ~ __~

T5 01
Fp2 Fa
Fa T4
T4 T6

T602
Fp1 F3
F3 C3
C3 P3
P3 01
Fp2 F4
F4 C4
C4 P4
P402
Fz Cz
Cz pz
1_-
--------------~w~---------------------------------------------------------------------------

Figure 1.5..53. Periodic lateralized epileptiform discharges and the left upper extremity. Filters: low frequency = 1 Hz, high
(PLEDS) in a patient with a glioma involving the right frontal frequency = 70 Hz. Calibrations: horizontal = 1 second, vertical
area. Vertical arrows point to the periodic discharges. The patient = 50 1lY.
was obtunded and had seizures involving the left side of the face

References Chatrian GE, Shaw CM, Leffman H: The significance of periodic

lateralized epileptiform discharges in EEG. Electroencephalogr
American Electroencephalographic Society Guideline Three: Glin Neurophysiol1964; 17: 177-193.
Minimum technical standards for EEG recording in suspected de la Paz D, Bremer RP: Bilateral independent lateralized epilep-
cerebral death. ] Glin Neurophysiol1986; 3 (suppl 1): 12-17. tiform discharges - clinical significance. Arch Neuro11981; 38:
Chatrian GE, Bergamini L, Donday M, et al: A glossary of terms 713-715.
most commonly used by clinical electroencephalographers. Kuroiwa y, Celesia G: Clinical significance of periodic EEG pat-
Electroencephalogr Glin Neurophysiol1974; 37: 538-548. terns. Arch Neuro11980; 37: 15-20.
Chapter 16
Activation Procedures

When using the EEG as a clinical tool, one should always special importance in the case of patients suspected ofhav-
keep in mind that the EEG recording is simply a random ing seizure disorders, particularly absence seizures.
sampling of the person's brain electric activity taken at a
particular period of time. Hence, in those neurologic dis-
Procedure
orders that produce transient abnormalities in the EEG,
an EEG may be interpreted as normal unless the time of The standard procedure is to have the patient take deep
occurrence of the abnormality coincides with the time of breaths at the rate of about 20 per minute for three to five
recording. This issue becomes particularly important in minutes. The first step is to explain the procedure in detail
investigations of seizure disorders. Contrary to the notions to the patient. Tell the patient to relax, keep the eyes
of the uninitiated, a normal EEG in no way "rules out" a closed and mouth open, and to breath deeply in and out at
genuine seizure disorder, as interictal epileptiform abnor- a regular pace until told to stop. It is best to show the
malities mayor may not have been present at the time of patient what to do by giving a brief demonstration of deep
recording. One of the ways that is employed to mitigate this breathing. Explanations such as "try to completely empty
problem is to increase the probability of occurrence of the lungs, and then take in a lung full" may be helpful. Ask
abnormalities during the recording period. This may be the patient to refrain from making any unnecessary move-
achieved by using various activation procedures that can ments of the head and upper part of the body, as these can
elicit or enhance certain normal as well as abnormal introduce large artifacts into the recording. The patient
activity in the EEG. It must be understood, however, that also should be instructed to report, if possible, any warn-
while activation procedures are most valuable in the case ings of or actual occurrence of a seizure immediately.
of seizure disorders, they may also be useful in the study of Symptoms like tingling of the extremities, muscle spasms,
many other neurologic disorders. or lightheadedness are known to occur during hyperventi-
lation in some individuals.
During hyperventilation, the technician should care-
Hyperventilation fully observe the patient to detect the occurrence of
absence seizures, which may simply consist of a brief (last-
Hyperventilation is perhaps the most widely used activa- ing only a few seconds) interruption of hyperventilation
tion procedure in EEG laboratories. The procedure, which with associated staring and unresponsiveness. When this
is simple and relatively safe, consists of three to five happens, it is important to try to assess the patient's
minutes of deep breathing. It is, however, difficult to per- responsiveness by asking questions and/or giving verbal
form in patients who are uncooperative, mentally retarded, commands promptly. The command given and the
or below the age of 4 or 5 years, and it is preferable to avoid patient's response or lack of response should be clearly
in patients with recent stroke or subarachnoid hemor- indicated on the EEG chart. Sometimes the patient may
rhage, recent myocardial infarction, chronic obstructive become drowsy halfway through the procedure and may
pulmonary disease, and other conditions causing difficulty stop hyperventilating. The technician should be on the
in breathing. Although hyperventilation has become a lookout for such a problem and prevent it from occurring
common procedure during routine EEG recording, it is of by repeatedly calling the patient by name and encouraging
Hyperventilation 191

Fp1 F7

F7 T3

T3 T5

T5 01

Fp2 Fa

Fa T4

T4 T6

T6 02

Fp1 F3

C3 P3

P3 01

Fp2 F4 -...,...~~

F4

C4 P4

P402

Fz Cz vr"'~"""''''''

Cz pz

Figure 16.1. Intermittent slow activity during hyperventilation. a burst of slow activity. This is a normal response to hyperventila-
The high amplitude, 3- to 3 ..'5-Hz rhythmic activity is present on tion. Filters: low frequency = 1 Hz, high frequency = 70 Hz.
both sides and is symmetrical. Each arrow indicates the onset of Calibrations: horizontal = 1 second, vertical = 50 ~v.

him or her to keep up the deep breathing. Also, the techni- hand, if no abnormalities appear in the first three minutes,
cian should carefully observe whether the patient actually then have the patient continue overbreathing for two addi-
stops overbreathing when he or she is told to do so. Some- tional minutes. For such patients, it is a good practice to
times a patient may continue to overbreath for a prolonged repeat the hyperventilation twice or even three times if the
period of time even after being told to stop; this can lead to initial attempt fails to elicit the typical abnormal discharge.
prolonged slowing of the EEG (see below) thus creating
problems in interpretation of the tracing.
Normal and Abnormal Response
It is good practice to mark the time elapsed since start-
ing hyperventilation on the EEG chart every 30 seconds so The normal response to hyperventilation consists of the
that the electroencephalographer will know how long the occurrence of symmetrical slow activity on both sides. The
patient has been hyperventilating. If the patient is referred absence of any change in the EEG is also normal. Although
for evaluation of absence spells, and if the typical three per this slow activity may be diffuse theta activity, a more
second spike and wave discharges (see Chapter 1.5) occur characteristic finding is the occurrence of intermittent or
in the EEG tracing during the first three minutes, there is continuolls 3- to 4-Hz high amplitude activity that is fron-
no need to prolong the hyperventilation. On the other tally or occipitally dominant (Figs. 16.1 and 16.2). If the
192 16. Activation Procedures

Fp1 F7

F7 T3

T3 T5

T5 01

Fp2 Fa

Fa T4

T4 T6

T6 02

C3 P3

P3 01

Fp2 F4

F4 C4

C4 P4

P402

Fz Cz

Cz pz

Figure 16.2. Gradual buildup of bilaterally symmetrical slow pare with Fig. 16.1. Filters: low frequency = 1 Hz, high fre-
activity in a 10-year-old child after two minutes of hyperventila- quency = 70 liz. Calibrations: horizontal = I second, vertical =
tion. Note that some of the waves, which are about 3 Hz, show 1.50 ~V.
amplitudes in excess of 250 ~ V. This is a normal response. Com-

activity is continuous, it may build up gradually to ampli- The most striking EEG abnormality seen during hyper-
tudes in excess of 250 ~ V, as seen in Fig. 16.2. The slow ventilation is the 3-Hz spike and wave discharges often
activity may persist for up to a minute after hyperventila- brought on in patients with absence seizures. Figure 16.4
tion ceases, and the EEG may not return to its pre hyper- illustrates this. These discharges usually are frontally
ventilation state for two to three minutes. The amplitude dominant and may occur in brief epochs, or they may per-
and frequency of the slow activity are of no clinical impor- sist for several seconds during which time an episode of
tance unless there is consistent asymmetry between the unresponsiveness may be documented. Sometimes, other
two hemispheres. The side that shows a slower frequency types of epileptiform abnormality, such as generalized
and/or a lower amplitude is usually considered to be the spike discharges or even focal spikes, may be brought on by
abnormal side. Figure 16.3 shows an abnormal response to hyperventilation. Hyperventilation may be performed
hyperventilation. while recording any of the commonly used montages;

•
Figure 16.4. Generalized 3-lIz spike and wave discharges follow- and occur in brief epochs. Arrows point to several of the spikes.
ing three minutes of hyperventilation in a patient suffering from Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibra-
absence seizures. Note that the discharges are frontally dominant tions: horizontal = 1 second, vertical = 50 ~V.
Hyperventilation 193

F7 T3
+ +

T5 01

Fp2 Fa

Fa T4 ¢
T4 T6

T6 02
1_-
Figure 16.3. Asymmetrical slow activity and sharp wave after 1.5 left between the horizontal solid arrows; these abnormal features
minutes of hyperventilation. The presence of slow activity in the are not present on the right side (horizontal open arrows). Filters:
theta band on the left side (vertical solid arrow) but its absence on low frequency = 1 Hz, high frequency = 70 Hz. Calibrations:
the right side (vertical open arrow) is abnormal. Also abnormal horizontal = 1 second, vertical = 50 !Lv.
are the sharp wave and the brief paroxysm of delta activity on the

T3

T5 ~V'..rv-\t\jr-vvvV~f\/\!~~

F8 ~"v'\.I\;"'~i'vV'''''''',~ .
T4 '----'~./_--------/,JV-'-v'vV'V"~v-/\j'j\AJ~vvv-v"v~~
T6 ~~/~\JJ\A!\j~v~'J\\/~'~'V--V'v'V\/V!VvVVV-f\~~
Fp1 ~vV\('I\~~j\J~j~;J',~V~\(/~\~~
F3 ~fJ~IV0\J\J\Af'../IJ \,r~~I\rvJ~~~Jl{1,)~f,fvJ\fVrj\r~~
C3 -----('Y\f\~

P3

01

Fp2

F4

C4

P4
194 16. Activation Procedures

selection of a particular montage is dictated by the sus- flashes of light at frequencies ranging from 1 to 50 flashes
pected abnormality. For example, if absence is suspected it per second. One of the commonly used models provides
is important to have a montage that includes the fronta\' flashes of 10-lls duration with an intensity of 1.5 million
parietal, and occipital electrodes. In the case of complex foot-candles. In some models the intensity of the flash is
partial seizures, the montage should include not only the adjustable; others are capable of providing colored as well
parasagittal but also, and more importantly, the temporal as white flashes (red flashes are said to be more effective in
chain of electrodes. eliciting photoparoxysmal responses). The device also
How does hyperventilation bring about such dramatic delivers a signal that is synchronous with each flash; this
changes in the EEG? The major biochemical finding dur- signal is recorded as a stimulus marker on one of the EEG
ing hyperventilation is a drop in carbon dioxide content of channels. Alternatively, a photoelectric cell may be
the blood (hypocarbia). It is well known that the most attached to the patient's forehead and connected to one of
important vasodilatory stimulus for the blood vessels of the the EEG channels.
brain is carbon dioxide. The higher the carbon dioxide
content, the greater the vasodilatation. So when there is
Technique
hypocarbia, the reverse occurs, namely, vasoconstriction.
This presumably alters the metabolic rate of the neurons The test begins by explaining the procedure to the patient.
and leads to the slow activity. Tell the patient that he or she will be seeing very bright
The effect of hyperventilation on the EEG is much more flashes of light (bright even with the eyes closed) and to
marked in children than in adults, with children's EEGs keep the eyes closed or open as instructed during the
sometimes showing an enormous buildup of slow activity. course of the test. The flash lamp is positioned approxi-
Blood sugar level also appears to influence the response to mately 30 cm in front of the eyes. Start with one or two
hyperventilation. The lower the blood sugar, the more flashes per second and increase the rate gradually up to 30
marked the hyperventilation-induced slow activity. When flashes per second. Each flash rate is presented for a dura-
an adult EEG shows marked and prolonged slowing as a tion of about 10 seconds, and the eyes are kept closed in
result of hyperventilation, one should consider the possi- the first 5 seconds and open in the next .5 seconds. If a
bility of hypoglycemia and should repeat the procedure 15 photoparoxysmal response (explained later) is elicited, the
to 30 minutes after giving a drink containing glucose. It IPS should be stopped to avoid precipitating a seizure. If
should be obvious, in this context, why documentation in the response occurs only during a brief part of the stimula-
the EEG worksheet concerning the time of the preceding tion, the technician needs to confirm that it is, indeed, a
meal is important. photoparoxysmal response by cautiously repeating the
stimulation at the same flash rate. The technician should
be on the lookout for evidence of seizures or seizure-like
Intermittent Photic Stimulation phemonena, and should make appropriate notations in the
EEG chart.
Visual stimuli are perhaps one of the most effective means
of stimulating the brain. The ready availability of user-
Photic Driving
friendly stroboscopes has resulted in the routine use of
intermittent photic stimulation (IPS) as an activation pro- EEG activity that is time-locked to the photic stimuli often
cedure during electroencephalography. The method is is seen over the posterior head regions during IPS. This
most valuable in documenting photosensitivity, which activity has the same frequency as the photic stimuli, or it
has a high clinical correlation with primary generalized may be a harmonic or subharmonic of the flash rate. Nor-
epilepsy. mally, the activity is symmetrical on the two sides. Such a
response to photic stimulation is called photic driving.
Photic driving is a physiological response; it may be
Apparatus
observed in all age groups. Figure 16 ..5 is an example of
The device used is called a stroboscope or photic stimula- photic driving at different flash rates, and Fig. 16.6 shows
tor. It is capable of delivering single or continuous bright photic driving at subharmonics of the flash rate.
 Intermittent Photic Stimulation 195

Fp1 F7

T3 T5

T501

Fp2 F8

F8 T4

F3 C3

C3 P3

P3 01 ~'\J!\f'0NV../'vNlfvJvlc

Fp2F4~~

F4 C4

C4 P4

P402

FzCz~~fill
8 15 1-
CzPz~~
III1III1IIIII "11'" (I! // I ! / I I ' " '" J I' ! I J I (/1111 !J I J 111111 J I! .1111111/11 ! ~/' /11' III , II J (

Figure 16.5. Photic driving at 8, 12, and 1.5 flashes per second. Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibra-
The time-locked activity, which is most prominent in the tions: horizontal = 1 second, vertical = 50 ~v.
posterior regions, is a normal response to photic stimulation.
196 16. Activation Procedures

r1
Fp1F7~~

T501

F8 T4

Fp1 F3 """""_.........-

Fp2 F4 -~--

P402

15 18 20 1_-
111111111111111111111111111111111111111111111111111111111111111111111111111 mm111111111111111111111111111111111111111111111111111111111111111111111111111111111111 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111

Figure 16.6. Photic driving at 15, 18, and 20 flashes per second, low frequency = 1 Hz, high frequency = iO Hz. Calibrations:
and also at the subharmonics of the flash rates, namely, 7.5, 9, and horizontal = 1 second, vertical = 50 1lV.
10Hz, respectively. Both kinds of response are normal. Filters:
Intermittent Photic Stimulation 197

Fp1 F7

F7 T3

T3 T5

T5 01

Fp2 Fa

Fa T4

T4 T6
t

Fp1 F3

F3 C3 ",,..,.v"V"''V.

C3 P3 ~(\.,~~~~~
_I

P3 01

Fp2 F4

C4 P4
I. t
17 1-
~
..
fillllilliillllmnl1lillliinilllllli11i1im11lIlhihliiihihiltlillhnhiliifAiillIihMilIliilliltUmmllmlllllfllhlilhhhhhfilhhhhihlhm,ihinmnnilifhMiihiiiiiiiihiriHirikMiMMiNhhiiMriMi

Figure 16.7. Asymmetrical photic driving. Solid vertical arrows spikes in the parietal and posterior temporal regions. Some of the
indicate low-amplitude driving at 25 flashes per second in the spikes are indicated by the horizontal arrows. Note the mu
posterior region on the right side; open vertical arrows indicate activity in the central regions on both sides. Filters: low fre-
the relative absence of driving on the left. The left side shows quency = 1 Hz, high frequency = 70 Hz. Calibrations: horizon-
other abnormal features, namely, slowing of the background and tal = 1 second, vertical = 100 1lV.

Absence of any response to IPS or a bilaterally sym- lesions involving the occipital lobe, driving is less pro-
metrical, low-voltage response is not considered abnormal. nounced or absent on the side of the lesion (see Fig. 16.7);
On the other hand, a marked, consistent asymmetry in also, the affected side may show no driving for only certain
amplitude between the two sides is considered abnormal. frequencies of stimulation. Exceptionally, there may be
Similarly, consistent absence of driving to many flash fre- more prominent driving over an irritative lesion in the
quencies on one side, with intact driving on the other side, occipital lobe, such as a meningioma.
is also abnormal. Thus, in unilateral destructive structural
198 16. Activation Procedures

'\,r\nnn r,Iln,n,,\n n\;,:!\:~,r,:0 ":'(\(-""0. NI"n,nn,In/,n~n\,nn n[",fi0/\,~

295
Fp1 F7 _ _ _~_../
0"0,,
1\ ; I Ii, I i i " '), "
il 1
,I I; Ii', , 1 ,1
,II \" \1" ',i " 1
'~ ~ 'u ~;r.}~fl~~**~~
t_. . . . . -.__
F7 T3 -----.......-, " Uu 2-......- - " " " "

T3 T5 ....... a ........ _ . , . . " . . . . . .." ....... _ oM.,... WJIA~, ·f....,...... ... 1.411' 4'"f'~" ......... ~.....01____
-'.....
, ......... ,~'

T5 01 --~------~~~~~~~~~~~~~~~~~~~-y~~~~~~-------------

Fp2 F8
Fa T4
'
~iw\.n:n\tIN1tl~!~:1N0.~tn!~r:~tIW:~.r,l~rll~nr,M
hv.J~»~~~rvr--~
/

15 Hz HFF .

F4

P402

Fz Cz
1-
Cz pz
I //11 II ! II/I'! ' II /' /' III/ ! /11//1/, ' /11 ! 1/1 /1 I / i /, /1 1/ 1 I II 11//11 ,
Figure 16.8. Photomyogenic response to photic stimulation at 6 severely reduced. As a result, the large-amplitude muscle spikes
flashes per second. Note that the response is most prominent in that normally accompany photomyogenic responses are greatly
the frontal electrodes and stops abruptly when photic stimulation attenuatt'd. Filters: low frequency = 1 Hz, high frequency = 1.'5
ceases. 1() accentuate the clonic movements seen in the tracing, Hz. Calibrations: horizontal = 1 second, vertical = 100 Il\'.
the high-frequency response of the EEG machine has been

Photomyogenic Response Table 16.1. Comparison of Photomyogenic and Photoparoxysmal

Responses to Photic Stimulation
The normal reflex reaction to a flash of light is a blink dur- Photomyogenic Photoparox)'smal
ing which time there is contraction of the orbicularis oculi, Response Rl'sponse
the muscles that are situated around the eyes. In some sub-
jects, the response may be accentuated and a number of EEG Filldillgs
periorbital and facial muscles may take part. When this Morphology Muscle spikes Spike and Waye com-
happens, the EEG shows prominent muscle spikes that are plexes
time-locked to the light flashes and are most conspicllous Location Frontopolar and Generalized
over the frontal electrodes (Fig. 16.8). This phenomenon is frontal
Frequency Follows nash Independent of nash
called a photomyogenic response. It is important to distin- frequency frt'quenc),
guish this response from a photoparoxysmal response. Relationship to Ahrupt onset Often outlasts the dura-
Unlike the photoparoxysmal response, the clonic move- onset and ofT- and ofTset tion of photic
ments of the photomyogenic response stop abruptly as set of the simultaneous stimulation
soon as photic stimulation is discontinued (see Table 16.1); stimulation with photic
stimulation (COlltiIlIlCd)
it is a nonspecific finding, known to occur in a small per-
Intermittent Photic Stimulation 199

F7 Av
t
T3

T5

F8

T4

T6

Fp1

F3

C3

P3

01

Fp2

F4

C4

P4

02

Fz
1_-

Figure 16.9. Typical photoparoxysmal response to photic stimula- last the flashes-which cease after the vertical arrow- nearly by
tion at 12 flashes per second. The generalized, 3- to 4-Hz bilater- a second. Filters: low frequency = 1 Hz, high frequency = 70
ally symmetrical and synchronous spike and wave discharges out- Hz. Calibrations: horizontal = 1 second, vertical = 50 !ly.

Table 16.1. Continued centage of the normal population. No clinical significance

Photomyogenic Photoparoxysmal
is attached to the occurrence of photomyogenic responses.
Response Response
Photoparoxysmal Response
Clinical Findings Contraction of Tonic clonic seizure or
periocular and myoclonic jerks or Also known as a photoconvulsive response, the diagnostic
facial muscles absence spell feature of the photoparoxysmal response is the occurrence
synchronous of spike and wave or multiple spike and wave discharges
with flashes
during photic stimulation. These discharges are bilaterally
Significance None Suggestive of symmetrical, synchronous, and generalized; they often
photosensitivity- high outlast the stimulus duration (Fig. 16.9). A sustained dis-
correlation with charge that persists after the cessation of stimulation is
primary generalized more significant than a brief response (Fig. 16.10).
epilepsy
Although generalized, the discharges may be most
pronounced in the frontal, central, or occipital areas.
Sometimes occipital spikes alone are noted; these are con-
sidered to carry little clinical significance. Photopar-
oxysmal responses occur most often at flash rates of 15 to
200 16. Activation Procedures

6H
Fp1F7~~

F7 T3

T3 T5

T5 01

Fp2 Fa ~~-.-...vY'fV

Fa T4

T4 T6

F3 C3 ~-~~'VJ

C3 P3 --.rv--.. . . ."""'.
P3 01

Fp2 F4

C4 P4

Fz
1_-
1I11111111111i111111111111111111111111111111111111111111111111111111111111111IIIIIIIIIIIIIIIillllllllllllllllllllllli"llill,[III~1I1
Figure 16.10. Brief photoparoxysmal response to photic stimula- central areas. Filters: low frequency = 1 Hz, high frequency =
tion at 15 flashes per second. The generalized discharge, which 70 Hz. Calibrations: horizontal = 1 second, vertical = 50 ~v.
lasts less than 2 seconds, is most pronounced in the frontal and

20 per second. Table 16.1 compares these responses with drug or alcohol withdrawal, and in diffuse encephalopa-
photomyogenic responses. thies including metabolic encephalopathies like uremia.
Photoparoxysmal responses indicate photosensitivity. Occurrence of high-amplitude spikes in response to stimu-
They are known to occur in a significant proportion of lation at three flashes per second has been known to occur
patients having seizure disorders of the primary general- in children with the late infantile form of sphingolipidosis.
ized type, particularly absence seizures. Sometimes a frank
seizure is precipitated by photic stimulation. Figure 16.11
Photoelectric Electrode Artifacts
shows an absence seizure precipitated by a flash rate of 20
per second. Note that the patient was found to be unre- It will be apparent that the light flashes produced during
sponsive during the spike and wave discharges. photic stimulation subject some of the electrodes placed
It should be understood that the presence of a photo- on the patient's head to some very bright illumination.
paroxysmal response does not necessarily indicate that the Occasionally, this light produces a photochemical reaction
patient suffers from epilepsy: rarely, photosensitivity may at the electrode interface that results in the occurrence of
exist unassociated with clinical seizures. A transient photo- artifacts in the EEG tracings. Predictably, these arti-
paroxysmal response may occur in other conditions, e.g., in facts appear chiefly in the Fpl-F7, Fp2-F8, Fpl-F3, and
Sleep 201

Fp1 F7 ,,~/\J:\/'V;J,'(\r'1I!I~rVv~f/\j~f\J~~~'""'-"-\r
F7 T3 vvV\ 1'J'Ji'j~'/'I~~{\l""/V'.l'\.f\f'vV'
T3 T5 ~~VV\~/iAJV'J~p
T5 01 J\/"-J\~

Fp2 Fa ~V\f:vJ"1//\'Jr,:~'r\y'--4/\f\

Fa T4 ~tJ\r""'!\l\JJ\["\N
T4 T6 ~~~"r\jr-1~(\f'rt~vV'vN\J'J'y/\~\J\/\rv~

T602
~.
~
..
~iV;,-,{J:/,"AJv/VV~
~,ftAr\ IvMrvW/VV\ttVV'
Fp1 F3

F3 C3

C3P3~'J~~)
P3 01 ~:':::tj"N\"'/ A,\tV\P-J'V'.j\/'V'.NV\
Fp2 F4 ~ \(f~~:\/I,;\I\~~\{'l';\'(.1 I \/v/\j~'V'i\I
F4 C4 J\lVIjV~',~J(t,~J\(V'V\f"t'\\fI.\j(;,v\JVVJVJVlfvV'Jv.J~
C4P4~~nWfJ
P4 02 ~(\I\{\i\()l\/\f(\h~~)~~
Fz Cz v\"I!Y\JffN\(\;:\V\I.\I\~V
1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111

Figure 16,11, Absence seizure produced by photic stimulation at until several seconds later at the three consecutive arrows.
20 flashes per second, The patient was called by name at the Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibra-
times indicated by the large arrowheads, but did not respond tions: horizontal = 1 second, vertical = 100 ~v.

Fp2-F 4 bipolar derivations. The artifacts are seen as spikes procedure in many EEG laboratories, especially in
or sharp waves occurring in time with the light flashes. patients suspected of having seizure disorders. The impe-
They are readily identified as artifacts since they disappear tus derives from a number of studies that have docu-
when the electrodes concerned are covered with a piece of mented the effect of both naturally occurring and hypnotic-
opaque cloth or plastic. For the most part, these artifacts induced sleep in bringing out or accentuating epileptiform
can be avoided by ensuring that electrode impedances are abnormalities in the EEG. The augmenting effect of sleep
below 5K ohms. is seen both in generalized as well as in focal epilepsies. In
a significant proportion of patients with epilepsy, general-
ized epileptiform discharges may become evident only
during sleep. A dramatic increase in the number of spike
Sleep discharges during drowsiness and light sleep is a charac-
teristic feature of benign Rolandic epilepsy. Also, epilepti-
It is debatable whether sleep, being a natural phenome- form activity may appear for the first time or may be exag-
non, can be considered an activation procedure. In the gerated during sleep in patients with temporal lobe seizure
past several years, sleep recording has become a routine foci. In general, drowsiness and light sleep (stages I and II)
202 16. Activation Procedures

are more effective in bringing out epileptiform abnormali- epileptic patients. This has been variously attributed to the
ties in the EEG than the deeper stages of sleep. increased percentage of time that a person is likely to
spend asleep during the EEG following overnight sleep
deprivation, and also to a specific potentiating effect of
Sedation sleep deprivation per se on epileptiform activity. The tech-
nique followed in sleep deprivation studies varies in differ-
At the time the appointment for the EEG is made, the
ent laboratories. Some laboratories require that the patient
technician should ascertain whether a sleep recording is
stay awake only until midnight; others require all-night
required. Since it may not always be possible to obtain
sleep deprivation prior to taking the EEG.
natural sleep in the EEG laboratory, the referring physi-
cian should authorize the EEG laboratory to administer
sedation if a sleep recording is necessary. Orally
administered chloral hydrate is the preferred drug because
Pharmacological Activation
it produces much less beta activity in the EEG (see Chap-
A number of pharmacological agents have been used to
ter 14) than other sedative agents and also because it is
induce epileptiform activity in patients with seizure dis-
rapidly metabolized. Side effects are minimal, although
orders, the purpose being to determine whether one is
like most other sedative drugs it can also provoke paradoxi-
dealing with a primary generalized or a focal onset seizure.
cal excitation, particularly in hyperactive children. The
The drugs used include certain convulsants such as Metra-
recommended dosage is 25 to 50 mglkg body weight, with
zole (pentylenetetrazol) and bemegride and the bar-
a maximum total dose of 2,000 mg for adults and 1,000 mg
biturates. Metrazole by itself or combined with IPS can
for children. Chloral hydrate can be administered in the
lead to the appearance of epileptiform abnormalities in the
form of a syrup or a capsule. The technician, however,
EEG with progression to generalized seizures. Bemegride
should make a sincere effort to obtain natural sleep before
or p-ethyl-p-methylglutarimide is also a convulsant drug
resorting to administration of the sedative drug. If sedation
with similar effects. Potentially, these drugs can induce
is to be used, it is important that someone who can take the
major seizures and, therefore, should be used with greatest
patient home accompany the patient to the EEG labora-
caution. There are few occasions for the clinical use of
tory, as an automobile should not be driven after a sedative
these drugs at the present time. Some centers utilize them
has been taken.
in the evaluation of possible candidates for seizure surgery.
Among the barbiturates, thiopental injected intraven-
ously has been used to distinguish focal seizures with
Sleep Deprivation secondary bilateral synchrony from primary generalized
seizures. This drug may also be useful in determining
Although there is still some debate as to the value of sleep whether a particular spike focus represents a mirror focus
deprivation as an activation procedure, the majority of (focus occurring in the contralateral side at a homologous
electroencephalographers believe it to be a very useful site, driven by the primary focus) or an independent focus
procedure, particularly in patients with seizure disorders. in some cases of temporal lobe epilepsy. Brevital (metho-
There have been several studies documenting that there is hexital) is another barbiturate derivative; it is a rapidly act-
a significant increase in the yield of EEG epileptiform ing drug that has been shown to activate focal and general-
abnormalities following overnight sleep deprivation in ized epileptiform discharges.
Chapter 17
Average Evoked Potentials

In the decade of the 1980s, many clinical EEG laboratories there was a lack of adequate technology. Let us review
have added average evoked potential studies to their rou- some of the high points that led to this development.
tine procedures. Indeed, short-latency brain-stem audi- As we have seen in the earlier chapters of this text, the
tory-evoked potentials, as well as short- and intermediate- EEG or spontaneous electrical activity of the brain is read-
latency cortical-evoked potentials, lately have proved to be ily picked up and recorded from electrodes placed on the
valuable clinical tools for objectively testing afferent func- patient's scalp. Because the activity produced at the cortex
tions in patients with neurological and sensory disorders. by sensory stimulation is also electrical, it is reasonable to
This being the case, there is need for the EEG technician expect that this activity could be recorded by means of
to become familiar with evoked-potential methods and to scalp electrodes as well. But while this is true in theory,
add a variety of new skills to his or her repertoire. At the serious problems are encountered in practice. When
same time, the person reading and interpreting the records picked up by scalp electrodes, evoked electrical activity
will find it necessary to deal with concepts and techniques appears against a background of spontaneous electrical
that are markedly different from those encountered in activity. In other words, what is seen in reality is a mixture
EEG interpretation. of evoked and spontaneous electrical activity. More often
This chapter is intended to address and, hopefully, to than not, the spontaneous activity is of much greater
meet some of these needs. It is not intended to be an ex- amplitude than the evoked activity.
haustive treatment of the topic of average evoked poten- In technical language, the evoked activity is the "signal"
tials. This would require several chapters or an entire vol- we desire to record and the background activity is "noise:'
ume, and such texts are already available. Rather, our pur- As we just noted, the signal is normally of much lower
pose is only to present a bird's-eye view of the essentials. amplitude than the "noise" so that the proportion of signal
in relation to noise - the signal-to-noise ratio - is low. A
low signal-to-noise ratio means that although a signal is
Historical Background present, it may go undetected because it is hidden or
masked by the noise. To detect an evoked potential it is
It is well known that the sensory modalities are laid out in essential to increase the signal-to-noise ratio; and one can
an orderly fashion throughout the brain right up to the do this either by increasing amplitude of the signal,
level of the cerebral cortex. In the somatosensory system, decreasing amplitude of the noise, or both. Because ampli-
for example, peripheral stimulation evokes electrical activ- tude of signal is governed by the intensity of stimulation,
ity at the cortex that has topographical features - the famil- it is easy to see that the chief way of increasing signal-
iar sensory homunculus. The possible clinical value of to-noise ratio is by reducing the amount of noise. One
recording such evoked electrical activity from the brain to obvious way of doing this is to have the patient keep the
investigate sensory and neurological deficits is obvious and eyes open. Under such conditions the alpha rhythm, which
has long been recognized. On the other hand, the routine for purposes of evoked electrical activity is "noise:' will
recording of evoked brain electrical activity by noninvasive be reduced in amplitude. In the awake, alert individ-
procedures using scalp electrodes has only recently been ual, this leaves a background consisting mostly of low-
realized, although the basic methods for doing so have long amplitude activity in the alpha and beta frequency bands.
been available. The reason for this is that until recently, However, as cortical evoked potentials are commonly less
 204 17. Average Evoked Potentials

than a few microvolts in amplitude, they still may be hid- Signal Averaging
den in the remaining noise of the background activity.
Obviously some other, more powerful method is needed to The advent of digital computers marked the beginning
reduce noise. of a practical, effective, truly quantitative method of en-
It is interesting to note that a method for detecting hancing evoked potentials. Although signal averaging is
small, systematic fluctuations among larger, irregular ones quite complex in the details of the method, it is rela-
was already available in principle during the 18th century. tively simple in principle. To begin with, the mixture of
Laplace, the French mathematician whom we mentioned electrical activity composed of spontaneously generated
in an earlier chapter, hypothesized that it should be possi- voltages and the voltage evoked by stimulation is picked up
ble to demonstrate a lunar tide in atmospheric pressure from scalp electrodes and amplified. This changing pat-
that was smaller than the error in reading a barometer by tern of electrical activity with time is divided into seg-
combining and averaging a sufficiently large number of ments or epochs of equal duration. The start of each epoch
observations. In a similar vein, Sir Francis Galton, the 19th coincides with the presentation of a stimulus, whereas
century English scientist, suggested that the facial char- its duration varies, depending on the nature of the evoked
acteristics common to a number of different individuals potential of interest. In the case of brain stem auditory-
could be extracted from the minor details peculiar to each evoked potentials (BAEPs), for example, the epoch is only
individual by the technique of superimposition. This tech- 10 ms long. On the other hand, for cortical evoked poten-
nique involves optically superimposing a number of simi- tials the epoch may have a duration of several hundred
lar drawings or photographs of different persons. In doing milliseconds.
so, the regular features common to all individuals are The electrical activity contained within each of the
emphasized while the irregular, idiosyncratic features wash epochs is referred to as an analog voltage. This voltage is
out and appear only as a diffuse thickening of the compo- converted to digital form by a process known as analog-to-
site.1 The technique was both simple and ingenious and digital conversion or A-D conversion. The process is akin to
could be applied to enhancing the typical features of a vari- feeding the electrical activity contained within the epoch
ety of different data. What was lacking at the time, into a voltmeter and then reading and tabulating the vol-
however, was the technology needed for rapidly and tages shown at consecutive, equal time intervals following
accurately combining or superimposing the data. the stimulus to the end of the epoch. For example, the volt-
meter might be read at the time the stimulus is presented
and then at 1 ms, 2 ms, 3 ms, and so on following the stimu-
lus. How frequently readings are taken is known as the
Method of Superimposition
sampling rate. Just as a curve plotted from many points will
show more detail than one plotted from a few, a high sam-
At the time of World War II, the method of superimposi- pling rate will better define the way in which the voltage
tion was put to practical use in the early radar systems. By changes within an epoch than a low sampling rate. The
superimposing many faint blips on a cathode-ray tube, it string of numbers corresponding to the voltages present at
was possible to detect signals from a target that were other- specified times within the epoch is stored in a bank of
wise masked by an irregular or noisy background. As early adding counters having a separate bin for each of the num-
as the late 1940s, G. D. Dawson in England applied this bers. Thus, for example, if an epoch lasts for 250 ms and the
same method to detect and enhance cerebral responses to sampling rate of the A-D converter is 1,000 Hz, 251
electrical stimulation of peripheral nerve. Figure 17.1 separate numbers will be entered into a 251-bin counter,
shows a visual-evoked potential obtained on a cathode-ray one number in each bin.
tube using the technique of superimposition. For the The process just described repeats itself in the same way
method to work, all of the separate tracings have to be for each epoch. If, in our example, the stimulus is
lined up so that the times when the stimuli occur coincide. presented a total of 100 times, there will be a total of 100
Although the method is capable of detecting an evoked separate 250-ms epochs. When the A-D conversion has
potential in a noisy background, it does not permit been carried out on each, a total of 100 numbers will have
accurate quantification of the waveform's features. For this been added into each of the 251 bins of the counter. There-
purpose, practical methods of signal averaging are needed. upon, the computer controlling the bank of counters
divides the total in each of the bins by 100 to obtain the
average. Finally, these 251 mean values are used to plot the
I Galton reported that Herbert Spencer, the English philosopher, average evoked potential. This is accomplished by means
also had the idea uf using the teclllliquc uf superimposition to
obtain a composite photograph of several individuals (Pearson K: of the process of digital-to-analog conversion, which is the
The Life, Letters, and Labors of Francis Galton. Cambridge, reverse of A-D conversion. The average evoked potential is
England, The University Press, 1924, vol 2, p 229). displayed on a cathode-ray tube or a hard copy of it is made
Coherent Averaging 205

Figure 17.1. Visual-evoked potential obtained on a cathode-ray sion of the author and publisher from Ciganek L: Excitability
tube using Dawson's superimposition technique. Calibrations: cycle of the visual cortex in man. Ann NY Acad Sci 1964;
5 J.l V, 10 ms (100- Hz calibration signal). (Reproduced by permis- 112:241-253.)

on an X-Y plotter. The whole process is referred to mathe- square root of the number of stimulus repetitions aver-
matically as coherent averaging. aged. Thus, after 100 epochs have been summed, the
evoked activity or signal may be 100 times larger. By con-
trast, the spontaneous activity or noise will have increased
Coherent Averaging only by ";TIm or 10 times. It is apparent that the result in
this case will be a 10:1 signal-to-noise enhancement. What
This term derives from the fact that an evoked potential happens to signal-to-noise enhancement when the num-
that may be present in an epoch will be coherent with, or ber of stimulus repetitions varies is shown in Table 17.1.
time-locked to, the evoking stimulus. Since the brain's Note that in order to double the signal-to-noise enhance-
spontaneous electrical activity is essentially random with ment, the stimulus repetitions need to be quadrupled.
respect to this stimulus, algebraic summing of the signal Table 17.1 makes it clear that a very large number of repe-
containing both evoked and spontaneous activity over a titions is necessary in order to achieve high levels of signal
sufficient number of summing cycles causes the spontane- enhancement. This means that as the size of the evoked
ous activity to sum to zero whereas the evoked activity will activity decreases relative to the spontaneous activity, a
sum linearly. This happens because, on the average, the greater degree of enhancement is needed to detect the
polarity of the evoked activity will always be the same at evoked activity, which, in turn, necessitates a larger num-
any given point in time relative to the evoking stimulus, ber of stimulus repetitions.
whereas the spontaneous activity or noise can be of either As an example, suppose that the amplitude of the evoked
polarity and thus will tend to cancel out. Figure 17.2 shows potential elicited by some form of stimulation is 5 11 V,
how this process works. while the amplitude of the brain's spontaneously generated
Mathematically speaking, the evoked potentials sum up activity is 50 1lV. Now, if there are 200 repetitions of the
linearly, and the spontaneous activity sums up as the stimulus, Table 17.1 shows that the signal-to-noise
 206 17. Average Evoked Potentials

Stimulus Table 17.1. Enhancement of Evoked Activity

Sample t i?Response Buried in Noise Achieved by Signal Averaging in Relation to
the Number of Stimulus Repetitions
Stimulus
Repetitions Signal-to-Noise
2 (SR) ~ Enhancement

10 3.16 3.16:1
3 2,5 5.00 5: I
49 7.00 7:1
4 81 9.00 9:1
100 10.00 10:1
200 14.14 14.14:1
5 400 20.00 20:1
800 28.28 28.28:1
6 1,600 40.00 40:1
2,000 44.72 44.72:1

Average has Increased

amplifiers, filters, A-D converter, and microprocessor or
of 6 built-in microcomputer to perform the summing and aver-
Samples aging operations, The program of the computer is fixed or
\~--~\ Random Noise
Components
hard-wired into the instrument so there is no software to
Hove Diminished deal with, All changes in system parameters-duration of
an epoch, number of stimulus repetitions, repetition rate,
Figure 17.2. Simplified diagram illustrating how coherent averag- etc, - are accomplished by operating various switching
ing enhances a low-level signal. The method depends on the fact devices on the machine, This type of averager also has its
that in each sample. the stimulus evokes a response at the same own self-contained display system, usually a cathode-ray
latency. The responses. therefore. are aligned when the six traces
tube, A hard copy of the data may be obtained by use of a
are added together. Unwanted signals like the EEG rhythms. on
peripheral unit like an X-Y plotter.
the other hand. are not systematically related to the stimulus and
will not be aligned in the six traces. These signals tend to cancel The other type of signal averager is the integrated,
when the traces are added together. When the average is taken. component-type system. This type of system may have its
the response becomes enhanced while the other signals present own amplifiers and filters but sometimes makes use of an
are averaged out. (Taken from Fig. 6. p 4,57 of Bickford RG: EEG machine to amplify and filter the raw signal. The
Newer methods of recording and analyzing EEGs. in Klass OW. amplifier output or IRIG output (see Chapter 3) of the
Daly DO (eds): Current Practice of Clinical Electroencephalogra- EEG machine is then fed into an A-D converter and the
phy. New York. Raven Press. 1979. pp 451-480. by courtesy of digitized output is connected to a general purpose micro-
author and publisher.) computer. Appropriate signal-averaging software controls
processing of the data. The average evoked potentials are
then displayed on a graphics display terminal. Depending
enhancement is 14.14:1. This is equivalent to reducing the upon the software available, a variety of descriptive statis-
noise by a factor of 14.14. which means that combining tics relevant to the features of the waveforms of the average
and averaging two hundred 5 IlV evoked potentials will evoked potentials may be calculated and displayed on the
reduce the 50 IlV background activity to 50 x 1/14.14 = terminal as well. In addition, an assortment of statistical
3.54 1lY. Although this amount of signal enhancement tests using these data may also be carried out at the same
makes it possible to detect an evoked potential that is time.
otherwise buried in the noise, it is clear that the specific It should be evident from the foregoing that the inte-
features of the waveform will be marred if not partially grated, component-type system is more flexible and more
obscured by the presence of the residual background sophisticated than the hard-wired, fixed-program averager.
activity. But it is usually more costly, in terms of both time to set up
and operate and money to purchase. By contrast, the hard-
wired averager is simpler to use, usually cheaper, and fre-
Instrumentation quently more reliable since reloading of programs from
disk or tape whenever a program change is needed is elimi-
Signal averaging systems are of two main types. First of all, nated. For these reasons, the hard-wired. fixed-program
there is the hard-wired. fixed-program ave rage r. This is a averager has been the standard in many clinical laborato-
self-contained system that has its own preamplifiers, ries. In the interest of simplicity, the material and dis-
Practical Clinical Methods 207

cussion that follow assume that this type of system is being present time, hard copies are produced either by an X-Y
used. In the case of the newer systems that employ soft- plotter or by a high-speed, computer-controlled printer.
ware and microchip control of operations, consult the The X-Y plotter performs the function for which it is
appropriate instruction manuals for operational details. aptly named. This instrument is a peripheral recording
device having a pen that traces out the X and Y coordinates
of a voltage (Y) that varies with time (X). The plotting is
Display Systems done on graph paper, which is inserted, a sheet at a time,
by the technician before the plot mode of the averager is
enabled. If a computer-controlled, high-speed printer is
The display systems employed have already been men-
substituted for the X-Y plotter, the production of a hard
tioned briefly in the previous section. Almost universally,
copy of the average evoked potential becomes completely
the hard-wired averager will have a self-contained, cathode-
automated. In this case, graph paper is not used; instead,
ray tube for display of the waveforms of the average evoked
the printer prints a set of axes and identifying labels
potential. Although the appearance of the waveforms
directly onto the perforated, blank paper that normally
varies with the sensory modality stimulated, the location of
comes with the machine. The waveform of the average
the recording electrodes, and the duration of the epoch,
evoked potential is printed on it simultaneously. Such dis-
the waveforms commonly consist of a number of different
play systems usually incorporate a data-point printer
peaks (positive deflections) and troughs (negative deflec-
associated with the cursor so that latencies or ampli-
tions). In general, three kinds of data are derived from the
tudes of particular waves of interest may be printed on
waveforms and used clinically: (1) measures of the latency
the hard copy.
of the various peaks and troughs from the time of stimula-
tion, (2) measures of the time elapsing between particular
peaks and/or particular troughs, and (3) measures of the
amplitude of certain peaks and troughs in the waveforms. Practical Clinical Methods
These data usually are acquired with the help of a clever
device referred to as a cursor or bug. Many of the methods used in conjunction with the record-
The cursor is an intensified portion of the waveform ing of clinical EEGs are appropriate for the recording of
traced on the cathode-ray tube. This bright spot may be average evoked potentials. The same kind of recording
shifted from right to left and vice versa by means of a con- electrodes and methods of application are employed, and
trol on the front panel of the instrument whence it appears electrode placement follows the 10-20 International Sys-
to ride along on the trace. Associated with the cursor is a tem described earlier in the text. As is the case with EEG
readout display that shows the latency of the selected point recording, low-impedance-recording electrodes are essen-
from the time of stimulation as well as the amplitude from tial, and the same precautions regarding the patient's
the zero baseline. Thus, by setting the cursor directly on safety need to be observed. But here is where the direct
the peak or trough of a wave, the machine will display the similarity ends.
latency and amplitude of that wave in digital form on the For routine clinical EEG recordings, a total of 21 elec-
cathode-ray tube. Some averagers also have a second, trodes normally are attached to the patient's scalp. In aver-
independently controlled cursor. When both cursors are age evoked-potential studies, on the other hand, the full
used, the display shows the time between two selected array of electrodes is not needed. Thus, for example, only
points (as the milliseconds between two peaks) and the Cz, AI, and A2 are commonly used in recording BAEPs.
peak-to-peak amplitude of a particular wave (as the num- Fewer recording electrodes, of course, mean that fewer
ber of microvolts between consecutive peaks and troughs) recording channels are necessary. For this reason, most
in the waveform displayed. In actual use, the technician clinical averagers have no more than two to four channels
has to jot down the data from the readout display, prefer- available for simultaneous recording.
ably on a hard copy of the average evoked-potential wave- In recording average evoked potentials, the EEG techni-
form. Some systems have a data-point printer associated cian encounters some unique problems that are not
with the cursor, which relieves the technician of this experienced in routine EEG recording. These problems
manual operation. derive mainly from the fact that whereas in EEG recording
Most signal averagers have some means of providing a the technician receives continuous feedback from the
hard copy, or permanent record, of the average evoked- record concerning the state of the patient and the status of
potential waveform. In the early days of signal averaging, the recording electrodes, in evoked potential recording
the user simply photographed the trace on the cathode-ray he/she does not. The technician mllst wait IIntil all the
tube. But this requires a camera, some bulky equipment stimuli are presented and the averaging process is com-
for mounting it, as well as an optical system for simultane- pleted before knowing with certainty whether or not the
ously viewing and photographing the waveform. At the technique was adequate and the waveform obtained is
208 17. Average Evoked Potentials

acceptable. As one experienced EEG technician has put it: Physiological artifacts due to eye movements and muscle
"With EEGs, you always know from moment to moment twitches, as well as artifacts resulting from mechanical
what's going on; but with average evoked potentials you are movement of the leads, can pose severe problems. Such
working blind:' It is true, of course, that many averagers artifacts may be quite large - sometimes 200 J.1V or more in
provide a "live" display that allows the technician to con- amplitude. Occasionally the eye-movement artifacts may
tinually observe the averaging process and to view the be coherent with the stimulus. If there is reason to suspect
partial results. But it is rarely possible to judge whether a that this may be the case, an eye electrode has to be
waveform that looks like it may be acceptable after 50 attached and the signal from this derivation averaged in the
stimulus repetitions will actually be acceptable after 500 same way as the signal from the scalp electrodes. Should a
repetitions. Similarly, a waveform that looks like pure back- clearly discernible waveform appear in this average, the
ground noise after 50 stimulus repetitions may be trans- possibility exists that the average evoked potential of
formed into a classic, textbook example of an average interest may be contaminated by this eye activity. Aside
evoked potential after 500. This means that the technician from employing rather elaborate subtraction procedures
must learn to depend more and more on the results of vari- that are hardly appropriate in clinical work, the only solu-
ous routine checks -like electrode impedance tests - to tion to this problem is to have the patient exert some volun-
assess the adequacy of herlhis technique rather than wait- tary restraint over hislher eye movements.
ing for the actual test data to become available. If the physiologic artifacts we have been considering are
The presence of artifacts, whether they be instrumental, not coherent with the stimulus, they will average out-
environmental, or physiological, can result in formidable assuming, of course, that there are a sufficient number of
problems for the technician recording average evoked stimulus repetitions. But this is usually not practically
potentials. Instrumental artifacts that occur at random feasible. Consider a simple example: as we learned earlier,
with respect to the stimulus will generally average out if 200 stimulus repetitions will reduce a 50-J.1V background
their amplitude is not too large and a sufficient number of of spontaneously occurring activity to 3.54 J.1y. But sup-
stimulus repetitions are used. On the other hand, instru- pose, now, that in one third of the 200 repetitions some
mental artifacts that are caused by the stimulus or by large amplitude (200 J.1V) eye-movement artifacts are
stimulus-generating circuits will likely be coherent with present. After the 200 repetitions, the average background
the stimulus and are serious sources of contamination. activity would be
They must be eliminated. Fortunately, their presence is
easily documented or ruled out. This is accomplished by 50 x 133 + 200 x 67 _1_ = 708 V
200 x 14.14 . J.1.
going through the usual recording procedure in every
detail except that the stimulus is not allowed to reach the Note that this is twice the amplitude of the average back-
patient's sense organ; in other words, a "sham" test is per- ground activity when the spontaneously occurring activity
formed. Thus, for example, if the stimulus employed is a in each of the 200 repetitions is 50 J.1y. If the average
flash oflight, a tight-fitting cover is placed over the lamp so evoked potential were only 5 J.1 V as in our earlier example,
that the patient cannot see the flash. Under these condi- it would be lost in the higher-amplitude noise of the back-
tions, the averaged waveform should show no evidence of ground. To halve the amplitude of the background activity,
evoked activity. Any such activity that may be present is an we would need to increase the stimulus repetitions from
artifact. The elimination of such artifacts is a job for a 200 to 800.
specialist. The foregoing makes it clear that some technique
Artifacts from the environment, especially 60-Hz besides the brute force method of increasing the number
pickup, can be particularly burdensome. This problem of stimulus repetitions is required to deal with such arti-
comes about because 60-Hz electrical fields from the elec- facts. Most clinical averagers, therefore, contain an artifact
tric power lines are present almost everywhere. If the rejection feature. Sometimes referred to as an overvoItage
stimulus repetition rate happens to be an even multiple of detector, the operation of this device is relatively simple.
60 Hz, the latter can become coherent with the stimulus. Each epoch of digitized data is first stored in a buffer
In other words, the stimulus occurs at the same phase of memory before being entered into the bank of counters. If
the 60 Hz activity each time. When this takes place, the this signal exceeds preset limits in either the positive or
60-Hz activity will sum up as signal rather than as noise, negative direction, this is taken as evidence that an artifact
whereupon it may be significantly enhanced. The simple has occurred. The upshot is that the epoch in question is
solution of the problem is to ensure that the stimulus repe- not added to the counters and an additional trial is auto-
tition rate is not an even multiple of 60. It is essential, of matically taken to make up for the epoch that was rejected.
course, that the impedance of the recording electrodes be Adjusting the setting of the artifact rejection "window"
checked. As with EEG recording, impedance should be represents a compromise. If the window is too narrow, a
less than 5K ohms, and the loop area between the wires large percentage of the epochs will be rejected and some
running to the electrodes must be kept to a minimum. good data may be lost in the process. On the other hand.
General Principles of Interpretation 209

if the window is too wide, epochs containing obvious the case of EEG recording, the technician frequently can
artifacts will be accepted and the degree of signal reduce restlessness by repositioning, relaxing, or reassur-
enhancement reduced. ing the patient. If these measures do not help, the failure to
As is the case with EEG recording, the best approach to replicate might suggest the absence of a normal waveform
artifact reduction is to eliminate the artifacts at their and represent an abnormality. This is taken up in the fol-
sources. Whenever possible, the technician should try lowing section on interpretation.
this approach. Thus, for example, eye movements can fre-
quently be reduced by properly instructing the patient or
by the use of eye pads. Similarly, muscle activity can be
controlled by repositioning the patient, or by providing
General Principles of Interpretation
some help with relaxation. Finally, artifacts due to
mechanical movements of the electrode wires can be mini- The useful clinical information in an average evoked
mized by ensuring that the wires are properly supported potential resides in the latencies and amplitudes of certain
and are not allowed to dangle, sway, or otherwise move waves or components that are typically present in the
about during the recording. waveform. Therefore, the first step in interpretation entails
An aspect unique to the recording of average evoked the identification of the various components of which the
potentials is the stimulus repetition rate. Because a large average evoked potential for a particular sensory modality
number of stimuli need to be presented to obtain an aver- is formed. This may be relatively easy to do in the case of
age evoked potential, the rate of presentation is important. a waveform that is readily replicable and has all of the usual
If the rate is too slow, an untoward amount of time will be waves present at the expected latencies. But if one or more
consumed in obtaining the necessary data. On the other of the usual components appear to be absent, or if the
hand, if a very fast rate is used and one stimulus follows latency of one or more of the waves is prolonged, the inter-
another too closely, the effects of the second stimulus will preter may be faced with a dilemma. Delayed or absent
be contaminated or confounded by the response to the first waves are suggestive of pathology, but they may equally
stimulus. For this reason, the repetition rate varies, depend- well be due to the presence of artifacts that obfuscate the
ing on the particular evoked-potential study underway. waveform.
The actual repetition rates used in practice are taken up A variety of special techniques have been devised to
later in sections dealing with specific average evoked- help identify certain of the waves in an average evoked
potential studies. potential and, hence, to alleviate the dilemma. For exam-
As we will see in the next section, the first step in the ple, as we will see in the section dealing with BAEPs, data
interpretation of an average evoked potential is the iden- simultaneously obtained from the contralateral side can
tification of the various components of the waveform. In aid in identifying waves IV and V of the complex waveform.
doing this, how can we be sure that a particular wave we Similarly, the use of alternating compression and rarefac-
pick out is really the component we think it is, and not an tion clicks as the stimuli can help to distinguish wave I
artifact or part of the spontaneously generated activity that from stimulus artifact and cochlear potentials. However,
is noise? The answer is that we cannot be certain, having when these techniques fail, or when special techniques of
only the single average evoked potential upon which to this kind are not available to help identify certain waves,
base our judgment. But if the study is repeated again and the person interpreting the data must fall back on replica-
again, and the particular wave is replicated, we can be tion as the criterion for identifying the waves. The rule
fairly confident that the wave is indeed signal and not here is simple and straightforward. Waveforms that fail to
noise. In actual practice, every average evoked-potential replicate are considered to be unreliable and hence unin-
study is repeated at least once. If the waveform or wave- terpretable, even though the possibility exists that they
forms replicate, these data are taken to be representative might represent some kind of abnormality.
and are used to define the latency and amplitude param- Once the various components of a waveform have been
eters of the average evoked potential. Conversely, if the identified, the person interpreting the data is ready for the
waveforms fail to replicate, the study is repeated a second next step. This involves comparison of the relevant param-
and sometimes a third time. eters of the patient's recorded waveforms with a set of
Failure to replicate a study- or failure to obtain closely norms. Normative data for average evoked potentials for
similar waveforms on several studies - is sometimes the different sensory modalities have been published by a
attributable to restlessness of the patient. Thus, restless- number of laboratories. These data continue to be up-
ness produces artifacts that contaminate the averaged dated, and so it is essential for the person interpreting aver-
waveform; this contamination, in turn, obscures identifica- age evoked potentials to keep abreast of the latest work in
tion of the waveform's components. In averagers having an the area. As it is important to be familiar with the pub-
artifact reject feature, restlessness is accompanied by a lished norms, it is likewise important for each laboratory to
large number of stimulus repetitions being rejected. As is have its own normative data as well. Norms vary somewhat
210 1i. Average Evoked Potentials

with sex and vary markedly with age of a patient. For pre- Table 17.2. Relationship Between Check Size and Visual Angle at
mature infants they show considerable variability as well. a Distance of 1 m a
In the following three major sections, we take up Visual Angle
Number of Width of One
specific aspects of technique and interpretation relevant to Checks Check (em) Degrees Minutes of Arc
visual-evoked potentials, BAEPs, and somatosensory-
8 x 8 3.2 1.113 110.4
evoked potentials. 10 x 10 1.0 0.92 .5.5.2
32 x 32 0.11 0.46 2i.6
64 x 64 0.4 0.23 13.8
Visual-Evoked Potential (VEP) aThe TV monitor measures 211 x 23 em.

Anatomical Basis of the YEP

Visual-evoked potentials represent electrical activity reverse without there being any change in the luminance,
induced in the visual cortex by light stimuli that reach the or total light output of the screen. A number of stimulus
macular and perimacular areas of the retina. The macula is parameters are known to influence the VEP. These include
rich in cones that are retinal receptors that convert light the rate of pattern reversal, the size of the checks, and
energy into electrical energy. The electrical impulses are the luminance. There are also patient-related factors that
carried through the optic nerve, which consists ofaxons affect the degree of retinal stimulation, namely, visual
arising from the ganglion cells of the retina. Axons from the acuity, visual fixation, and pupillary size.
nasal half of the retina (including nasal half of the macula) A pattern-reversal rate of 1 to 2/s has been found to be
cross to the opposite side at the optic chiasm. From there, optimal for recording the transient visual-evoked potential,
fibers from the temporal half of the ipsilateral retina and which is used most often in routine clinical practice; a
from the nasal half of the contralateral retina form the steady-state evoked potential is recorded when the stimu-
optic tract on each side. The axons forming the optic tract lus rate exceeds 10 per second. Although the VEP can be
synapse at the lateral geniculate body. Thenceforth, the obtained with even slower rates of stimulation, there are
neuronal cell bodies in the lateral geniculate body give rise disadvantages. With a slower rate, the test becomes more
to the optic radiation. The optic radiation is located in the time-consuming, and there is a greater chance that the
subcortical regions of the parietal and temporal lobes. It patient may not fixate on the screen. If the stimulus rate is
terminates in the visual cortex, which is situated in the too fast, the response to one stimulus may contaminate the
medial part of the occipital lobe, in and around the calca- response to the subsequent stimulus.
rine fissure and the occipital pole (see Fig. A2.5). The The visual angle, or the angle that the individual checks
result is that the left visual cortex is connected to fibers subtend at the retina, has a significant effect on the latency
that carry signals from the temporal half of the left retina of the response and, hence, needs to be standardized. It
and the nasal half of the right retina and vice versa. This depends upon the height or width of the checks, as well as
means that objects situated in the right half of the visual the distance between screen and eye. The formula used for
field are perceived by the left visual cortex. the calculation is: Visual angle = 57.3 (WID), where W is
It should be obvious that when either eye is stimulated the width of one check and 0 is the distance between eye
separately (full-field stimulation), signals pass onto both and screen, both in centimeters. Table 17.2 gives the rela-
visual cortices because the nasal fibers cross to the oppo- tionship between check size and the visual angle at a dis-
site side at the optic chiasm. Such stimulation is more use- tance of 1 m.
ful in evaluating the anterior visual pathways (optic nerves The brightness setting of the monitor should be kept
and chiasm) than the retrochiasmal pathways (optic tract, constant to maintain the same mean luminance of the
radiation and visual cortices). However, each half of the checkerboard pattern. Similarly, ambient luminance of the
retina can be stimulated separately (half-field stimulation), room needs to be kept at a constant level. Consistency of
thereby enabling one to determine the functional status of these settings is essential for obtaining consistent data.
the retrochiasmal visual pathways more accurately. The luminance can be measured using a spot photometer.
The patient is asked to fixate on a dot placed in the
center of the TV monitor screen. The purpose of the fixa-
Stimulus Parameters of the YEP
tion point is to ensure that the macular and peri macular
Two types of stimuli are used for recording VEp, namely, areas of the retina are stimulated. The visual-evoked
pattern and flash. In the case of pattern visual stimuli, the potential becomes smaller in amplitude whenever good
standard technique makes use of a black-white shift or visual fixation is not achieved.
reversal in a checkerboard pattern electronically produced The size of the pupil determines the amount of light that
on a TV monitor. The black and white squares are made to enters the eye and, hence, can affect the VEP The patient
Visual Evoked Potential (VEP) 211

should not have mydriatics or cycloplegics for at least 12

hours prior to the test. Visual acuity can also influence the
latency and amplitude of VEP. The patient should wear
03Cz
corrective glasses, if any, during the test. If there is a
marked deficiency in visual acuity, the checks should be
made larger so that the patient can see them clearly. The
technician should assess the patient's visual acuity- using
a Snellen chart - and pupillary size and enter these data in
the worksheet before commencing the test. Oz Cz
Flashes from a photic stimulator positioned 30 to 45 cm
in front of the subject's eye may also be used as the stimuli.
The stimulation rate is usually between 0.5 to lis. The flash
YEP is useful in patients whose visual acuity is poor or in
comatose/anesthetized patients. However, it shows more
variability than the pattern-reversal YEP and, hence, is less 04 Cz
reliable for clinical use.

Recording Parameters of the YEP

Figure 17.3. Normal VEPs to pattern-reversal, full-field stimula-
The recommended filter settings are 0.2 to 2 Hz low fre-
tion of the right eye using a checkerboard image of 16 x 16
quency and 100 to 500 Hz high frequency. Analysis time is
checks at a distance of 1 m. Stimulation rate at 1.88/s. The band-
250 ms; but if no response is obtained, the study should be pass is at 1 to 100 Hz, and 2.'50 trials were averaged. Two separate
repeated at 500 ms before it is presumed that the YEP is tests were run, and the paired tracings show good replication.
absent. The number of trials averaged can vary from 100 to The downgoing arrow points to N7.'5, while the upgoing arrow
200, although a larger number may be needed if the poten- indicates PI 00. Calibrations: horizontal = .'50 ms, vertical =
tials are not well delineated. Recording electrodes are .'5 11 V.
standard EEG electrodes placed over the occipital areas.
The American EEG Societey (American Electroencepha-
lographic Society Guidelines, 1986) recommends a mid- Abnormal YEP
line occipital electrode 5 cm above the inion and right and
The abnormalities include absence of a YEP, prolonged
left occipital electrodes, each 5 cm lateral to the midline
PIOO latency, and an excessive interocular difference in
electrode. These are referenced to a midfrontal electrode
PIOO latency.
that is located 12 cm above the nasion. The ground elec-
When the technician discovers that the YEP is absent, a
trode may be placed over Fpl" At least two trials should be
number of steps have to be taken to ensure that a technical
done to ensure that the waveforms recorded are replicable.
problem is not to blame. These include: (I) making sure
that the TV monitor is connected to the evoked-potential
Normal YEP machine and that the two are synchronized so that a pat-
tern shift occurs each time the averager is triggered; (2)
The normal YEP often contains three peaks. The initial ensuring that the patient is focusing on the checks; and (3)
peak is negative and occurs at a mean latency of 7.5 ms; it making sure that the electrodes are properly applied, that
is designated N75. The most prominent and consistent their impedances are less than 3K ohms, and that the elec-
wave is a positive peak (Fig. 17.3), which has a mean trode box is connected to the machine. Once these condi-
latency of 100 ms and is called PIOO. A subsequent nega- tions are satisfied, the test should be run again using a
tive peak may be seen at a mean latency of 145 ms (NI45). .500-ms sweep so that a possible delayed response is not
The latency to the peak of the PIOO wave is measured missed. If the YEP is still absent, the finding is definitely
along with PIOO amplitude, taken from the peak of N75 to abnormal. If monocular full-field stimulation results in an
the peak of PIOO. The absolute latency of PIOO, and any absent response on one side and a normal response on the
interocular differences in latency and amplitude of PIOO, other, a lesion of the ipsilateral optic nerve is most likely,
are used as criteria for interpretation. Normal values provided ocular pathology, including retinal lesions, is
should be established in each laboratory. Latency values excluded. Absence of the YEP on monocular stimulation
exceeding three standard deviations are considered abnor- of right and left eyes suggests either bilateral optic nerve or
mal. An interocular difference in latency of more than 8 to chiasmallesions, or less commonly, bilateral retrochiasmal
10 ms is often considered abnormal. lesions.
212 17. Average Evoked Potentials

Prolonged PIOO latency characteristically occurs in Anatomical Basis of the BAEP

demyelination of the anterior visual pathways; amplitude
attenuation is more typically seen in compressive lesions. It is helpful to have a basic understanding of the mechanics
If a prolonged latency occurs only on left or right eye of the ear when attempting to record the BAEP. The exter-
stimulation, a lesion of the ipsilateral optic nerve is most nal ear-which consists of the auricle or pinna and the
likely. Such findings are most characteristically seen in external auditory meatus - serves to funnel sound waves
optic neuropathies, particularly the demyelinating type as onto the tympanic membrane (eardrum), which separates
occurs in multiple sclerosis. On the other hand, if latency the external ear from the middle ear. The middle ear is a
is prolonged on stimulation of either side, bilateral optic small cavity within the temporal bone. It contains three
nerve or retrochiasmal lesions are to be suspected. An tiny bones (ossicles) called malleus, incus, and stapes.
excessive interocular difference in latency suggests an These bones transmit the vibrations of the tympanic mem-
optic nerve lesion on the side with the longer latency. brane onto the inner ear. The stapes, or innermost ossicle,
has a foot plate that sits in the oval window, separating the
middle ear from the inner ear.
Clinical Correlation of Abnormal YEP
Unlike the middle ear, the inner ear is a fluid-filled
The pattern-reversal YEP is particularly useful in the diag- cavity with two components. One component, the cochlea,
nosis of multiple sclerosis. This is because of the high inci- is concerned with hearing and the other, the vestibular
dence of optic nerve demyelination in these patients. It has apparatus, is concerned with balance. The cochlea is a
been estimated that 20% to 50% of patients presenting spiral-shaped channel that has basal and apical turns. A
with optic neuropathy may develop multiple sclerosis in part of the cochlea called the scala media contains the
the future. The test is particularly useful in confirming a actual receptors for hearing-the organ of Corti. The
diagnosis of optic neuropathy when the symptoms are major components of the receptors are the hair cells
atypical. In addition, abnormalities resulting from demye- attached to the basilar membrane, which forms one of the
lination of the optic nerve tend to persist for several years walls of the scala media. The movements of the stapes in
even after return of visual functioning to normal. Thus, response to sound waves reaching the eardrum cause
abnormal YEP is useful in documenting a past optic neu- movements of selected areas of the basilar membrane,
ropathy, thereby making it a valuable tool in the diagnosis depending on the frequency of the sound. This, in turn,
of multiple sclerosis. In definite cases of multiple sclerosis, leads to movement of the hair-like processes, which
abnormalities in YEP have been reported to occur in about triggers the electrical potentials in the auditory nerve
85% of patients. The changes noted in the PlOO response endings. The electric signals are carried through the audi-
include excessive interocular difference in latency, tory nerve (axons derived from the spiral ganglion), which
prolonged absolute latency, decreased amplitude, and dis- serves as the connection between the cochlea and the
torted appearance. The first two have been found to be the brain stem.
most reliable criteria. Entering the brain stem at the pontomedullary junc-
The optic nerve and optic chiasm may be compressed tion, the auditory nerve fibers make connections with
by tumors like optic nerve glioma and sellar masses. the ventral and dorsal cochlear nuclei and subsequently
Decreased amplitude and sometimes prolonged latency of with the superior olivary nucleus situated in the pons.
the PlOO response may be seen in such cases. The fibers that cross from one superior olivary nucleus
As mentioned earlier, full-field, pattern-reversal YEP is to the other form the trapezoid body. Axons arising from
not quite effective in diagnosing retrochiasmal disorders. the superior olivary nucleus travel dorsally in the lateral
With half-field stimulation, there is a greater chance of lemniscus. Both crossed and uncrossed fibers are present
documenting disorders of the optic tract, optic radiation, in the lateral lemniscus. The lateral lemniscus makes
and occipital cortex. But even in cortical blindness, it has connections with the inferior colliculus situated in the
been observed that the VEPs are not consistently lost. dorsal aspect of the midbrain. This structure, in turn,
There are a number of other clinical indications for YEP, sends signals to the medial geniculate body. From there
but these are beyond the scope of this text. they reach the auditory cortex in the temporal lobe of the
brain (Figs. A2.6, A2.7).
The multiple components of the BAEP arise at the dif-
Brain-Stem Auditory-Evoked Potential ferent tracts or cell stations comprising the auditory path-
way. Wave I is believed to reflect activity in the auditory
The short latency BAEP consists of a series of electrical nerve; waves II and III, activity in the cochlear and super-
potentials generated in the auditory nerve and the brain- ior olivary nuclei of the pons; and waves IV and V, activity
stem auditory pathways in response to auditory stimuli. We in the lateral lemniscus and the inferior colliculi of the
begin by considering the anatomical basis of these poten- midbrain. Thus, I to III interpeak latency reflects conduc-
tials. tion between auditory nerve and the pons; III to V inter-
Brain-Stem Auditory-Evoked Potential 213

peak latency reflects conduction between pontine and III

midbrain components of the brain stem auditory pathways.
!
Stimulus Parameters of the BAEP
Although the auditory stimulus may be given in the form
of clicks, tone pips, or tone bursts, most often broadband Cz A1
clicks are used. A broadband click is one in which a wide
range of audio frequencies - from 100 Hz to 8K Hz - is
present so that the entire cochlea is stimulated. The clicks
are generated by driving a standard audiometric ear
speaker with a brief electrical pulse of 100-l1s duration.
The BAEPs obtained may show variations, depending on a
number of stimulus parameters. These include polarity,
rate, and intensity of the click.
Cz A2
Stimulus Polarity. Two types of clicks may be produced,
one that moves the earphone diaphragm away from the
eardrum (rarefaction click), and one that moves it in the
opposite direction (condensation or compression click).
One may use rarefaction clicks, condensation clicks, or
clicks with alternating polarity for the test. Since the
response characteristics can vary, depending on click Figure 17.4. Normal brain-stem auditory-evoked potentials to left
polarity, the type of stimulus used should be specified in ear stimulation at 60 dbSL. Rarefaction clicks were used at a
the worksheet. stimulation rate of 11.1/s. The bandpass is at 30 to 3,000 Hz, and
2,000 trials were averaged. The two tests run show excellent
Stimulus Rate. Many of the waveforms are reduced in replication between the paired tracings. Arrows point to waves I
amplitude at high rates of stimulation. The preferred to Y, which have average latencies of 1.58, 3.00, 3.90, 5.12, and
stimulus rate for BAEP is 8 to 10/s. Most machines on the 6.12 ms, respecti\'ely, for the Cz-A1 derivation. Calibrations:
market are capable of rates ranging from 1 to 70/s. horizontal = 1 ms, vertical = 0.5 ~\'.

Stimulus Intensity. There are many ways of defining the

stimulus intensity. Most laboratories use two scales: hear- intensity of the stimulating click is used as the mask-
ing level (HL) and sensation level (SL). To establish !the ing stimulus.
HL value, a number of normal persons are tested to deter~
mine the hearing threshold, or the lowest click intensity
that can be heard, and rthe mean value is determined. BAEP Recording Techniques
This is taken as zero dBHL, and may vary from 5 to 30~aB,
The recording electrodes are placed on the earlobes (or
depending on the characteristics of the stimulator, ear-
mastoids) and over Cz, the vertex. The ground electrode
phone, and laboratory environment. If we assume zero
may be placed at Fz. With a two-channel system, channel
dBHL to be 20 dB, then a 50-dB dick has an actual in-
1 should record between vertex and ipsilateral earlobe,
tensity of 50 minus 20, or 40 dBHL, which is 40 dB above
and channel 2 between vertex and contralateral earlobe.
hearing level. Alternatively, the patient's own hearing
The recommended filter settings are 30 to 100 Hz low fre-
threshold may be taken as the zero measure. If the hearing
quency and 2,500 to 3,000 Hz high frequency. Although an
threshold is ;30 dB and a 50-dB click is used, then the
. analysis time of 10 ms is often used, it is better to increase
actual intensity is 50 minus 30, or 30 dBSL, which is 30 dB
it to 15 ms so that any delayed responses will not be
above sensation level. The click intensity used should be
missed. The number of trials may vary from 1,000 to 4,000,
recorded in dBHL or dBSL.
but usually 2,000 trials are adequate.
During monaural testing, it is important to mask the
contralateral ear to avoid recording a crossover response
from inadvertent stimulation of the contralateral ear via Normal BAEP
bone conduction of the stimulus;, This is particularly
important when a high-intensity click is used on the The normal BAEP typically shows five distinct peaks (Fig.
side with poor hearing, and the contralateral ear happens 17.4) in the Cz to ipsilateral ear derivation (positivity at
to be normal. Usually, white noise at 30 dB below the Cz). These are named serially I through V. Wave I is distin-
214 17. Average Evoked Potentials

guished by its presence in the Cz to ipsilateral ear deriva- Clinical Correlation of Abnormal BAEP
tion and absence in the Cz to contralateral ear derivation.
Eighth-Nerve Tumor. The BAEP is a very sensitive indica-
Wave V is distinguished by its prominent trough below the
tor for tumors that arise from or compress the eighth nerve.
baseline. Waves IV and V are sometimes fused, but tend to
In the case of an acoustic neurinoma, wave I may be absent
be more distinct in the Cz to contralateral ear derivation.
on the side of the lesion or the I to III interpeak latency
Wave III is normally equidistant between waves I and V
may be prolonged. The test has been found to be highly
and is less prominent in the Cz to contralateral ear deriva-
sensitive in this regard, with some studies suggesting 90%
tion. The measurements taken are the peak latencies of
to 95% sensitivity. With a large cerebellopontine angle
waves I, III, and V and the amplitudes of waves I and v.
tumor compressing the brain stem, the III to V interpeak
Interpeak latency values for I to III, III to V, and I to V are
latency may be prolonged, often on the contralateral side.
calculated. The peak amplitude ratio between V and I is
In the case of intra-axial tumors, such as brain-stem gli-
also estimated.
oma, bilateral prolongation of III to V interpeak latency is
Each laboratory should have its own normative data.
the more common finding.
Values beyond three standard deviations (SD) of the mean
of normal age-matched controls are considered to be Demyelinating Disease. In a patient with a single episode
definitely abnormal. It should be noted that the latency of neurological deficit such as optic neuropathy or diplo-
values may vary with the age and gender of the patient, pia, it is often difficult to make a diagnosis of multiple
apart from stimulus parameters. Published normative data sclerosis. Although the magnetic resonance imaging (MRI)
(Chiappa KH, Gladstone KJ, and Young RR, 1979) suggest scan has become the most useful tool for diagnosing this
the following upper interpeak latency values (mean + 3 condition, multiple pathway dysfunction is best docu-
SD) at a click rate of lOIs: I to III, 2.6 ms; III to V, 2.4 ms; mented by a battery of evoked-potential tests. In this con-
and I to V, 4.7 ms for a group aged 15 to 51 years. Values in text, the BAEP is a very useful technique, particularly to
excess of these are considered to be abnormal. An inter-ear document subclinical lesions. A high incidence of abnor-
I to V interpeak latency difference of more than 0.5 ms is malities has been reported in definite cases of multiple
also considered to be abnormal. The latency values are sclerosis. The abnormalities may be in the form of
mildly prolonged in old and very young persons. Females prolonged interpeak latencies and absence or distortion of
have slightly shorter III to V and I to V interpeak latencies the waveforms.
than males. Body temperature also influences latency of
the BAEP waves.
Coma. Since the BAEPs are not affected to any significant
degree by metabolic derangements or by drugs, BAEP is a
It should be obvious that identification of the various
good test for detecting structural abnormalities of the
waveforms is crucial for proper interpretation of the BAEP.
Absolute latency values are of less significance than inter- brain stem in patients in coma. Thus, if a good wave I is
peak latencies. This is because changes in wave I latency present and all the subsequent waveforms are absent or
disorganized, or the interpeak latencies are prolonged, one
that occur from cochlear or other ear disorders can pro-
long the latencies of the subsequent waves. Without iden- may conclude that there is some structural abnormality of
tification of wave I, the interpretation becomes less the brain stem. Of course, if wave I is also absent, such a
specific. Sometimes wave I may be obscured by the stimu- conclusion cannot be drawn because of the possibility that
lus artifact or by cochlear microphonics; in such cases, use the clicks may not be stimulating the cochlea and trigger-
of alternating clicks may be quite helpful. With alternating ing signals in the auditory nerve. Total absence of all waves
subsequent to wave I in a patient with suspected brain
clicks, the cochlear potential reverses in polarity and can-
cels out during averaging so that wave I is easier to detect. death may be used as a confirmatory test for the lack of
brain stem function. The BAEP also serves to distinguish
between metabolic coma and coma resulting from struc-
Abnormal BAEP turallesions of the brain stem.
Apart from the above indications, the BAEP studies are
The BAEP is considered to be abnormal and suggestive of
retrocochlear dysfunction when there is (1) complete loss very useful in assessing hearing in pediatric patients who
of all waveforms (in the absence of severe middle ear or cannot cooperate in standard audiometric testing.
cochlear disease), (2) absence of waveforms following
waves I or III, (3) abnormally prolonged interpeak laten-
cies, or (4) abnormal inter-ear difference in the I to V inter- Short-Latency Somatosensory-Evoked
peak latencies. A low VII amplitude ratio is also considered Potential (SSEP)
to be abnormal, especially when accompanied hy other
abnormalities (American Electroencephalographic Soci- Recording of SSEPs may be viewed as an extension of
ety Guidelines, op. cit). nerve conduction studies to the central somatosensory
Short-Latency Somatosensory-Evoked Potential (SSEP) 215

pathways. The short-latency SSEPs are electrical responses The cathode (negative-stimulating electrode) is placed
generated in the sensory pathways normally within the first proximal to the anode (positive-stimulating electrode).
50 ms following the stimulus. Stimulus parameters are detailed below.

Stimulus Rate. The number of electrical stimuli delivered

Anatomical Basis of the SSEP per second determines the degree of discomfort experi-
Some knowledge of the anatomy of the peripheral nerves enced by the patient and, to some extent, the response
and the somatosensory pathways in the spinal cord and obtained. A stimulus rate of 4 to 7/s has been suggested
above is essential for a clear understanding of the SSEPs. A (American Electroencephalographic Society Guidelines,
1986).
large number of different types of receptors are present in
the skin and other tissues that can be activated by different Stimulus Duration. Duration of the electric stimulus,
stimuli. However, since stimuli such as touch and pain are which is in the form of a square-wave pulse, can be varied
difficult to quantify, electrical stimulation of the nerve to obtain an optimum response. With longer durations,
fibers is employed in SSEP studies. The most commonly there is more discomfort and more artifacts. With very
tested nerves are the median and the posterior tibial brief durations, the response may not be adequate. Usually
nerves, but any peripheral nerve such as the ulnar or the 0.1- to O.2-ms pulses are used.
common peroneal nerve may also be used. The site for
stimulation of the median nerve is in front of the forearm Stimulus Intensity. This is measured in terms of the
close to the wrist, between the tendons of palmaris longus amount of current delivered during the stimulus. The cur-
and flexor carpi radialis. The site for tibial nerve stimula- rent can vary from 1 to 20 mA, depending on the amount
tion is at the medial aspect of the ankle, between the needed to elicit a muscle twitch. A stimulus twice the sen-
medial malleolus and the tendo Achilles. In the case of the sory threshold is used as a guideline if an obvious twitch is
common peroneal nerve, the stimulation site is at the neck not observed. As the intensity of the stimulus is increased,
of the fibula behind the knee. The ulnar nerve is easily more artifacts are likely to occur and more traces will be
stimulated on the medial aspect of the forearm, close to rejected by the averager, thus prolonging the test.
the wrist. Stimulation of these nerves should induce When using surface stimulating electrodes, reducing
twitching of the muscles supplied by them. In the case of the skin resistance decreases the voltage needed to deliver
the median nerve, there will be movements of the thumb; sufficient current. With needle electrodes placed sub-
for the ulnar nerve, there will be movement of the little cutaneously, much smaller currents may be used.
finger. In the case of the tibial nerve, movements of the big
toe will be observed. Recording Parameters of the SSEP
Electrical impulses are carried through the nerve
trunks, plexuses, and nerve roots to the spinal cord. For the Electrode Placement and Montages. For obvious reasons,
median and ulnar nerves, the brachial plexus and cervical the electrode placement varies, depending on the nerve
nerve roots are the pathways, whereas for the tibial and that is stimulated. In the case of the upper-extremity
peroneal nerves the corresponding pathways are the lum- nerves, electrodes are placed over the brachial plexus at
bosacral plexus and component nerve roots. The signals Erb's point, which is 2 em above the midpoint of the collar
travel in the dorsal columns of the spinal cord and reach bone, and the cervical spine (C-2, C-5, or C-7 spine). Scalp
the lower end of the medulla. At this point the fibers syn- electrodes are located over the contralateral somatosen-
apse, cross to the opposite side, and form the mediallem- sory area, i.e., 2 em behind C3 or C4. These placements
nisci. The medial lemnisci carry the impulses to the thala- are designated C3' and C4', respectively. The reference
mus where these fibers synapse. From the thalamus, the electrode may be placed over Fz. A ground electrode is
sensory signals reach the sensory cortex through the located on the forearm on the side of stimulation. Channel
thalamocortical fibers (see Fig. A2.10). . 1 records between Eros point on the side of stimulation
Electrical potentials generated in response to periph- and Erb's point on the contralateral side. Channel 2
eral nerve stimulation can be recorded percutaneously records between the cervical spine electrode and Fz,
over the plexuses, the spinal cord, and the sensory cortex. while channel 3 records between C3' or C4' and Fz. Some-
times potentials apparently arising from the medial lem-
niscus may be recorded by connecting the C3' or C4' elec-
Stimulus Parameters of the SSEP
trode to the contralateral Erb's point.
As already noted, electrical stimuli are used for inducing For lower-extremity nerves, the recording electrodes are
SSEPs. The site of stimulation depends on the particular placed over the tibial nerve in the middle of the popliteal
nerve under investigation. The sites for median, ulnar, fossa, the L-3 spine or spinous process above a line con-
peroneal, and tibial nerves have already been indicated. necting the highest points of the iliac crests of the hip
216 17. Average Evoked Potentials

waves are named after their polarity- N for negative and P

for positive-and a suffix, which gives the mean latency in
milliseconds. Thus, the negative potential over the brachial
plexus is called an N9 response, the one over the cervical
spine is called N13, and the first significant negative poten-
LErb.-Fpz tial seen over the cortex is designated N 19 or N20. The
latter is often followed by a positive potential called P22
(Fig. 17.5). The N9 potential is believed to arise from pas-
sage of the stimulus through the brachial plexus. The N 13
wave is a complex response and may have more than one
peak, in which case the component peaks are designated
NIl and N13. NIl is believed to be due to the passage of
Cr7- Fp z signals through the cervical nerve roots, and N 13 to signals
passing through the dorsal columns and arriving and syn-
apsing at the lower end of the medulla. The N 19 potential
signals the arrival of the stimuli at the sensory cortex. P 14,
a peak representing the passage of signals through the
medial lemniscus, may be seen in farfield recording 2
between scalp and contralateral Erb's point.

Tibial Nerve. The negative potential recorded over the

Figure 17.5. Normal somatosensory-evoked potentia\' left popliteal fossa usually has a latency of 6 to 10 ms, depend-
median nerve study. Stimulation rate at 6.lIs. The bandpass is at ing on limb length and temperature. The lumbar potential
20 to 3,000 Hz, and 500 trials were averaged. The two tests run is often seen between 14 and 24 ms, again varying with
show good replication between the paired tracings. From top to limb length and temperature. The lumbar potential is the
bottom, arrows point to N9, N13, and N19; their average values benchmark on which further calculations are made and
are 9.60, 13.20, and 19.00 ms, respectively. Calibrations: hori-
for this reason is crucial for interpretation. The cortical
zontal = 10 ms, vertical = 2.5 1lV.
response shows a positive wave at a latency of about 37
ms-the P37 response. This may be followed by a negative
bones and the T -12 spine. Scalp electrodes are located 2 deflection at a latency of 45 ms, which is designated the
cm behind the vertex and at Fz. The former is designated N45 response.
Cz~ A ground electrode is placed over the calf. Channell It is important again to point out that each laboratory
records between the electrode in the popliteal fossa and an should have its own normative data. Variation of more than
electrode placed on the medial surface of the knee. Chan- 3 SDs from the mean of the normal group is considered
nel 2 records between the L-3 spine electrode and the definitely abnormal. Figure 17.6 shows a normal tibial
T-12 electrode. Channel 3 records between the T-12 elec- nerve study.
trode and an additional electrode that is placed 4 cm ros-
trally over the spine. Finally, channel 4 records between
Abnormal SSEPs
Cz' and Fz.
Filter Settings. The recommended filter settings are 5 to In the case of the median nerve SSEP, the interpeak
30 Hz low frequency and 2,500 to 4,000 Hz high fre- latency between N9 and N13, as well as between N13 and
quency. N20, is taken into consideration. Prolongation of the inter-
peak latency between N9 and N13 suggests a slowing of
Analysis Time. For upper-extremity studies, a 50-ms
conduction in the cervical nerve roots and/or the cervical
epoch is suitable. For lower-extremity studies, 100 ms is
dorsal columns. A prolonged interpeak latency between
more appropriate. This should be increased if no cortical
the N 13 and N20 responses would suggest delayed con-
responses are observed so as not to miss a delayed
duction in the pathway between the medulla and the sen-
response.
sory cortex. Absence of cortical potentials in the presence
Number of Trials. The number of responses averaged may of a normal N13 response suggests a lesion involving the
vary from 500 to 2,000. medial lemniscus, the thalamocortical projections, and/or
the sensory cortex. Excessive left-right interpeak latency
Normal SSEP
Median Nerve. Distinct potentials can be recorded over 2Farfield recording is a term used to indicate that the source of
Erb's point, the cervical spine, as well as the scalp. The the recorded potential is a field remote from the recording site.
Short-Latency Somatosensory-Evoked Potential (SSEP) 217

differences are also used as criteria to detect abnormali-

+
ties. Since absolute latency values are of much less signif-
icance than interpeak latency values, absence of the N9 I Kn.-L5
response makes interpretation very difficult. If none of the
potentials are obtained, a troubleshooting procedure
should be carried out to make sure that the stimuli are
actually being given, that the recording electrodes are
properly applied, and that the electrodes are indeed con-
nected to the evoked-potential machine.
In the case of the tibial nerve SSEPs, the interpeak
latency between the spinal and the cortical potential is
t
taken as a criterion for abnormality. Prolongation of the

~-
central conduction time would suggest a lesion anywhere
in the dorsal columns of the spinal cord, the medial lem-
niscus, or the thalamocortical projections. When central L1 -IC
conduction time is found to be prolonged, a median nerve
study should also be done to differentiate lesions below the
cervical cord from those above the cervical cord. In the
! Cz-Fz
case of the latter, both median and tibial nerve SSEPs will
be abnormal. It is not uncommon to find absent lumbar
potentials and intact cortical potentials. The absolute
latency values of the cortical potentials are not very relia- Figure 17.6. Normal somatosensory-evoked potential, left tibial
ble as criteria for abnormality because too many variables nerve study. Stimulation rate at 6.1/s. The bandpass is at 5 to
1,500 Hz, and 500 trials were averaged. The two tests run show
are involved in conduction through the peripheral nerve.
excellent replication between the paired tracings. From top to
For this reason, a technician should strive to obtain a lum-
bottom, the arrows point to potentials at the popliteal fossa, L-5,
bar potential. This may involve special effort in getting the and L-l, and to the cortical potential designated P37. Their aver-
patient to relax. Sometimes administration of sedatives age values are 7.6, 15.6, 19.6, and 37.6 ms, respectively. Calibra-
becomes necessary. tions: horizontal = 10 ms, vertical = 2.5 ~v.

Clinical Correlates of the SSEP

The major disorders for which SSEPs are of value include recording their transit through the nerve roots and spinal
multiple sclerosis, spinal cord lesions (traumatic, compres- cord, may be helpful in documenting lesions of the
sive, and other etiology), and lesions of brachial and lum- brachial and lumbosacral plexuses.
bosacral plexuses. The SSEP is also useful in cases of head In patients with head injury, evoked potentials - both
trauma and in the determination of brain death. SSEPs and BAEPs-may give prognostic indications. The
The somatosensory pathways are some of the longest evaluation of patients with brain death is also made easier
myelinated pathways in the body. For this reason, the by studying SSEPs as they are not significantly altered by
changc of detecting subclinical demyelinating lesions is drugs and metabolic problems. This is an advantage over
high ifboth upper- and lower-extremity nerves are studied. the EEG.
In patients diagnosed as having definite multiple sclerosis,
bilateral upper- and lower-extremity SSEP studies may
detect abnormalities in as high as 90% of the cases. References
In spinal cord lesions the SSEPs are useful in localizing
the lesion and in assessing its extent; they are also useful American Electroencephalographic Society Guidelines in EEG
and Evoked Potentials. ] Clin Neurophysiol 1986; 3 (suppl 1):
for prognosis if serial studies are employed. These poten-
54-70.
tials are monitored in spinal cord trauma and other forms
American Electroencephalographic Society Guidelines in EEG
of spinal surgery. Combining tibial nerve and median and Evoked Potentials, op. cit, pp 71-79.
nerve studies results in better localization of lesions. Chiappa KH, Gladstone KJ, Young RR: Brain stem auditory
Since it is difficult to stimulate the plexus directly, evalu- evoked responses: Studies of waveform variations in 50 normal
ation of SSEPs by stimulation of peripheral nerves, and human subjects. Arch Neuro11979; 36:81-87.
Chapter 18
Seizure Monitoring and Ambulatory EEGs

Infrequent abnormalities in a person's EEG, particularly tems are quite complex and sophisticated; in the case of
those associated with epilepsy, pose severe problems, as the custom designs, the ultimate capability possible is
they may not be identified in a routine laboratory study. To limited only by the cost.
address this problem, a special technique known as seizure A simple, basic system consists of:
monitoring is increasingly being used at many hospitals
and epilepsy centers. In some EEG laboratories, seizure 1. TV camera with manual zoom feature
monitoring is used routinely with patients suspected of 2. electronics for displaying the video on one half of the TV
having seizures. Additionally, some laboratories have monitor screen
begun doing prolonged monitoring on ambulatory patients 3. patient hookup and electronics-sometimes called the
using a system in which the EEGs are recorded on a porta- signal conditioner - for filtering and amplifying the
ble tape recorder worn by the patient. In view of these EEG voltages to IRIG levels
recent developments, a discussion of these topics is war- 4. electronics for converting the EEG voltages to video sig-
ranted in a general text dealing with the technique and nals suitable for display on the other half of the TV
practice of clinical electroencephalography. We begin with monitor; these electronics include circuits for generat-
a discussion of seizure monitoring. ing moving grid lines on the TV monitor like the grid
lines on EEG chart paper
5. digital clock that displays real time on the TV monitor
Seizure Monitoring 6. video cassette recorder for recording live video, EEG
video, and real time on magnetic tape.
Seizure monitoring provides for simultaneous recording of
a patient's EEG and behavior. This is made possible by the In using this simple basic system, the EEG technologist
use of a split-half TV screen. One-half of the screen shows attaches electrodes and connects the patient in the usual
the patient on camera, while the other half displays hislher way. Rather than observing the EEGs on the moving chart
continuous EEG tracings. The EEGs appear on the screen of the EEG machine, however, the technologist sees them
of the TV monitor in much the same way as they are seen on one half of the TV monitor screen. The patient may be
on the chart paper as it comes out of the EEG machine. In observed either directly or via the TV monitor. The techni-
most modern installations, the patient may be seen on the cian watches for electrographic or behavioral evidences of
screen either in a closeup or in full figure lying in bed, or a seizure and notes the times of occurrence from the digi-
both simultaneously. As a result, subtle changes in the tal clock on the screen of the TV monitor. These times are
patient's behavior may be observed and correlated with then used to determine which portions of the record will
events taking place in the EEG. Since both halves of the be played back by the person interpreting the seizure
screen are recorded on magnetic tape, the entire sequence monitoring test.
may be played back later on the TV monitor for review
and evaluation.
Patient Hookup
System Design
Three different kinds of hookups are available. The sim-
A variety of different seizure-monitoring systems are com- plest and least expensive as far as equipment costs are con-
mercially available or may be custom designed. Many sys- cerned makes use of a standard EEG machine. The patient
Seizure Monitoring 219

is connected to the electrode board in the routine manner, note of the time when evidence of a seizure occurred, the
and the EEG machine filters and amplifies the EEG vol- entire recording may have to be played back to retrieve
tages in the usual way. But the penmotors are not activated the data.
and no chart paper is run through the machine. Instead, To help with this problem, some seizure-monitoring
the IRIG outputs of the machine are connected to the systems incorporate an alarm button in the equipment.
electronics of the seizure-monitoring system. This button is given to the patient with the instruction to
This type of system has several disadvantages. First, as press it whenever he/she feels that a seizure may be com-
seizure monitoring can involve many hours of recording, it ing on. The button press causes the time registered on the
ties up an expensive EEG machine for long periods of digital clock to be placed into storage. This time can then
time. Second, the EEG machine is bulky piece of equip- be retrieved later by the person interpreting the record
ment and, together with the basic seizure-monitoring and the relevant portion of the record replayed.
instrument, the total system occupies a good deal of space. As seizure monitoring may go on for a number of hours,
Finally, during a seizure, artifacts associated with move- electrodes attached to the scalp by means of paste are
ment of electrode wires and of the cable running from the likely to dry out and require reapplication. Because of this,
electrode board to the EEG console can be quite severe collodion is frequently used instead of paste to connect the
and capable of obliterating the brain electrical activity. electrodes. The collodion-attached electrodes also have
The first two aforementioned problems can be eliminated, better adhesion properties; this is an advantage because
and the last can be mitigated by the use of a telemetry sys- they are less likely to be pulled loose from the scalp by the
tem, either of the cable or wireless type. movements accompanying a seizure.
A cable telemetry patient hookup consists of a small box One serious shortcoming of this simple, basic seizure-
about the size of a bar of soap with jacks for plugging in the monitoring system that has already been alluded to is that
EEG leads. This box, which contains the signal condi- no permanent, hard copy of the EEG tracings is available.
tioner or electronics for amplifying and filtering the EEG The EEG tracings, of course, are recorded on videotape
voltages, is located on the bed close to the patient. After cassette. But in this form, they are incompatible with and
being amplified, the EEG voltages are combined in a spe- cannot be played back on the EEG machine. To overcome
cial way and used to modulate a high-frequency carrier sig- this limitation, some seizure-monitoring systems provide a
nal that is generated within the small box. In other words, means of converting the EEGs back to a signal that can be
the information contained in all of the EEG channels is recorded on the EEG machine. Other systems have an ana-
compressed into a single channel containing a frequency- log tape recorder as well as a videotape machine for
modulated voltage. This voltage is fed by a thin, flexible recording the EEG voltages directly on magnetic tape. In
cable to the rest of the seizure-monitoring system. the case of the latter-type system with an EEG machine
A wireless telemetry system is identical to the cable sys- used as the patient hookup, the IRIG outputs from the
tem except that there is no cable connecting the signal machine are fed into the analog tape recorder at the same
conditioner with the rest of the system. Instead, the signal time that they are fed into the electronics of the seizure-
conditioner contains a radio transmitter and antenna for monitoring system. On the other hand, seizure-monitoring
beaming the high-frequency signal to a nearby receiving systems like the one described using cable or wireless
antenna located on the seizure-monitoring console. The telemetry do not possess these EEG voltages in a form
wireless telemetry patient hookup can be mounted close suitable for recording directly on analog tape. As already
to the patient's head or even on the patient's body. This mentioned, they are compressed into a single, frequency-
means that short lead wires may be used on the electrodes, modulated video signal. To record them using an analog
and these can be joined together into a harness. With such tape recorder, the video signal needs first to be demodu-
a system, artifacts produced by movements of the patient lated and the various EEG voltages reformatted. Once
during a seizure can be greatly reduced. recorded on tape in analog form, the EEG voltages can be
played back directly onto the chart paper by connecting
the tape recorder to the IRIG inputs of the EEG machine.
Operation
Although operating the seizure-monitoring system is not
Time Synchronization of Data
unlike running an ordinary EEG, the EEG technologist
quickly discovers that the absence of a hard copy of the To synchronize the EEGs recorded on analog tape and
tracings is a distinct handicap. It is difficult to appreciate at played back On the EEG machine with the video signal and
every moment what is happening on all eight or 16 chan- the events displayed on the TV monitor, real time must be
nels of a 14-in. TV monitor. With no hard copy available, it recorded on both videotape and analog tape. We already
is impossible to confirm an observation by looking back noted that a digital clock is part of the video display and
quickly at, say, the previous 10 seconds of the record. that the time shown (to the closest second) is recorded
Moreover, if the technician should fail to correctly take continuously on the videotape. To synchronize the analog
220 18. Seizure Monitoring and Ambulatory EEGs

data with the video data, a time code is recorded on the tage of being able to assess cardiac functioning over a wide
analog tape along with the EEGs. The code is in binary range of normal activities while the patient is awake as well
form and is referred to as binary-coded decimal or BCD. as during sleep. With the introduction of the Holter moni-
This code may be written out every 5 or 10 seconds on one tor, the potential applicability of ambulatory-recording
of the channels of the EEG machine as the analog tape is equipment to EEG monitoring became obvious. Ambula-
played back. The code is learned quickly and is easy to tory monitoring affords the patient increased mobility and
read. In this way, a specific section of the hard-copy tracing makes hospitalization unnecessary, thereby freeing the
can be precisely correlated with the patient's behavior as patient from the unfamiliar, artifical environment of the
seen on the TV monitor. hospital. This is especially important in the case of sleep
disorders. In addition, ambulatory monitoring can provide
long-term recordings without the continuous supervision
Interpretation of an EEG technician. However, being limited to but a sin-
gle channel, the early recorders were not immediately
Although the entire recording session consisting of both
applicable to EEG monitoring.
the patient's EEGs and hislher behavior on camera can be
The development of a solid-state, on-head preamplifier
played back on the video display, this is rarely done in prac-
chip in the 1970s made three- and four-channel EEG
tice. Because a seizure-monitoring session may involve
recording feasible. Coupled with this was the introduction
many hours of recording, the record is sampled instead.
of a rapid video/audio playback device that made it possi-
Sampling is based upon the observations made of the
ble to play back data on a video display at speeds as fast as
patient's behavior by the EEG technician. As mentioned
60 times real time. At such fast replay speeds, 24 hours of
earlier, the technician notes the times when behavioral or
recording could be reviewed by the electroencephalogra-
electrographic evidences of seizures are observed. Record-
pher in 24 minutes. Moreover, simultaneous audio
ings from those intervals are then brought up on the screen
reproduction of one data channel was also provided so that
for review. In addition, hard copies of the EEGs for these
certain prominent auditory cues could be used to detect
times can be made to assist the electroencephalographer
and identify various EEG features and physiological
in the interpretation.
artifacts in the recording. These technological develop-
If an alarm button is used, the recordings taken at the
ments resulted in the appearance in 1983 of a cassette sys-
times it was pressed by the patient are also reviewed. For
tem capable of recording eight channels of continuous
obvious reasons, data for review here are limited to inter-
EEGs. As this is being written, 16-channel systems are
vals when the patient is awake. Finally, some samples taken
becoming commercially available.
at random from different portions of the recording may be
played back.
The foregoing highlights the vitally important role System Design
played by the EEG technician in seizure monitoring. A
Eight-channel ambulatory EEG systems, or AiEEG sys-
large block of the technician's time, of course, is required.
tems as they are called, appear to be the current standard.
He or she needs to be alert, observant, and quick to report
The systems are battery operated and can run continu-
upon the patient's behavior. Barring this, the procedure,
ously for 24 hours. The preamplifier is secured to the scalp
which is inherently expensive, can become excessively
along with the electrodes, and the preamplifier output
costly and impractical. Seizure monitoring has other dis-
wires are fed to the recorder, a rectangular box weighing
advantages besides being expensive. It frequently requires
about I.51b and worn on a belt or strap by the patient. The
hospitalization and severely restricts the patient's mobility,
eight channels of EEGs are recorded on 1/8 _ or 1/4-in.
sometimes for long periods of time. For these reasons,
cassette tape. Technical details need not concern us
ambulatory EEG recording was developed. In this tech-
here; they can be obtained by consulting more advanced,
nique, the patient's EEGs are recorded on a cassette
specialized texts.
recorder that is carried by the patient.
Playback units of some systems provide a variety of high-
technology features. Some of the features available are
automatic search to a specified time in the recording; a
Ambulatory EEG Monitoring limited memory that stores portions of the record so that
segments occurring before and after the segment being
The idea of using a portable tape recorder to monitor phys- viewed on the monitor can also be viewed without having
iological data on mobile patients for prolonged periods of to rerun the tape; and alphanumeric registry of gain and
time was first introduced by N.J. Holter in 1961. As is well filter settings. The user should consult the instruction
known, this method has been used successfully in the manual that comes with the particular equipment for
ECG evaluation of cardiac arrhythmias. It has the advan- operational details.
Ambulatory EEG Monitoring 221

Patient Hookup selecting samples for review when the tape is interpreted
by the electroencephalographer.
Collodion electrodes must be used. They should be When the monitoring session is over and the patient has
applied with the greatest care, as they need to give stable returned to the laboratory, a briefEEG should be recorded
recordings that are free of electrode artifacts for up to 24 and printed out before the electrodes are removed. This is
hours. Electrode impedances should be 3K ohms or less; essential to confirm that the electrodes have, indeed, been
impedances should be tested at the beginning and at the functioning satisfactorily. Finally, a postcalibration should
end of the recording. It is good practice to keep a record of be run to verify that the system is operating properly.
the impedance of each electrode. Knowing that electrode
impedance was excessively high at the end may help to
explain the presence of artifacts observed in the EEGs Interpretation
when the tape is reviewed. We take up here only the essentials of interpretation.
Since electrode problems or failures go undetected until A/EEG is a rapidly expanding area with new equipment
after the monitoring session is over, referential recording is and techniques under development that are expected to
not employed, and separate electrodes frequently are used simplify interpretation. The periodical literature should be
for each input grid instead of bipolar linkages. This pro- consulted for details and further information.
vides a greater margin of safety, as only one channel With 24 hours of EEG recording obtainable from eight
becomes disabled rather than two channels if a single elec- channels, there are clearly more data available than can be
trode fails. In hooking up the patient, it is essential that the assimilated successfully even when using rapid playback.
loop area between the electrode wires of a pair be kept to Nevertheless, rapid playback is the only practical approach
a minimum. Unless this is done, electrical fields present in to this problem. When searching for ictal events, review
the patient's surroundings may cause significant electrical speeds of 40 to 60 times real time are used in video scan-
currents to be induced in the loops as the result of their ning of the tape. Slower rates of 20 to 40 times real time are
being moved through the field when the patient is in employed in the detection of isolated interictal discharges
motion. Shoes with rubber soles should be avoided, espe- and focal events. Simultaneous monitoring of the audio
cially when the humidity is very low, to prevent large elec- output of the EEG channels during video scanning has
trical charges from building up on the patient's body while been found to be useful, as seizures, interictal discharges,
he/she is walking. If electrical charges produced in this way normal transients, and various artifacts all have charac-
present a significant source of artifacts, the problem can be teristic sounds that can aid in their detection. Verification
alleviated by having the patient wear carbon-soled shoes of of events discovered in this way is best carried out at video
the type worn in operating rooms. display rates of 30 mm/s. If the playback unit is IRIG com-
patible, hard copies of selected segments from the taped
Operation EEGs can be made by connecting the playback unit to the
IRIG inputs of a standard EEG machine.
After electrodes have been applied and tested, and a The differentiation of artifacts from normal activity and
calibration has been run, it is good practice to make a few from true EEG abnormalities is a major problem in inter-
brief recordings before letting the patient leave the labora- preting A/EEGs. Active wakefulness is filled with a super-
tory. A recording while the patient is at rest and recordings abundance of various artifacts. In contrast to conventional
obtained while he or she is engaged in various activities EEGs, artifacts in A/EEGs confront the electroen-
that produce artifacts - such as blinking, moving the eyes, cephalographer without the benefit of an experienced
chewing, swallowing, coughing, sniffing, and talking-are technologist's observational information concerning the
recommended. These recordings may be helpful in patient's behavior. To be sure, the patient's diary can be
differentiating EEG abnormalities from artifacts when the useful in this regard; but the diary usually lists only major
tape is reviewed. Before letting the patient go, ask himlher events such as eating a meal, going for a walk, jogging, and
to keep a diary while the monitoring is going on. Instruct the like. This problem is somewhat mitigated by the fact
the patient to record the exact time of day that various sus- that epileptiform abnormalities in the EEG occur more
picious episodes occur and to briefly describe the epi- frequently during sleep - mostly during stage I and II
sodes. Various activities capable of generating rhythmic sleep - when artifacts are less numerous than during
artifacts such as walking, eating, brushing teeth, talking, wakefulness. Nevertheless, as is the case with any newly
scratching, and the like should be entered in the diary as developed procedure, the ultimate value of the A/EEG
well, along with their times. If the diary is carefully main- technique rests upon its proven clinical usefulness over the
tained, it can be helpful in identifying artifacts and in long term.
Chapter 19
Clinical Use of Brain Electrical
Activity Mapping

The past 10 years have witnessed rapid growth in the use the standard practice?" To understand the contribution of
of signal analysis techniques by clinical neurophysiologists. topographic analysis, one must know what underlies the
Prominent among these emerging techniques is brain use of EEG and EP in clinical diagnosis.
electrical activity mapping (BEAM)l, defined as the topo- There are basically two elements of EEG. First, the
graphic analysis of scalp-recorded EEG or evoked- neurologist wishes to distinguish real discontinuities in
potential (EP) data (Duffy FH, Burchfiel JL, and Lom- brain electrical activity, such as epileptic "spikes;' from
broso CT, 1979; Duffy FH, 1986). Technically, topography artifactual discontinuities such as electrode "pops" and
refers to the analysis of spatial dimensions, whereas topo- eye blink. With training and experience, the task of dis-
graphic mapping is a cartographic science. A better under- tinguishing these discontinuities becomes relatively easy.
standing of the current usage of BEAM is to define the However, there is a second element of EEG, the analy-
technique as incorporating topographic mapping (spatial) sis of the background EEG, i.e., the electrical activity
and analysis (temporal, statistical) of electrical activity not related to discontinuity. This is a more difficult task,
recorded from the scalp. as the process consists of a series of complex steps. First,
A good example of topographic mapping is provided by the electroencephalographer must mentally perform a
the colorful daily weather maps shown in national news- decomposition of the electrical activity recorded at each
papers. Regional average temperature gradation is depicted channel into its spectral content of frequency (delta, theta,
on a national map consisting of a discrete outline and alpha, beta). Second, the lengthy EEG record is ana-
based on discrete points for which measured data are lyzed for continuity or consistency of electrical activ-
taken. Interpolation between these points using a contour- ity over time (temporal analysis). Third, the electro-
ing algorithm provides a basis for drawing isothermal con- encephalographer must create a mental map of the spa-
tour lines. The spaces can then be filled in with a color tial distribution and trajectory of the brain waves. These
range representing temperature range differences. BEAM three kinds of analyses - spectral, temporal, and spatial-
is based on very similar cartographic elements and inter- must all, in turn, be analyzed in terms of what is normal
polation techniques. Instead of temperature, however, and what is abnormality. That is, the electroencephal-
parameters derived from brain electrical activity are ographer must also perform a statistical analysis. This
mapped. Figure 19.1 (see color insert page 229) provides complex process probably represents a major factor in
a standard example of a topographic map based on what has been considered the failure of EEG to achieve
recorded EEG data. its full potential. It also points to the potential contribu-
tion of modern computer technologies and statistical
paradigms.
Why Brain Electrical Activity Mapping? There are similar problems in the analysis of data based
on EPs, i.e., data based on the brain's electrical activity
One may ask, "Why do we need brain electrical mapping?
responses to external stimulation. The demonstration of
Aren't traditional EEG and EP recording established as
signal averaging in the 1950s (Dawson GO, 1950) en-
gendered an optimism that long-latency EPs would go
I BEAM is a registered trademark of the Nicolet Biomedical beyond the diagnostic power of EEG in analyzing brain
Instrument Company. function, but these long-latency waves proved to be ex-
The Use of Topographic Analysis in Interpretation of EEG and EP 223

ceptionally difficult to analyze in terms of latency, locus theta (4 to 8 Hz), alpha (8 to 13 Hz), and beta (> 13 Hz).
of origin, spatial extent, and interaction of multiple waves Such decomposition may be compared to listening to an
(Callaway E, 1969; Chiappa KH, 1983; Jeffreys DA, and orchestral piece by a symphony orchestra. The overall
Axford JG, 1972) by unaided visual inspection of the musical sound may be broken into the contributions of the
polygraphic record. bass, baritone, tenor, and soprano notes. A means of track-
ing the separate elements of brain electrical activity is
depicted in Fig. 19.3 (see page 230), where a histogram is
The Use of Topographic Analysis in formed based on the separate frequency components.
However, simple viewing of a series of maps to analyze
Interpretation of EEG and EP spectral content does not enhance their utility. In our
experience, analysis of spectral data is best accomplished
To assist clinical appraisal of such data, Duffy and col- by (1) the creation of a topographic image of spectral
leagues began studies of BEAM (Duffy, Burchfiel, and content averaged over a user-selected period of time and
Lombroso, op cit; Duffy FH, 1982; Duffy FH, Bartels PH, (2) the creation of a second map for comparison, which
and Burchfiel JL, 1981). It was believed that the major provides the coefficient of variation - a statistical measure
limiting factor in extraction of meaningful data from EEG of standard deviation from the mean spectral values. This
and EP was the massive amounts of information contained comparison readily isolates values in areas that unexpect-
in the ostensibly simple polygraphic tracings. Figure 19.2 edly deviate from a relatively uniform visual image and,
(see page 229) provides the paradigm used to resynthesize in doing so, alerts the clinician to an area of potential
the spatial and temporal data gathered from EP record- concern.
ings. Resultant topographic images are displayed on a As with analysis of EEG data, the use of topographic
computer-based video monitor using a colored "gray-scale:' mapping ofEP data provides for spatial analysis directly by
To capture temporal change, these images can be displayed viewing each map of the data. Unlike EEG, temporal anal-
sequentially at 4-ms intervals, creating a cartooning effect ysis of EP data is best accomplished by viewing in progres-
for observing the spatial range, trajectory, and latency of sion a series of maps ("cartooning"). Our experience has
the EP waveforms. not found spectral analysis of EP data to be clinically
productive.

Topographic Mapping Algorithms and

Spatial Analysis Significance Probability Mapping

As with the isothermal maps described in the introduc- Early on in the development of BEAM, it became clear
tion, the paradigm for mapping brain electrical activity that normal subjects often demonstrated a degree of asym-
must include an algorithm for interpolating values to fill in metry or focality of topographic brain-wave distributions.
the scalp areas between the recording electrodes used in The question often became whether or not an obvious
performing a topographic analysis. We use a three-point, focality or asymmetry constituted a clinical abnormality or
three-dimensional linear interpolation, creating values for whether the degree of asymmetry could be explained by
unknown locations based on the three nearest electrode normal variation. In 1981, in conjunction with Dr. Peter
sites. It may be noted that there are numerous approaches Bartels from the University of Arizona, a technique known
to interpolation among current practitioners (e.g., refer to as significance probability mapping (SPM) was developed
Duffy, op cit, 1986) and that no optimal paradigm has yet (Duffy, Bartels, and Burchfiel, op cit; Bartels PH, Subach
been agreed upon. Keeping in mind that all interpolation JA, 1976). In this process, a single subject's topographic
techniques are approximations, we have adopted the image can be compared with that of a control or reference
three-point paradigm as providing images that are smooth data set. This results in a new image in which the original
and biological in appearance when recorded data are real, data are replaced by the delineation of individual deviation
but are dramatically and reliably discontinuous when elec- from the collected data on normal subjects. Essentially, the
trode artifact occurs. A valuable test of reliability on a subject's data are replaced by their Z transform, thus dis-
given interpolation algorithm is to compare interpolated playing an image of standard deviation from the norm. The
values with real measured values. SPM process is depicted graphically in Fig. 19.4A (see
The spectral content of brain electrical activity provides page 230). This fulfills the final and complicated step in
crucial data on the normal and/or abnormal functioning of the clinical evaluation of EEG and EP data, namely, the
the various regions of the brain. The electrical signal delineation of regional abnormality. Clinically, the tech-
recorded at a given electrode site can be decomposed into nique of SPM has proved singularly valuable in the diag-
its constituent frequency components: delta « 4 Hz), nostic delineation of abnormalities in clinical subjects.
224 19. Clinical Use of BEAM

Further, for research applications, one may wish to com- subjects prefer to be instructed as to when they should
pare BEAM data for two populations, a research or blink and others prefer to demonstrate the need to blink
experimental group and a control group. This may be very vividly.
accomplished via a comparable SPM process using Stu- Eye movements and even blinks are surprisingly more
dent's t statistic (Fig. 19.4B). difficult to control during eye closure than during the
eyes-open state. Upon closing the eyes, a fully awake
normal subject may initiate obvious blinking even though
Tips for the Conduct of Successful the lids are shut. Allowing the patient to "relax" so that
BEAM Studies the blinking ceases is often tantamount to allowing the
subject to fall asleep or at least to become drowsy. The
Quantified electroencephalography requires greater care best strategy, here, is to place very lightly applied gauze
in electrode placement, artifact management, and state pads over the closed lids. This gives feedback to the
control than standard EEG. Whereas electroencephalogra- patient; he will sense his eyelashes brushing against the
phers may readily "accommodate" obvious errors or faults pad. If absolutely necessary, a technologist or the patient
of recording, computers do not. Accordingly, all electrode can press upon the eyes to prevent eye movement. Care
locations must be carefully measured and electrode must be taken, of course, not to introduce 50- or 60-Hz
impedances checked before, during, and at the end of interference at this point.
studies to ensure good placement, low impedance, and In analyzing the eyes-open and eyes-closed states after
consistent contact. Impedance asymmetries will produce digitization on the computer display screen, eye move-
unusual and asymmetrical changes in spectral analysis of ments (both vertical and horizontal) should be identi-
signals from the offending electrodes. Whereas these sig- fied according to their appropriate signals in the Fpl
nals may appear normal on paper, the higher sensitivity of and Fp2 electrodes and in the eye-artifact electrodes
spectral analysis causes artifact to stand out. In the course placed below the eye and lateral to both eyes. In addi-
of a run, if a single electrode "pop" is observed, that run tion to frank blinks and frank horizontal saccades, some
must be discarded, the electrode repaired, and the run subjects have intermittent rhythmic eye movements.
repeated. Subjects should generally be studied in the By noting phase reversals in the recordings one can
upright position to assist in maintaining alertness. The clearly demonstrate eye movement. The technologist
chairs used must be adjustable so as to minimize truncal should be trained to eliminate eye movement artifact
muscle tone and thereby reduce muscle artifact. All clini- but not randomly eliminate all frontal slow activity. The
cal studies should consist of a minimum of five study con- distinction is difficult, but often crucial for mapping
ditions. These are eyes open (alert and awake), eyes closed studies.
(alert and awake), drowsy to sleep, the flash visual-evoked Unfortunately, in our experience even the most
response (VER), and the click auditory-evoked response experienced observer cannot eliminate all vertical or
(AER). horizontal eye movement. A crescent of frontal delta
The somatosensory-evoked response is useful, but activity can be seen on the subsequent maps when small
primarily for the detection of abnormalities in specific cor- amounts of vertical eye movement remain. In normal sub-
tical pathways. It is not useful, however, as a screening jects with very low background delta, a surprisingly promi-
procedure. The pattern-reversal VER produces activity nent amount of eye-induced delta may be seen.
that is largely occipital and is therefore of limited value in The flash VER is ordinarily performed with supra-
mapping studies. On the other hand, when detailed infor- maximal stimulus intensity. For the commonly-used Grass
mation is required about the occipital cortex, or when the photic stimulator, intensity settings of 8 or 16 are used and
standard pattern-reversal VER is morphologically com- the strobe is placed within 25 cm of and directly in front of
plex, multiple-electrode-mapping studies can sometimes the face. Such high intensities will often induce involun-
be helpful. tary blinks. Conversely, placement over the eyes of a thin
In the eyes-open state, subjects should be seated com- film of transparent plastic (Saran® Wrap) secured
fortably, and a visual fixation target should be placed peripherally with transparent tape will often minimize eye
in a comfortable position for viewing so as to minimize blink, while allowing light to pass through. Recording
frontalis muscle tone. During the recording session the equipment should be adjusted to eliminate movement
subject is instructed to look at the object and not blink, artifact and random blink on the basis of an "over voltage"
until no longer able to suppress blinking. At that point or threshold voltage criteria, which may be customized for
the subject is instructed to blink as often as desired and, each patient. On the other hand, some subjects will blink
when comfortable again, the run resumes. This procedure with every flash; in those instances it is best to allow all
is referred to as the "blink holiday" technique. Some recordings to pass through. One, of course, must then
Tips for the Conduct of Successful BEAM Studies 225

interpret frontal positivities and negativities on the result- linear and seldom stable for more than a decade. Indeed,
ing maps with caution. norms are needed for every few years of childhood and for
The AER should be generated by supra-maximal stimuli every few weeks of early infancy.
via earphones. Commonly, 50-ms tone pips at 92-dB sound It is also imperative that normative data be provided for
pressure level are used. Normal-appearing long-latency the artifact electrodes as well. It is very difficult in a topo-
AERs will be seen even in the moderately hearing- graphic map to distinguish real frontal slowing from that
impaired subjects. induced by eye movement. However, if comparable
Crucial to good VER and AER recordings is the neces- increases of delta are seen on the eye-movement artifact
sity to maintain the fully alert state. For this reason, the channel then the probability is high that the slow activity
classic EEG must be collected simultaneously with these is induced by the eyes. Conversely, if slowing is seen only
recordings and the run interrupted whenever drowsiness is over the frontal region and not in the eye channels then
detected. Often we find that the evoked-response method real slowing of brain origin is inferred. The analogous situ-
is so conducive to drowsiness that it is wise to interrupt a ation may be seen for increased beta activity over the tem-
run and actually record drowsiness, taking advantage of the porallobe and increased beta in a temporal artifact chan-
sleep-inducing effects of repetitive stimulation. Both the nel. Beta-like activity is commonly produced by muscle; it
VER and AER morphologies are extremely sensitive to is mandatory, therefore, that no simultaneous changes be
drowsiness, which may produce alterations of vertex wave seen in the artifact channel if one wishes to declare that
activity, either increasing or decreasing amplitude and increased beta over the temporal region is of brain origin.
increasing latency. On subsequent topographic maps, In the course of studies it is quite common for small
drowsiness appears as abnormal but symmetrical central regional abnormalities to be seen that are clearly not
vertex waves. artifactual but seem to have no clinical correlation. Before
It goes without saying that drowsiness must be carefully these regions can be considered electrophysiologically
controlled in the eyes-open and eyes-closed states as well. aberrant, it must be demonstrated that they reappear
Our experience indicates that first signs of drowsiness can when the patient is restudied. Since this happens so fre-
often be seen in the sagittal midline electrodes with the quently, it is now recommended that all studies be
appearance of some paroxysmal theta. The finding of slow repeated a minimum of three times and the results com-
horizontal eye movements constitutes an inadequate pared. Thus, a small region of increased theta or an EP
criterion, since subjects are almost asleep at this point and abnormality in one limited region becomes much more
they will show marked changes in spectral amplitude in convincing if seen three times in a row than if noted only
the slow ranges. once.
The slowing due to encephalopathy can be distin- Finally, it is important to emphasize that the neurologist
guished from the slowing induced by sleep, based on the should not be overreliant on the SPM. This map demon-
topographic distribution. Slowing related to loss of atten- strates only electrophysiological deviation from the normal
tion, fatigue, or drowsiness is largely maximal in the central data base. Such differences can occur for many reasons
vertex region whereas encephalopathic slowing is more besides pathology, e.g., eye blink, muscle artifact, state
uniform and involves more the temporal lobes. Drowsiness change, electrode artifact, inappropriate control groups,
also accentuates "time locking" of alpha, which can seri- etc. It is incumbent upon the reader to be sure that there
ously confound the late portions of an evoked-response are no trivial explanations for statistically replicable devia-
recording. tions from normal.
A clinician reading a topographic analysis can detect The evaluation of drowsiness is extremely difficult for
poor state control by the appearance of excessive central there is no true "standard" state, and it is virtually impossi-
theta during the waking state, abnormal central vertex ble to prepare a normative data base for the drowsy state.
wave activity, especially in the AER, and large amounts of Under those circumstances, relative comparisons to the
time-locked alpha in the VER. eyes-closed state are often useful in picking up greater
The use of control subjects for comparison is absolutely deviations from normal than one might ordinarily expect.
mandatory, since it is impossible to maintain standards in The recommended sequence for evaluation of a topo-
one's own mind. It is, of course, crucial that equipment graphic study is (1) evaluate the EEG in the normal man-
used for the gathering of control population data be elec- ner for clinically important information, (2) reevaluate the
trically and functionally identical to that used for the study EEG looking for artifact and drowsiness or state change
of patients. Subtle differences in amplifier characteristics abnormality, (3) evaluate the spectral data from the EEG,
can produce systematic abnormalities. It is also crucial and (4) evaluate the VER and AER data. Spectral data are
that the control population be stratified by age since the best understood by developing a hypothesis from the
developmental curve of the EEG rhythms is rather non- evaluation of the EEG and confirming it by the spectral
226 19. Clinical Use of BEAM

data. For example, the finding of increased slowing by read as within normal limits. Spectral analysis showed
spectral analysis is much more meaningful if the reader delta entirely within the normal range. Theta, however, was
has observed the fully alert EEG state than if the subject seen to be asymmetrical and, by the SPM process,
was actually allowed to become drowsy. Both VER and enhanced in the left parietal region by 3.50 standard devia-
AER data are analyzed keeping in mind the state of the tions. The possibility of a regional organic pathology was
subject during data collection. The EEG taken during EP raised on the basis of these findings, but a subsequent com-
recording is particularly important to evaluate. Changes puted tomography (CT) scan was within normal limits. The
in vertex wave activity in the evoked response, especially patient was seen again 16 months later with complaints of
the AER, are somewhat analogous to EEG slow activity. increased difficulty. However, his neurological examina-
Vertex wave changes may be seen in drowsiness, in re- tion was again normal, including tests of memory. His
sponse to medications, and from pathological influences. BEAM study was repeated. In this study, delta activity was
To decide whether a vertex wave abnormality is clinically now seen to be increased in the left parietal region by 2.49
significant, one must be sure that the subject was not standard deviations. It had been normal in the previous
drowsy and that there were no medications that might have study. Theta was again abnormal in the left parietal region
affected central nervous system function. Vertex wave by 7.65 standard deviations, up from the previously noted
change can be particularly valuable in the early detection 3.50 standard deviations. In this study the EEG was
of encephalopathic change but only if care is taken in thought to be somewhat slow due to drowsiness. On the
interpretation. other hand, the BEAM analysis was done during the fully
It is clear that the conduct of a BEAM study places alert state. The patient experienced no difficulty remain-
greater demands on the conduct of the technologist, the ing alert and appeared normal. Statistical comparison of
patient, and the reader than ordinary EEG studies. the first and the second study by the t-SPM process
showed delta to be increased in the second study by 5.32
t units (P = .00001), and theta increased in both left and
The Application of BEAM right parietal regions by a maximum of 5.39 t units (P =
.00001) (see Fig. 19.5). The BEAM study was read as con-
to Clinical Practice sistent with an asymmetrical but bilateral posterior abnor-
mality, left greater than right. Given the patient's com-
The utility of BEAM and topographic analysis in clinical
plaint of memory difficulty, the possibility of Alzheimer's
practice lies in its increased sensitivity over traditional
disease was now singled out among the many possible
EEG and EP analysis and its increased objectivity in estab-
organic processes that might cause this EEG picture. A
lishing the presence or absence of brain-related disease
repeat CT and magnetic resonance imaging (MRI)
and/or disability. As such, it is an added weapon in the cli-
remained normal and unchanged, showing no evidence of
nician's arsenal of diagnostic tools. We consistently caution
atrophy or loss of brain substance. Repeat neuropsycholog-
the users of topographic techniques that BEAM does not
ical examination showed some decrease in memory perfor-
provide a "stand alone" diagnosis, but rather one of several
mance, but it still remained well above normal, as did the
inputs into comprehensive clinical analysis. We feel,
full-scale IQ, which was now at 140.
however, that it can provide a vital and, in many cases,
Approximately 6 months later the patient developed the
unique contribution to the diagnostic process.
full-blown symptomology of Alzheimer's disease complete
Following are three case studies that demonstrate the
with profound memory loss and loss of other cognitive
efficacy of the BEAM technique in clinical practice.
skills, including judgment and awareness.
This case exemplifies the difficulty in diagnosing
Case Study 1: Presenile Dementia Alzheimer's disease early in patients whose overall cog-
in an Adult Male nitive abilities are in the very superior range. The pa-
tient may be very aware of some intellectual loss, only to
A 64-year-old successful businessman complained to his have formal testing procedures indicate superior per-
internist offailing memory. Neuropsychological evaluation formance. In such cases BEAM studies are particularly
revealed a superior overall performance level with full useful for detecting unilateral or bilateral evidence of
scale IQ of 148. Tests of memory demonstrated relative deviation from normal, particularly involving the lower
reduction but scores were still superior. Despite the EEG frequency ranges of delta and theta. For this par-
patient's complaint, the physician felt that these issues ticular patient, BEAM was the only technique that demon-
were largely emotional, having to do with the patient's strated clear deviations from normality almost 2 years in
impending retirement. A BEAM study was nonetheless advance of the clear and unequivocal presentation of the
ordered. In this particular analysis, the standard EEG was clinical syndrome.
The Application of BEAM to Clinical Practice 227

Case Study 2: Temporal Lobe Epilepsy view, it was found that she had discontinued her use of car-
in a Female Adult bamazepine, having felt so well some weeks before that she
decided medication was no longer necessary. She had
A 29-year-old woman was referred for BEAM evaluation by recently experienced the first "fainting" spells she had had
her clinician whose diagnosis to date was a "chronic since those of her teen-age years. She was, of course,
ruminative syndrome" not responding to medication. She restarted on medication, and her well-being was restored.
had previously had a classic EEG read as normal and no This clinical example demonstrated the ability of BEAM
seizure discharges were evidenced. The results of her first to suggest an alternative diagnosis leading to successful
BEAM, however, indicated abnormal spectral analysis therapeutic treatment of a behavior dysfunction.
delta readings in the left and right posterior temporal
regions of the brain (Fig. 19.6A). These findings were cor-
roborated by the topographic SPM maps of eight EP Case Study 3: Sylvian Seizure Syndrome in
epochs. The SPM of two of these, the VER and the AER, an 8-Year-Old Boy
are provided in Figs. 19.6B and 19.6C.
This boy was initially referred for minor seizures involving
As such focal findings could not be interpreted as simple
speech difficulty and facial seizure affecting the mouth
depression, the patient was referred for neurological con- regions. Nocturnal grand mal seizures were reported and
sultation to search for organic pathology. Her subsequent the classic EEC reading located focal seizure discharges
CT scan was normal, as was the classic neurological assess-
emanating from the left frontotemporal, midtemporal
ment. However, the patient had an unusual personality
region of the brain. This symptomatology led to the diag-
profile characterized by obsessive behaviors. She devoutly
nosis of Sylvian seizure syndrome, generally a mild, self-
maintained a detailed diary in which she reported extreme
limited epileptic syndrome (Lombroso C, 1967). The topo-
moral concerns, alternating periods of hypo- and hypersex- graphic analysis was also performed and revealed a spike
uality, and periods of religious preoccupation. She was
discharge beginning in the left frontal region (Fig. 19.7 A),
intensely verbal, very serious and persistent, and over-
but rapidly reaching maximal value in the left midtemporal
focussed in discussing any given topic that gained her
region in 19 ms (Fig. 19.7B). These BEAM findings ran
attention. These personality characteristics led us to sus-
counter to the Svlvian seizure syndrome diagnosis as virtu-
pect a conditional temporal lobe epilepsy (Bear OM, 1979;
ally all patients ~ho experienc~ this syndrome will demon-
Bear OM and Fedio P, 1977).
strate central-parietal initiation. The BEAM spectral anal-
The patient, however, denied any incidence of seizures
vsis and VER results revealed nothing unusual, but the
in her life. But on further questioning, she acknowledged
AER indicated a large abnormality beginning at 260 ms
incidents of "fainting" as a teen-ager, wherein she
and lasting 40 ms. During this epoch, the left midtemporal
experienced a strange feeling in her back and stomach that
region was excessively positive, while both frontal regions
moved into her mouth previous to sensing fear and "faint-
and much of the right hemisphere were excessively nega-
ing:' On the basis of the BEAM findings and a suspected
tive (Fig. 19.7C).
history of partial complex seizures, she was placed on car-
The simultaneous appearance of both negative and posi-
bamazepine.
tive deviations from normal on an SPM indicated a "dipole
After 6 months, the woman was reevaluated. The classic
abnormality;' which is highly correlated with pathology. A
EEG report was unchanged. The spectral analysis BEAM
CT scan was recommended for this patient, the results
was analvzed via SPM and indicated that increased delta
indicating a subtle but definite left thalamic tumor. This
was still in evidence but less dramatically so (5.39 standard
finding was then confirmed by MRI. The contribution of
deviations) than her previous BEAM (Duffy, op cit, 1986).
BEAM in this instance was the instigation of further radio-
On Iv one EP abnormalitv was noted. She was clinically
graphic examination leading to early detection of a pathol-
mu~h improved, having e~ded reliance on family financial ogy. This examination probably would not have happened
support, started her own acting workshop, and discon-
for several more months given the relatively benign course
tinued her diary. She cancelled her next 6-month follow-up
of the condition when initially diagnosed.
appointment.
After an additional 6 months, she contacted the labora-
torv for a return appointment. This time, her EEG was
distinctly abnormal, clearly indicating left temporal dis-
A Cautionary Note: Potential Errors in
charges. Her BEAM data showed increased delta abnor- Clinical Usage of Topographic Analysis
mality (6.79 standard deviations), more extensively involv-
ing the left hemisphere than before. She had reestablished We have witnessed the highly successful application of
the extensive and compulsive use of a diary. Upon inter- topographic analysis to clinical practice and to neurologi-
228 19. Clinical Use of BEAM

cal research. It cannot, however, be overemphasized that Yet another analytic issue regards the occurrence of a
simple inspection of topographic images is insufficient to minor regional abnormality when reading an SPM of a
establish a reliable diagnosis of neurological condition. given patient and then not encountering consistent evi-
BEAM is designed to provide more detailed, objective, and dence of the abnormality in the rest of the record. The cli-
efficient analysis of EEG and EP data to assist the clinician nician will want to establish the biological significance of
in supplementing neurological, clinical, and other techno- this single event. One of the ways to deal with such
logical assessments of a given patient's condition. Follow- instances is to repeat the study. One repeats the study
ing are described a number of examples demonstrating three times in an attempt to search for a consistent neuro-
potential errors in topographic analysis if not performed in logical abnormality or to find evidence that the initial read-
a thorough and highly trained milieu. ing was statistical noise or artifact. Figure 19.9 provides an
Figure 19.8 provides a topographic SPM image depict- example of a topographic analysis that initially shows
ing a very abnormal evoked response (Duffy FH, in press). abnormality but upon reassessment was normal. With the
The actual interpretation of this image was nonetheless substantial number of variables in a complete BEAM, one
that of a normal reading. The basis for this interpretation might occasionally experience a variable falling outside
was the simultaneously recorded EEG indicating that the the normal range, even though these variables are cor-
patient in question was extremely drowsy during this related. This emphasizes the importance of study repeti-
phase of the recording and could not be roused to a full tion, examining each state and each EP, and establishing
waking state by the EEG technician. This instance illus- consistent findings.
trates how essential it is for the clinician to obtain a back-
ground EEG for two reasons: (1) quality control in terms of
excision of artifact and avoidance of artifactual recordings, Topographic Analysis in
and (2) extraction of useful information intrinsic to the
EEG recording itself. the Clinical Setting
A second example of a common anomaly in topographic
analysis is created by the incidence of "time-locked alpha:' Today, there are a substantial number of manufacturers
Topographic images indicated an asymmetrically increased and designers of topographic mapping systems throughout
negativity located primarily in the right occipital region for the United States and worldwide. This analytic method is
a 40-ms epoch of the late AER that reached 3.83 standard gaining increased acceptance as a diagnostic aid in the
deviations and involved at least four electrodes. The neurological clinic. However, it is crucial to recognize that
patient had been referred for bipolar depression. The EEG the instruments of topographic analysis are not automated
recordings indicated highly asymmetrical alpha, greatest to the point where they can be applied by people who are
in the right hemisphere. Analysis of the AER waveforms not knowledgeable nor can they be run by technologists
indicated a time-locked alpha component in the right without specific training in the equipment. Clinicians still
occipital region that was absent on the left. Although the must have legitimate background and knowledge in elec-
topographic image indicated a significant difference from troencephalography and EPs. They must be able to recog-
normal EP reading, the clinician correctly interpreted nize artifact and to eliminate artifactual data from the
these data as indications of time-locked alpha, an anomaly record as well as recognize its occurrence in the topo-
that sometimes contaminates late portions of long-latency graphic images. They must monitor the state of the patient
EPs when the subject is fatigued or drifting off to sleep. and be able to detect drowsiness. The use of topographic
The asymmetry recorded by the BEAM image is not an analysis, rather than diminishing the skill requirement
organic abnormality, but an actual asymmetry caused by of electroencephalographers, actually places greater
the drowsiness of the patient, a frequent occurrence with demands on their skill repertoire. They must know both
younger subjects. Time-locked alpha is the leading cause traditional EEG and EP analysis and the newly emerging
of incorrectly detected "abnormalities" in .clinical mapping agenda of knowledge and skills particular to topographic
studies. analysis.
Another frequent analytic issue that the clinician may The dividend paid by reliance on the evolving technolo-
have to deal with concerns spectral analysis. The EEG of a gies of topographic analysis is increased reliability, sensi-
patient may contain a spike or a benign variation paroxysm tivity, and objectivity of EEG and EP analyses. The pay-
such as ~14 and 6:' Since it is benign, the technologist may ment required is increased knowledge levels and care by
assume that it can be included in a spectral analysis. The neurologists and technicians and a full awareness of the
clinician must be aware that inclusion of such data would strengths and limitations of this technique. It is designed
contaminate the analysis, thereby making it impossible to for, and capable of, enhancement of the traditional array of
discern legitimate abnormality in the background EEG neurological assessment strategies; it is not meant to
spectral content. replace them.
Topographical Analysis in the Clinical Setting 229

Figure 19.1 . Sample topographic map of EEG data recorded dur- lower right indicates range of spectral amplitude measured in
ing eyes-closed resting state. Image is shown in vertex view, nose microvolts. This and subsequent topographic maps shown were
toward the top of page, left to reader's left. Rainbow color scale in obtained using the BEAM system.

FPl FP2
F3 .
FZ ':4 F F4

P3
CZ
.~
.
C4
C4
P4
F7
T3 . P4.
PZ
T6
FB
T4
T5 01 qz 02 T6
01 02

FZ*
I
192 ms CZ 20 uvL
PZ 250 ms
OZ
~ £. Q.

Figure 19.2. Paradigm for the construction of a topographic map region is treated as a 64 x 64 matrix; the resulting 4,096 spatial
for EP data. Mean EPs are formed from each of 20 recording domains are illustrated in (C). Each domain is assigned a voltage
sites. Each EP is divided into 128 4-ms intervals, and the mean value by linear interpolation from the three nearest known
voltage value for each interval is calculated. In (A) the individual points. Finally, for display, the raw voltage values are fitted to a
EPs are shown for the electrode locations indicated on the head discrete-level, equal-interval intensity scale as shown in (D).
diagram. In (B) the mean voltage values at these locations are Although a VER is used to illustrate the mapping process, the
shown for the interval beginning 192 ms after the stimulus (the same procedure is used for mapping other data, including EEG.
vertical line in A indicates this time on the EPs). Next the head (From Duffy et al [1979], with permission.)
230 19. Clinical Use of BEAM

E.E.G.
., "

ANALYSE
(SPECTRA)
k-,-~>j~
Delta 4 Theta 8 Alpha 12
, 16

SMOOTH
I~
4
A
8 12 16

Figure 19.3. A schema illustrating the creation of spectral plots cumulative increase in the delta histogram of the lower tracing.
(bottom line segment) from raw EEG tracings (top line segment). This may be repeated for all spectral bands. (From Bickford
Every appearance of delta in the upper tracing is reflected by a [1977], with permission.)

REFERENCE SET UNKNOWN SET 1 SET 2

SUBJECT
/mapl /
Sum Lma p 17
+ Individual +
Calculate /map2 / /map 2 /
Maps
z = Ii - X I + Point- by - point +
S
Paint - by - point + +
and
/ mapn 7 Calculate Mean
/ mapn 7
l
and Variance
and
Make Maps
~
Calculate t - Statistic
and
A UN KNOWN vs REFERENCE

Figure 19.4. Topographic imaging of abnormality: SPM. (A)

demonstrates the formation of a Z-statistic SPM. The Z-transform
represents the number of standard deviations by which an
individual's observations differs from the mean of a reference set.
For BEAM, the Z statistic is calculated individually for each of
the 20 to 32 scalp electrodes from the data of a single subject and SET 1 vs SET 2 B
the data of a normal control population. The resulting 20 to 32 Z
values are then interpolated according to the procedure shown in same difference in group means when the variance in either or
Fig. 19.2 to produce the Z-SPM. The result is a display of a sub- both groups is larger. For BEAM, the t-statistic is calculated
ject's deviation from normal in units of standard deviation in such individually for each of the 20 to 32 scalp electrodes from the
a way that the spatial relations of the original BEAM image are data of the two groups of subjects. The resulting 20 to 32 t values
retained. Z-SPMs are ordinarily used in clinical practice to define are then mapped using the procedure in Fig. 19.2 to produce the
abnormality in individual subjects. (B) demonstrates the forma- t-SPM. The result is a topographic display of where the brain
tion of at-statistic SPM. Student's t statistic quantifies the separa- electrical activity of one group differs from that of the other.
tion between two sets of measures, taking into account not only Ordinarily, t-SPMs are used in research to delineate the way in
the difference between the mean value of each group but also the which a pathological population differs from a control popula-
variability within each group. Thus the t value is lower for the tion. (From Duffy et al [1981], with permission.)
Topographical Analysis in the Clinical Setting 231

B
Figure 19.5. Comparative BEAM topographic images of a man diagnosed as basically healthy early on, but was ultimately diag-
with progressive stages of presenile dementia. Data displayed nosed, with input from these images, as having Alzheimer's dis-
according to the convention of Fig. 19.1. (A) and (B) provide ease. The apparent difference in the theta frequency maps of the
maps of delta and theta spectra, respectively, based on testing in control groups study 1 versus study 2 is the result of scaling con-
early 1986. (C) and (D) provide comparabfe maps in the summer vention applied to the second study to enhance the Visibility of
of 1987. Note the progressive increase of delta and theta in the regional differences demonstrated in the SPM image. The control
left parietal region. As noted in the text, the patient was clinically groups are identical for both studies (continued).
232 19. Clinical Use of BEAM

Figure 19.6. Left posterior temporal abnormality in a patient 7.41 standard deviations. (B) shows augmented negative activity
with temporal lobe epilepsy personality syndrome. Three Z- of the VER from 344 to 380 ms by 3.65 standard deviations in the
statistic SPMs are shown for a 29-year-old woman with the left posterior temporal/parietal region. (C) shows augmented
presenting complaint of "chronic ruminative condition" and the negative activity of the AER in the left posterior temporal/parie-
final diagnosis of temporal lobe epil~psy personality syndrome. tal region from 160 to 196 ms. These three spatially congruent
Three sets of three BEAM images are shown. Within each set the abnormalities lead to the recognition of an electrophysiological
patient data are shown to the upper left, the control data to the abnormality and, eventually, the collection of complex historical
upper right, and the corresponding Z-SPM below. (A) shows data to synthesize the clinically important diagnosis (see text).
globally augmented 0.5 to 3.5-Hz delta maximal in both posterior (From Duffy in Physiology of the Ear [in press], with permission.)
temporal regions (left> right) reaching a maximum Z value of
Topographical Analysis in the Clinical Setting 233

Figure 19.6.
234 19. Clinical Use of BEAM

Figure 19.7.
Topographical Analysis in the Clinical Setting 235

Figure 19.8. Topographic mapping of AER and resulting SPM provided clear evidence of drowsiness in the patient. These
image showing comparison with normative data. The SPM image results underscore the continued importance of traditional EEG
would indicate an extreme abnormality. However, traditional recording in clinical diagnosis.
EEG data were recorded simultaneously with the EP testing and

..
Figure 19.7. BEAM (eyes open EEG), displayed according to the mality, with augmented left temporal positivity, by 2.31 standard
convention of Fig. 19.1, derived from an 8-year-old boy who deviations, and broadly increased frontal and right hemispheric
presented with clinical signs and symptoms consistent with the negativity, by 3.98 standard deviations (C). This degree of abnor-
Sylvian seizure syndrome, which is generally believed to be a mality is unusual in the Sylvian seizure syndrome. Owing to these
benign, self-limited disorder. In contrast to the usual findings, unusual BEAM findings, radiographic studies were performed,
however, the distribution of activity at the onset of a typical spike revealing a left thalamic tumor. Had it not been for the topo-
was maximal in the left frontal region (A) and 19 ms later moved graphic deviations from the normal pattern, prompt radiographic
secondarily to the left midtemporal region (B). Ordinarily, dis- investigations would not have been performed. (From Duffy in
charges in this syndrome commence in the centroparietal, not Topographic Brain Mapping of EEG and Evoked Potentials [in
frontal, regions. Although spectral and VER data were normal press], with permission.)
(not shown), the AER demonstrated a very large "dipole" abnor-
236 19. Clinical Use of BEAM

B
Figure 19.9. Comparable BEAM SPM images based upon testing paring him with group norms. As can be seen, the abnormality
and retesting of an individual. (A) indicates an AER abnormality only occurs during one of the three testings, suggesting a tran-
in the posterior region, based on comparison with control group sient, probably artifactual abnormality. Supporting neuropsycho-
data. (B), however, depicts the same individual retested under the logical and clinical examination resulted in no indication of
same conditions three times. The images in the top row are based pathology. These findings stress the importance of replication
on recordings of the patient; those on the bottom are SPMs com- testings.
Topographical Analysis in Clinical Setting 237

References Duffy FH (ed.): Topographic Mapping of Brain Electrical Activity.

Boston, Butterworths, 1986.
Bartels PH, Subach JA: Automated interpretation of complex Duffy FH: Topographic mapping of brain electrical activity: clini-
scenes, in Preston K, Onoe M (eds.): Digital Processing in Bio- cal applications and issues, in Maurer K (ed.): Topographic
medical Imagery. New York, Academic Press, 1976. Brain Mapping of EEG and Evoked Potentials. New York,
Bear DM: Temporal lobe epilepsy- a syndrome of sensory-limbic Springer-Verlag, in press.
hyperconnection. Cortex 1979; 15:357-384. Duffy FH: Clinical electroencephalography and topographical
Bear DM, Fedio P: Quantitative analysis of interictal behavior in brain mapping: technology and practice, in Jahn AF and
temporal lobe epilepsy. Arch NeuroI1977; 34:454-467. Santos-Sacchi JR (eds.): Physiology of the Ear. New York, Raven
Bickford RC: Computer Techniques in Neonatal EEC, in Werner Press, in press.
SS, Stockard JE, and Bickford RC (eds.): Atlas of Neonatal Elec- Duffy FH, Bartels PH, Burchfiel JL: Significance probability
troencephalography. New York, Raven Press, 1977; 193-200. mapping: An aid in the topographic analysis of brain electrical
Callaway E: Diagnostic uses of the averaged evoked potential, in activity. Electroencephalogr Clin Neurophysiol 1981; 51:455-
Donchin E and Lindsley DB (eds.): Average Evoked Potentials. 462.
Washington, D.C., NASA, 1969; 299-332. Duffy FH, Burchfiel JL, Lombroso CT: Brain electrical activity
Chiappa KH: Evoked Potentials in Clinical Medicine. New York, mapping (BEAM): A method for extending the clinical utility of
Raven Press, 1983. EEC and evoked potential data. Ann Neuro11979; 5:309-321.
Dawson CD: Cerebral responses to nerve stimulation in man. Br Jeffreys DA, Axford JC: Source locations of pattern-specific com-
Med Bull 1950; 6:326-329. ponents of human visual evoked potentials. Exp Brain Res 1972;
Duffy FH: Topographic display of evoked potentials: Clinical 16:1-40.
applications of brain electrical activity mapping (BEAM). Ann Lombroso C: Sylvian seizures and mid temporal spike foci in chil-
NY Acad Sci 1982; 388:183-196. dren. Arch Neuro11967; 17:52-57.
Chapter 20
Recommended Standards and Practices for
Brain Electrical Activity Mapping and
Topographic Analysis

Topographic mapping of neuroelectrical data has experi- It is clear that the practice of neurophysiology in these
enced a rapid escalation in acceptance and usage over the three settings could vary tremendously. A patient with a
past several years. Neuroscientists and clinicians are given neurological condition might well experience differ-
becoming increasingly reliant on the powerful data-inter- ing diagnosis and treatment, depending on which clinic he
pretation and statistical-analysis capabilities of the various or she was referred to. There is currently an unfortunate
topographic mapping technologies to assist them in clini- tendency in some neurology laboratories in the United
cal diagnosis and research. Unfortunately, the standardiza- States to rely solely on the topographic map as the basis of
tion of practice and quality control ~hat should be con- diagnosis. As we have noted in Chapter 19, this approach
comitant with this growth is lacking. There appears to be is limited and potentially harmful. On the other hand, it is
a substantial range of perceptions by users of these devices also an incorrect perception that all one needs is a "quali-
as to what BEAM can and should be used to do. fied electroencephalographer" as the user responsible for
Current topographic mapping practice manifests three these devices in order to produce consistent and reliable
very different approaches to clinical application. Some results. In fact, the knowledge required to function in the
devices, for example, allow the clinician to directly connect environment of quantified electroencephalography goes
the patient to the device, obviating the need for the stan- substantially beyond the training and experience of a tradi-
dard recording of EEGs. These devices produce color- tionally trained electroencephalographer. The optimal
coded maps of spectrally analyzed EEG and, in some contributions of computerized brain electrical activity
cases, single or cartooned topographic images of evoked- mapping devices lie in their reliability, objectivity, flexibil-
potential (EP) data. In these instances, it is not unusual for ity, and speed of analytic function. It is a dangerous mis-
the user to develop a clinical diagnosis solely on the basis conception to regard them as stand-alone diagnostic
of visual review of the spectral analysis of topographic devices designed to obviate the need for technically and, in
maps. Alternatively, the more sophisticated devices empha- fact, specifically trained professional neurophysiologists.
size the concurrent need to record and analyze EEGs, also The intent of this chapter, therefore, is to present a set of
providing the clinician with the capability of comparison recommended minimum standards for the practice of
of their subjects' EEG and EP with normative age-appro- BEAM and quantified electroencephalography. These
priate standard polygraphic data. The clinical assessment standards have been cooperatively discussed and designed
then includes the standard EEG, the spectrally analyzed in concert with developers of several leading topographic
EEG and EP topographic images, and topographic images mapping devices; as such they do not reflect a prejudice
comparing the patient with a control group, thereby favoring any particular manufacturer's device. Indeed,
enhancing detection of abnormality. In a third clinical the recommendations are based on the authors' view of
paradigm, the topographic devices are used only as topographic mapping as a part of clinical neurophysiology,
appendage, with raw data and topographic images used including both neurology and psychiatry. The recom-
primarily for illustrative purposes. These devices have as mendations first address issues of personnel: minimal
their basis precalculated multivariate discriminant training and appropriate testing protocol. Then, issues
paradigms used to generate subject assignment into one or of operating environment and equipment standards will
more clinical groupings. be addressed.
Personnel 239

Personnel given paradigms. They must be capable of modifying

behavioral paradigms to minimize such artifact.
6. Recognition of classic EEG features and abnormalities.
EEG Technologists Finally, it is desirable that technologists have skill in the
recognition of epileptiform discharges, normal variant
The technologists are clearly the most critical link in the rhythms, drowsiness and sleep, encephalopathy, and any
sound clinical practice of topographic analysis. They stand other features commonly occurring in EEG technology.
as the "keystone" in terms of machine operation and The inclusion, for instance, of undetected segments of
patient state. Technicians are in the best position to detect drowsiness, or segments of waking state with "14 and 6"
and ameliorate artifact of all types. Moreover, they are in a discharges, can radically alter the outcome of topo-
position wherein it is possible to make costly mistakes that graphic spectral analysis, causing the appearance of an
would be very difficult to detect subsequently. The cen- apparent pathological condition where none actually
trality of their role in the topographic process implies exists.
thoroughgoing, multifaceted training. Several of the skills
are demanded of any qualified EEG technician; BEAM In summary, technologists enter the field of BEAM from
requires additional specialized knowledge. two backgrounds. The most common background is that of
The key elements in technologists' skill repertoire would registered EEG technologists. They should come with
be the following: good skills in measurement and electrode application, and
an understanding of EEG rhythms. Many, however, are
1. Accurate measurement and proper placement of unskilled in the management of patient state and are prone
low-impedance electrodes of a stable sort such as cup to allowing subjects to become drowsy. They typically do
(disk) electrodes attached with collodion. Accurate not have sufficient rigor in artifact detection and removal.
placement is of paramount importance. This is a lengthy Furthermore, they will, of course, need special training in
process, so speed and dexterity become criteria for management of topographic mapping equipment. Tech-
judging performance, along with the essential accuracy. nologists may also enter the area of BEAM from allied
2. Familiarity with operation of the equipment, including fields such as electrocardiography, radiology, etc. Still
all its options. Not only must the technician know others enter the field while deciding whether or not to
the basic operational skills of classic EEG, slhe must pursue academic studies. In our experience, intelligent
acquire the knowledge unique to the topographic map- technologists with no background in EEG can be taught
ping devices and their computer-based peripherals. the mechanical and technical aspects of the job, including
3. Artifact management skills (equipment). This is of para- electrode application in approximately 3 months. How-
mount importance. Technologists must possess com- ever, they cannot be expected to have a feel for state con-
plete knowledge of sources of artifact. They must know trol of EEG or for detection or management of unusual
the location of electrodes used to detect and measure EEG rhythms for some time. Such technologists can func-
artifact and the technique of applying them. They must tion well but only with very close supervision by a knowl-
be capable of recognizing the occurrence of artifact on edgeable neurophysiologist or more qualified technologist.
the polygraph tracings and/or on the computer screen
for the purpose of marking artifact-contaminated seg- Neurophysiologists, BEAM Readers
ments and eliminating them prior to spectral analysis.
4. Artifact management skills (patient/subject manage- Most typically, the BEAM reader is a neurologist with
ment). Technologists must be capable of detecting state special training in neurophysiology. Alternatively slhe may
changes such as drowsiness; they must be knowledge- be a Ph.D. with background in electroencephalography or
able of strategies to control patient state. Similarly, they clinical neurophysiology, or a psychiatrist or pediatrician
need to be skilled at recognizing the presence of arti- with particular interest in electroencephalography.
facts such as electrode "pop;' eye blink, and muscle con- Qualification (boards) in EEG is extremely desirable but,
tamination, and they must work with patients to reduce in our experience, there are many individuals who have
or eliminate the occurrence of these artifacts where used electroencephalography in their practice extensively
possible. but have never bothered to qualify because they have not
5. Artifact management skills (behavioral paradigms). considered this a major portion of their practice. Such
Technicians will be called upon to manage patient per- knowledgeable individuals are often quite qualified to
formance of specific behavioral paradigms while col- enter into the field of quantified EEG and BEAM.
lecting data (e.g., EPs). They should possess specific Individuals with a background in electroencephalogra-
awareness of unique potentials for artifact related to phy, including official qualification, require substantial
240 20. Standards and Practices for BEAM and Topography

additional training before they can function adequately that there be a means of visualization either through a one-
in the field of topographic analysis. Given the basic way mirror or through a low-light television system. There
knowledge of electroencephalography, the following are must also be a means of verbally communicating with and
minimal additional requirements of reader/interpreters of listening to subjects. The stimulating (EP) equipment and
topographic images: the EEG instrumentation used with the patient must have
the same electrical characteristics as the equipment used
1. Complete familiarity with operation of the topographic
to gather data from the control population. Any differences
mapping device as well as its hardware and software,
in frequency characteristics of the EEG equipment will
analytic capabilities and limitations, and intended usage.
produce difficulties. All the other requirements of a good
2. Basic understanding of signal analysis, including such
EEG laboratory need to be fulfilled such as a relatively
precepts as data-sampling rates, spectral analysis, signal
noise-free environment that is distant from sources of elec-
averaging, scaling of spectral plots, differences between
trical interference such as certain radiology equipment,
microvolt and microvolt squared spectra, and differ-
elevators, etc.
ences between raw spectral and percent (normalized)
spectra.
3. Knowledge of normative inferential statistics as applied Equipment Requirements
to topographic analysis. The reader should be familiar
generally with univariate and multivariate statistics; and Regardless of manufacturer, the ideal operating system for
particularly with data Gaussianity; interactive effects of display and management of data should be designed by
multiple measurements; t, Z, and F statistics; and alias- appropriate human engineering methods to allow for sim-
ing. ple and rapid data management. Slow operation of equip-
4. Familiarity with artifact detection, reduction, and elimi- ment can be the most damaging feature of BEAM studies.
nation, not only in raw signal but in statistical outcome. Minor options that can improve diagnosis should be easily
implemented and not require extra time. Even the most
The reader should understand and be wary of capitaliza- conscientious physician, when hurried, will omit some-
tion on chance. The reader must be consistently able to
thing simply because it takes too long to perform. Such
detect change of subject state and its effect on mapped systems, therefore, are best built around enhanced micro-
data. As interpreter of topographic maps, slhe should be
processors or minicomputers with hard disks and floating
fully conversant in sources of artifact and the strategies point processors, since these allow faster processing time
previously discussed to deal with them.
and generally have better data-handling capabilities.
These recommendations generally address the standards
Ideally, interaction should occur through touch screen or
to be applied to the training and requisite skills of the mouse as well as keyboard.
professional clinician involved in interpretation and ana-
There are a substantial number of specific recommen-
lytic application of topographic mapping systems. Experi-
dations for equipment performance capabilities:
ence has shown that it takes approximately 1 week of work
for a bright, qualified electroencephalographer to acquire 1. A minimum of the standard 19 scalp electrodes, of the
sufficient skills to begin a practice of BEAM. Obviously, 10-20 International System, must be used. An additional
fellowship training of 6 to 12 months is much preferable. four artifact electrodes are recommended. These should
be placed so as to optimally monitor vertical eye move-
ment, horizontal eye movement, muscle and cardiogram
Recommended Standards for artifact. The topographic device should record all artifact
Topographic Mapping Environment channels through to final analysis such that false abnormal-
ities produced by artifact can be detected through the
and Equipment demonstration of statistical differences in the artifact as
well as from the scalp electrodes.
General Laboratory
2. Frequent monitoring of electrode impedance, prefer-
Much of the value of BEAM comes from the use of norma- ably on an automatic basis, must be facilitated by the
tive data and the individual deviation from the normative equipment design.
data that is indicative of abnormality. Accordingly, stan- 3. There must be means to gather, store, and display
dardization is very important. Data in most laboratories are EEG data during an entire study. The EEG serves first, to
gathered in a controlled environment where light and provide ready detection of artifact and, second, as a source
sound are held at minimal levels. This generally means that of intrinsic clinical information. The EEGs must be
within the laboratory a patient must be studied in a room recorded both during spectral data collection and during
separate from control equipment, telephones, physician/ EP recording. All such data should be clinically evaluated.
technologist discussions, etc. Nonetheless, it is necessary It becomes important to know, for example, if a subject was
Recommended Standards for Topographic Mapping 241

drowsy during EP recording or iflambda or "14 and 6" con- alter visual B&W and color scales as necessary, arraying
taminates spectral data. Although automatic artifact detec- the colors in a variable scale.
tion techniques are useful, no machine system surpasses 8. Color topographic displays should show positive elec-
the trained human eye in the detection and elimination of trical activity in red and negative in blue, with shading of
artifact. Accordingly, the presence of a polygraph (ink hue and color determining positive and negative magni-
writer) or very high-quality video monitor capable of tude. Data that range from 0 in only one direction should
producing near-paper quality EEG tracings is required for be scaled with the rainbow colors, with black set at 0, white
every laboratory. Ideally, it should be possible for EEGs at maximum and the typical colors of heated metal in
gathered at time of analysis to be stored and redisplayed in between (i.e., from maximum to minimum: red, orange,
other montages to assist in interpretation. Finally, the abil- yellow, green, blue, indigo, violet). Care should be taken
ity to view EP and unprocessed EEG data in a time- that color change promotes a sense of gradient from high
sequential manner (cartooning) should be provided. to low. Care should also be taken to avoid abrupt changes
4. The many analytic techniques and the huge volume of in color, which potentially create false impression of a
data generated, including individual EEG and EP data, and region of significance. On the other hand, the use of abrupt
normative group data on large numbers of parameters, color steps to intentionally recognize criterion areas is per-
require immense data-handling capabilities. Therefore, fectly legitimate.
very large hard-disk storage is required. 9. Basic states available for analysis should include, as a
.5. The system must provide means to facilitate the minimum, unprocessed EEG activity, unprocessed EP
detection and elimination of artifact during a recording tracings, results of EEG spectral analysis, and EEG coher-
session, both prior and subsequent to spectral analyses. ence analysis. Wherever topographic images are viewed,
Visual inspection or automatic artifact filtering of EEG the underlying data and/or polygraphic tracings should be
segments to be submitted for spectral or coherence analy- readily available. This would apply equally to EEG, EP, and
sis is mandatory as a minimum protective measure. Over- spectral mapping.
voltage detection must be provided for on-line signal aver- 10. All systems should provide the user with a normative
aging for EP data as a minimal protective measure. The data base against which to compare individual brain elec-
system should allow all analytic processes to be carried out trical activity data for normalcy. The detailed composition
on artifact as well as scalp electrodes. and characteristics of the normative data base must be
The system must provide means to inspect the actual delineated. The normative group should be stratified by
EEG segments used for spectral analysis at the time of this age and sex, and criteria for inclusion or exclusion of sub-
analysis. The results of "de-glitching" should be available jects should be explained in detail. To facilitate individual
for later inspection and should be reversible. versus group comparison, univariate and multivariate
6. Topographic imaging devices must be designed to statistical capabilities must be available and relatively eas-
permit calibration of the entire system prior to data collec- ily applied.
tion for DC level and peak-to-peak measures. At a min- 11. Data derived from the normative population must
imum, a sine wave of specified amplitude should be passed be addressed for "normality" or Gaussianity if parametric
through the entire system at a frequency near the main procedures are to be used. Members of the normative sub-
power maximum point of the signals being analyzed (e.g., ject pool must have been drawn from the normal healthy
10 Hz). Square-wave pulse calibration signals are inade- population, not clinically referred or unknown. However,
quate for calibration of amplifiers in quantified electroen- patients with idiosyncratic findings should not have been
cephalography. Nonetheless, they should be provided as a eliminated, since this approach tends to excessively nar-
final check of system performance. There should be means row the band defined as normal. Caution must be used in
to detect amplifier distortion and nonlinear characteris- the interpretation of data based upon percent spectral
tics. The system should also provide means to facilitate values given the lack of operational independence. For
analysis of the sine-wave calibration signal and of the bio- example, increased delta as a raw finding may produce
logical calibration signal (biocal), where all channels are concurrent reduction in other frequencies when
presented the very same data. Inspection and assessment expressed as a percentage measure. In addition, for exam-
of the outcome of this process should be facilitated by ple, the presence of excessive muscle activity may artifi-
statistical printouts and/or maps. cially reduce the percentage of slow activity present and
7. Ability to select between topographic mapping in reduce the sensitivity of a detection procedure.
color or in black and white (B&W) should be possible. The 12. A number of statistical manipulations and analytic
user should also have the freedom to modify scaling capabilities outside of spectral analysis and signal averag-
parameters, i.e., slhe should be able to have a given scale ing are recommended, and these include coefficient of var-
range from zero to maximum, minimum to maximum, and iation, symmetry functions, the "Hjorth" parameters
between any two chosen values. Slhe should be able to (Hjorth B, 1986) and coherence. Complete systems should
242 20. Standards and Practices for BEAM and Topography

include the ability to calculate such parameters and pro- Summary

vide means to readily add more as they are developed. One
should also be able to readily compare these parameters to
normative values. In summation, we recommend the following primary con-
13. The system should incorporate processes to avoid siderations be intrinsic to the design of any regulatory stan-
capitalization upon chance or randomly positive results. dards in the clinical use of topographic mapping:
The most common method is to facilitate the repetition of
individual study states to ensure replicability. This is analo- 1. Personnel already trained in neurophysiological pro-
gous to the overlaying of several EPs in classic neu- cedures must receive additional specialized train-
rophysiology. ing.
14. The topographic device should facilitate the gather- 2. Standard EEGs should be collected at the time of data
ing of at least one repetition of each data-gathering session gathering to enhance artifact and state control. The
with capability of simultaneous comparisons of both EEGs should be clinically interpreted as well.
unprocessed data (polygraphic tracings) and analyzed data 3. A normative data base is mandatory for clinical use.
(spectral waveforms and topographic images). Exclusionary and inclusionary criteria should be care-
15. There should be means provided for the digitized fully enumerated. The data base must be stratified
storage of all data - both processed and unprocessed - on by age.
digital tape, hard disk, or optical disk. 4. Equipment used to evaluate patients should be techni-
16. There should be means to obtain printed copies of cally identical or electronically equivalent to that used
all graphics materials such as topographic maps (B&W or to gather normative data.
color), unprocessed EEG and EP waveforms, and sta- 5. At least 19 scalp and four artifact electrodes should be
tistical outcomes - numeric or graphic. used.
6. As a minimal requirement for topographic maps a
With the substantial number of topographic mapping vertex view, equal-area display format should be pro-
researchers and manufacturers of topographic imaging vided.
devices, there are several areas where neurological 7. More than one technique for electrode referencing,
research scientists hold differing views as to testing pro- interpolation, and data normalization should be avail-
tocol. The following two issues are so central to the process able.
of topographic mapping that any enumeration of quality- 8. All systems should facilitate the detection and elimina-
control standards would be very incomplete without them. tion of artifact prior to map formation.
They do, however, remain the subject of keen disagree- 9. Every system must provide means for complete cali-
ment. bration and detection of amplifier distortion.
17. The technique for interpolation between electrode 10. Clinical studies should include repeat testings so as to
recorded data points should be carefully described. Its avoid false conclusions owing to chance findings.
relative benefits and deficiencies compared with other 11. Systems providing means for automatic classification
methods should be addressed. Ideally the user should have must detail appropriate inclusionary and exclusionary
the option to employ more than one method for interpola- criteria to ensure appropriate use.
tion. Minimally, three-, or four-point linear interpolation 12. All manufacturers should provide courses of instruc-
should be available. tion in their instrumentation.
18. As there exists no unanimity as to the best reference
electrode site, it is recommended that data be recorded
referenced to a single point, such as linked ears, with provi- Reference
sion for unlinked ears, for connecting or calculating
another physical reference site, for employing the average Hjorth B: Physical aspects of EEG data as a hasis for topographic
reference, and for use of the Laplacian reference (Hjorth, mapping, in Duffy FH (ed.): Topographic Mapping of Brain
op cit.). Electrical Actirity. Boston, Butterworths, 1986.
Chapter 21
EEG in Clinical Diagnosis and Its
Relationship to Other Neurological Tests

Recent years have witnessed an unprecedented develop- the extent of absorption of the x-rays by various tissues is
ment in techniques for diagnosis of neurologic disorders. quantified during small-dose x-ray penetrations of the
Notable among them are computerized tomography (CT), head from multiple directions. By the use of computer
magnetic resonance imaging (MRI), neurosonography, analysis, an entire cross-section of the brain can be map-
positron-emission tomography (PET), brain electrical ped out, with clear differentiation of the densities (x-ray
activity mapping, and averaged evoked potentials. Most of absorption coeffiCients) of the different areas. Such tomo-
these procedures are imaging techniques in which an graphic "slices" can be visualized as images or pictures on
image or map of the brain is constructed that reveals struc- a cathode-ray tube in which the shading of each point in an
tural and, in some cases, functional details. These proce- image is proportional to its x-ray absorption coefficient.
dures have virtually revolutionized neurologic diagnosis These images can, in turn, be printed out on an x-ray film.
and management. It may be said without reservation that Intravenous injection of iodinated contrast material
the practice of neurology and neurosurgery has drastically (intravenous pyelogram dye) may be used to enhance the
changed with the advent of the CT scan, the first practical density of the vascular structures and delineate areas
brain-imaging technique to become available to the clini- where there is a disruption of the blood-brain barrier.
cian. It may even be impossible for a current neurology The CT scan is a relatively non-invasive procedure that
trainee to imagine how one could have practiced neurol- gives an image of the brain resem bling the tissue slices that
ogy or neurosurgery without the help of CT scans and rely- the neuropathologist examines. The test is indicated in
ing purely on clinical judgment and certain "indirect" patients presenting with focal neurological deficits, altered
investigations such as pneumoencephalogram or ven- mental status, head trauma, new onset seizures, increased
triculogram to arrive at the diagnosis. intracranial pressure, suspected mass lesions, and sub-
In this chapter we discuss the use of electroencephalog- arachnoid hemorrhage. Although it is highly sensitive and,
raphy in clinical diagnosis and its relative value in the con- to some extent, specific in documenting a large variety of
text of some of these recently developed investigative intracranial pathology, its limitations include inability to
procedures. The aim is to give the physician an insight into show lesions that are very small or isodense with the brain
the optimal use of electroencephalography in neurological tissue. Thus, small plaques of multiple sclerosis may not be
diagnosis. The technologist will also benefit from reading visible in the CT scan. Even a large infarct, being isodense,
this chapter by gaining some understanding of the various may not be visible in the first 24 to 48 hours. Similarly, an
neurodiagnostic procedures. Let us first briefly look at isodense subdural hematoma may also be missed.
these procedures. Moreover, it is also important to remember that the CT
scan may show abnormalities that are not relevant to the
patient's current illness, e.g., old infarcts, agenesis of the
Computerized Tomography corpus callosum, etc.
Thus, although the cr scan is a highly sensitive test, a
In the routine x-ray examination of the head, only the skull normal study does not completely exclude intracranial
bones are visualized. However, it is well known that there pathology; nor does the presence of a lesion necessarily
are significant differences in the quantity of x-rays ab- imply that the particular lesion is responsible for the cur-
sorbed by the different tissues. In a CT scan of the head, rent illness of the patient. For these reasons the CT scan
244 2l. EEG in Clinical Diagnosis

does not replace other investigations like EEG or arteri- Neurosonography

ography. In many instances these investigations should be
viewed as complementary rather than mutually exclusive. Using ultrasound, an image of brain anatomy can be
created since the sulci, gray-white junctions, ventricular
walls, and blood vessels constitute multiple reflective
Magnetic Resonance Imaging interfaces. The technique is used to study the structural
details of the brain; it is particularly useful in infants as the
Magnetic resonance imaging, which is rapidly becoming ultrasound can be introduced through the open fontanelle.
the "ultimate test" for neurologic diagnosis, is an excellent It has been quite valuable in the diagnosis and manage-
method, indeed, for visualizing the structural details of the ment of intracranial hemorrhage, particularly in the pre-
brain and the spinal cord. Both sagittal and coronal sec- mature infant.
tions can be visualized using this technique. The patient is
placed in a powerful magnetic field that tends to make the
protons of the tissues align themselves in the orientation of Brain Electrical Activity Mapping
the magnetic field. These protons can be made to resonate
and change their axis of alignment by introducing a radio- This topic is discussed in detail in Chapter 19: "Clinical
frequency pulse into the magnetic field; when the radio- Use of Brain Electrical Activity Mapping:'
frequency pulse is turned off, the protons return to their
original position. An image of the tissue is constructed by
computer analysis of the radio-frequency energy that is Evoked Potentials
absorbed and then emitted by the protons in the tissue.
It seems likely that the MRI scan will replace the CT The theory and practice of evoked potential methods are
scan in the near future as the test of choice in most central taken up in detail in Chapter 17: "Average Evoked Poten-
nervous system (CNS) disorders as it provides better reso- tials:'
lution than the CT scan. Because of its present limited
availability and high cost, the MRI scan currently is used
primarily for (1) patients suspected of having multiple Role of EEG in Relation to
sclerosis (MS) - it probably is the best means of visualizing Other Neurodiagnostic Tests
the plaques of MS, (2) patients with posterior cranial fossa
lesions, as the CT scan tends to show too many artifacts in The availability of a number of relatively noninvasive diag-
posterior cranial fossa images, and (3) demonstrating nostic tests raises the challenge of optimal utilization of
spinal cord lesions. No currently available test is capable of these tests in a given clinical setting. To use the tests
showing spinal cord parenchyma like the MRI scan. appropriately, one needs to have a clear understanding of
the sensitivity and specificity of each. The practice of
ordering several tests Simultaneously without sufficient
Positron-Emission Tomography rationale is not only uneconomical but also often counter-
productive. Thus, it is possible to be misled by trivial find-
Unlike the CT and MRI scans, which reveal static struc- ings in one or more tests that may be totally irrelevant to
turallesions, the PET scan provides insight into the func- the patient's current illness. On the other hand, it must
tional or biochemical anatomy of the CNS. Here the brain also be pointed out that the tests may not be mutually
images are constructed on the basis of the amount of radio- exclusive; they may even be complementary, depending on
activity emitted from certain chemicals taken up by the the nature of the clinical problem.
brain. Specifically, positron-emitting isotopes of very brief With the exception of the PET scan, brain electrical
half-life that are produced in a cyclotron are injected into activity mapping, and evoked potentials, the tests men-
the patient's circulatory system for the purpose of con- tioned will show abnormalities only if structural or ana-
structing such images. One of the common chemicals tomical changes have resulted from the disease process.
used, 18F-fluoro O-oxyglucose (FOG), is handled by the But there are a number of neurologic disorders in which
brain cells as glucose, and hence it provides a measure of cerebral dysfunction is known to occur without an obvious
the cerebral glucose metabolism. One may also study structural lesion. The classic examples are those disorders
structures that produce or transport a number of neuro- that cause (1) intermittent disturbance of function such as
transmitters, like dopamine, using suitable radioisotopes. epilepsy and sleep disorders, and (2) persistent distur-
The test is becoming increasingly useful in the study of the bance as in the case of diffuse encephalopathies. Presently,
metabolic basis of a large number of neurologic disorders the EEG and evoked-potential recordings are the only
including epilepsy. readily available tests capable of providing information on
Seizure Disorders - General Considerations 245

functional alterations in such disorders. Electroencepha- does not necessarily rule out a genuine seizure disorder.
lography is totally noninvasive, is of modest cost, and pro- Interictal abnormalities are more likely to occur if a sleep
vides exclusive second-to-second information on the func- record is also done, the yield being even greater if the
tional status of the cerebral cortical neurons over a period patient has been sleep deprived overnight (see Chapter 16:
of time. These facts are sometimes overlooked and often "Activation Procedures"). Sequential EEG studies also
underemphasized. increase the chance of detecting interictal abnormalities.
Before discussing the specific indications for electroen- From the standpoint of specificity, there are a number of
cephalography in relation to other neurodiagnostic tests, it EEG patterns that are highly correlated with certain types
must be stressed that the EEG is a recording of electrical of specific seizures disorders. Thus, the typical 3-Hz gen-
activity originating from large numbers of neurons in the eralized spike and wave discharge present on a normal
cerebral cortex and that these neurons are known to react background rhythm has a high correlation with absence;
in a somewhat stereotyped manner to different types of however, it should be pointed out that about one third of
injuries and insults. Hence, only rarely do we find a situa- asymptomatic siblings of patients with absence seizures
tion where the EEG is conclusively and specifically diag- may also show this EEG abnormality. In other words, the
nostic of a particular disease. Nevertheless, there are a presence of this EEG pattern does not necessarily indicate
number of conditions in which certain EEG abnormalities that the patient suffers from absence and needs treatment:
point to the "most likely" diagnosis. In other situations, the
it is important to make sure that there is adequate clinical
EEG and evoked-potential recording are used as com- correlation. In this context, it is appropriate to point out
plementary investigations to other tests like the CT or MRI that one is treating the patient and not the EEG abnor-
scan; in this way, they help to arrive at the final diagnosis.
mality.
The conditions in which the EEG provides somewhat Certain patterns like hypsarrhythmia and slow spike and
specific diagnostic information include seizure disorders, wave discharges show a high correlation with infantile
sleep disorders, and certain forms of encephalitis. It is spasms and the Lennox-Gastaut syndrome, respectively.
similarly useful in the documentation of brain death. The On the other hand, there are certain patterns like 6-Hz
EEG may provide supportive diagnostic information in phantom spike and wave, 14- and 6-Hz positive spikes, and
conditions such as cerebrovascular disease and head inju- small sharp spikes (SSS) that mimic epileptiform activity
ries. In addition, it is also quite useful as a prognostic tool
but have no significant correlation with seizure disorders
in a variety of CNS disorders. Let us take a look at some of (see Pseudoepileptiform Patterns, Chapter 15).
these disorders from the viewpoint of the role of electroen- The distinction of seizures from seizure-like phenomena
cephalography in relation to other neurodiagnostic tests. such as syncope, transient ischemic attacks (TIA),
cataplexy and conversion reaction may, in some instances,
ultimately depend on EEG studies. Sometimes, long-term
Seizure Disorders - General EEG recording with simultaneous video monitoring (see
Chapter 18) may be necessary in such cases.
Considerations There are a number of other questions that may uni-
quely be answered by EEG evaluation of patients with
The EEG is the most important test in the evaluation of seizure disorders. Determining the probability of recur-
seizure disorders, as it provides diagnostic and prognostic rence of seizures after a patient has had his first seizure is
information in the majority of patients. Let us briefly a common problem. The EEG is particularly useful in this
review the practical aspects of the role of electroencepha- regard. In one study involving children, it was found that
lography in the evaluation of seizure disorders. the risk for recurrence of seizures is twice as great if the
The two basic questions to address are the sensitivity of EEG showed an epileptiform abnormality as compared
the EEG for the diagnosis of seizure disorders and the with a normal EEG. The distinction between primary
specificity of individual abnormal EEG patterns relative to generalized seizures and focal seizures with secondary
the different types of epilepsy. There are a number of synchrony may be impossible without an EEG recording,
investigations that have addressed these questions. The especially in patients who present with seizures that occur
routine EEG study (awake, hyperventilation, and photic primarily during sleep. The type of abnormality noted also
stimulation) has been found to show epileptiform abnor- helps in categorizing the seizure and in choosing the
malities in 90% of patients with absence. In primary appropriate anticonvulsants. Selecting suitable candidates
epilepsy manifesting as generalized tonic-clonic seizures, for surgery from among patients with intractable epilepsy
the sensitivity is less and can vary from 20% to 60%, also depends on adequate EEG studies. Decisions regard-
depending on whether the patients have associated fea- ing discontinuing anticonvulsants following a prolonged
tures like myoclonic jerks. These data should be adequate seizure-free period are often based on whether the EEG
to communicate the essential message: a normal EEG has remained normal or abnormal; the chances of recur-
246 2l. EEG in Clinical Diagnosis

rence tend to be higher if the EEG has continued to be typical EEG pattern is one of generalized sharp- and slow-
abnormal. Yet another situation where EEG recording is wave complexes (Fig. 15.30) that usually occur at a fre-
invaluable is in the diagnosis of nonconvulsive status quency of less than 2.5 Hz. This slow spike and wave
epilepticus (see below). activity, or petit mal variant as it is termed, differs from that
Some important aspects relating to the EEG evaluation in absence which typically shows 3-Hz spike and wave
of various specific seizure disorders are discussed in the activity. Unlike the tracing in absence, the background
following sections. activity in Lennox-Gastaut syndrome tends to be slow.
During seizures, the initially high-amplitude sharp and
slow-wave complexes may be followed by paroxysmal
Febrile Seizures activity that consists oflow-voltage fast activity in the alpha
or beta frequency band; at this time, there may be transient
The interictal EEG is normal in patients with febrile suppression of the interictal sharp and slow-wave activity.
seizures except in the immediate postictal period. Slow
activity, focal or generalized, may persist for up to 1 week
following a seizure and should not be considered signifi- Primary Generalized Epilepsy
cant for predicting future seizures. However, in a child
apparently presenting with febrile seizures, the occur- There are two major types of primary generalized epilepsy,
rence of a persistent, definite focal epileptiform abnormal- namely, absence (petit mal) and tonic-clonic seizures
ity in the EEG shifts the diagnosis from benign febrile sei- (grand mal). Interictal patterns are extremely important in
zures to seizures probably resulting from an underlying the diagnosis of these disorders, as ictal patterns may not
structural disorder. In such a patient, one may need fur- occur during routine EEG recording.
ther tests such as the CT scan. Thus, the EEG plays a sig-
nificant role in the investigation and management of a
Absence Seizures
child with febrile seizures.
The most common clinical presentation is in the form of
staring spells. These are best described as lapses of cons-
Infantile Spasms ciousness that last for a few seconds. Characteristically, the
onset is in childhood, and the seizures seldom persist
Hypsarrhythmia is the characteristic EEG pattern; it beyond adolescence. The typical EEG pattern of absence
consists of a high-amplitude, disorganized and chaotic is high-amplitude, generalized 3-Hz spike and wave com-
background rhythm with shifting multifocal spikes and plexes occurring bisynchronously. The rate may vary from
episodes of electro-decrement, which may accompany the 21/2 to 4 Hz; the highest amplitude is in the frontal area,
seizures (Fig. 15.33). The clinical presentation consists of although rarely it may occur in the occipital area instead.
minor motor seizures manifesting as flexor or extensor The discharges may last from one to several seconds.
spasms, usually associated with arrest of psychomotor Although discharges of very brief duration « 3 seconds)
development. This is an age-related syndrome and has an are considered interictal and prolonged discharges ictal,
onset usually in the first year of life. In the proper clinical the distinction is rather nebulous and depends on the
setting, the pattern of hypsarrhythmia is diagnostic of feasibility of detecting changes in level of consciousness
infantile spasm (West's syndrome), which may be idio- within very short intervals of time. Prolonged discharges
pathic or secondary to disorders like cerebral anoxia, lasting 12 seconds or more often lead to automatisms and
tuberose sclerosis, phenylketonuria, etc. Although elec- confusional states.
troencephalography is the most important diagnostic test A characteristic feature of absence seizures is the ease
in infantile spasms, other investigations like CT scan and with which they can be brought on by hyperventilation
neurometabolic screening are complementary procedures (Fig. 16.4). As mentioned earlier in Chapter 16, hyperven-
for arriving at an etiological diagnosis. tilation should be continued for five minutes in a suspected
case of absence if no discharges occur in the first three
minutes. During sleep, the discharges tend to become less
Lennox-Gastaut Syndrome well organized. In most patients, high-amplitude general-
ized 3-Hz delta paroxysms are seen; but by themselves
The diagnosis of this condition is again based on the clini- these are not diagnostic of absence seizures. The back-
cal presentation coupled with a typical EEG abnormality. ground activity tends to be normal in children with
The disorder occurs in early childhood; it presents with a absence, and there is no postictal slowing. When the typi-
multiple variety of seizures (myoclonic, tonic, tonic-clonic, cal EEG pattern is noted in a child with a clinical history
absence, etc.) accompanied by mental subnormality. The suggestive of absence, there is little indication for further
Partial (Focal) Epilepsy 247

tests like the CT scan. However, if there is a consistent in the motor cortex may cause clonic movements of the
asymmetry of the discharges or the onset occurs later in contralateral upper or lower extremity, whereas an occipi-
life, one may have to rule out an underlying lesion by other tal focus will cause visual sensations like flashes of light.
tests like the CT or MRI scan. These are simple partial seizures. Further components of
the seizure are dictated by the mode of spread of the
epileptic discharge. Transcortical spread leads to Jackso-
Generalized Tonic-Clonic Seizures (Grand Mal)
nian march,l which sequentially involves areas of the body
The ictal pattern is quite typical in generalized tohic- represented in the motor and sensory cortex (see Appen-
clonic seizures, but the interictal pattern may take differ- dix 2). If the discharges spread rapidly and involve both
ent forms. During a seizure, there initially is a repetitive cerebral hemispheres through secondary bilateral syn-
discharge of spikes, or fast rhythmic activity, which may be chrony, the patient develops a generalized tonic-clonic sei-
in the range of 10 to 20 Hz. Following this, there is a pro- zure. When the discharge originates in certain areas like
gressive slowing of the discharge rate and an increase in the temporal or orbitofrontal cortex, there is associated
the amplitude of the activity. During these periods, the confusion and automatisms; the term complex partial
patient goes through the tonic phase. Soon the clonic epilepsy is used in this context.
phase sets in, during which time generalized spikes coin- Partial seizures should alert the physician to the possibil-
ciding with the clonic jerks are noted. These are bilaterally ity of an underlying focal structural lesion. However, there
synchronous and symmetrical, although muscle artifacts are forms of familial partial epilepsy in children where no
usually make identification difficult. The spikes are often structural lesions are found; such cases are designated
followed by slow waves, which correspond to the periods of benign partial epilepsy of childhood. The role of EEG test-
relaxation noted in between the clonic jerks. The clonic ing in the partial epilepsies is discussed below.
movements gradually become less frequent and then stop
abruptly; thereupon, there is a marked suppression of
EEG activity for varying periods of time. Following this Rolandic Epilepsy
period of attenuation, the EEG is very slow (postictal slow-
Known by several eponyms, such as benign epilepsy of
ing) after which it gradually returns back to the preictal
childhood with Rolandic spikes (BECRs), Sylvian epilepsy,
pattern.
and centromidtemporal epilepsy, this is an electroclinical
Interictal abnormalities may consist of 2 to 4 Hz or
syndrome in which the diagnosis depends upon a charac-
faster, bilaterally synchronous, spike and wave complexes
teristic EEG pattern. The epileptiform activity, which is
or spikes in generalized distribution (Fig. 15.29). Some-
markedly accentuated in drowsiness and stage II sleep,
times polyspikes (multispikes) or polyspike and wave com-
consists of spikes arising from the central and midtemporal
plexes are noted. The terms generalized atypical, irregular
(C3, T3 and C4, T4) or central and parietal (C3, P3, and
spike and wave, and fast spike and wave, have all been used
C4, P4) areas unilaterally or bilaterally. When appearing in
to describe these discharges in order to distinguish them
both hemispheres, the spikes switch sides from time to
from the 3-Hz spike and wave discharges that are charac-
time (Figs. 15.19 and 15.20). This is considered to be a
teristic of absence.
common seizure disorder, accounting for about 25% of
A child with grand mal seizures who has a positive family
childhood epilepsies. The most common age of onset is
history and an EEG pattern of generalized epileptiform
between 5 and 8 years. Rolandic seizures seldom persist
activity may not need other tests like the CT scan.
beyond 14 to 15 years of age.
However, adult onset of the seizures or suspicion of secon-
The clinical manifestations include parietal or some-
dary synchrony in the EEG (Fig. 15.41) should alert the
times generalized seizures, usually nocturnal. Partial
physician to the possibility of an underlying structural
seizures manifest as clonic movements of facial and oro-
lesion. Grand mal seizures with a definite aura should also
pharyngeal muscles (leading to guttural sounds), tongue,
suggest that one is probably dealing with a focal-onset sei-
and upper extremities. Speech arrest and salivation are
zure with secondary generalization. Under such circum-
common. There is usually a positive family history. Al-
stances, CT or MRI scan should be the next step.
though the EEG pattern in conjunction with the clinical
picture is specific or diagnostic, it must be pointed out that
Rolandic spikes may occur without an accompanying
Partial (Focal) Epilepsy seizure disorder; hence, the presence of spikes alone is not
an indication for treatment. A CT scan may not be neces-
Unlike generalized epilepsy, patients with partial epilepsy
show clinical and/or EEG evidence of focal onset of the sei-
zures. The initial symptoms will depend upon the site of I Named after Hughlings Jackson, the 19th century neurologist

origin of the discharge. Thus, for example, a seizure focus and father of epileptology who first described the disorder.
248 21. EEG in Clinical Diagnosis

sary in a child with the typical type of seizure, a positive matisms should arouse the suspicion of NCSE. The EEG
family history, and the characteristic bilaterally shifting pattern may be one of continuous, generalized 2.5- to 3-Hz
centromidtemporal spikes on a normal background. spike and wave complexes, which would suggest absence
Nevertheless, any unusual features-e.g., presence offocal status (Fig. 15.34). Repetitive focal or lateralized activity
neurologic deficits, focal slowing in the EEG, or delayed consisting of spikes, sharp waves, spike and wave com-
age of onset of the seizure - should alert one to the possi- plexes, rhythmic slow waves, or fast activity characterize
bility of an underlying disorder such as an arteriovenous partial complex status. Without the EEG, the distinction
malformation, a tumor, or a scar. In such cases, further between the two conditions cannot be made.
neurologic testing should be undertaken.
A similar syndrome with occipital or parieto-occipital
spikes or spike and wave complexes has also been Sleep Disorders
described. The clinical seizures are characterized by a
visual aura followed by hemiclonic, tonic-clonic, or com-
Recording of the sleep EEG together with other physio-
plex partial seizures. However, occipital spikes that are
logic parameters (polysomnography) like respiratory move-
unassociated with epilepsy may occur in children with
ments, air flow, eye movements, muscle activity, and blood
early-onset visual problems.
oxygen concentration is essential for confirming the diag-
nosis of sleep apnea syndrome and categorizing into
Other Forms of Partial Epilepsy obstructive, central, or mixed apnea. For the diagnosis of
narcolepsy, the multiple sleep latency test is perhaps the
Except in conditions like Rolandic epilepsy, patients with
most useful investigation. In this test, one tries to docu-
clinical focal seizures need tests like the CT scan because
ment excessive sleepiness as well as rapid eye movement
the EEG does not reveal the specific cause of the seizure.
In newly occurring seizures, especially those starting after (REM)-onset sleep in order to confirm the diagnosis of nar-
colepsy. For details about technology and information con-
the age of 20 years, a cr scan should be done even when
cerning interpretation of such sleep recordings, the reader
the clinical presentation is one of a generalized seizure.
is referred to various available monographs that deal with
This is necessary because a focal onset may not be obvious
the subject.
clinically. The additional neurologic testing becomes even
more important if there is a history of aura, focal neuro-
logic deficit, or an EEG focus.
It must be remembered that the EEG is not very sensi- The Comatose Patient
tive in the case of simple partial seizures and may even be
normal in focal motor seizures. Here the clinical findings Performing an EEG study in comatose patients is a chal-
are more important in diagnosing the type of seizure and lenge to the EEG technologist as the procedure is usually
ordering of further investigations. done at the bedside in the hostile environment of the
In complex partial seizures, special recording tech- intensive care unit (leU). An equally formidable challenge
niques like sphenoidal leads may be necessary. Moreover, faces the electroencephalographer who interprets these
as there is a higher incidence of spikes in a sleep EEG, it tracings, as numerous artifacts are all too common in such
is important to obtain a sleep recording. Anterior and tracings.
mesiotemporal spikes are considered more significant in To obtain an acceptable recording from the comatose
the diagnosis of complex partial epilepsy than midtempo- patient, there are a number of steps the technologist must
ral spikes. Spikes in frontopolar, orbitofrontal, and follow. One of the first is to determine the patient's level of
tempera-occipital areas may also be associated with com- consciousness. Find out whether the patient responds
plex partial seizures. In most patients with complex partial when you call his or her name aloud or when a verbal com-
epilepsy, the CT or MRI scan may be necessary to rule out mand is given. If there is no response, this should be
underlying structural lesions in the temporal or frontal clearly noted in the worksheet. It is important to repeat
lobes. some of these commands while taking the EEG and to
enter them, as well as any response, directly on the tracing.
In an unresponsive patient the reactivity of the EEG to
Nonconvulsive Status Epilepticus passive opening of the eyes as well as to painful stimuli like
(NCSE) pinching or squeezing the calf muscle tendon should also
be noted. A reactive tracing will show a decrease in the
The EEG is valuable in confirming a diagnosis of NCSE. amplitude of the background activity; sometimes higher
Sudden onset of confusion, inappropriate behavior, amplitude slow activity may appear. Reactivity suggests a
memory problems, decreased responsiveness, and auto- more favorable prognosis.
Diffuse Encephalopathies 249

Another aspect of recording in the ICU is the presence Thus, a patient who appears comatose and has an alpha
of various artifacts not usually seen in the EEG laboratory. rhythm in the EEG may have alpha coma resulting either
Intravenous pumps, respirators, and other devices com- from cerebral hypoxia or brain-stem lesions or from drug
monly found in the ICU produce artifacts that have cer- intoxication; or he/she may have psychogenic coma or
tain distinctive characteristics. The technician needs to locked-in syndrome. In the latter two conditions, the
become familiar with these various artifacts so that their EEG shows an alpha rhythm having a normal distribu-
sources can be identified and the artifacts eliminated if tion and normal reactivity; hence, these patients are not
possible. Monitoring of respiration, ECG, eye movements, really comatose.
and bodily activity-which can be picked up by an elec- Another condition that is diagnosed on the basis of the
trode placed on the forearm - can be quite useful in this EEG pattern is NCSE-causing coma. Additionally, the dif-
regard. ferential diagnosis of a patient with prolonged confusional
The EEG recording should be considered as comple- state requires that a number of conditions be considered.
mentary to the CT scan in the evaluation of the comatose These include postictal state, transient global amnesia,
patient. If the CT scan is normal, the differential diagnosis drug intoxication, electrolyte imbalance, and psychiatric
can be further narrowed down by EEG evaluation; how- disorders. The EEG shows focal discharges in complex
ever, the EEG abnormalities seen in a comatose patient are partial status as against 3-Hz generalized spike and wave
often nonspecific. There is a progressive slowing of the activity in absence status. In psychiatric disorders, the
background activity with decreasing levels of conscious- EEG tends to be normal, whereas in electrolyte imbalance
ness, and a comcomitant increase in the amount of activity the pattern is one of diffuse slowing.
in the theta or delta frequency bands. The delta activity
may be intermittent and rhythmic in the case of diffuse
encephalopathies like metabolic disorders; it may be Electrocerebral Silence
diffuse and polymorphic as in certain forms of encephali-
tis; or it may be focal or lateralized and polymorphic in Absence of electrocerebral activity above 2 IlV is consid-
cases of supratentorial lesions. The focal and diffuse ered to be indicative of electrocerebral silence (ECS). The
encephalopathies are discussed in detail in later sections American EEG Society has stipulated the technical stan-
of this chapter. dards to be followed when such recordings are done. The
The EEG does not give adequate clues concerning the technician should consult the American EEG Society
specific cause of coma, although it is easy to make a dis- guidelines for details (American EEG Society Guidelines
tinction between psychogenic stupor, diffuse encephalopa- Three, 1986). Electrocerebral silence may result from
thy, and focal encephalopathy. Nevertheless, there are cer- brain death, hypothermia, or drug intoxication. The last
tain EEG findings that may aid in identifying the possible two are reversible and should be excluded before suggest-
cause of the stupor or coma. These are considered in what ing brain death as the cause of ECS.
follows.
The presence of typical triphasic waves (Figs. 15.50
and 15.51), although not pathognomonic, should suggest Diffuse Encephalopathies
the possibility of hepatic encephalopathy. A combination
of slow background activity, rhythmic delta waves, and Diffuse encephalopathies may result from a number of
a photoparoxysmal response to photic stimulation is often etiological factors ranging from infections to dementia.
seen in uremic encephalopathy. Presence of generalized The clinical presentation may vary from seizures to coma.
beta activity on a diffusely slow background in a coma- Except in a few circumstances, the EEG abnormalities are
tose patient is most likely to be the result of drug intox- nonspecific and do not point to the cause. Thus, in
ication. Diffuse slowing, burst suppression, or electro- encephalitis resulting from a number of different viruses,
cerebral silence may follow cerebral hypoxia; myoclonic the finding may simply be diffuse slowing. Similar find-
jerks accompanying periodic epileptiform activity on a ings are noted in metabolic encephalopathies as well. In
markedly attenuated background is another common many of these conditions when the EEG is grossly abnor-
pattern (Fig. 15.49). Yet another EEG pattern that occurs mal, the CT scan may not reveal any specific change.
following hypoxia is alpha coma. In alpha coma, activity Although the EEG findings are generally nonspecific,
in the alpha frequency band that is unresponsive to pas- there are a few instances where they may give important
sive eye opening is seen in diffuse distribution (Fig. 15.3), clues to the underlying disorder. For example, the
often with greater amplitude in the anterior regions. presence of triphaSic waves suggests a metabolic
This pattern is also known to occur following bilateral encephalopathy like hepatic encephalopathy- although
brain-stem lesions that involve the pontine tegmentum. similar EEG findings have been reported in uremic and
Such lesions usually are due to infarction or hemorrhage. hypoxic encephalopathies as well as in encephalopathy
250 21. EEG in Clinical Diagnosis

following head trauma. In the following sections, we dis- years, dialysis dementia (progressive dialysis encephalopa-
cuss the metabolic and infectious encephalopathies. thy) may set in. Clinically, the patient becomes progres-
sively demented and devlops focal abnormalities in the
EEG pattern. Epileptiform abnormality in the form of
Metabolic Encephalopathies sharp- and slow-wave complexes may be seen. As the EEG
abnormalities may precede the onset of the clinical syn-
These disorders lead to progressive obtundation and even- drome, they may be of predictive value.
tually coma. The EEG pattern shows parallel changes con-
sisting of diffuse slowing of background rhythms resulting
in theta or delta activity. Intermittent bursts of rhythmic Infectious Encephalopathies
high-amplitude, often frontally dominant delta activity are
a common feature. This is referred to by the acronym In the acute phase the EEG shows diffuse slowing, often
FIRDA, or frontal intermittent rhythmic delta activity with epileptiform abnormality. There are certain EEG
(Fig. 15.11). Sometimes the amplitude may be posteriorly findings that may provide clues to the underlying cause.
dominant, in which case the acronym OIRDA-which The types of encephalitides that show more specific
stands for occipital intermittent rhythmic delta activity- is changes include conditions like herpes simplex encephali-
used (Fig. 15.12). The various metabolic encephalopathies tis (HSE) and subacute sclerosing pan encephalitis
are taken up in turn. (SSPE).
In HSE, focal slowing and epileptiform discharges are
noted over the temporal or frontotemporal areas early in
Hepatic Encephalopathy
the course of the disease (Fig. 15.47), followed by periodic
As mentioned earlier, about one third of these patients may complexes either lateralized to one side or generalized.
show typical triphasic waves (Figs. 15.50 and 15.51), Indeed, if HSE is suspected in a given patient, an emer-
although the finding is in no way pathognomonic. Reye's gency EEG study is indicated so that specific antiviral
syndrome, which is a form of hepatic encephalopathy agents may be started promptly if the EEG shows the typi-
occurring in children, seldom shows triphasic waves, cal features.
although all the nonspecific findings of diffuse Another condition in which EEG abnormalities may be
encephalopathy may be present. diagnostic is SSPE. In this condition, generalized periodic
complexes are noted at specific intervals, often associated
with myoclonus. The complexes are of high voltage (100 to
Hypoglycemia and Hyperglycemia 1,000 IlV) and recur at intervals of 4 to 14 seconds. An
During hypoglycemia there is an accentuated EEG infectious encephalopathy that leads to dementia is the
response to hyperventilation and progressive slowing of slow viral infection known as Jakob-Creutzfeldt disease. As
background activity. Later, intermittent rhythmic delta in the case of SSPE, periodic complexes are seen that
activity (IRDA) appears. The condition is reversible, with recur at about I-second intervals (Fig. 15.46). In these dis-
the EEG becoming normal on restoration of normal blood eases, the EEG is much more useful than the CT scan for
sugar. Hypoglycemia may also enhance preexisting epilep- an early diagnosis.
tiform activity.
In hyperglycemia that accompanies the diabetic non-
ketotic, hyperosmolar state, nonspecific slowing of the Dementia
background rhythms is present. Apart from this, focal
seizure activity is not uncommon. However, a focal struc- In patients suspected of having dementia, the EEG is often
ttlrallesion is seldom demonstrable. quite informative. A decrease in the frequency of the alpha
rhythm, although nonspecific, is a consistent finding in
different forms of dementia - including Alzheimer's dis-
Renal Disorders
ease - early in the course of the disease. In making the dis-
Uremic encephalopathy is characterized by slowing of the tinction between pseudodementia (often due to depres-
background rhythm, FIRDA, occasional triphasic waves, sion) and true dementia, definite slowing of the back-
and photoparoxysmal or photomyogenic response to pho- ground rhythm of the awake EEG is a very helpful finding.
tic stimulation. The slow activity gradually disappears fol- Of course, one needs to remember that a patient with
lowing dialysis. Some patients show a temporary worsen- pseudodementia may be taking one or more antidepres-
ing of the EEG pattern and a decline in mental status sant medications that can potentially cause fast activity
(dialysis dysequilibrium syndrome) during dialysis. In and/or some degree of slowing of the background rhythms.
some patients who have undergone dialysis for several In a patient with dementia, the presence of generalized
Cerebrovascular Disorders 251

periodic complexes strongly suggests the possibility of ties may be less striking. The tracing may show only a
Jakob-Creutzfeldt disease. A very low-amplitude EEG decrease in amplitude of the background activity-
with background slowing suggests advanced dementia and particularly the beta activity- on the side of the lesion, or
has been classically described in Huntington's disease. In it may even be normal. Remember that beta attenuation
patients with dementia, the CT scan is an essential comple- may occur not only with cortical involvement but also in
mentary test. Apart from ruling out conditions like chronic conditions like subdural hematoma, epidural fluid collec-
subdural hematoma and intracranial tumors, the CT scan tion, or even scalp edema.
documents the amount of cortical atrophy and can detect Electroencephalography is useful as a screening tool in
specific findings like the atrophic caudate nucleus seen in the evaluation of patients with chronic and recurrent
cases of Huntington's disease. The CT scan is also essential headaches. In such patients, presence of focal slowing
for the diagnosis of normal pressure hydrocephalis, a treat- should suggest the possibility of an intracranial tumor,
able form of dementia. although similar findings may also occur transiently in
classical migraine. The EEG tends to be normal in pseudo-
tumor cerebri. Similarly, the presence of focal PDA in a
Focal Encephalopathies patient being evaluated for a seizure disorder should alert
the physician to the possibility of an intracranial tumor.
It is perhaps in the field of focal cerebral lesions that the Electroencephalography is oflittle value in distinguishing
approach of the neurologist has undergone such drastic between different types of intracranial tumors. While it
changes with the advent of CT and MRI scans. Until can correctly lateralize supratentorial tumors, accurate
recently, patients with focal neurologic deficits had EEGs localization is not always possible. However, this is of little
taken prior to having invasive procedures such as angiogra- concern in the present era of CT and MRI scans.
phy or ventriculography carried out. With the universal If the EEG shows focal PDA but the CT scan is normal,
availability of CT scanners, this pattern has changed. In one needs to consider the possibility of a recent non-
this context, it may be stated at the outset that there are hemorrhagic infarct, trauma, recent episode of migraine,
some situations where the EEG provides valuable infor- or postictal slowing. Another situation where EEG testing
mation, and others where it is worthless. Take, for example, tends to be extremely valuable is in patients with HSE,
a suspected case of intracranial tumor. Irrespective of where focal slowing and/or epileptiform activity may pre-
whether the EEG findings are normal or abnormal, it is cede the appearance of CT abnormalities.
the CT scan - especially when both routine and contrasted
scans are obtained-or the MRI scan that will determine
the diagnosis as well as the management. However, this Cerebrovascular Disorders
may not always be true. In a patient with a space-occupying
lesion and rapidly progressive obtundation, the latter In a patient presenting with an acute neurologic deficit
might be the result of accompanying subclinical seizures; like hemiplegia, the CT scan is the most important test to
without an EEG this cannot be established nor can appro- distinguish between a hemorrhagic and a nonhemorrhagic
priate treatment be instituted. It should also be noted that lesion so that appropriate management can be instituted.
there are certain situations in which the EEG may show In those patients with normal CT findings, electroen-
abnormalities while the CT scan may be spuriously nor- cephalography is useful in assessing the degree and extent
mal, e.g., isodense subdural hematoma and early infarct. of damage. With a large infarct involving subcortical and
In focal lesions the type ofEEG abnormality depends on cortical areas, the abnormalities are striking and consist of
the site and size of the lesion. When the focal lesion is in PDA, lack offast (beta and/or alpha) activity, suppression of
the subcortical white matter, thereby disrupting the sleep spindles, and sometimes periodic lateralized epilep-
thalamocortical connections, one can expect to see dys- tiform discharges or PLEDS (Fig. 15.52). In the case of
rhythmic and polymorphic delta activity (PDA). The area small cortical lesions, the EEG abnormalities may be
over which such activity is seen will depend on how exten- minimal. In deep lesions at the capsular and upper brain-
sively the thalamocortical connections are severed. If stem level (for example, lacunar infarcts), they also may be
there are multiple areas of slow activity, the site of the minimal. Transient ischemic attacks cause transient EEG
lesion is likely to be underneath the area that shows the changes, mainly focal or lateralized slowing, but persis-
slowest and most irregular activity, irrespective of its tence of slowing should alert the physician to the possibil-
amplitude. If the lesion involves both the white and the ity of impending infarction.
gray matter, one also can expect PDA; but the amplitude is Subarachnoid hemorrhage mayor may not cause signifi-
likely to be smaller in the area directly over the lesion than cant EEG changes. Often nonspecific slowing occurs,
in the surrounding areas. When the lesion is superficially depending on the patient's level of consciousness.
placed and only involves the cortex, the EEG abnormali- Presence of focal abnormalities may be helpful in locating
252 21. EEG in Clinical DiagnosiS

the site of the aneurysm, but at best this is only a support- Can the EEG serve as a prognostic index? Is EEG record-
ing piece of evidence to be used in conjunction with angio- ing useful in predicting the occurrence of posttraumatic
graphic findings. epilepsy?
In arteriovenous malformations, focal or lateralized Diffuse slowing of the EEG is a nonspecific finding that
slowing and/or focal epileptiform abnormality may occur. may be seen after concussion. Localized slowing, espe-
In Moyamoya disease, a condition associated with child- cially polymorphic delta, suggests a contusion, even in the
hood hemiplegia that has subsequent potential for intra- absence of clinical or CT abnormalities. The gradual
cranial hemorrhage, excessive and prolonged slowing in change of the EEG pattern back to normal but with symp-
response to hyperventilation may occur. toms persisting may be helpful in separating neurologic
sequelae from psychological problems. Early EEG pat-
terns following head trauma have shown no consistent
Head Trauma predictive value for posttraumatic epilepsy. In recent
investigations, multimodality-evoked-potential studies
It may be stated at the outset that EEG testing has only have been shown to be better predictors of the extent of
a secondary role in the diagnosis and management of brain injury and sequelae than EEG studies. For details
head trauma. Imaging techniques such as the CT scan about the indications for evoked-potential studies, refer to
are the most important investigations for this purpose. Chapter 17.
This is particularly true in the case of severe head in-
jury when life-threatening complications like intracranial
hemorrhage may occur. When considering the role of
Reference
electroencephalography in head trauma, a number of American EEG Society Guidelines Three: Minimum technical
questions are often asked. How can EEG recording help standards for EEG recording in suspected cerebral death. J
in delineating the extent and severity of brain damage? Clin Neurophysiol1986; 3 (suppll):l2-17.
Appendix 1
Glossary of Major Terms Used in the Text

AI: Denotes an electrode location on the left ear lobe. type and has a frequency of 60 Hz; in Europe the frequency is
A2 : Denotes an electrode location on the right ear lobe. 50 Hz. Abbreviated AC.
Absence: Refers to an epileptic attack characterized by a brief Ammeter: An instrument used to measure the amount of current
lapse of consciousness in which there is a sudden, momentary flowing in an electric circuit.
pause in conversation or movement. Ampere: The unit of measurement of electric current that
AC: Alternating current. expresses its rate of flow. In electroencephalography, current
Action potential: A propagated change in which the membrane flow is more conveniently expressed in milliamperes
potential of a neuron suddenly becomes positive for a brief (thousandths of an ampere) or in microamperes (millionths of
period of time. This change is known as depolarization. Neu- an ampere).
rons communicate with each other through generation of Amplification: The process of increasing the strength of an elec-
action potentials. trical signal; it is expressed in a ratio called the amplification
Activation: (1) Any procedure designed to enhance or elicit nor- factor, or gain.
mal or abnormal EEG activity, especially paroxysmal activity. Amplification factor: See gain.
Examples are hyperventilation, photic stimulation, sleep, and Amplifier: A combination of electrical and electronic compo-
injection of convulsant drugs. (2) An EEG tracing consisting of nents designed to increase the voltage, current, or power of an
low-voltage activity that results from the attenuation of EEG electrical signal.
rhythms by physiological or other stimuli. Amplitude: Voltage of EEG waves. Generally expressed in
Active ear: The case in which a focus of activity is located in the microvolts (IlV) and measured peak-to-peak. The amplitude of
temporal lobe adjacent to the ear. EEG waves recorded from the surface of the head is influenced
AlEEG: Acronym for ambulatory cassette EEG. by a number of extracerebral factors. These include the
Alpha activity: See alpha rhythm. impedances of the meninges, cerebrospinal fluid, skull, scalp,
Alpha band: Frequency band of 8 to 13 Hz denoted by the Greek and electrodes.
letter (1. Anode: The positive electrode of a battery. In a vacuum tube the
Alpha rhythm: Rhythmic activity at 8 to 13 Hz occurring during anode is the element to which electrons are attracted from the
wakefulness over posterior regions of the head, generally of cathode. This element is referred to as the plate.
higher amplitude over the occipital areas. Amplitude is varia- Artifact: In EEG, any recorded signal that does not originate in
ble but is mostly below 50 IlV in the adult. It is best seen with the brain. The EEG artifacts may be of physiological origin
the eyes closed and under conditions of physical relaxation and (e.g., muscle activity), instrumental origin (e.g., defects in the
relative mental inactivity. The alpha rhythm is attenuated by recording amplifiers), environmental origin (e.g., 60-Hz vol-
attention, especially visual attention, and by mental effort. tage from the power line), or may originate from the recording
Alpha variant rhythm: Applies to certain characteristic EEG electrodes.
rhythms that are recorded most prominently over the posterior Asymmetry: Unequal amplitude and/or form and frequency of
regions of the head and differ in frequency but resemble the EEG tracings over homologous areas on opposite sides of the
alpha rhythm in reactivity. The frequency of the variant rhythm head, or unequal development of EEG waves about the base-
may be either an even fraction or multiple of the person's alpha line.
rhythm. Asymptote plot: The straight line approximation of a frequency-
Alpha wave: Wave with duration of 1/8 to I/IJ (0.l25-0.077) response curve.
seconds. Asynchrony: The non simultaneous occurrence of EEG activities
Alternating current: An electric current that undergoes periodic over regions on the same or opposite sides of the head.
reversals in the direction of its flow. The current supplied by Attenuation: Reduction in amplitude of EEG activity. This may
power lines in the United States is almost universally of this occur transiently in response to stimulation or result from
254 Appendix 1. Glossary of Major Terms

pathological conditions; cf blocking. May also be used to 19th centuries was referred to as animal electricity; cf
denote the reduction in sensitivity of an EEG channel, as when biopotential.
the pen deflection is decreased by adjustment of sensitivity or Biopotential: A difference of potential (voltage) of biological ori-
filter controls. gin.
At:: Abbreviation for average potential reference. Bipolar, bipolar derivation: A method of recording that uses two
Average potential reference: The average of the potentials of all or scalp electrodes connected to an EEG channel. Both leads
many EEG electrodes, used as a reference. Synonyms: Average pick up significant activity from the underlying brain.
reference, Goldman-Offner reference. Bipolar montage: Multiple bipolar derivations with no electrode
Average reference: Same as average potential reference. being common to all derivations. In most instances, bipolar
Averaged common reference: Same as average potential reference. derivations are linked so that adjacent derivations along the
Axon: The single, long nerve fiber that conducts impulses from a same array have one electrode in common.
nerve cell body to the synaptic terminals. Blocking: In an EEG tracing, the apparent, temporary oblitera-
Background activity: Any EEG activity representing the setting tion of EEG rhythms in response to stimulation; cf attenuation.
in which a given normal or abnormal pattern appears and from In an amplifier, a condition of temporary unresponsiveness of
which such pattern is distinguished. Not used as a synonym for the amplifier that is caused by a major overload. Amplifier
any individual rhythm such as the alpha rhythm. blocking is manifested by extreme, flat-topped pen excur-
BAEP: Acronym for brain-stem auditory-evoked potential. sion(s) sometimes lasting up to a few seconds.
Balanced amplifier: An amplifier consisting essentially of two Buffer amplifier: An amplifier, generally with a voltage gain of 1,
identical single-ended amplifiers that are operated as a pair in having a high-input impedance and a low-output impedance.
opposite phases. Buffer amplifiers are used to isolate the input signal from the
Band: Portion of the EEG frequency spectrum; cf alpha, beta, loading effects of an immediately following circuit.
delta, and theta bands. C: Abbreviation for a capacitor in electrical circuits.
Bandwidth, EEG channel: Range of frequencies that an EEG C/sec, cis, cps: Abbreviations for cycles per second. Equivalent to
channel is capable of recording. Determined by the frequency Hz, which is the preferred form.
response of the writer unit and the settings of the frequency Calibration: (1) Procedure for testing and recording the
filters. The EEG channel bandwidths specified by different responses of EEG channels to voltages of known magnitude
manufacturers are not standardized. Thus, in one instrument a applied to the inputs of the machine, and (2) refers to the
bandwidth of 0.5 to 50 Hz may indicate that 0.5- and 50-Hz procedure of testing the accuracy of the paper speed by means
signals are attenuated 30% (3 dB), wbereas in anotber instru- of a time marker.
ment they may be attenuated only 20%. Cancellation: In EEG, the effect produced when the input signals
Base (or base elemerlt): An electrode of a transistor that cor- on the two grids in any channel are similar with respect to fre-
responds roughly to the grid of a triode vacuum tube in that it quency, amplitude, polarity, waveform, or any combination.
serves to control electron flow. When the signals at the two inputs have similar characteristics,
Baseline: In an EEG tracing, the line obtained wben an identical the output will be decreased; when they are identical, the out-
voltage is applied to the two input terminals of an EEG ampli- put becomes equal to zero.
fier, or when the instrument is in the calibrate position but no Capacitor: A device for storing electric charge. The simplest type
calibration signal is applied. consists of two conductors separated by an insulator. Used in
BCD: Acronym for binary-coded decimal. the filters of an EEG machine to attenuate both high- and low-
BEA~f®: Acronym for brain electrical activity mapping. frequency waves. Direct currents are blocked by a capacitor;
Beta band: Frequency band over 13 Hz. Denoted by the Greek alternating currents can pass across a capacitor. Also called
letter ~. Normally, this defines frequencies up to and including condenser.
35 Hz. Cathode: The negative pole or electrode of a battery. In a vacuum
Beta rhythm: In general, any EEG rhythm over 13 Hz. Char- tube, the cathode is the element that emits electrons.
acteristically it denotes a rhythm from 13 to 35 Hz recorded Channel: The complete system for the detection, amplification,
over the frontocentral regions of the head during wakeful- and display of potential differences between a pair of elec-
ness. Amplitude of the frontocentral beta rhythm is vari- trodes. The tracings on the chart coming off an EEG machine
able but is mostly below 30 1lV. Other beta rhythms may also are referred to as channels.
be present; these are most prominent in other locations or Charge, electric: The quantity of electricity held by an object.
are diffuse. When the object has more electrons than normal, it has a nega-
Beta wave: Wave with a duration of less than 0.077 second and tive charge; when it has fewer electrons than normal, it has a
usually forming a part of a beta rhythm. positive charge. The term also refers to energy stored in a bat-
Binary-coded decimal: A system of indicating real time on an tery as when one says that a battery is charged.
EEG chart in which the numbers corresponding to hours, Circuit: Any complete path over which electric current can flow.
minutes, and seconds are represented by a pattern of deflec- Also refers to the drawing that shows the way in which the com-
tions on a marker channel. ponents that comprise an electrical or electronic device are
Bio-cal (bio-calibration): Procedure in which one pair of EEG hooked together.
electrodes is connected to all channels of the EEG machine. Coherent averaging: The process whereby signal averaging is car-
Bioelectricity: Electrical activity of living tissue. In the 18th and ried out by a computer. See signal averaging.
Appendix 1. Glossary of Major Terms 255

Coil: A number of turns of wire, sometimes wound on an iron the outSide) is made positive by the influx of positive charges
core. A coil is one of the basic elements of a pen motor or writer inside the cell membrane.
unit. Derivation: The process of recording from a pair of electrodes on
Collector: The element of a transistor that collects charges. This an EEG channel; or, the EEG record obtained by this process.
corresponds roughly to the plate of a triode vacuum tube, since Differential amplifier: An amplifier whose output is proportional
it is usually part of the output circuit. to the voltage difference between the signals applied to its two
Common-mode rejection (CMR): A characteristic of differential input terminals. The input stages of EEG machines employ
amplifiers whereby they provide markedly reduced amplifica- differential amplifiers.
tion of common-mode signals, compared with differential sig- Differential signal: The difference between two signals applied to
nals. Expressed in quantitative terms as common-mode rejec- the respective two input terminals of a differential EEG ampli-
tion ratio (CMRR), or the ratio of amplifications of differential fier.
and common-mode signals. For example: Diffuse: Used to describe acti\'ity that occurs over large areas of
one or both sides of the head.
amplification, differential _ 20,000 Diphasic wave: Wave consisting of two phases, one negative and
20,000:1
amplification, common mode 1 the other positi\'e.
Dipole: In EEG, a theoretical concept in which an EEG pattern
Common-mode signal: Common component of the two signals is assumed to originate from small areas of brain tissue. Each
applied to the two respective input terminals of a differential area is thought to contain equal but opposite electrical poles or
EEG amplifier. In EEG recording, external interference like charges that are separated in space and that change their posi-
60-Hz pickup from the power line occurs as a common-mode tions or magnitudes.
signal. Direct-coupled amplifier: An amplifier in which the successi\'e
Complex: A sequence of two or more waves that occur together stages are connected together (coupled) by devices that are not
and repeat at fairly consistent intervals. frequency-dependent; i.e., condensers are not used.
Condenser: See capacitor. Direct current (DC): A flow of electrons in only one direction.
Conductor: Any material (solid, liquid, or gas) that offers little This type of current does not alternate or change directional
opposition to current flow. Metals and salt solutions are exam- flow as with AC.
ples of conductors. Silver and copper are among the best con- Disk (disc) electrode: Metal disk that is attached to the scalp with
ductors. collodion, paste, or wax. Disks are frequently cup-shaped to
Coronal: Refers to a crown or circle about the head; a coronal provide space for the electrolyte.
montage consists of electrodes placed in transverse arrays Double banana: Popular name for the 16-channel longitudinal
across the head from left to right. bipolar montage consisting of left and right temporal and
Convulsion: An involuntary paroxysm of muscular contraction. It parasagittal chains.
may be either tonic (without relaxation) or clonic (showing Driving: A condition in which waves in the EEG occur at the
alternate contractions of opposing groups of muscles). It may same or harmonically related frequency as rhythmically
be generalized or focal (localized to a specific part of the body). presented stimuli in a phase-locked relationship.
Current: An electrical current is the directional movement offree E: Abbreviation sometimes used for voltage. Stands for elec-
electrons in a conductor under the force provided by a differ- tromotive force.
ence of potential. A biological electrical current is the move- Earth connection: Cf ground connection.
ment of ions. Electrical double layer: Two layers, one consisting of positively
Cursor: A mark or indicator, such as an intensified dot or pip on charged ions and an adjacent layer consisting of negatively
the screen of a cathode-ray tube. The cursor can be positioned charged ions that form when a metal electrode comes in con-
to measure amplitude and/or time of a waveform as in an tact with an electrolyte.
evoked potential; or it can select a particular item or event Electrocardiogram: Electrical activity generated by the heart.
from the screen. Sometimes called a "bug:' Abbreviated ECG or EKG.
Cycle: The complete sequence of potential changes undergone Electrode hoard: A device with multiple receptacles Uacks) into
by a wa\'e before the sequence is repeated. which the plug ends of electrodes are inserted and from which
Cycles per second: Unit of frequency. Abbreviated as elsec, els, or a multiconductor cable connects the signals to the console of
cps. The synonym Hertz (Hz) is preferred. the EEG machine. Also known as an electrode box or jack box.
DC: Abbreviation for direct current. Electrode box: See electrode board.
Deflection sensitit;ity: See sensiti\'ity. Electrode, EEG electrode: A conducting de\'ice that makes phy-
Delta hand: Frequency band under 4 Hz denoted by the Greek sical and electrical contact with the subject. An electrode
letter ~ pro\'ides a direct connection between the subject and one
Delta rhythm: Rhythmic activity at frequencies less than 4 Hz. terminal of the amplifier input. Sometimes referred to as a
Delta wave: Wave with duration greater than 1/4 second. lead.
Dendrite: One of the many branching processes of the nerve cell Electrode impedance: The opposition offered by an electrode and
that serve as the points of input of signals to the neuron. the scalp to the flow of an AC current. It is measured between
Depoiari::R or depolari;;ation: Process whereby the negative rest- pairs of electrodes or, in some electroencephalographs,
ing membrane potential (negative on the inside compared with between each individual electrode and all the other electrodes
255 Appendix 1. Glossary of Major Terms

connected in parallel. Expressed in ohms (generally kilohms, complexes in 1 second. Measured in Hertz (Hz), a unit that is
KQ). preferred to its equivalent, cycles per second.
Electrude paste: A blend of materials used to decrease the electri- Frequency response: In general, the response of an electrical cir-
cal resistance between skin and electrodes and sometimes, as cuit to an alternating applied voltage of constant amplitude
in the case of disk electrodes, to hold the electrode in place. that is allowed to vary in frequency. In EEG, the term
Electrode potential: The voltage that develops between metal and represents the range over which the EEG machine records
an electrolyte when a metal electrode is placed in contact with waves or components in a fairly linear fashion without signifi-
the electrolyte. Also known as a half-cell potential. cant attenuation or distortion; the lower limit of response is set
Electrode resistance: Opposition offered by an EEG electrode by the low-linear frequency switch, the upper limit by the high-
and the scalp to the flow of a direct current. Resistance is meas- linear frequency control.
ured between pairs of electrodes or, in some EEGs, between Frequency-response curve: A graph of the amplifier output and/or
each individual electrode and all the other electrodes con- pen deflection in response to an input signal of constant ampli-
nected in parallel. Expressed in ohms (generally kilohms, KQ). tude at all relevant frequencies. A separate curve is derived for
Electrode selectors: The switching system on an EEG machine each combination of low- and high-frequency filter settings,
that permits the operator to connect various pairs of electrodes and these curves may be shown individually or in groups.
to different channels of the machine. Frequency spectrum: The range of frequencies composing the
Electron: A negatively charged particle; the basic element of EEG. The spectrum is divided into four bands termed alpha,
electricity. beta, delta, and theta; cf alpha, beta, delta, theta bands.
Emitter: An electrode of a transistor corresponding roughly to F wave: A sharp transient that occurs during sleep with maximal
the cathode in a triode vacuum tube in that it emits electrons. amplitude appearing in the frontal region at the midline.
Epilepsy: Cf seizure. Gl: Abbreviation for grid 1 of the differential amplifiers of an
Epoch: A particular interval of time in an EEG tracing, the dura- EEG machine.
tio~ of which is arbitrarily selected. G2: Abbreviation for grid 2 of the differential amplifiers of an
EPSP: Acronym for excitatory postsynaptic potential. EEG machine.
Equipotential contour: Certain limited region in a volume con- Gain: The ratio of the voltage obtained at the amplifier output to
ductor surrounding a dipole where tbe voltages referred to a the voltage applied to the input of an EEG channel. Example:
distant reference electrode are all tbe same. Equipotential con-
tours demarcate the electrical field that surrounds the dipole. Gain = output voltage = 10 volts = 1 000000
input voltage 10 microvolts ' ,
Equipotential zone: Refers to a region on the head in which two or
more adjacent electrodes record the same potential at a partic- Often expressed in decibels (dB), a logarithmic unit. Exam-
ular instant in time. ples: a voltage gain of 10 = 20 dB; of 1,000 = 60 dB; of
Error of the arc: In curvilinear tracings, the error due to the cir- 1,000,000 = 120 dB. Cf sensitivity.
cumstance that the deflection of the pen describes an arc of a Gain control switch: The switch that controls the deflection sen-
circle rather than a straight line perpendicular to the baseline. sitivity of the channels on the EEG machine.
Ethmoidal electrode: Special electrode of flexible, insulated silver Galwnometer: A device for converting variations in electrical
wire with a bulbous tip. Introduced into the nose under topical energy to mechanical deflections. In EEG machines, usually a
anestbesia so that its tip lies in contact with the cribriform coil of wire (with an attached stylus or pen) that is suspended
plate of the ethmoid bone, it is useful ill recording activity from in a magnetic field and rotates in response to the electrical sig-
the orbitofrontal cortex. nals from the output of the amplifier. Commonly called a
Farad: A unit of electrical capacitance. In EEG work, the com- writer, penmotor, or oscillograph.
monly used unit is microfarad or millionth of a farad, Generalized: Used to describe activity that occurs over all regions
abbreviated IlF or MFD. of the head.
Filter: A device that allows preselected frequencies or wave com- Goldman equation: Equation for estimating the membrane
ponents to pass without change but attenuates all other fre- equilibrium potential when more than one ion is involved.
quencies. On tbe EEG machine, the low-frequency filters Goldman-Offner reference: Synonym for average reference.
attenuate the amplitude of the low-frequency components of Grand mal: Refers to an epileptic seizure that is characterized by
the signal but pass tbe higber frequencies unchanged; the a sudden loss of consciousness, tonic convulsion, followed by
high-frequency filters do the exact opposite. The 50-Hz notch clonic spasms. Following the convulsion, the patient is con-
filter affects primarily those frequencies close to 60 Hz but fused and frequently sleeps (postictal state).
allows others to pass unchanged. Grid: The control element in an amplifier vacuum tube. (In a
FIRDA: Acronym for frontal intermittent rhythmic delta activity. transistor the corresponding element is the base.)
Focal: Refers to activity that is restricted to one region, as, for Grid 1: Input terminal 1 of a differential amplifier. Abbreviated
example, a focal seizure or focal slowing. See focus. Gl.
Focus: In general, the center of a limited region displaying the Grid 2: Input terminal 2 of a differential amplifier. Abbreviated
electrical activity generated by a dipole; in EEG, the limited G2.
region on the scalp displaying a particular kind of activity, Ground: The earth; the arbitrarily designated point of zero
whetber normal or abnormal. potential from which potential differences are measured. See
Frequency: The number of complete cycles of repetitive waves or also ground connection.
Appendix 1. Glossary of Major Terms 257

Ground connection: Conducting path that runs between the by the magnetic field produced by current flowing in the
earth and the EEG machine. Also, the electrode wire that con- power lines.
nects the subject to the ground connection of the EEG Inion: The prominent protrusion or bump at the back of the
machine. head.
Ground loop: The condition that occurs when a patient or a piece In-phase: Coincidence in time of different voltages as, for exam-
of equipment has more than one connection to ground. To ple, peaks of the same polarity. Commonly, the simultaneous
ensure the patient's safety and to minimize the amount of appearance of components being deflected in the same direc-
externally generated interference in the EEG recording, tion in two or more channels of the EEG machine.
ground loops should be avoided. In-phase discrimination: Characteristic of a differential amplifier
Gyrus: One of the prominent ridges or rounded elevations on the that permits in-phase signals to be discriminated against-or,
surface of the hemispheres of the brain. in preferred terms, common-mode signals to be rejected.
Halfcell potential: See electrode potential. In-phase signals: Waves with no phase (or time) difference
lIert::,: Unit of frequency. Abbreviation: Hz. Preferred to the syn- between them.
onym cycles per second. Input: The signal fed into an EEG amplifier. Also, the input ter-
High-frequency filter: A circuit that reduces or attenuates the minal or terminals of an amplifier.
sensitivity of the EEG channel to relatively high frequencies. Input circuit: The total circuit composed of EEG electrodes and
For each position of the high-frequency filter contro\, the intervening tissues, the electrode lead wires, jack box input
attenuation is expressed as a percent reduction in pen deflec- cable and electrode selectors. Also used to denote the first part
tion at a given, stated frequency, relative to frequencies of the electrical circuit of the amplifier.
unaffected by the filter. Input impedance: Impedance that exists between the two input
High-frequency response: Sensitivity of an EEG channel to rela- connections of an EEG amplifier. Measured in ohms (generally
tively high frequencies. Determined by the high-frequency megohms, MQ).
response of the amplifier-writer combination and the high- Input tenninal 1: One of the input terminals of the differential
frequency filter used. Expressed as the percent reduction in amplifier of an EEG machine. When this terminal is negative
pen deflection at certain, stated high frequencies, relative to relative to the other input terminal, the pen deflects upward.
other frequencies in the midfrequency band of the channel. Synonyms: "Grid 1:' Gl, or black lead.
High-pass filter: Synonym for low-frequency filter. Input tenninal 2: One of the input terminals of the differential
Hyperpolarize or hyperpolarization: Process whereby the resting amplifier of an EEG machine. When this terminal is negative
membrane potential, which is negative on the inside with relative to the other input terminal, the pen deflects down-
respect to the outside, is made more negative by the influx of ward. Synonyms: "Grid 2:' G2, or white lead.
negative charges inside the cell membrane. Instrumental phase reversal: Simultaneous pen deflections in
Hyperventilation: Deep respiration performed at a slow, regular opposite directions in two bipolar derivations. This reversal is
rate for a period of several minutes. Used as an activation purely instrumental in nature and is due to the same signal
procedure. being simultaneously applied to input terminal 2 of one
Hypnagogic hypersynchrony: Paroxysmal, high-amplitude rhyth- differential amplifier and to input terminal 1 of the other
mic slow activity that occurs during drowsiness, mainly in amplifier.
infants and young children. Insulator: Any material (solid, liquid, or gas) offering very high
Hypnopompic hypersynchrony: Paroxysmal, high-amplitude rt:'sistance to tht:' flow of any electric current. Commonly used
rhythmic slow activity that occurs upon arousal from sleep, to support or separate conductors so as to prevent undesired
mainly in infants and young children. flow of current between them or to other objects.
Hypsarrhythmia: A chaotic EEG pattern consisting of high- Inteiface: When used as a noun, the boundary or junction
amplitude, arrhythmic slow waves interspersed with multifocal between two objects, media, or bodies. The metal-electrolyte
spike discharges. The activity is without consistent synchrony inteiface is the boundary between the metal of an EEG elec-
between left and right sides, or between different areas on the trode and the electrolyte between it and the surface of the
same side. scalp.
H::,: Abbreviation for Hertz. Intenllittent activity: Activity that appears only from time to time.
I: Abbreviation for current. The term discontinuous is also used.
Ictal: The adjective that refers to seizure (ictus). Ion: An atom or group of atoms carrying an electric charge and
Impedance: The total opposition to the flow of current in an AC forming one of the elements of an electrolyte.
circuit. Includes direct resistance (from wires plus any resis- IPSP: Acronym for inhibitory postsynaptic potential.
tors) and resistance offered by other components (as capaci- lRDA: Acronym for intermittent rhythmic delta activity.
tors). lRIG level: Inter-Range Instrumentation Group. Convention that
Impedance meter: An instrument used to measure impedance; cf specifies a standard interface and recording level for
electrode impedance. instrumentation tape recorders (1 volt RMS or 2.828 volts
Induction: The production of an electrical field around, or cur- peak-to-peak).
rent in, any conductor; due to a change with respect to current Isoground: A specially designed ground connection, used for
in a conductor or magnetic source around the conductor. In safety purposes, that limits any current flowing in the ground-
EEG recording, 60 Hz can be induced in the electrode wires ing electrode to a safe level in the event of equipment failure.
258 Appendix 1. Glossary of Major Terms

lsopotentialline(s): See equipotential contour. the position of a single switch. Also called a master electrode
Jack: A terminal that is a spring-type receptacle used in elec- selector.
tronic apparatus lilr temporary connections. The electrode Mu rhythm: EEG rhythm at 7 to 11 Hz; composed of arch-
board or electrode box of the EEG machine uses terminals of shaped waves (points being negative polarity) occurring
this type. over the central or centroparietal regions of the head dur-
Jack box: See electrode board. ing wakefulness. Amplitude varies but is mostly below 50 ~v.
K complex: A bipbasic slow-wave transient of variable appearance Blocked or attenuated most clearly by contralateral move-
occurring during sleep with maximal amplitude at the vertex. ment, thought of movement, readiness to move, or tactile
May occur in association with a sleep spindle. stimulation.
Lambda wave: A sharp transient that occurs over the occipital Nasion: The indentation where the nose joins the forehead.
regions of the head while awake, with the eyes open, and the Nasopharyngeal electrode: Special rod electrode introduced
subject is engaged in visual exploration. In the main, tbe waves through the nose so that its tip is in contact with the roof of
are positive relative to other regions. the nasopharynx. Useful in picking up activity from the uncus,
Laterali::.ed: Used to describe activity that is present only on one hippocampus, and orbitofrontal cortex. Abbreviated NPG.
side of the head. Negative deflection: By clinical EEG convention, the upward
Lead: Strictly speaking, the wire connecting an electrode to the excursion of the pen when the voltage of the electrode con-
electrode board of the EEG machine. Loosely, a synonym for nected to input terminal 1 (grid 1) is negative with respect to
electrode. the voltage of the electrode connected to input terminal 2 (grid
Leakage current: Inherent and undesirable currents that flow 2) of that channel.
through conductive paths, such as between tbe AC power line Nernst potential: The membrane equilibrium potential for an
and the chassis of an EEG machine. This current normally ion, which is the electrical force required to balance the
flows tbrough a third wire that connects the EEG machine to ionic movements across a membrane that are caused by diffu-
ground. sion.
Linear: In EEG refers to the recording of signals on the chart in Noise: Random variations in the output of an amplifier that are
such a manner that the pen deflections are directly propor- seen on the chart as fluctuations of the baseline in the absence
tional to the magnitudes of the voltages at the input. This of any input signal. Noise is usually due to random movement
means that if 50 ~ V gives a pen deflection of 7 mm, then 100 of electrons in the amplifier components. In some cases it
~V sbould equal 14 mm, and so on. originates from a poor electrode-scalp junction.
Localized: See focal. Notch filter: A filter that selectively attenuates a very narrow fre-
Low-frequency filter: A circuit that reduces the sensitivity of tbe quency band and, in so doing, produces a sharp notch in the
EEG channel to relatively low frequencies. For eacb position frequency-response curve of an EEG channel. A 60-Hz notch
of tbe low-frequency filter control, this attenuation is filter is used in some EEG recordings to provide attenuation of
expressed as a percent reduction in pen deflection at a given, 60-Hz interference under extremely unfavorable recording
stated frequency, relative to frequencies unaffected by the conditions.
filter. Positions of the low-frequency filter control may also be NPC electrode: Acronym for nasopharyngeal electrode.
designated by the corresponding time constant in seconds. Ohm: The unit of measurement of electrical resistance. Desig-
Lowjrequency response: Sensitivity of an EEG channel to rela- nated by the Greek capital letter omega (0). Also, the unit of
tively low frequencies. Determined hy the low-frequency measurement of impedance.
response of the amplifier and by the low-frequency filter (time Ohm:s law: The relationship between the steady voltage, current,
constant) used. Expressed as the percent reduction in pen and resistance of any circuit. The law states that the current (I)
deflection at certain, stated low frequencies, relative to other is directly proportional to the voltage (E) and inversely propor-
frequencies in the midfrequency band of the channel. tional to the resistance (R) in the circuit. Expressed symboli-
Low-pass filter: Synonym for high-frequency filter. cally as I = E/R, R = Ell, or E = IR.
Master electrode selector: See montage switch. Ohmmeter: An instrument used to measure resistance; cf elec-
Membrane potential: Generally, the voltage that exists between trode resistance.
the two sides of a permeable membrane. In the case of a neu- OIRDA: Acronym for occipital intermittent rhythmic delta
ron, the potential difference present between the inside and activity.
outside of the cell. Out-ofphase: Lack of coincidence in time of different voltages as,
Microvolt: One-millionth of a volt; the standard voltage unit in for example, when waves recorded simultaneously on two or
EEG; symbol, micro V or ~v. more channels show completely opposite deflections. When
Millivolt: One-thousandth of a volt; symbol, mV or my. the voltages are exactly opposite, they are referred to as being
Monophasic wave: Wave having only a positive or negative phase. 180 degrees out-of-phase.
Monorhythmic: Term sometimes used when a particular EEG Out-ofphase signals: Two waves of opposite phases.
pattern shows rhythmic components of a single frequency. Paper speed: The rate at which the EEG chart paper moves
Montage: The particular arrangement by which a number of deri- through the EEG machine. Expressed in millimeters per
vations are displayed simultaneously in an EEG record. Also second (mm/s) or centimeters per second (cm/s).
known as a run. Parameter: A characteristic element or feature of a phenomenon,
Montage switch: A device that permits the EEG technician object, or system. Resistance and capacitance are parameters
to change from one montage to another simply by changing of electrical circuits.
Appendix 1. Glossary of Major Terms 259

Paroxysmal actit;ity: Denotes activity that is distinguishable from tern shows rhythmic components of several different frequen-
the background activity and that occurs with sudden onset and cies.
offset. Polysomnography: The simultaneous recording of multiple phys-
Pattern: Any characteristic EEG activity seen in a tracing. iological parameters during sleep, such as EEG, ECG, eye
PDA: Acronym for polymorphic delta activity. movements, muscle tonus, respiration, etc.
Peak: Point of maximum amplitude of a wave. Positive occipital sharp transients of sleep: Sharp transients that
Peak-to-peak: A way of measuring and expressing the amplitude occur during sleep; they are maximal over the occipital regions
of sinusoidal waves. Amplitude peak-to-peak corresponds to and are positive relative to other areas. Abbreviated POSTS.
the voltage measured between consecutive peaks and troughs Posterior slou: u:aves of youth: Slow transients recorded in the
of the waves. Compare with RMS voltage. waking EEG of normal children from the posterior regions.
Pen motor: The electromechanical device that converts the out- POSTS: Acronym for positive occipital sharp transients of sleep.
put signal of the amplifier to a mechanical movement that Postsynaptic potelltial: See synaptic potential.
deflects the writing stylus. Synonyms: galvanometer, galvo, Potelltiometer: A continuously variable resistance. When suitably
writer unit. connected to a source of voltage, the potentiometer becomes a
Period: Duration of a complete cycle of a wave or complex that voltage divider.
occurs in a sequence of regularly repeated waves or complexes. Pou:er amplifier: An amplifier in which current as well as voltage
Period is the reciprocal of frequency. is increased in order to augment the input signal.
Periodic: Term applied to EEG waves or complexes that recur at POleer supply: A device that converts alternating current from the
approximately regular intervals. power line to direct current of various voltages for use by the
Petit mal: See Absence. amplifiers and other electrical and electronic devices in EEG
Phase: The time or polarity relationship between a point on a machines. When circuitry is included to maintain voltages at
wave displayed in one derivation and the identical point on the constant levels that are unaffected by changes in line voltage,
same wave recorded simultaneously in another derivation. the device is referred to as a "regulated" power supply.
phase ret;ersal: The condition existing when similar waves Preauricular point: The point in front of the ear that is situated
recorded on two or more channels are 180 0 out-of-phase, that just above the tragus, or triangular piece of cartilage that covers
is, when the waves reach peak values of opposite polarity at the the opening of the external ear canal. Used as a landmark in
same instant. See instrumental phase reversal and true phase the 10-20 System of electrode placement.
reversal. ProtOIl: A positively charged particle; protons reside within the
Photic dridng: The rhythmic activity elicited over the posterior nucleus of an atom and are electrically balanced by the nega-
regions of the brain by repetitive photic stimulation at frequen- tive charges of the electrons that surround the nucleus.
cies of about 5 to 30 Hz. Tbis activity is time-locked to the R: Abbreviation for resistance in electrical circuits.
stimulus; frequency is identical to or harmonically related to Reactidty: Refers to alterations in the amplitude and waveform of
the stimulus frequency. activity in response to stimulation.
Photic stimulation: In clinical EEG, an activation procedure in Record: The end product of the EEG recording process.
which a series of brief, brilliant light flashes from a stroboscope Recording: (1) The process of obtaining an EEG record. Syno-
provide visual stimulation. Intensity and flash frequency may nym: tracing. (2) The end product of the EEG recording
be varied. The purpose is to evoke latent paroxysmal activity. process. Synonymous with record.
Photic stimulator: Device for delivering intermittent flashes of Reference electrode: In general, any electrode against which the
light. potential variations of another electrode are measured. A suita-
Photomyogenic response: A response to intermittent photic ble reference electrode is an electrode that is customarily con-
stimulation in which brief, repetitive muscle spikes and move- nected to input terminal 2 of an EEG amplifier and that is so
ment artifacts associated with eyelid flutter are seen in tracings placed as to minimize the likelihood of picking up the same
from anterior regions of the head. The response ceases EEG activity recorded by an electrode connected to input ter-
abruptly as soon as the stimulation is discontinued. minal 1 of the same amplifier.
Photoparoxysmal response: A response to intermittent photic Referelltial deriwtion: Recording from a pair of electrodes, one of
stimulation in which generalized, bilaterally symmetrical, syn- which is any EEG electrode (usually connected to input termi-
chronous spike and wave or multiple spike and wave discharges naIl) and the other, a reference electrode (usually connected
are seen in the EEG. to input terminal 2 of an EEG amplifier).
Pill plug: The Ills-in. diameter metal plug on the end of an Referential montage: A montage employing referential deriva-
electrode wire. Pin plugs are frequently gold-plated; they fit tions, or recordings simultaneously taken from different elec-
into the jacks found on the electrode board of an EEG trodes in comparison with a common reference electrode.
machine. Refomwtting (of mOlltages): The process whereby the pattern of
Polarization: The accumulation of electrical charges on the sur- activity observed in one montage may be used to derive or infer
face of an electrode resulting from chemical or other changes the pattern of activity that would be seen in another.
in the electrode or its medium. Rejection ratio: The gain of an amplifier for out-of-phase signals,
Polymorphic: Irregular, as electrical activity that assumes various as for example the EEG, divided by the gain for in-phase sig-
forms. Sometimes used to describe irregularly shaped waves nals such as 60 Hz artifact. See common-mode rejection.
appearing in the delta and theta bands. REM: Acronym for rapid eye movement. Used to describe one of
Polyrhythmic: Term sometimes used when a particular EEG pat- the stages of sleep.
260 Appendix 1. Glossary of Major Terms

Resistance: The property of a substance that limits the flow of Signal: Any electrical wave or activity that enters the input of an
electricity through it; or the opposition a conductor displays to amplifier. Usually used to describe the "wanted" EEG activity
the passage of an electric current. The unit of measurement is as contrasted to the "unwanted" concomitant activity, which is
the ohm. noise.
Resistor: A device that has electrical resistance and is used in an Signal averaging: In general, the technique of enhancing the
electrical circuit. Abbreviated by the capital letter R. signal-to-noise ratio of signals that are coherent in time. Used
Resting membrane potential: The voltage between the inside and in recording evoked potentials.
outside of a neuron when at rest. The inside is negative com- Signal-to-noise ratio: A ratio, the numerator of which is the vol-
pared with the outside. tage of a wanted signal and the denominator is the unwanted
Rhythm: EEG activity consisting of waves of approximately the signal or noise.
same period. Significance Probability Mapping (SPM): A statistical method of
RMP: Acronym for resting membrane potential. comparing the topographical image of a single individual with
RMS: Abbreviation for root-mean-square, which is a way of meas- that of a reference group, or the topographical images of two
uring and expressing the amplitude of sinusoidal waves; I volt groups. The method produces a new image that shows the
RMS = 2.828 volts peak-to-peak; cf peak-to-peak. probabilities of any differences between the original images
Rolandic seizure: Refers to seizures arising from the Rolandic area occurring by chance.
of the brain. They manifest as clonic movements of facial and Sine wave: A fundamental form of wave that represents periodic
oropharyngeal muscles, tongue, and upper extremities; speech oscillation in which the amplitude at each point is proportional
arrest and salivation may also occur. to the mathematical sine function.
Run: A recording in which a particular group of derivations is dis- Single-ended amplifier: An amplifier that operates on signals that
played simultaneously. Preferred term in montage. are asymmetric with respect to ground; hence, an amplifier
Salt bridge: The situation that occurs when the areas to which having only a single input terminal. Compare with differential
two scalp electrodes are attached have such an excess of elec- amplifier.
trolyte spread over them that they overlap each other. When Sinusoidal: Term applies to EEG waves that resemble sine waves.
this happens, the electrolyte creates a short-circuit between Sleep spindle: A burst of rhythmic 11- to IS-Hz activity that
the two electrode sites. Under such conditions, the recording occurs during sleep, frequently in Widespread distribution.
from this derivation is meaningless. Amplitudes, which are mostly below 50 ~V, are commonly
Scalp electrode: Electrode held against, attached to, or inserted highest in the central regions.
into the scalp. Sodium-potassium pump: The process or mechanism whereby
Seizure: A disorder of the brain manifested by transient episodes sodium ions are actively expelled from within a cell and potas-
of motor, sensory, or psychic dysfunction that occur with or sium ions are taken in. In so doing, the ionic concentrations are
without loss of consciousness or convulsive movements. maintained, and a constant resting membrane potential is
Epilepsy is a disorder in which there is a tendency for recur- assured.
rent seizures. Solid state: Electronic components that transfer or control elec-
Semiconductor: A class of solids whose electrical conductivity is tron flow within solid materials, such as transistors, crystal
between that of a conductor and that of an insulator. Com- diodes, and integrated circuits.
monly, the elements germanium and silicon. Semiconductors Step junction: An instantaneous change in voltage. A step func-
are used in transistors; cf solid state. tion is commonly used in the calibration of an EEG machine.
Sensitivity: Ratio of input voltage to output pen deflection in an Spatial summation: The summation of several postsynaptic
EEG channel. Sensitivity is measured in microvolts per mil- potentials produced simultaneously or nearly simultaneously
limeter (~V/mm). Example: at different sites on a postsynaptic membrane.
Sphenoidal electrode: Special electrode of thin, flexible, insulated
input voltage
Sensitivity = _ _--0.-_--:---:-_ _ platinum wire. Inserted under local anesthesia so tbat its tip
output pen deflection lies in close proximity to the foramen ovale, it is useful in
50 ~V recording activity from the basal and mesial temporal cortex.
= - - = S~V/mm Spike: A transient having a pOinted peak that is clearly distin-
lOmm
guishable from the background activity. Spikes have a duration
Sharp wave: A transient having a pointed peak that is clearly dis- of from 20 to less than 70 ms. Generally, the main component
tinguishable from the background activity. Sharp waves may is negative relative to the surrounding areas. Compare with
have a duration of 70 to 200 ms. Generally, the main compo- sharp wave.
nent is negative relative to the surrounding areas. Compare Spindle: A group of rhythmic waves in which there is a gradual
with spike. increase and then a decrease in amplitude.
Shielding: The covering of an apparatus, cables, or rooms with SPM: Acronym for significance probability mapping.
metal or metal-screen that is connected to ground; used to SSEP: Acronym for somatosensory-evoked potential.
diminish pickup of external interference, such as 60 Hz artifact Stroboscope: A device that delivers high-intensity flashes of light
and radio-frequency signals. of extremely short duration. The flash rate is variable and can
Short circuit: The condition that exists when any two points on an be controlled by the user. In EEG work, the device is called a
electrical circuit are connected together. photic stimulator.
Appendix 1. Glossary of Major Terms 261

Sulcus: Groove or cleft in the cerebral hemispheres. The deepest loudspeakers, photo cells. strain gauges, and galvanometers.
sulci are called fissures. Transient: An isolated wave that stands out from the background.
Summation: The effect produced when the input signals on ter- Transient response: The response of an electrical circuit to an
minal 1 and terminal 2 of a channel are different with respect instantaneous step change in applied voltage. It refers to the
to frequency, amplitude, polarity, waveform, or any combina- behavior of the circuit during the interval of time that a change
tion thereof. An increase in amplitude, change of frequency. or is applied to it. and the circuit is still adjusting to the change.
distortion of polarity and waveform can occur. Transistor: A solid-state device made from semiconductor
Suppression: Denotes that little or no e1ectrocerebral activity is materials, such as germanium or silicon, which can act as elec-
discernible in a tracing or tracings. trical insulators or conductors, depending on the electrical
Symmetry: In general, refers to the occurrence of approximately charges placed upon them.
equal amplitude. frequency, and form of EEG activities over Triphasic wave: Wave consisting of three distinct components or
homologous areas on opposite sides of the head. phases.
Synapse: The interface or functional junction between two neu- True phase reversal: Simultaneous pen deflections in opposite
rons. The synapse is the point at which a nerve impulse is directions in two adjacent referential derivations having a com-
transmitted from one neuron to another. mon reference electrode. Occurs when the axis of a dipole that
Synaptic potential or postsynaptic potential: The electrical is the source of the electrical activity is not perpendicular to
change in the postsynaptic membrane produced by the action the scalp.
of neurotransmitter at the synapse. Synaptic potentials are V or v: Abbreviation for voltage.
either excitatory (EPSPs) or inhibitory (IPSPs). Vacuum tube: An evacuated tube containing two or more elec-
Synchrony: Refers to the simultaneous appearance of morpholog- trodes between which conduction of electricity through the
ically identical waveforms in area~ on the same side or opposite partial vacuum may take place. Also, a general term for all elec-
sides of the head. tronic tubes.
TC: Abbreviation for time constant. Vertex sharp transient: Synonym for vertex wave.
Temporal summation: The summation of successive potential Vertex wave: A sharp transient that occurs during sleep with max-
changes at a single site on the postsynaptic membrane such imal amplitude appearing at the vertex. Usually of high ampli-
that one postsynaptic potential is superimposed onto another. tude, it can attain magnitudes of 250 JlV; it is negative with
Ten-percent system: An extension of the 10-20 System in which respect to other areas.
the number of available derivations is expanded so that more Volt: The unit of measurement of voltage, electromotive force. or
than 60 electrodes may be placed on the scalp. potential difference.
Ten-twenty (10-20) International System: See ten-twenty System. Voltage: The potential (energy) present when different electrical
Ten-twenty (10-20) System: System of standardized scalp elec- charges are separated. This potential represents the force or
trode placement recommended by the International Federa- pressure that can cause the movement of free electrons
tion of Societies for Electroencephalography and Clinical Neu- between the two points when a complete circuit is present.
rophysiology. According to this system, electrode placements Also termed potential difference.
are determined by measuring the head from external land- Voltage divider: An electrical circuit that, in its simplest form,
marks and basing electrode locations upon 10% or 20% of consists of two resistors RI and R2 connected in series with a
these measurements. voltage. This voltage divides itself across the two resistors in
Theta band: Frequency band from 4 to less than 8 Hz. Denoted proportion to their values. A voltage divider may contain any
by the Greek letter 9. number of resistors or it may use a potentiometer, in which
Theta rhythm: Rhythm with a frequency of 4 to under 8 Hz. case the voltage may be divided in an infinite number of ways.
Theta wave: Wave with duration of 0.25 to more than 0.125 Volume conductor: An electrical conductor that occupies three-
second. dimensional space so that current flow can take many path-
Time axis: In the EEG the time axis is the chart paper speed. The ways.
vertical axis is the voltage. V wave: Abbreviation for vertex wave.
Time constant, EEG channel: The time (in seconds) required for Wave: In EEG, any change of voltage between any pair of elec-
the pen to fall to 37% of the deflection initially produced when trodes used in EEG recording. May arise in the brain (EEG
a DC potential difference (a step input) is applied to the input wave) or outside it (extracerebral potential).
terminals of the amplifier. The value (TC) is determined by the Waveform: The shape or morphology of an EEG wave.
values of resistance and capacitance in the circuit and is Writer: Device for direct write-out of the output of an EEG chan-
mathematically related to the frequency response. Filters to nel. Most writers use ink delivered by a pen. In some instru-
control the low-frequency response are sometimes marked ments the ink is sprayed as a jet stream. Some writers use car-
with both parameters. Time constant in this context is a decay bon paper; others heat sensitive paper instead of ink.
time constant. Amplifiers also have a rise time constant, related Z: Abbreviation for the impedance of an electrical circuit. Meas-
to high-frequency response. ured in ohms. See impedance.
Tracing: See recording. Zygomatic electrode: Special electrode placement situated over
Transducer: A device that converts energy from one form to anoth- the zygomatic arch; used for picking up activity from the tip of
er. Examples of transducers include microphones. earphones, the temporal lobe.
Appendix 2
Neuroanatomy for EEG Technologists

An understanding of the basic anatomy of the brain is an tion (the dura is the thick membrane that covers the brain)
essential requirement for an EEG technologist. Without called the tentorium cerebelli. The portion above the ten-
such knowledge, the technician will have little insight into torium, known as the supratentorial compartment, con-
the appropriate anatomical placement of the electrodes or tains the cerebrum. This compartment is subdivided into
the significance of what he or she is recording. Some left and right spaces-each of which contains the cor-
knowledge of the anatomy of the spinal cord and responding cerebral hemisphere - by a vertical dural par-
peripheral nerves has also become crucial, since in recent tition called the falx cerebri. The space below the tento-
years many EEG technologists are called upon to perform rium is the posterior cranial fossa, which accommodates
evoked potential recording as well. As explained in Chap- the cerebellum and the brain stem.
ter 17, evoked potential recording is a technique for The skull bones are named after the area of the brain
troubleshooting the various sensory pathways and is based that they overlie. Thus, the frontal bone is over the frontal
simply upon sound anatomic and physiologic concepts. In lobe, the parietal bone over the parietal lobe, the temporal
this appendix, the technologist will find descriptions of bone over the temporal lobe, and so on. Figure A2.1 shows
essential aspects of neuroanatomy as it is applicable to the relationship between the skull bones and the underly-
EEG and evoked potential recording and interpretation. ing areas of the brain along with the location of nasion and
This material is meant only as an introduction; readers inion; Fig. A2.2 shows the cranial compartments formed
interested in more detailed information should consult one by the dural partitions. The brain lies directly above the
of the many excellent neuroanatomy text hooks that are base of the skull, which has a number of holes (foramina)
currently available. through which the cranial nerves exit and the carotid arter-
The nervous system has two major subdivisions: the cen- ies enter the cranium. The largest of these foramina, the
tral nervous system, which consists of the brain and spinal foramen magnum, accommodates the lowest part of the
cord, and the peripheral nervous system, which comprises brain stem, which continues downward and exits as the
the cranial and peripheral nerves. We will take up the anat- spinal cord.
omy of the brain first.

The Cerebral Hemispheres

Topographical Relationship Between
Skull and Brain As seen in Fig. A2.l, the brain can be divided into four
major, anatomically distinct areas. These are the cerebral
It is important to examine the topographic relationship hemispheres, which are connected to each other by the
between the various parts of the skull and the underlying corpus callosum; the diencephalon; the brain stem, which
areas of the brain in order to gain some perspective into consists of midbrain, pons, and medulla oblongata; and the
the most likely source of the electrical activity that is cerebellum. Each cerebral hemisphere has within its
recorded by individual scalp electrodes. The skull may he center a cavity filled with cerebrospinal fluid (CSF) called
looked upon as a bony box with a space inside (the cranial the lateral ventricle.
cavity) that accommodates the brain. The cranial cavity is If one looks at a cross-section of the cerebrum, two dis-
divided into two compartments by a horizontal dural parti- tinct areas can be seen throughout, namely, an outer layer
The Cerebral Cortex 263

Corpus callosum Cranial bone Falx cerebri

Cranial bone

Cerebral
hemisphere

.....~~::u.l- Lateral
ventricle

- Inion Tentorium
cerebelli

Cerebellum

Figure A2.2. Cross-section of the cerebral hemispheres through

pz showing the cranial compartments formed by the dural parti-
tions.

(Fig. A2.l), a structure made up of a large number ofaxons

Figure A2.1. Median section of the brain showing the divisions of
that connect the two cerebral hemispheres together.
the central nervous system : 1. cerebral hemisphere; 2. dienceph-
alon; 3. midbrain; 4. pons; .5. cerebellum; 6. medulla oblongata;
When viewed from the side, the cerebral hemisphere
7. spinal cord. Also shown are the locations of the frontal pole shows a very prominent fissure that seems to cause a
(Fpzl, frontal (Fz), central (Cz) , parietal (Pz), and occipital (Oz) cleavage starting at the inferior surface and extending
regions along the midline. upward and backward (Fig. A2.4). This is called the Syl-
vian or lateral fissure and is responsible for the reversed C-
shape of the left cerebral hemisphere when it is viewed
of gray matter and an inner area of white matter. The gray from the side.
matter, which forms a mantle covering the entire surface of Another important sulcus is the central sulcus, which
the cerebrum, constitutes the cerebral cortex. It is about 5 can be traced from a point close to the vertex to the Sylvian
to 6 mm thick and is made up of billions of neuronal cell fissure, coursing obliquely downward and forward over the
bodies. The cerebral cortex is the most important struc-
ture from the point of view of the electroencephalographer
since the scalp-recorded EEG is generated by the activity
of the neurons of the cerebral cortex (see Chapter 10). The
white matter, on the other hand, consists mostly ofaxons
originating from the neurons of the cerebral cortex as well
as axons of neurons located elsewhere in the central ner-
vous system. The whitish appearance is attributed to the
myelin sheath that surrounds the axons.

The Cerebral Cortex

The gray matter of the cerebral cortex is thrown into folds
leading to the presence of ridges (gyri) and fissures (sulci),
which constitute a distinct macroscopic feature of the
cerebral cortex. By this means, the total surface area of the
cortex is greatly increased. It is important to be familiar
with some of the easily identifiable gyri and sulci. The
most obvious fissure when viewed from the top or front is
the midline superior longitudinal fissure that divides the
Central fissure
cerebrum into the left and right hemispheres (see Fig.
A2 .3). At the bottom of this fissure is the corpus callosum Figure A2.3. Top view of the cerebral hemispheres.
264 Appendix 2. Neuroanatomy for EEG Technologists

Central sulcus (Rolandic fissure) evoked potentials (SSEPs), the Cz' (Cz prime, 2 cm directly
Precentral gyrus j behind Cz) electrode is behind the central fissure and
Sylvian (latera\) Postcentral gyrus close to the sensory area for the lower extremities. Cor-
fissure respondingly, the C3' and C4' electrodes are over the left
and right somatosensory areas for the upper extremities.
Another important fissure to be noted is the calcarine
sulcus, which extends from the medial surface of the occip-
itallobe toward the occipital pole, as shown in the medial
surface view of the right cerebral hemisphere in Fig. A2.5.
It will be apparent from a perusal of Fig. A2.6 that the
division of each cerebral hemisphere into different lobes
depends on many of the anatomic landmarks noted above.
Thus, the frontal lobe is the part that lies in front of the
occipital central fissure and above the Sylvian fissure. The part
temporal pole below the Sylvian fissure constitutes the temporal lobe.
pole
The occipital lobe is the part that lies behind an imaginary
line joining the parieto-occipital fissure and the preoccipi-
Figure A2.4. Lateral view of the left cerebral hemisphere showing
tal notch. Finally, the area between the central fissure and
major sulci and gyri.
this line above the Sylvian fissure constitutes the parietal
lobe.
Table A2.1 gives a summary of the functional anatomy of
superolateral surface. The central sulcus is also called the the cerebral cortex; it should be studied in conjunction
Rolandic fissure after Luigi Rolando, the Italian scientist, with Fig. A2.5. As mentioned earlier, it is important for the
who first described it in 1825. This fissure separates the EEC technologist to know the localization of various func-
motor area in front from the sensory area behind. The tions in the cerebral cortex. This is especially important if
Rolandic fissure is a very important landmark; the letter he or she is to obtain a clear understanding of the tech-
"C" used in the 10-20 System of electrode placement refers niques of recording evoked potentials. Thus, for example,
to the central fissure. It may be pointed out that in the Fig. A2.5 shows why Cz' is chosen as the recording site for
placement of electrodes for recording somatosensory- tibial nerve SSEP and C3' and C4' for median nerve SSEP.

Primary
Primary motor somatosensory
Premotor cortex Rolandic cortex
cortex fissure Corpus
collosum

Prefrontal Parieto-
cortex occipital
fissure

Calcarine
fissure
Broca's Primary auditory Mesiotemporal Primary
area cortex visual
cortex area
(a)
(b)

Figure A2.5. Functional anatomy of the cerebral cortex. The lateral surface of the left hemisphere is shown in (a), and the medial sur-
face of the right hemisphere is shown in (b). Abbreviations are as follows: ue, upper extremity; Ie, lower extremity; t, trunk; h, head.
Microscopic Anatomy of the Cerebral Cortex 265

Postcentral gyrus Table A2.1. Functional Anatomy of the Cerebral Cortex U

Precentral gyrus Parieto-occipital sulcus Art'a Location Function
Broca's Anterior to prect'ntral Motor speech
gyrus close to Sylvian
fissure (posterior part
I Somatost'nsory
of frontal lobe)
Postcentral gyrus Interpretation of sen-
(anterior part of sory information from
parietal lobe ) opposite side of body
Wernicke's Temporal lobe (upper Interpretation of speech
and postt'rior region.
at the junction of
parietal. occipital. and
temporal lobes)
Superior Visual Occipital lobe Interpretation of visual
temporal
gyrus \
Preoccipital notch
Auditory Temporal lobe (upper
part)
sensations
Interpretation of audi-
tory sensations
Middle Inferior
temporal temporal Olfactory Temporal lobe (medial Interpretation of smell
gyrus gyrus part)
Short-term Temporal lobe (inferior Temporary memory for
Figure A2.6. Lobes and important gyri of the cerebral hemi- memory part) visual and auditory
sphere. events
Prefrontal Frontal lobe (anterior Elaboration of thought.
part) behavioral control.
inhibition
It is also important to know where the primary areas for
vision and hearing are located so that the appropriate elec- U Refer to Fig. A2 ..5 for the anatomic locations.

trode placement can be used for the particular sensory

modality that is being stimulated.
Although a large portion of the cerebral cortex is visible forms. With the exception of the hippocampal region of
on the superolateral surface, it must be realized that a sig- the temporal lobe, one can identify six distinct layers in the
nificant proportion of this structure lies hidden in the cortex. The six layers from surface to depth are shown
inferior as well as the medial aspect of the cerebrum. This diagrammatically in Fig. A2.8. It will be noted that layer I
will be clear from a perusal of Fig. A2.7, which shows the contains dense arborizations of dendrites and axons (the
inferior surface of the cerebrum. Portions of the temporal term neuropil is used for this). There is general consensus
lobe cortex that lie medially and inferiorly are particularly
noteworthy because of their known propensity for seizure
genesis. The usual array of 10-20 System electrodes often
fails to record activity from these hidden areas of the tem- OptiC chiasm
porallobe; hence, there is need for specially placed elec-
trodes such as the sphenoidal and nasopharyngeal elec-
trodes. These electrodes are discussed in Chapter 11.
Another significant observation is that the medial portion
of the occipital lobe around the calcarine sulcus represents
the primary visual area (Fig. A2.5b). It is interesting to
Inferior
note that with this location of the primary visual cortex, temporal
the electrical activity from the right visual area is better gyrus
seen over 01 than 02, and vice versa.

Microscopic Anatomy of the

Cerebral Cortex Collateral
sulcus

The cerebral cortex needs to be discussed in more detail Figure A2.7. Sulci and gyri in the inferior surface of the cere-
since it is thought to be the generator of the EEG wave brum.
266 Appendix 2. Neuroanatomy for EEG Technologists

(a) x

(b)

Longitudinal
fissure
White matter
Lateral
ventricles
afferent
efferent fiber efferent '\ eflf5;rnt
fiber fiber

Figure A2.B. Simplified microscopic anatomy of the cerebral cor- Cerebral

tex. P = pyramidal cells; G = granule cells; S = stellate cells; cortex
~
I = molecular layer; II = external granular layer; III = external
pyramidal layer; IV = internal granular layer; V = internal
pyramidal layer; VI = multiform layer.

among scientists that inhibitory and excitatory postsynap- Lentiform

tic potentials originating in this layer are the agents nucleus
responsible for the production of the waveforms recorded Brainstem
in the EEG (see Chapter 10). Certainly, the vertical orien- Figure A2.9. Section through the brain as in (a) showing in (b) the
tation of the pyramidal neurons, with their apical dendrites thalamus and structures of the basal ganglia.
arborizing in layer I and their cell bodies located in the
deeper layers, is ideally suited for the creation of vertical
dipoles with their resultant field currents. These, in turn,
could generate the EEG waveforms. outgrowth or projection of the thalamic system . The thala-
mus receives sensory input from all parts of the body and
relays information on to specific portions of the cerebral
cortex. Although stimulation of the specific sensory nuclei
Diencephalon of the thalamus leads to activation of discrete regions of the
cerebral cortex, stimulation of the nonspecific or general-
If a cross-section of the brain is examined, one sees a num- ized thalamic nuclei activates much larger areas of the
ber oflarge masses of gray matter in the depths of the brain cerebral cortex. The thalamus is one of the most-important
surrounding the ventricles. Figure A2.9 shows some of structures from the point of view of the generation of
these structures. Most notable among them is the mass of EEGs. As noted in Chapter 10, thalamic neurons are con-
gray matter situated on either side of the third ventricle sidered to be crucial in the production of the rhythmicity
called the thalamus. The thalamus, which is a major divi- that is characteristic of EEG waveforms.
sion of the diencephalon, contains a number of distinct The other major part of the diencephalon is the
collections of neurons (nuclei). It has a close topographic hypothalamus. This structure is situated on the floor of the
relationship to different parts of the cerebral cortex; so third ventricle and is important in the control of many of
much so, that the cortex may actually be considered as an the autonomic functions of the body such as the heart rate,
Spinal Cord 267

temperature, etc. As seen in Fig. A2.9, there are also other Sensory cortex for Sensory cortex for
collections of gray matter surrounding the thalamus. lower extremity upper extremity
These are called the basal ganglia and consist of the cau-
date nucleus, which is adjacent to the lateral ventricle, and
lentiform nucleus, which is lateral to the thalamus and is
separated from the caudate nucleus and thalamus by the
internal capsule, a large bundle of fibers from the overlying
cortex. The basal ganglia play an important role in certain
aspects of motor function.

The Brain Stem and Cerebellum

The brain stem consists of the midbrain, pons, and medulla

oblongata, all structures being contained in the posterior Thalamus
cranial fossa. The cranial nerves (other than the olfactory
and optic nerves) arise from the brain stem. The brain stem Medulla
is an important structure in the coordination of eye and
head movements. In addition, it contains the ascending Dorsa l column
reticular activating system (ARAS), which consists of a
large number of neuronal collections and interconnecting
fiber systems important in the maintenance of alertness. From upper
The ARAS can cause synchronization or desynchroniza- extremity
tion of the EEG through its connections with the thala-
mus. The brain stem is also involved in the mechanisms
that control and regulate sleep. Thus, lesions of the raphe
nuclei of the lower pons and medulla are known to abolish From lower
extremity
sleep. Similarly, lesions of the locus ceruleus, a collection
of neurons situated at the junction of pons and midbrain,
can reduce the amount of rapid eye movement (REM)
Figure A2.1 O. Somatosensory pathways.
sleep. Finally, the pons and medulla contain important
centers for the control of respiration and vasomotor func-
tion.
The cerebellum is a structure important in motor con-
these segments gives rise to the spinal nerves from which
trol. As mentioned earlier, it is situated below the tento-
the various peripheral nerves originate. The ventral part of
rium, in the posterior cranial fossa (Fig. A2.2). The cere-
the spinal grey matter is concerned more with motor func-
bellum has close connections with the brain stem, the
tions whereas the dorsal part is concerned more with sen-
cerebral cortex, and the thalamus. Details concerning this
sory functions.
structure need not concern us here.
The white matter is made up of distinct bundles of nerve
fibers called tracts, columns, or fasciculi. The tracts that
are the most important to be familiar with are the ascend-
Spinal Cord ing dorsal columns (sensory) and the descending cor-
ticospinal tracts (motor). In the study of SSEPs, one
The spinal cord is located in the spinal canal of the ver- attempts to record the passage of signals evoked by electri-
tebral column and extends from the level of the foramen cal stimulation at the periphery through the somatosen-
magnum to L-l, the first lumbar vertebra. The spinal cord sory pathways, of which the dorsal columns are perhaps the
has a central canal with gray matter surrounding it and most important. Fig. A2.10 is a schematic of these path-
which contains the cell bodies of the neurons. Superficial ways. The corticospinal tracts, which connect the motor
to the grey matter is the white matter. White matter is cortex to the spinal motor neurons, are important for initia-
made up of columns ofaxons and dendrites traveling to and tion of voluntary movements. These pathways can be
from the brain. The spinal cord consists of several seg- studied by the recently developed technique for the
ments (cervical, thoracic, lumbar, and sacral). Each of recording of motor-evoked potentials.
268 Appendix 2. Neuroanatomy for EEG Technologists

Peripheral Nervous System palmaris longus and flexor carpi radialis, the ulnar nerve on
the medial aspect of the wrist near the tendon of flexor
capri ulnaris, and the tibial nerve below and behind the
The peripheral nerves of the extremities arise from plex- medial malleolus (refer to Chapter 17).
uses, e.g., the brachial plexus in the case of the upper
extremity and the lumbosacral plexus in the case of the The foregoing has been a brief excursion into human
lower extremity. Some knowledge of the anatomic position neuroanatomy. For the EEG technologists who would like
of peripheral nerves as well as the plexuses is important for to pursue the topic in greater detail, there are many excel-
the recording of SSEPs. Thus, the median nerve can easily lent texts available. Consult the director of your EEG
be stimulated over the wrist between the tendons of laboratory for some suggested titles.
Appendix 3
Grounding Checks

The importance of properly grounding the EEG machine reading somewhere under 10 ohms. This indicates that the
or any other electrical equipment used in the EEG labora- machine is indeed grounded and that the building's
tory is taken up in detail in the chapter on electrical safety. grounding system is intact. If the meter does not deflect to
By connecting the three-prong plug on the end of the EEG the right, or shows a reading significantly higher than 10
machine's power cord to an appropriate electrical outlet on ohms, try connecting the second probe to another ground
the wall or floor of the laboratory, the EEG technician connection - for example, the ground wire on another wall
should be properly grounding the machine. But in doing socket in the room or in an adjacent room. If, now, a proper
so, he or she is assuming that there are no faults in the elec- ohmmeter reading is obtained, the cold-water pipe in the
trical outlet and that there is electrical continuity between room may not be making proper contact with the build-
the plug, cable, and chassis of the machine. To assure that ing's earth connection. Since this could point to a possibly
the EEG machine is indeed grounded, the technician dangerous condition, consult the building's electrician. On
should carry out a few simple continuity tests. the other hand, if the meter still fails to give the proper
Using an ordinary ohmmeter set to its lowest scale set- reading, you need to test the ground system within the
ting,! connect the end of one of the probes to the metal EEG machine.
chassis of the EEG machine and the end of the other probe To carry out this test, unplug the power cord of the EEG
to some metal in the room (e.g., a cold-water pipe) that machine from the electrical outlet and check for con-
ought to be connected to earth. The pointer of the ohm- tinuity between the ground prong on the plug and chassis
meter should deflect to the right and then settle down to a of the machine. This is done by connecting the ohmmeter
between the ground prong (the longest of the three) and
any metal point on the chassis. The ohmmeter should show
1 All ohmmeters need to have their zero settings adjusted before
using them. After selecting the scale that you would like to use, a reading close to zero ohms. If it does not, contact the
touch the two probes of the meter together. As is the case manufacturer of the machine for help; for safety's sake, do
whenever using an ohmmeter, make sure that the probes are not use the machine. On the other hand, if this test shows
touching surfaces where the metal is clean and free of corrosion. that there is continuity in the EEG machines ground sys-
With the probes connected together in this manner, turn the tem, the fault may be in the electrical outlet you are using
zero-adjust knob on the meter until the pointer reads exactly zero
ohms. If this adjustment cannot be satisfied, the battery inside or in the building's ground system. These are serious and
the meter will need to be replaced. Consult the instruction potentially dangerous conditions, and you should consult
manual for help. the building's electrician for help at once.
Appendix 4
Measurement of Chassis Leakage Current

The way in which leakage currents affect the safety of of the machine at the same time that your body is touching
patient and technician during EEG recording is discussed ground. Also, never use an extension cord of any kind to
in Chapter 8. One important source of such leakage cur- make this hookup as this will generally increase the
rents is the chassis leakage current. We already noted in amount of the chassis leakage current measured. Next,
the chapter on electrical safety that the maximum allowa- connect one probe of the meter to the ground socket of the
ble chassis leakage current with the ground wire of the electrical wall outlet and the other probe to the metal
EEG machine's power cord interrupted is 100 IlA. chassis of the EEG machine. The meter should read no
Measurements of chassis leakage current are relatively more than 100 IlA. Iflarger readings are observed, contact
easy to make if an accurate AC ammeter capable of meas- the manufacturer immediately.
uring currents in the 0.025 to 0.25-mA root-mean-square
(RMS) range is available. Proceed as follows: disconnect
the power cord of the EEG machine from the electrical
'This converter is commonlv referred to as a "cheater:' A cheater
outlet and reconnect it to the electrical outlet via a three- should never be used with 'the EEG machine for any purpose
way to two-way converter.' Because doing this leaves the except to measure chassis leakage currents. It should be removed
machine ungrounded, be careful not to touch the chassis immediately after the measurement is made.
Appendix 5
The 10-20 International System of
Electrode Placement

The essential features of the 10-20 System have already To correctly locate the positions of the 19 scalp elec-
been taken up in Chapter 11: "Recording Systems:' The trodes, follow the instructions contained in the succeeding
following is a step-by-step "how to" procedure for the EEG six steps. The tools you need include a narrow measuring
technician who is starting herlhis training. This procedure tape scaled in centimeters and millimeters, a pair of
should be carefully followed and thoroughly mastered, as straight calipers, and wax pencils (e.g., china marker pen-
the importance of accurately placed electrodes cannot be cils) in two different colors. One color is used for the initial
overemphasized. Electrodes that are not symmetrically marking of the locations; the second color is used only if
placed over homologous areas on opposite sides of the corrections or modifications to the original markings
head can result in left-right asymmetries in the EEG trac- become necessary. The second color avoids the confusion
ings that may lead to an erroneous interpretation of the that results from having more than one mark at a particular
record. site.
As explained in Chapter 11, electrodes in the 10-20 Sys-
tem are defined by two characters - a capital letter and a Step 1. In this step, you establish the positions that the z
number. The letter refers to the particular region of the electrodes assume along the midline. Using the measuring
cerebral cortex, and the number indicates whether the tape, measure the distance from nasion to inion. To the
electrode is on the right or left side. Odd numbers nearest millimeter, compute 10% and 20% of the total
represent the left side of the head and even numbers nasion-to-inion distance; using these values, mark off the
represent the right side. For electrodes located along the locations of the frontal pole, frontal, central, parietal, and
midline, the second character is a lower-case z. Thus, for occipital regions on the scalp with the wax pencil, as
example, P3 represents the left parietal region; 02, the shown in Fig. A5.2a. Draw a vertical mark in the exact mid-
right occipital region; AI, the left auricle or left earlobe, dle of the patient's forehead through the frontal pole loca-
and Cz, the central region at the midline. The frontal pole
electrodes are an exception and are defined by two letters
and a number. Thus, the frontal pole electrode on the left
is designated Fpl' Pre-Auricular Point
The location of the 19 scalp electrodes of the 10-20
International System is based upon four fixed landmarks
~
0~
on the head. These landmarks are the nasion, or indenta-
tion where the nose joins the forehead; the inion, a promi- N.o."- /-
...~-Inion
nent protrusion or bump at the back of the head located by
running your finger from the back of the neck toward the
top of the head; and the preauricular points. As the name
suggests, the preauricular point is in front of the ear. It is
located just above the tragus, or triangular piece of car-
tilage that covers the opening of the external ear canal. Figure AS.1. Landmarks of the 10-20 International System of
Figure AS.l shows the location of these landmarks. Electrode Placement.
272 Appendix 5. The lO-20 International System

(a) (c) (e)

Nasion Frontal Pole

10% -= . :.::... Frontal
Central
Parietal
20%€=.::·. Occipital
10% -=:::::: .. -
Inion

B
(b) (d) (f)

Left Cz Right
I
Fp, Fp2

Central ~' Central \ /

Temporal ~ Temporal Frontal Frontal
I I +I I C3 ++ C.
Parietal - - Parietal

'Ii~il'
/ \
0, O2

10% 20% 10%

Figure AS.2. The six steps (a through f) used to locate the positions of the 19 scalp electrodes in the lO-20 International System. The
two other electrodes, Al and A2, are located on the left and right earlobes. In all cases, the view is from the top of the head.

tion. This establishes a primary reference point, Fpz, that distance between the occipital positions on the left and
will be used in step 3. right sides is equal to 10% of the head circumference
measurement. Finally, again place the tape measure along
Step 2. This step establishes the positions of the elec-
the circumference of the head as previously instructed and
trodes on the coronal line that runs across the head from
draw horiwntal marks through the 5 % and three of the
ear to ear. Measure this distance from the preauricular
four 10% points on each side (the midtemporal regions
point on the left to the preauricular point on the right, and
already have horizontal marks, made in step 2).
compute 10% and 20 % of the total distance to the nearest
Step 3 marks the locations of 10 electrodes: Fpl' F7, T3,
millimeter. Mark off the locations of the central and tem-
T5, and 01 on the left, and Fp2' F8, T4, T6, and 02 on the
poral regions on the right and left sides of the scalp and the
right. These are shown diagrammatically in Fig. A5.2c. It is
midline central position, as shown in Fig. A5.2b. Together
apparent from the diagram that each electrode is distant
with the mark locating the central region in step 1, the
from its immediately adjacent, neighboring electrodes by
midline central mark defines Cz, the vertex electrode.
10% of the head circumference measurement.
Step 3. In this step, you establish the positions of the elec-
trodes that are placed along the circumference of the head. Step 4. This step establishes the locations of the elec-
Using the measuring tape, measure and record the head trodes along the left and right parasagittal rows. Begin by
circumference, making sure that the tape lines up with the measuring the distance from Fpl to 01 with the tape meas-
frontal pole, and temporal and occipital marks already ure; in doing so, be sure that the tape lines up with the cen-
trar:ed on the scalp. Set the straight calipers to 5% of the tral mark already placed on the scalp in step 2. Now locate
total head circumference and, using them as a guide, mark the frontal region by a mark that is 25% of the way back-
off 5% of this distance to the left and right of Fpz, the ward from Fpl. Continuing backward, place similar marks
primary reference point established in Step 1. Moving to define the central and parietal regions. These marks are
backward from the 5% point on the left side, mark off 10% placed so that the frontal to central and central to parietal
of the head circumference each for the anterior temporal, distances are also 25% of the distance from Fpl to 01.
midtemporal, posttemporal, and occipital positions. Repeat these measurements and markings on the right
Repeat these steps going backward from the 5% point on side of the head. Figure A5.2d diagrams this step. Note
the right side. As a check on the accuracy of the measure- that in completing step 4 you establish the positions of the
ments and the precision of the markings, verify that the left and right central electrodes, C3 and C4.
The 10-20 International System 273

Step 5. This step fixes the locations of three electrodes to T6, making sure that the tape measure lines up with the
in the frontal coronal row, namely, F3, Fz, and F4. Start- left, midline, and right parietal marks already present on
ing from F7, measure the distance across the top of the the scalp. Next, measure and mark off 2S% of the way to
head to F8; make sure that the tape measure lines up the right of TS. Continuing on to the right, measure and
with the left, midline, and right frontal marks already mark off SO% of the way and 7S% of the way from TS.
present on the scalp. Next, measure and mark off 2S% Figure AS.2f diagrams this step. Note that the 2S%, SO%,
of the way to the right ofF7. Continuing to the right, meas- and 7S% marks, together with marks already placed in
ure and mark off SO% of the way and 7S% of the way from steps 1 and 4, establish the locations of the P3, Pz, and P4
F7. Figure AS.2e diagrams this step. Note that the 2S%, electrodes.
SO%, and 7S% marks, together with marks already placed The procedure is completed by attaching an electrode
in steps 1 and 4, establish the locations of the F3, Fz, and to each earlobe. These electrodes are designated Al on the
F 4 electrodes. left and A2 on the right. Together with the others, they
make up the full complement of21 electrodes of the 10-20
Step 6. This step fixes the locations of three electrodes in International System. Finally, a ground electrode is added;
the parietal coronal row, namely, P3, Pz, and P4. Beginning this usually is attached to the middle of the patients's fore-
from TS, measure the distance across the top of the head head, between Fpl and Fp2'
Appendix 6
A Glossary of Common Artifacts
in the EEG

Many of the different artifacts that are commonly encoun- common of all artifacts, were discussed in Chapters 7, 11,
tered in electroencephalography have been discussed in and 13, respectively. Along with these discussions, ways of
various chapters throughout the text. Electrode artifacts eliminating or reducing the artifacts were considered.
and physiological artifacts, which are probably the most The following illustrations are presented as an aid to the

993
F7Av~
t
T3

T5

F8

T4

T6

Fp1

F3

C3

P3

01

Fp2

C4

P4

02
,--
Fz
Glossary of Common Artifacts 275

Fp1 F7 .............. ' ~ ... __ ....~.......,~~ ,'J,\!. A~

'J v'
F7T3~~~

T3 T5

T5 01

Fp2 Fa ....-...------.-....,,---..,--.-..-~-......_..-_. . . . . v~
.
Fa T4 ~ ____________~___________~

T6 02 _ _ _ _-~ ~~~. ...

Fp1 F3

P3 01

Fp2 F4 ....... .,.

F4 C4 . . . . .- - - - - -.........--~-~--~------~------------

Fz Cz ,'-------~-~--~--~~----.....
1_-
Cz pz

Figure A6.2. Eye-movement artifact. These artifacts may have attaching an electrode to the cheek below the eye and recording
amplitudes greater than 100 IN, as is the case with those marked between this and the ipsilateral ear lobe. This derivation will
by the arrows. They are readily identified by their anterior- show waves that are out of phase with the deflections in question
posterior distribution; amplitude is highest in the derivations if they are indeed eye-movement artifacts. Filters: low frequency
containing the frontal pole electrodes and diminishes as the elec- = 1 Hz, high frequency = 70 Hz. Calibrations: horizontal = 1
trodes move backward. At times, the artifacts can be quite rhyth- second, vertical = 50 Ilv'
mic and may be mistaken for FIRDA. Any doubts are resolved by

recognition of such artifacts. They are offered with only forms. Only through experience can the EEG technolo-
brief comments in the legends. If the reader has studied gist, neurology resident, and electroencephalographer
the text, he/she will already be familiar with these artifacts. gain the knowledge needed to quickly and correctly iden-
Some of them are present in the numerous illustrations tify all of them.
that comprise the main body of the text and are pointed This glossary includes illustrations of the following
out along the way. Although the illustrations given artifacts: ECG, eye movement, eye lid (blink), yawn, swal-
herewith represent typical examples, the same kind of lowing, respiration, muscle spike, electrode "pop;' sweat-
artifacts sometimes may assume a variety of different ing, nasopharyngeal electrode, and ventilator.

•
Figure A6.1. An ECG artifact. The artifact is readily identified by that the artifacts are exactly in phase with the voltages from the
its repetitive, periodic character. Any lingering doubts concern- heart. The ECG artifacts are more common when using a
ing the origin are settled by attaching an electrode to the person's referential montage. Filters: low frequency = 1 Hz, high fre-
chest and recording the ECG directly. The bottom channel shows quency = 70 Hz. Calibrations: horizontal = 1 second, vertical =
the ECG as recorded between the chest electrode and A2. Note 50 Ilv'
276 Appendix 6. A Glossary of Common Artifacts

T5 01 . . -','j." '.'.',~:. ,",','

Fp1 F3

F3 C3

C3 P3 ~N-~~JVV_'''_''I\J''-''''''''~~~~J~~~~~''''~~V''J~~A_''N'';~tr~~

P3 01 'v"~,',,:~,~.,r.'/,;'\/,."'~"'~",•."'i.";:';""""\\';~',\\ \"'.;'/; .,:.~:,:" ";'.'./"~'...r.,\, ',", ,','i'," .",.\\ \W·I'.'\\·.\.......·,...'// )\;~\\ .! .., •• ·,.:.\~.f,... .I... \1 ",~, "'\\":j':, '.~:{\: ,~~: I~, ..,r.~,~ •.J"'"V" ~~~~~ I

Fp2 F4 --.
"V
(I"'''''\r'·-'~.J~-.l<''-·.,r'-\~~/'''W'i
• • • • ••
r"'' ' ',j. .·''\r-¥i\j-...'
J, '
" ..........._rr
· !""' ........~I\!-~""""',... . . .-.t.'v'"'V~'
F4 C4 . . . . . . . .~ -F,.,_,:"""\A,~,J../'.I/'v\...""""-~..f'..", ~
'"'vv........ ,~\'" -~,r' . . . ./j.......
,/
/\'-"'11,,1('
(J
""~-""';l.4,..~~~~ ,
I
C4 P4 ~~n/'~",vvv>v v"v_NW~_V~'V~Vc-.··V',~~~.~""""·-'-../'"-~~~~~~\,,,,,,~~"';""~I~
........

P4 02 ~I\JV'V..."-,,,,~' ~ :V/V"l.i."Ii,,,·.'
. 'H\;'f',,'\V fit",. \1'1,\ \,1.'~':>L"J' \,~,,\,,,V';\,",;,, '.•....,....IV\,~:", ',";, \,'\ ·~\',,\'\t-.:~/\'1.,'I:~t'f'~·.(I..,;,/,I'/', ·/,/~;-'/../'.,\V..,'y"" /"
'.. .";.;.'....
r ....
"',,:"
\""i\,~,'~ ~. ''\'VVV~''/<~\~li,~,,"ut.A ~~4~" J~W.J\v.~~;~
"'I'''''1'II~['Pl''f'''' "1, ,.
Fz Cz ~-~·~V'v-A""""""_~~V~"A"'<~'-.r"'v~"-'~J"'r~'vv·---v--~./.''''</''·w.~,,,,,,,,,~.I\,.....,..,...~~~
1_-
Cz pz ~~IV"""""~~~~~~~~"""""~'-"'-""''''''''~I\t.-~~

Figure A6.3. Eye-lid (blink) and yawn artifacts. The blink artifacts marked "XX." Aside from consisting of large-amplitude muscle
(triangles) are recognized by the sharp contours of the waves, spikes, it has no specific distinguishing features. Filters: low fre-
their prominpnt appearance in the anterior derivations, and their quency = 1 Hz, high frequency = 70 Hz. Calibrations: horizon-
often repetitive nature. Placing pads over the eyes may help, but tal = 1 second, vertical = .50 1lY.
sometimes doing so makes the problem even worse. The yawn is
Glossary of Common Artifacts 277

Fp1 F7

F7 T3

T3 T5

-..;"""'--''/''\ " .\,,' .. ,: ·,'/V"/V\.~··\.'.j)"'I'''\'·'I'\;'''·'~'

,
Fp2 Fa

Fa T4

Fp1 F3 ~-'~~~~~~~"~"'~'~";_~~_'~__ ~'~"V ~-"-"-~~~, '~-""'''', ;'~~_ .r',~",:~,,,,,,,,",,,,,,~,~~~,,--,,,

__

F3 C3 'f'/YVWNt~"""",,Y'<'fv~i"~~""""''''~~--'PN'''v'/V'v{':{'''''>~..wfllfJ.J'{~~~~\Nr.-v~~~~

C3 P3 "'-~~~~~~~-'''''fl'N''''''~'~~4~~~''''''''~
I I'
P3 01 "".J/'vvJ-vJ"""'~~!lIW,'tvV',N:!"'/~'~'"-<Vyvv~JVY'f,"/,~~N'tI':(/V;'rNV''''''·:>N\''''''''''''"-.v,'''f1"'I';';'-'''~,'vI{vvI''\lrM,~""V\~

FP2F4~~~~~'~~~
F4 C4 vJ'-VVW'I'fNN~""~~'l'rlVrN,vl\~-~~-~r--v----,~) f',,"\'.N'r_~"'~''''''''Ar-''w,,~~
\
C4 P4 ",~~ _ _ ~_~_~_~_-"'~~",~~~-'~ I~~--"'~
r _ _Nv _ _ _

Fz Cz N""V-~~~--r..._v-~.--.~~-.,..-"I.o"''.''\rvVV'-''''..,r-V~~~~ _ _ _
, 1_ _-

Figure A6.4. Swallowing artifact. Occurring at "S;' this artifact is distinguished by its rhythmic character. Filters: low frequency
Hz, high frequency = 70 Hz. Calibrations: horizontal = 1 second, vertical = 50 JlV
278 Appendix 6. A Glossary of Common Artifacts

'''''Ii, ... " .. " " .. ,,", """'" """ .. , "'ii"" llli ..... II . . . . . . , "'''''4 ,,,,,,,,, "" ..... i"""" .. i i i i i i i .. ,,", . . . . . . ,i ... ", ... 11' ,

Fp1 F7~-- __~--~~~~------~~----------------~~--~__--~__~_____

F7 T3~~f~f~lt~l~ff4~+t~'----~1M1~~----~~----~---------~~
T3 T5 ~1\HH~\ +\..HIHI ---' \ ~
• •
T5 01 ----------~-------------------------------------------------~
•
Fp2 F8--~~--~--~--~------~----------~------~~~~~--~----~-- ___
F8 T4 --------~--~------~.------~--~----------~------~----------~--­
T4 T6 ----------------------~.~I~· LI-------------------------------------
T602
Fp1 F3 ~-~~-~-----------~~ -----------------------------~
F3 C3~~--------~~----~~~~~--~--------~-~~~--~--~ ____ ____- ~~

C3 P3~~~~---------~~~~----------~----~----~----------~~
P301

Fp2 F4 .().
~
F4 C4
C4 P4
P4 02
• •
Fz Cz~
1_-
Cz pz
--------------------------------------------------------------w,-----------------
Figure A6.5. Muscle-spike artifacts (solid arrows), respiration with the artifacts. Electrode "pops" are always mirror-image
artifacts (triangles), and an electrode "pop:' Muscle spikes com- deflections in adjacent channels of a bipolar montage. The
monly occur in clusters and are recognized by their sharp "pop" originates in the electrode tbat is common to the two
contours at the standard 70 Hz, high-frequency filter setting (see channels (F4 in the tracing). Filters: low frequency = 1 Hz,
also Fig. 14.10). Respiration artifacts are best confirmed simply high frequency = 70 Hz. Calibrations: horizontal = 1 second,
by observing that the rise and fall of the patient's chest coincide vertical = 50 J.1\'.
Glossary of Common Artifacts 279

Fp1 F7

F7 T3

T3 T5

T5 01

Fp2 Fa

Fa T4

T4 T6

T6 02

Fp1 F3

F3 C3
C3 P3

P3 01

Fp2 F4

F4 C4 14

C4 P4

P402
Fz Cz
1_-
Cz pz

Figure A6.6. Sweating artifact. These artifacts are recognized by switching the low-frequency filter setting from 1 to 5 Hz; but of
the slow, pendulous character of the waves. As in the present trac- course, this will reduce low-frequency cortical activity as well.
ing, they usually occur in the frontal and temporal regions. Sweat- Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibra-
ing artifacts may be reduced or sometimes even eliminated by tions: horizontal = 1 second, vertical = 50 !IV.
 280 Appendix 6. A Glossary of Common Artifacts

Pg1 Pg2

Pg2 Fa

Pg1 A1

.......... ~ . Pg2 A2

F7 T3
----------------~~------~-------- ------~------~--~--------~-----~
T3 T5 ..,

------------------~.~~~---------+---
T4 Te

T602

Fp1 F3
------------------------------~
F3 C3

C3 P3 .
--~~------~------------------------- Fp2 F4
F4 C4
--
------------------~----------~
C4 P4
1- 1-
Fz Cz

Figure A6. 7. Pulse artifacts (left) and respiration artifacts (right) in nasopharyngeal electrodes. Such artifacts are common and difficult
to get rid of. Filters: low frequency = 1 Hz, high frequency = 70 Hz. Calibrations: horizontal = 1 second, vertical = 50 11V.
Glossary of Common Artifacts 281

Fp1 F7 ,84

F7 T3

T3 T5

T5 01

Fp2 Fa

Fa T4

T4 T6

T6 02

Fp1 F3

F3 C3

C3 P3

P3 01
x x x x
Fp2 F4

F4 C4

C4 P4

P402
Fz Cz

Cz pz

Figure A6.8. Ventilator artifact. These artifacts, which are marked high frequency = 70 Hz. Calibrations: horizontal 1 second,
by "X's;' are among the artifacts most commonly seen in EEGs vertical = 50 ~v.
taken in the intensive care unit. Filters: low frequency = 1 Hz,
Appendix 7
EEG Recording in Patients with
Infectious Diseases

Although unlikely, a potential exists for the transmission of of a needle may be used. After using the needle, make
infectious diseases in the EEG laboratory. Transmission of sure that it is bagged in a special container, autoclaved,
disease may occur from a patient to the technician and also and discarded.
from one patient to another. As in any other laboratory or 5. After removing the electrodes from the patient, they
workplace, airborne or contact transmission of bacterial should be placed in a disinfectant solution before the
and viral infections are possible. Inadequate cleaning of electrode paste is cleaned off. Soaking in Dakin's
the laboratory, the equipment, or the electrodes; poor ven- solution' for several hours has been recommended
tilation systems; or inappropriate handling of infected (Report of the Committee on Infectious Diseases,
patients by technicians may all contribute to the spread of 1986). Thereupon, the electrodes are cleaned of elec-
infection. For this reason, careful attention should be paid trode paste using tap water (the technician should wear
to general principles of hygiene and infection control. gloves while doing thiS), bagged in a container, and
The three major diseases where risk for infections exists autoclaved. Steam autoclaving at 132°C for one hour
are Jakob-Creutzfeldfs disease (JCD), viral hepatitis B, inactivates the JCD virus (Committee on Health Care
and acquired immune deficiency syndrome (AIDS). Viral Issues, ANA, 1986), as well as the hepatitis B virus and
hepatitis B and AIDS are known to be spread by contami- AIDS virus (Report of the Committee on Infectious Dis-
nated blood or serum. In the case of JCD, such possibility eases, 1986).
also exists; bu t the primary mode of transmission has been 6. Alternatively, a solely chemical method of disinfection
through infected brain tissue. In this appendix we outline may be employed. For this purpose, use of a 5% solution
some of the more important procedures to follow to avoid of sodium hypochlorite (full strength household bleach)
transmission of these diseases in the EEG laboratory. For has been suggested (Brown P, Gibbs Jr. CJ, Amyx HL et
a detailed treatment of the topic, refer to the Report of the aI, 1982; Bond ww, Peterson NJ, Favero MS, 1977; Gaj-
Committee on Infectious Disease of the American EEG dusek DC, Gibbs CJ, Ashor DM et ai, 1977). Unfor-
Society (Report of the Committee on Infectious Diseases, tunately, such a high concentration of sodium hypoch-
1986), and the Special Report on Infection Control for lorite is corrosive to metal electrodes and reduces their
Patients with AIDS (Special Report on Infection Control useful life. As noted below, such high concentrations are
for Patients with AIDS, 1983). not needed to inactivate the AIDS virus.

Precautions with Known Cases of JCD, General Precautions Relevant to AIDS

Hepatitis, or AIDS
The precautions outlined in the previous section are
1. The technician should wear gloves, mask, and apron. appropriate when a patient is known to have AIDS. More
2. Needle electrodes should not be used.
3. Avoid using nasopharyngeal electrodes. If they must be
used, disinfect them as described below. I Dakin's solution is a dilute solution of household bleach with
4. Avoid abrading the skin. If electrode impedances cannot sodium bicarbonate added. Consult The Merck Index for formula-
be brought down to sufficiently low values, the blunt tip tion.
General Precautions Relevant to AIDS 283

often, however, there is risk from patients in whom the References

diagnosis has not yet been made. This risk is greatest in
places where AIDS is highly prevalent. Recently, the Bond WW, Peterson NJ, Favero MS: Viral hepatitis B: aspects of
Centers for Disease Control declared that blood and environmental control. Health Lab Sci 1977;14:235-252.
other body fluids from all patients should be considered Brown P, Gibbs, Jr, CJ, Amyx HL, et al: Chemical disinfection of
Creutzfeldt-Jakob disease virus. N Engl ] Med 1982;306:
infective (Centers for Disease Control, 1987). With this
1279-1282.
in mind, a prudent policy for the EEG technician to fol-
Centers for Disease Control. Recommendations for prevention of
low is to wear gloves during electrode application and HIV transmission in health care settings. MMWR 1987;36/
removal, and electrode cleaning. Care should be taken 2S:8S-18S.
to avoid breaking the skin at the electrope sites by too Committee on Health Care Issues, ANA. Precautions in handling
vigorous scrubbing. After the electrodes are removed, tissues, fluids, and other contaminated materials from patients
they should be soaked in a disinfectant. Soaking in a 2 % with documented or suspected CJD. Ann Neural 1986;10:
solution of glutaraldehyde for 30 to 60 minutes has been 75-77.
recommended (Report of the Committee on Infectious Gajdusek DC, Gibbs CJ, Asher OM, et al: Precautions in medical
Diseases, 1986). A 10% solution of ordinary household care of, and in handling materials from patients with transmis-
bleach is used in some laboratories. But this would seem sible virus dementia (Creutzfeldt-Jakob disease). N Engl ] Med
1977;297:1253-1258.
to be an excessively high concentration, as a recent study
Martin LS, McDougal JS, Loskoski SL: Disinfection and inactiva-
reported that the AIDS virus is inactivated by treating
tion of human T Iymphotropic virus Type IIIlIymphadenopa-
for 10 minutes with a 0.1 % solution of household bleach thy-associated virus. ] Infect Dis 1985;152:400-403.
at room temperature (Martin LS, McDougal JS and Report of the Committee on Infectious Diseases. ] Glin NeuTO-
Loskoski SL, 1985). Electrodes should be rinsed in tap physioI1986;3(suppI1):38-42.
water to remove the disinfectant before they are used on Special Report on Infection Control for Patients with AIDS.
a patient. N Eng/ ] Med 1983;309: 740-744.
Index

A in coma, 249 in viral encephalitis, 149

Abdominal pain in dementia, 135 IRDA, 145-147
and 14 and 6 Hz positive spikes, 178 in diffuse encephalopathies, 249-251 marked attenuation of background,
Abnormal BAEP, 214 in drug intoxication, 249 142-143
Abnormal EEG patterns, 135-189 in encephalopathies, 135-136, non-convulsive status epilepticus, 248
accentuation of beta activity, 249-250 nonspecific nature of, 245
138-141 in encephalopathy following head ORIDA,145-146
alpha coma, 136-137 trauma, 249-250 paroxysmal epileptogenic activity,
attenuation of beta activity, 138 in epidural hematoma, 136 151-181
background rhythms, 135-143 in focal lesions of subcortical white periodic paroxysmal patterns,
BIPLEDS, 188 matter, 251 181-189
categories of, 135 in focal lesions of white and gray mat- persistent slow activity, 148-151
definition of, 135 ter, 251 PLEDS, 188-189
during hyperventilation, 192-194 in generalized tonic-clonic seizures, polymorphic delta activity (PDA),
during intermittent photic stimula- 247 148-151
tion, 197, 199-200 in head trauma, 252 polyspikes, 152, 164, 166-167
electrocerebral silence, 249 in hepatic encephalopathy, 187, 249, sensitivitv of, 245
extreme suppression of background 250 sharp wa~es, 151-152, 153
activity, 142-143 in HSE, 250 slowactivitv, 144-151
FIRDA, 145-146 in hyperglycemia, 250 specifiCity ~f, 245
focal attenuation of beta activity, 251 in hypoglycemia, 250 spike and wave complexes, 152, 158,
focal differences in alpha rhythm, 137 in hypothyroidism, 135 163-166, 169, 172
focal epileptiform activity, 153-162 in hypoxic encephalopathy, 249 spike discharges, 151-162
focal intermittent slow activity, in infantile spasms, 246 suppression burst pattern, 184-185
147-151 in infectious encephalopathies, 250 triphasic waves, 186-187
following brainstem lesions, 249 in Jakob-Creutzfeldt disease, vertex waves, 142-143
following cerebral hypoxia, 249 181-182,250,251 Abnormal somatosensory evoked poten-
generalized atypical fast spike and in large infarct, 251 tial, 216-217
wave discharges, 164 in Lennox-Gastaut syndrome, 245, Abnormal visual evoked potential,
generalized discharges of focal onset, 246 211-212
176 in metabolic encephalopathies, Absence (petit mal) seizures, 163,
generalized epileptiform activity, 249-250 246-247
162-169 in mu rhvthm, 142 Absence seizures
3 Hz spike and wave discharges, in patien'ts with febrile seizures, 245 activation by hyperventilation, 246
163 in patients with tonic-clonic seizures, characteristics of, 246
generalized multispike and wave dis- 164, 166, 170, 171 clinical presentation, 246
charges, 166-167 in phenytoin intoxication, 135-136 EEG pattern in, 246
generalized slow spike and wave dis- in Rolandic epilepsy, 247-248 hyperventilation in suspected cases
charges, 165 in scalp edema, 136 of,194
herpes simplex encephalitis, 183 in seizure disorders, 245-248 occurrence of during hyperventila-
hypsarrhythmia, 168, 245, 246 in sleep, 143-144 tion, 190, 192-193
in absence seizures, 245, 246 in SSPE, 181,250 value of EEG in diagnosis of, 246
in alpha coma, 249 in subdural hematoma, 136-137 Absence status, 169
in alpha rhythm, 135-138 in uremia, 186 Acoustic neurinoma
in cerebral hypoxia, 142 in uremic encephalopathy, 249, 250 BAEP in, 214
286 Index

Acquired immune deficiency syndrome and the average potential reference, searching for ictal events, 221
(AIDS), 282-283 136 preventing buildup of electrical
EEG recording precautions in high- and toxic levels of phenytoin, charge on patient, 221
risk areas, 282-283 135-136 problems with electrodes, 221
mode of transmission, 282 as a contaminant in the average refer- rapid video/audio playback in, 220
precautions in EEG recordings with ence, 102 recording systems used in, 221
known cases of, 282 as "noise" in evoked brain electrical system designs, 220
Acquired immune deficiency syndrome activity recording, 203 system operation, 221
(AIDS) virus asymmetrical slowing of, 136 technique of, 220
inactivation of, 282-283 attenuation of, 3, 99-100 use of patient's diary in, 221
inactivation of using glutaraldehyde definition of, 99 use of rapid playback in interpreta-
solution, 283 distribution of, 99, 101 tion of data, 221
inactivation of using household focal increase in amplitude of, 137 American EEG Society, 211, 249
bleach solution, 283 focal increase in frequency of, 137 Ampere, A., 12
Action potential(s), 71 in alpha coma, 136, 137 Amplification
as fluctuations in membrane poten- in dementia, 135 amounts of in EEG machines, 6
tial,72-73 in encephalopathies, 135-136 stages of in EEG machines, 6
duration of, 73, 74 in epidural hematoma, 136 Amplifier(s)
initiation of, 71 in hypotbyroidism, 135 "blocking" of, 7
Activation procedures, 190-202 in locked-in svndrome, 249 distortion in, 7
hyperventilation, 190-194 in patients with dementia, 135 gain of, 7
increasing the occurrence of EEG in patients with hypothyroidism, 135 in EEG machines, 6-7
abnormalities, 190 in psychogenic coma, 249 malfunction of, 61
intermittent photic stimulation, in psychogenic unresponsiveness, 137 removal of, 61
194-201 in relation to a child's age, 124-125 sensitivity of, 7
rationale of, 190 in scalp edema, 136 troubleshooting procedures, 65
sedated sleep, 202 in subdural hematoma, 136-137 Amplifier(s), electronic
sleep, 201-202 paradoxical effect, 99, 101 amplifying bioelectric activity, 23-24
sleep deprivation, 202 reaction of to stimulation, 99 developmental history of, 21-23
use of pharmacological agents, 202 slowing of, Ill, 135-136 differential amplifier, 21-28
"Active" ear, 79 usage of term, 95 single-ended, 23-24
artifacts associated with, 91 use of average potential reference in Amplifier noise, 26
contamination of scalp electrodes by, recording of, 102 Analog-to-digital conversion
91 Alpha variant, 103 definition of, 204
A-D conversion definition of, 103 sampling rate, 204
see analog-to-digital conversion Alpha variant rhythm Analog voltage, 204
Adenosine triphosphate (ATP), 71 fast, 103 Andersen, p, 74, 76
Adrian, E.D., 1,24 reaction of to stimulation, 103 Andersson, S.A., 74, 76
AIDS slow, 103 Aneurysm, 251-252
see acquired immune deficiency syn- Alternating current (AC) Angiography, 251
drome definition of, 18 Animal electricity, 1
All-channel control, 7 Alternating current (AC) circuit(s) Anode
malfunction of, 65 analvsis of, 18-20 of a vacuum tube, 22
Alpha activity, 2, 95 Alzhei~er's disease Arteriography, 244
absence of, 251 EEG findings in, 250 Arteriovenous malformations, 252
asymmetrical photic driving of, 137 use of brain electrical activity map- Artifact( s)
distribution of, 102 ping in, 226,231-232 batterv effect, 51
following brainstem lesions, 249 Ambulatory ECG monitoring, 220 caused by calibrator malfunctions, 65
in alpha coma, 249 Ambulatory EEG, 220-221 due to amplifier malfunction, 65
"time-locked" in topographic EP rationale of, 220 due to power supply malfunction, 65
analysis, 225 Ambulatory EEG monitoring ECG
Alpha band, 3-4 advantages of, 220 see electrocardiogram
Alpha coma, 136, 249 and on-head preamplifier, 220 electrocardiogram (ECG), 79-80, 97
EEG pattern in, 249 artifacts encountered in, 221 illustration of, 274-275
Alpha rhythm, 3-4, 76, 99-102, 108 artifacts in, 221 electrode, 97
abnormalities in, 135-138 calibration methods in, 221 electrode board, 62
abnormalities in the distribution of, detection of isolated interictal dis- electrode induced, 51
136-137 charges, 221 electrode "pop;' 51,52,278
absence of, 99, 142 electrodes used in, 221 illustration of, 278
amplitude asymmetry of, 136 high-tech features in, 220 elimination of, 7-8
amplitude of, 99 hookup of patient, 221 environmental, 95
and lack of reactivity to eye opening, interpretation of data, 221 elimination of in average evoked
137 identification of artifacts, 221 potentials, 208
and skull defects, 137 role of patient's diary in, 221 externally-generated, 63-64
Index 287

extrinsic, 7 rhythmic rocking, 163 special techniques, 209

eye blink, 276 Single-channel during EEG record- use of norms, 209-210
eye lid (blink) ing,61-62 problems experienced in recording,
illustration of, 276 Single-channel in referential record- 207-208
eye movement, 275 ing,62 rationale for use of, 203
illustration, 275 60 Hz, 34, 40, 57 replication of waveforms and reliabil-
resemblance to FIRDA, 145-146 60 Hz artifact in average evoked ity,209
from electrode in bipolar recording, potential recording, 280 signal averaging systems, 206-207
62 sources of, 7-8 somatosensory evoked potentials
from electrode potentials, 47-48 sources of from the environment, 63 (SSEP),214-217
from faulty connector contacts, 62 swallowing, 277 stimulus repetition rate, 209
from ground, 63-64 illustration of, 277 visual evoked potentials (YEP),
detection of, 63 sweating, 279 210-212
elimination of, 64 illustration of, 279 Average evoked potential artifact(s)
from mechanical disturbance of elec- types of, 97-98 environmental, 208
trodes,51 ventilator, 281 instrumental, 208
from movement of lead wires, 51 illustration of, 281 physiologic, 208-209
from NPG electrodes, 83, 280 yawn, 276 role of stimulus repetition rate in
from power lines, 63 illustration of, 276 elimination of 60 Hz artifact,
from radio stations, 56-57 Artifacts in the EEG 208
from radio-telegraphy stations, 63 glossary of, 274-281 Average potential reference, 80-81
from residual potentials, 48 Artifact rejection "window;' 208 contamination of, 80-81, 93
from TY stations, 56-57 Ascending reticular activating system difficulties leading to incorrect
generated within the EEG machine, role of in generation of the EEG, 76 interpretations, 93
64-67 Asymptote plot(s) disadvantages of, 80-81
generation of by noisy connector and definition of, 31 principle of, 80
switch contacts, 66 examples of, 31, 33 purpose of, 93
hiccup, 163 Atomic structure reducing contamination of, 80-81
in EEG resulting from ground loops, basics of, 11-12 Axon
59 Atoms definition of, 68
in recording of average evoked poten- structure of, 11-12 function of, 68
tials, 208-209 Auditory cortex, 212 lengths of, 68
in single channel during calibration, Auditory-evoked response (AER), 224,
61 225, 226 B
instrumental, 97 Auditory meatus, 212 Background activity
elimination of in average evoked Auditory nerve, 212 abnormalities in, 142-143
potentials, 208 function of, 212 definition of, 95
intrinsic, 7 pathway of, 212 description of, 95-96
muscle activity in the EEG, 35-36 Auricle (pinna), 212 extreme suppression of, 142-143
muscle spike, 278 Average common reference following cerebral hypoxia, 142-143
illustration of, 278 see average potential reference in cerebral cortical death, 142-143
NPC electrode, 280 Average evoked potential(s), 203-217 marked attenuation of, 142-143
illustration of, 280 artifacts encountered in recording of, Bandwidth
of environmental origin, 63 208-209 of amplifier, 8
photoelectric electrode, 200-201 brain stem auditory evoked potentials of the EEC, 3
avoidance of, 201 (BAEP),212-214 Barbiturate spindles, 76
identification of, 200-201 contamination of waveforms by rest- Bartels, P., 223
physiological lessness, 209 Basal ganglia, 267
detection of, 97 duration of epoch, 204 and motor function, 267
ECG, 79-80,97,274-275 historical background of, 203-204 Base
elimination of in average evoked identification of components of, 209 of a transistor, 23
potentials, 208-209 identification of waveform compo- Basilar membrane, 212
EMG,97-98 nents,209 Battery effect
eye-movement, 98 importance of low impedance elec- in EEC recording, 48
galvanic skin, 98 trodes,208 BEAM
role of EEC technician in detec- interpretation of, 209-210 see brain electrical activity mapping
tion of, 95 method of recording, 207-209 Behavioral problems
sources of, 97 practical clinical methods of record- and 14 and 6 Hz positive spikes, 178
produced by ground loop, 63 ing,207-209 Bemegride, 202
pulse, 280 principles of interpretation, 209-210 Benign epilepsy of childhood with
illustration of, 280 absent waves, 209 Rolandic Spikes (BECRs),
reduction of muscle artifact, 35-36 delayed waves, 209 247-248
respiration, 278 identification of waves, 209 Benign epileptiform transients of sleep
illustration of, 278 replication of waveforms, 209 (BETS), 177
288 Index

Benign Rolandic epilepsy, 247-248 Brachial plexus, 215, 216 Brain-stem auditory-evoked potential
spike discharges in sleep, 201 Brain (BAEP),212-214
Bentonite, 49 as a volume conductor, 84 abnormal waveforms, 214
Berger, H., 1,2,68,99 Brain death, 142 absence of waveforms, 214
Beta activity, 2, 95 SSEP in, 217 characteristics of, 214
abnormalities in, 138-141 Brain electrical activity clinical correlation of, 214
absence of, 251 topographical mapping of, 82 absence of, 214
accentuation of, 138-141 Brain electrical activity mapping anatomical basis of, 212
amplitude of, 108 and significance probability mapping, anatomical origin of components of,
attenuation of, 138 223-224, 230 212-213
definition of, 108 and slOWing induced by sleep, 225 and assessing hearing in pediatric
distribution of, 108-109 and time locking of alpha, 225 patients, 214
effect on of high-frequency filtering, application of to clinical practice, characteristics of in comatose
109 226-237 patients, 214
effects of barbiturates on, 138-139 auditory evoked response, 225 components of
effects of drugs on, 138-139 cartooning, 223 anatomical source of, 212-213
effects of skull defects on, 138, case studies using, 226-237 duration of epoch, 204
140-141 clinical use of, 222-237 in acoustic neurinoma, 214
focal attenuation of, 251 control of blinking in, 224 in brain stem glioma, 214
frequency of, 108 definition of, 222 in cerebellopontine angle tumor, 214
in patient with craniotomy, 141 effect of electrode impedance asym- in coma, 214
in subdural hematoma, 138 metries in, 224 in demyelinating disease, 214
masking of, 108 encephalopathic slowing in, 225 in eighth-nerve tumor, 214
resemblance of breach rhythm to, evaluation of drowsiness in, 225 in head injury, 217
179 example of method using EP data, in intra-axial tumor, 214
response of to chloral hydrate, 113 223, 229 in multiple sclerosis, 214
Beta band, 3-4 eye movement artifacts, 224 major components of the waveform,
Beta rhythm, 3-4 importance of maintaining alertness 212-213
Beta spindle(s), 113-114 in, 225 normal waveforms, 213-214
Beta, subvigil, 113 importance of normative data in, 225 effects of age and sex, 214
Binary coded decimal (BCD), 220 importance of study repetition, 228, effects of body temperature, 214
Bio cal 236 features of, 213-214
see biological calibration in a case of Alzheimer's disease, 226, identification of, 214
Bioelectric activity 231-232 inter-ear interpeak latency differ-
recording of, 2 in a case of presenile dementia, 226, ences of, 214
Bioelectricitv, 1 231-232 interpeak latency values of, 214
Biological c~libration (Bio cal), 10, in Sylvian seizure syndrome, 227, parameters of stimulation
44-45 234-235 intensity, 213
definition of, 44 in temporal lobe epilepsy, 227, stimulus polarity, 213
purpose of, 45 232-233 stimulus rate, 213
technique of, 44 rationale of, 222 problems in interpretation of, 214
Biopotential isolator recommended standards and prac- recording techniques, 213
function of, 58 tices for, 238-242 electrode placements, 213
problems of, 59 requirements for BEAM readers, filter settings, 213
use of, 58 239-240 number of stimulus repetitions,
BIPLEDS requirements for EEG technologists, 213
common causes of, 188 239 stimulus parameters of, 213
definition of, 188 requirements for neurophysiologists, Brain stem glioma
Bipolar montage(s), 81 239-240 BAEP in, 214
advantages of, 81 skills required of BEAM technolo- Breach effect
definition of, 81 gists, 239 definition of, 84
disadvantages of, 81 standards for personnel, 239-240 Breach rhythm
Bleach tips for successful studies, 224-226 characteristics of, 179
use of household bleach to disinfect t-SPM process, 226 definition of, 179
EEG electrodes, 282-283 use of control subjects in, 225 Brevital, 202
Blink artifact visual evoked response, 224, 225, 226 Broad-bank click
in the EEG, 276 Brainstem, 226, 267 definition of, 213
"Blink holiday" technique, 224 and the ascending reticular activating Burst-suppression pattern, 142
Blocking capacitor system (ARAS), 267
definition of, 16 and the control and regulation of C
function of, 28 sleep, 267 Calcarine fissure, 210
Blood sugar level functions of, 267 Calcarine sulcus (fissure), 265, 269
effects of on EEG response to hyper- parts of, 262 Calibration
ventilation, 194 structures of the, 267 AC, 10,42,43,44
Index 289

as assessment of machine reliability, gross anatomy of, 263-265 Coherent averaging, 205-207
42,45 layers of the, 265-266 as signal-to-noise enhancement,
basic concept, 42 lobes of, 264 205-206
DC, 42, 43, 44, 45 major gyri of, 263-265 definition of, 205
methods of, 42-43 major sulci of, 263-265 effect of number of stimulus repeti-
procedure for, 9-10 microscopic anatomy of, 265-266 tions, 205-206
purpose of, 9, 42 pyramidal neurons, 266 mathematical aspects of, 205
rise time, 44 Cerebral hemispheres theory of, 205
standard input voltage used, 42 anatomy of, 262-263 Collector
standards in EEG work, 10 Cerebral hypoxia of a transistor, 23
Calibration signal EEG in, 185 Collodion
accuracy of, 42 effects of on EEG, 142 use of in attaching electrodes, 49
peak-to-peak measurement of, 42-43 periodic EEG patterns in, 183 Columns
range of voltages of, 42 Cerebrospinal fluid (CSF), 262 see tracts
tracing of on EEG chart, 43 Cerebrovascular disorders, 251 Coma, 248
Calibrator, 9-10 Cerebrum BAEP in, 214
checking and re-setting of voltage of, gray matter of, 262-263 caused by NCSE, 249
65 inferior sUiface of, 265 distinction from psychogenic stupor,
Cancellation, 25 white matter of, 262-263 249
complete, 89 Chart drive, 9, 40 the comatose patient, 248-249
definition of, 89 adjustment of, 40 Common lead
example of, 88, 89 as time base for EEG tracing, 67 significance of in EEG recording, 88
in EEG recording, 89-90 function of, 40 Common-mode rejection
partial, 89 loading paper in, 9 as a method of eliminating artifacts
principles of, 89-90 malfunctions of, 67 from the EEG, 25
Capacitance, 14-20 master writer switch, 67 definition of, 25
as a reactive element, 16 paper speeds, 40 Common-mode rejection ratio (CMRR)
Capacitive reactance, 16,30,56 troubleshooting of, 67 computation of, 25
role of in filter circuits, 29 writer control module, 67 definition of, 25
Capacitor, 43 Chart paper effect on of electrode impedance, 25
blocking characteristics of, 9 formula for, 25
see blocking capacitor speeds of, 9 of an amplifier, 25
effects of in an electrical circuit, standard speed of, 40 Common-mode signal
15-20 tracking of, 40 see in-phase signal
functional definition of, 15 weave and breakage of, 40 Complex
measurement of storage capacity of, Chart speed definition of, 95
15 accuracy of, 67 Complex partial epilepsy
structural definition of, 15 measurement of, 67 spike discharges in, 157, 158
transient response of, 15-16 purpose of different speeds, 40 Complex partial seizures, 247
Carbamazepine, 232 use of slow speed as a filter, 40 special recording techniques in, 248
Carotid arteries, 262 Chassis leakage current spikes in, 248
Cartooning, 241 maximum allowable levels of, use of Cf and MRI scans in, 248
in brain electrical activity mapping, 270 Complex waveforms
241 measurement of, 270 analvsis and svnthesis of, 3-4
use of in EP mapping, 223 use of AC ammeter to measure, Comp;essed sp~ctral array(s), 5
Cataplexy, 245 270 illustration of, 5
Cathode "Cheater" Computed tomography (Cf scan), 226,
of a vacuum tube, 22 use of, 270 227, see also computerized
Caton, R., 1 Chemical transmitters tomography
Caudate nucleus, 251, 267 function of, 72 in suspected intracranial tumor, 251
Cell body Chiasmal lesions Computerized EEG machines, 10
definition of, 68 visual evoked potentials in, 211 Computerized tomography (Cf scan),
Central fissure Chloral hydrate, 113 243-244,245,246,247,248,
see Rolandic fissure administration of, 202 249,250,251,252
Central sulcus recommended dosage in EEG lab, indications for use of, 243
see Rolandic fissure 202 IVP dye in, 243
Centromid-temporal epilepsy, 247 use of to induce sleep, 202 limitations of, 243-244
Cerebellopontine angle tumor Chronic ruminative syndrome, 227 methodology, 243
BAEP in, 214 Circuit parameters rationale of method, 243
Cerebellum, 262, 263, 267 capacitance, 14-20 Concentration gradient
connections of, 267 inductance, 14-15 across cell membrane, 69
Cerebral anoxia, 184,246 resistance, 14-20 Concussion, 252
Cerebral cortex Cochlea, 212 Condensation click
functional anatomy of, 264-265 Cochlear nuclei, 212 definition of, 213
290 Index

Condenser Dementia, 250-251 E

see capacitor EEG findings in, 250-251 Ear
Conductivity, 12 EEG slowing associated with, 132 mechanics of, 212
definition of, 12 Demyelinating disease Ear(lobe) electrode
Conductors BAEP in, 214 problems associated with use as a
examples of good and poor conduc- Demyelinating lesions reference, 91
tors, 12 SSEP in, 217 as a reference, 88
properties of, 11-12 Dendrite ECG artifact
Connector( s) definition of, 68 and interelectrode distance, 79-80
handling of, 61 Depolarization in the EEG, 274-275
malfunction of, 61 definition of, 71 Edison effect, 21-22
Connector contact(s) Derivation( s) Edison, T., 21
cleaning of, 66 definition of, 6, 78 EEG
Contact(s) number employed in EEG recording, ambulatory, 220-221
cleaning of in multiple-pin connec- 78-79 artifacts in, 274-281
tors, 66 selection of and EEG interpretation, as a prognostic tool in CNS disorders,
Continuitv 79 245
definiti~n of, 96 Dialysis dementia, 250 as test of cerebral dysfunction in the
Continuity test(s) Dialysis dysequilibrium syndrome, 250 absence of structural lesions, 244
of EEG machine's ground, 269 Diencephalon, 262, 266-267 background rhythms
use of ohmmeter, 269 anatomv of, 266-267 abnormalities in, 135-143
Contusion, 252 Differenti'al amplifier, 21-28 in CNS disorders, 135-143
Conversion reaction, 245 basic principle of, 24-25 characteristics of, 2-4
Corpus callosum, 262, 263 definition of, 24 common artifacts in, 274-281
Cortical blindness EEG convention in input connections contaminating electrical activity in,
visual evoked potentials in, 212 of,24 7-8
Corticospinal tracts, 267 operation of, 24-25 discontinuities in, 222
Cranial cavity polarity conventions, 85 evidence for synaptic potentials as
structure of, 262, 263 Diffuse encephalopathies, 249-251 source of, 73
Cranial nerves, 262, 267 clinical presentation of, 249 frequency spectrum of, 3-4
Cranium, 262 EEG patterns in, 249 generation of, 266
Cteniods, 178 etiological factors in, 249 in aneurysm, 251-252
Current flow Digital to analog conversion in arteriovenous malformations, 251
measurement of, 12 definition of, 204 in children, 124-132
Current-limiting devices Diode in coma, 249
use of in isolated ground systems, invention of, 22 in contusion, 252
58 Diphasic wave in diagnosis of narcolepsy, 248
Cursor definition of, 95 in diagnosis of non-convulsive status
definition of, 207 Dipole abnormality, 227 epilepticus (NCSE), 248
function of, 207 Dipole(s) in focal motor seizures, 248
use of, 207 concept of, 84-85 in large infarct, 251
Cutoff frequency definition of, 84 in Moyamoya disease, 252
computational example, 20 electrical field surrounding a, in old age, 132-134
definition of, 20, 44 84-86 in patients with absence seizures,
formula for, 20, 44 vertically oriented, 73 245
of series R-C circuit, 20 Direct current (DC) in patients with febrile seizures, 245
relation of to time constant, 44 definition of, 18 in primary epilepsy, 245
Disease Control, Centers for, 283 in relation to maturation, 124-132
D Disinfecting EEG electrodes, 282, in relation to other neurodiagnostic
Dakin's solution 283 tests, 244-252
use of in disinfecting EEG elec- Dizziness in simple partial seizures, 248
trodes, 282 and 14 and 6 Hz positive spikes, in subarachnoid hemorrhage, 251
Davis, H., 2 178 in the evaluation of seizure disorders,
Davis, P., 2 Dopamine, 244 24.5
Dawson, G.D., 204 Dorsal columns, 267 in TIA, 251
DC "pips" Drowsiness interictal abnormalities in sleep
definition of, 43 E EG features of, 111-113 recording, 245
De Forest, L., 22-23 Drug intoxication recording of, 5
Delta activity, 3-4, 95 EEG in, 249 role of in the diagnosis and manage-
in coma, 249 Du Bois-Reymond, M., 1 ment of head trauma, 252
in Stage III sleep, 122, 144 Duffy, FH., 223 sensitivity of in the diagnosis of sei-
in Stage IV sleep, 123, 144 Dummy patient, 65 zure disorders, 245
Delta band, 3 Dura, 262 sequential studies, 245
Index 291

specificity of for individual abnormal- in generalized tonic-clonic seizures, continuous, 96

ities, 245 247 delta, 95
use of in clinical diagnosis, 222, in head trauma, 252 fast, 95
244-252 in hepatic encephalopathy, 187, 249, intermittent, 96
use of in seizure disorders, 245 250 location of, 96
value as a diagnostic tool, 245 in HSE, 250 monomorphic, 95
value of in early infarct, 251 in hyperglycemia, 250 monorhythmic, 95
value of in evaluating patients with in hypoglycemia, 250 morphology of, 95
seizure disorders, 245-246 in hypothyroidism, 135 nonrhythmiclrandom, 95
value of in isodense subdural hema- in hypoxic encephalopathy, 249 polymorphic, 95
toma, 251 in infantile spasms, 246 polyrhythmic, 95
EEG, abnormal patterns, 135-189 in infectious encephalopathies, 250 slow, 95
accentuation of beta activity, in Jakob-Creutzfeldt disease, suppression of, 95
138-141 181-182,250,251 theta, 95
alpha coma, 136-137 in large infarct, 251 transients in, 95
alpha rhythm, 135-138 in Lennox-Gastaut syndrome, 246 EEG amplitude
attenuation of beta activity, 138 in metabolic encephalopathies, definition of, 95
background rhythms, 135-143 249-250 high,95
BIPLEDS, 188 in patients with febrile seizures, 245 low, 95
categories of, 135 in patients with tonic-clonic seizures, medium, 95
during hyperventilation, 192-194 164, 166, 170, 171 EEG analysis
during intermittent photic stimula- in phenytoin intoxication, 135-136 problems of, 222
tion, 197, 199-200 in Rolandic epilepsy, 247-248 EEG attenuation
electrocerebral silence, 249 in scalp edema, 136 definition of, 95
extreme suppression of background in seizure disorders, 245-248 EEG blocking
activity, 142-143 in sleep, 143-144 definition of, 95
FIRDA, 145-146 in SSPE, 181, 250 EEG electrode(s), see also electrode(s)
focal attenuation of beta activity, 251 in subdural hematoma, 136-137 application of
focal differences in alpha rhythm, 137 in uremia, 186 precautions for avoiding transmis-
focal epileptiform activity, 153-162 in uremic encephalopathy, 249, 250 sion of AIDS, 283
focal intermittent slow activity, in viral encephalitis, 149 chemical method of disinfection, 282
147-151 IRDA, 145-147 disinfecting after removal from
following brainstem lesions, 249 Lennox-Gastaut svndrome, 245, 246 patient, 282, 283
following cerebral hypoxia, 249 marked attenuati~n of background, diSinfecting with glutaraldehyde solu-
generalized atypical fast spike and 142-143 tion, 283
wave discharges, 164 mu rhythm, 142 disinfection of with sodium hypoch-
generalized discharges of focal onset, non-convulsive status epilepticus, 248 lorite, 282-283
176 nonspecific nature of, 245 importance of correct placement,
generalized epileptiform activity, OIRDA, 145-146 271
162-169 paroxysmal epileptogenic activity, steam autoclaving of to disinfect, 282
3 Hz spike and wave discharges, 151-181 EEG, features of the abnormal record,
163 periodic paroxysmal patterns, 135-189
generalized multispike and wave dis- 181-189 accentuation of beta activity,
charges, 166-167 persistent slow activity, 148-151 138-141
generalized slow spike and wave dis- PLEDS, 188-189 alpha coma, 136-137
charges, 165 polymorphic delta activity (PDA), alpha rhythm, 135-138
herpes simplex encephalitis, 183 148-151 attenuation of beta activity, 138
hypsarrhythmia, 168,245,246 polyspikes, 152, 164, 166-167 background rhythms, 135-143
in absence seizures, 245, 246 sensitivity of, 245 BIPLEDS, 188
in alpha coma, 249 sharp waves, 151-152, 153 during hyperventilation, 192-194
in cerebral hypoxia, 142 slow activity, 144-151 during intermittent photic stimula-
in coma, 249 specificity of, 245 tion, 197, 199-200
in dementia, 135 spike and wave complexes, 152, 158, extreme suppression of background
in diffuse encephalopathies, 249-251 163-166,169,172 activity, 142-143
in drug intoxication, 249 spike discharges, 151-162 FIRDA, 145-146
in encephalopathies, 135-136 suppression burst pattern, 184-185 focal differences in alpha rhythm, 137
in encephalopathy following head triphasic waves, 186-187 focal epileptiform activity, 153-162
trauma, 249-250 vertex waves, 142 focal intermittent slow activity,
in epidural hematoma, 136 EEG activity 147-151
in focal lesions of subcortical white alpha, 95 generalized atypical fast spike and
matter, 251 attenuation of, 95 wave discharges, 164
in focal lesions of white and gray mat- beta, 95 generalized discharges of focal onset,
ter, 251 blocking of, 95 176
292 Index

EEG, features of the abnonnal record during drowsiness and sleep, checking and re-setting calibration
(cont.) 128-131 circuit voltage, 65
generalized epileptiform activity, hypnagogic hypersynchrony, checking for noisy connector and
162-169 128-129 switch contacts, 66
3 Hz spike and wave discharges, hypnopompic hypersynchrony, checking power-supply voltages, 65
163 130-131 documentation of a malfunction, 61
generalized multispike and wave dis- paroxsymal theta activity, 126 externally-generated problems, 63-64
charges, 166-167 posterior dominant rhythm, fuse burnouts, 64
generalized slow spike and wave dis- 124-125 internally generated artifacts affecting
charges, 165 posterior slow waves of youth, 126 all channels, 64-66
herpes simplex encephalitis, 183 Stage II sleep, 130-131 internally generated breakdowns
hypsarrhythmia, 168 theta activity, 126-127 affecting all channels, 64
in cerebral hypoxia, 142 waking activity, 124-127 internally-generated problems, 64-66
in dementia, 135 in deep stages of sleep, 120, 122-124 method of isolation/elimination, 60,
in encephalopathies, 135-136 in old age, 132-134 62-66
in epidural hematoma, 136 slowing of the posterior dominant method of substitution, 60-62
in hepatic encephalopathy, 187 rhythm, 132 power supply malfunctions, 64
in hypothyroidism, 135 temporal slow activity, 132-134 problems common to all channels,
in Jakob-Creutzfeldt disease, in REM sleep, 124 62-66
181-182 in sleep, 111-124 replacing power supply fuse(s), 64
in scalp edema, 136 in Stage I sleep, 111-113 single-channel problems, 61-62
in sleep, 143-144 in Stage II sleep, 113-120 EEG, normal patterns
in SSPE, 181 in Stage III sleep, 122 during hyperventilation, 191-192
in subdural hematoma, 136-137 in Stage IV sleep, 123 during intermittent photic stimula-
in uremia, 186 K complex, 116-117 tion, 196-197
in viral encephalitis, 149 lambda waves, 110-111 EEG patterns
IRDA, 145-147 mu rhythm, 104-107 rhythmicity of, 73-74
marked attenuation of background, positive occipital sharp transients of EEG pseudoepileptiform patterns
142-143 sleep (POSTS), 120-121 BETS, 245
mu rhythm, 142 posterior dominant rhythm, 99-103 14 and 6 Hz positive spikes, 245
OIRDA, 145-146 sleep spindles, 118-119 6 Hz phantom spike and wave, 245
paroxysmal epileptogenic activity, theta activity, 110, Ill, 112 small sharp spikes, 245
151-181 vertex waves, 114-116, 118 EEG reactivity
periodic paroxysmal patterns, EEG frequency definition of, 36
181-189 definition of, 95 EEG reading
persistent slow activity, 148-151 EEG interpretation an analogy to language, 94
PLEDS, 188-189 and the clinical correlation, 97 commonly used terminology, 94-96
polymorphic delta activity (PDA), categorization of abnormalities, describing the record, 96
148-151 96-97 interpreting the record, 96
polyspikes, 152, 164, 166-167 in relation to age of patient, 96 introduction to, 94-98
sharp waves, 151-152, 153 problems in, 97 learning to read, 94
slow activity, 144-151 relationship to state of patient, 96 skills required, 97
spike and wave complexes, 152, 158, sex of patient, 96 synopsis of, 97
163-166,169,172 EEG machine EEG recording
spike discharges, 151-162 and "loaner" modules to replace mal- artifacts encountered in the ICU, 249
suppression burst pattern, functioning units, 61 general precautions relevant to AIDS,
184-185 calibration circuit failure, 64 282-283
triphasic waves, 186-187 composition of, 5-10 in patients with infectious diseases,
vertex waves, 142 computer control of, 10 282-283
EEG, features of the normal record, continuity tests of grounding, 269 in the ICU, 57-59, 248-249
99-134 importance of grounding, 269 procedure to follow with comatose
alpha activity, 99 malfunctions of, 60-62, 64-67 patients, 248-249
alpha rhythm, 99-102 menu-driven, 10, 67 EEG recording systems
alpha variant, 103 method of grounding, 269 historical development of, 77
beta activity, 108-109 overview of, 5-10 principles and techniques of elec-
during drowsiness and sleep in reliability of, 42 trode arrangement, 77-83
adults, III-120 validity of, 42 EEG report
during hyperventilation, 191-192 EEG machine troubleshooting parts of, 98
during intermittent photic stimula- all-channel control malfunctions, problems with, 98
tion, 194-197 64 writing of, 98
F waves, ll6 amplifiers, 65 EEG technologist
in awake adults, 99-1 II basic principles of, 60 importance of in brain electrical
in children, 124-131 calibration circuit, 64 activity mapping studies, 239
alpha rhythm, 124-125 chart drive malfunctions, 67 neuroanatomy for, 262-268
Index 293

requirements of, 262 ethmoidal, 83 Electrode placement

skills required of in brain electrical location of in 10-20 System, 78, using the 10-20 International System,
activity mapping studies, 239 271-273 78,271-273
EEG terminology, 94-96 metal disk Electrode "pop:' 51, 52
EEG waveforms application of, 48-49 Electrode "pop" artifact
as summated field potentials set up characteristics of, 48 in the EEG, 278
by EPSPs and IPSPs, 73 metals used in, 48 Electrode potential
origin of rhythmicity in, 74, 76 metals used in, 47 as a common-mode signal, 47
Eighth-nerve tumor methods of attaching to scalp, 49 as artifact in EEG recording, 47-48
BAEP in, 214 nasopharyngeal, 82-83, 157 definition of, 47
Electric current artifacts associated with, 83 in EEG recording, 47-48
dangers of, 54-55 disadvantages of, 83 Electrode selectors, 6
definition of, 11, 12 placement of, 83 Electrode-selector switches, 6
density of and physiological effects, removal of, 83 Electroencephalogram (EEG)
55 needle, 48 amplitude of waves in, 3
flow of in liquid media, 12 non-polarizable, 47 dynamic range of waveforms of, 7
measurement of, 12 polarizable, 47 frequency range of waveforms in, 3
physiological effects of, 54-55 purpose of, 46 history of, 1-2
Electric motor(s), 37 special, 82-83 Electrographic seizures, 173-175
Electrical activity sphenoidal, 83, 157, 173 Electrolyte
association of with life processes, 1 surface type electrical properties of, 46-47
definition of, 11 advantages of, 48 Electromagnetic induction
Electrical charges metal disk, 48 and ground-loop artifacts, 59
of elementary particles in atoms, 11 surgically placed, 83 principles of, 37
Electrical circuit(s) types of, 48 Electromotive surface, 84
analvsis of, 13-14, 16-18 use of collodion to attach, 49 Electromyogram (EMG), 1
defi~ition of, 12 use of electrode paste to attach, 49 Electron(s), 11
diagrams of, 12-14 widely-spaced vs. closely-spaced, 87 as current-carrying particles, 12
examples of, 12-14 zygomatic, 82 discovery of, 21
frequency response of, 19-20 Electrode artifact( s) Elektrenkephalogramm, 1
parallel circuits, 13-14 battery effect, 51 Emitter
parameters of, 14-15 detection of, 51 of a transistor, 23
series circuits, 13-14 electrode "pop:' 51, 52 Encephalitis, 249
series R-C circuit, 16-17 locating a "popping" electrode, 51, Epidural fluid collection, 251
steady-state response of, 15-17 52 Epidural hematoma, 136
transient response of, 15-17 mechanical disturbance of disk, 51 Epilepsy
Electrical concepts, 11-20 Electrode board, 5-6 complex partial, 157, 158
Electrical double layer, 47 cleaning of pin jacks, 62 generalized, 246-247
characteristics of, 47 corrosion of pin jacks, 62 absence, 246-247
Electrical resistance Electrode-board artifacts grand mal, 247
see resistance caused by electrode paste, 62 intractable, 245
Electrical safety, 54-59 confusion with electrode artifacts, partial (focal), 247-248
and electrode impedance, 58 62 post-traumatic, 252
and patient impedance, 57-58 Electrode cream/paste temporal lobe, 227
Electrocardiogram (ECG), 1, 77, 94, use of, 49, 51 use of seizure monitoring in sus-
220 Electrode impedance pected cases of, 218
artifacts from in referential recording, and salt bridges, 50 Epileptiform abnormalities
79-80 and 60 Hz artifact, 50 focal,153-162
as a common-mode signal, 79-80 devices for measuring, 51-53 generalized, 162-169
as artifact in EEG recording, 25 effect of size of electrode, 50-51 Epileptiform discharges, 151-152
characteristics of, 2 excessively low values of, 50 as spontaneous depolarization of the
rejection of in differential amplifier, factors affecting, 50-51 neuronal membrane, 152
79 measurement of, 49, 51-53 detection of, 152
Electrocerebral silence (ECS), 142,249 methods of reducing, 51 epileptogenicityof, 152
causes of, 249 problems associated with excessively of doubtful significance, 177-181
characteristics of the EEG in, 249 high values of, 49-50 parameters of, 152
guidelines for establishment of, 143 role of skin under electrodes, 51 polyspikes (multispikes), 152, 164,
technical standards for recording, 249 use of impedance meters, 49, 51-53 166-167
Electrode(s), 2, 46-53 use of Ohm's law in measurement of, pseudoepileptiform abnormalities,
application of, 48-49 52-53 177-181
artifacts induced by, 51 values offor optimal recording, 49 sharp waves, 151-152, 153
as field samplers, 77 Electrode paste, see also electrode spike and wave complexes, 152, 158,
as transducers, 47 cream/paste 163-166, 169, 172
definition of, 46 corrosion of pin jacks by, 62 spikes, 151-162
294 Index

Epileptogenic abnormalities Field potential midline spikes, 160-161

definition of, 151 definition of, 73 multifocal spikes, 162
Epileptogenicity generation of, 73, 75 multiple independent spike foci, 162
and location of spikes, 152 Filter( s), 7-8 OCCipital spikes, 159
and polarity of spikes, 152 as tuned circuits, 29-30 Rolandic spikes, 154-156
and size of spikes, 152 band elimination type, 34 Sylvian spikes, 154
assessment of, 152 basic concept and function of, 29-30 Focus
negative spikes, 152 combined high and low frequency definition of, 86
of positive Rolandic spikes, 152 response curves, 32-34 Foramen magnum, 262, 263, 267
positive spikes, 152 cut-off point of, 8 Foramina
Equilibrium potential definition of, 7-8, 29 definition of, 262
calculation of, 70 frequency response of and the true Forbes, A., 24
definition of, 70 curve, 32-34 Fourier, J.B., 4
Equipotential contour(s) function of, 7-8 Fourier series, 3-5
characteristics of, 85-86 high-frequency "Fourteen and six" activity, 241
definition of, 84 effect on EMG artifacts, 98 Fourteen and 6 Hz positive spikes, 178,
Equipotential zone, 88 see high-frequency filter 241
Erb's point, 215, 216 "ideal" filter, 30 and Reye's syndrome, 178
Error of the arc low-frequency characteristics of, 178
definition of, 38 see low-frequency filter distribution of, 178
in EEG tracings, 38 principles of operation, 29-30 occurrence of, 178
problems associated with, 38 roll-off point of, 8 Fragonard, Alexandre, 1
Evoked hrain electrical activity, 60 Hz, 8 Frequency analysis, 3-5
203-217, see also evoked poten- see notch filters, 29 Frequency response
tial(s) 60-Hz notch, 34-35 assessment of, 43-44
as signal buried in "noise;' 204 standard settings of in EEG work, 35 calculation of from circuit
clinical value of, 203 transfer characteristic of, 30-31 parameters, 20
problems of recording using scalp types of, 29 check of using bio cal, 44
electrodes, 203 usage of, 34-36 concept of, 19
Evoked potential(s) use of slow chart speed as high- contrasted with transient response, 19
use of in clinical diagnosis, 222 frequency filter, 40 of EEG channels, 43
Evoked potential analysis Filtering of EEG machine, 43
problems of, 222-223 need for, 29 relationship to transient response,
Evoked potential recording Filter settings 43-44
rationale of, 262 frequency response curves for, 34-35 Frequency-response curve, 31
Excitatory postsynaptic potential(s) FIRDA definition of, 19
(EPSP),266 in chronic renal failure, 145 determination of from cutoff fre-
definition of, 72 in focal encephalopathies, 146-147 quency,44
generation of, 72-73 resemblance to eye-movement interpretation of, 34-36
Excitatory synapse artifact, 145-146 of a series R-C circuit, 20
model of, 75 Fissure of an EEG channel, 43
Extracellular fluid central, 263-264 Frontal intermittent rhythmic delta
composition of, 69, 70 lateral, 263, 264 activity (FIRDA), 145-146,250,
Extracerebral reference e1ectrode(s), 80 midline superior longitudinal fissure, 275
Eye electrode 263 in metabolic encephalopathies, 250
use of in detection of eye-movement Sylvian, 263, 264 Frontallohe
artifacts, 98 Fleming, J.A., 21-22 location of, 264
Eye lid artifact Flexor carpi radialis, 268 Frontal wave(s)
in the EEG, 276 Flexor carpi ulnaris, 268 see F wave( s)
Eye-movement artifact Focal activity Fuse(s)
in the EEG, 275 definition of, 96 burn out of in amplifier, 60
Eye pads Focal encephalopathies, 251 replacement of in amplifier, 60
use of, 276 Focal epilepsy F wave(s)
see partial epilepsy asynchronous, 158
F Focal epileptiform abnormalities, characteristics of, 116
Facultative pacemaker theory 153-162 definition of, 116
and rhythmicity in the EEG, 74, 76 Focal motor seizures, 248 distribution of, 116
Falx cerebri, 262, 263 Focal spike patterns significance of, 116
Faraday, M., 15, 37 anterior temporal spikes, 157-158
Farfield recording, 216 centroparietal spikes, 154 G
Fasciculi frontal lobe spikes, 158 Cain
see tracts in head injury, 158 changes of and Ohm's law, 26
Febrile seizures, 246 inferior frontal spikes, 157-158 changes of in EEG amplifiers, 26
Field-effect transistor (FET), 27 mesiotemporal spikes, 157 of amplifiers, 26
Index 295

Galton, F, 204 in the EEG laboratorv, 55-56 High-frequency filtering

Galvani, L., 1 noise from, 69 . effect of on muscle spikes, 109
Gaussianitv, 241 special for EEG laboratory, 64 High-pass filter, 7-8
Geddes, L:A., 51 Grounding Hjorth parameters, 241
Generalized activity of EEG machines, 55-56 Holter monitor, 220
definition of, 96 of electric circuits, 54-56 Holter, N.J., 220
Generalized epileptiform abnormalities, principles of for electrical safety, Huntington's disease, 251
162-169 55-56 Hyperglycemia
atypical fast spike and wave dis- purpose of, 55-56 EEG in, 250
charges, 164 Grounding checks, 269 Hyperventilation, 96, 190-194
hypsarrhythmia, 168 and ground system within the EEG abnormal EEG response to, 192-194
multispike and wave discharges, machine, 269 and hypocarbia, 194
166-167 use of ohmmeter, 269 as an activation procedure, 190
slow spike and wave discharges, 165 Grounding of patient, 56-57 biochemical basis for EEG changes
3 Hz spike and wave discharges, 163 purpose of, 56-57 resulting from, 194
Generalized multispike and wave dis- risks associated with, 57 biochemical changes brought about
charges to reduce 60 Hz artifact, 57 by, 194
accompanied by myoclonic jerks, Ground loop(s), 63 definition of, 190
170,172 artifacts resulting from, 59 EEG asymmetry during, 192-193
in diffuse encephalopathies, 166 definition of, 59 effects of hypoglycemia on EEG
in generalized epilepsy, 166-167 problems associated with, 59 response to, 194
in Lennox-Gestaut syndrome, 166 Ground noise effects of on the EEG in children, 194
Generalized tonic-clonic seizures, 247 elimination, 64 focal spikes during, 192
adult onset of, 247 Ground rods, 64 influence of blood sugar level during,
clonic phase, 247 Gyrus 194
ictal EEG patterns in, 247 definition of, 263 in patients with absence seizures, 190
in children, 247 medical contraindications of, 190
interictal EEG patterns in, 247 H montage selection for, 194
postictal slowing, 247 Half-cell potential normal EEG response to, 191-192
suppression of EEG activity during, see electrode potential procedural details for EEG technolo-
247 Headache gists, 190-191
tonic phase, 247 and 14 and 6 Hz positive spikes, 178 procedural instructions to patient, 190
Gibbs, E., 2 EEG in, 251 standard procedure for, 190-191
Gibbs, F, 2 Head injury symptoms occurring during, 190
Glia BAEP in, 217 3 Hz spike and wave discharges
definition of, 68 Head trauma, 252 brought on by, 192-193
Glial cells and multimodality evoked potential Hypnagogic hypersynchrony, 163
permeability of, 70 studies, 252 characteristics of, 128-129
Glutaraldehyde, 283 CT scan in evaluation of, 252 definition of, 128
Goldman equation role of the EEG in, 252 distribution of, 128-129
application of, 70 SSEP in, 217 paroxysmal forms of, 181
formula for, 70 Hearing Hypnopompic hypersynchrony
Goldman-Offner reference, 80 assessment of and BAEp, 214 definition of, 130
Gram-Charlier series, 4 Hearing threshold illustration of, 131
Grand mal pattern, 169 determination of, 213 Hypocarbia
Grand mal seizure(s), 169 Helmholtz, H., 84 during hyperventilation, 194
see also generalized tonic-clonic sei- Hemiplegia Hypoglycemia
zures value of EEG in, 251 EEG in, 2.50
Grass Instrument Company Hepatic encephalopathy, 249-250 effects of on EEG response to hyper-
EEG machines, 33 triphasic waves in, 250 ventilation, 194
Gray matter Hepatitis B virus Hypothalamus
composition of, 263 inactivation of, 282 anatomical location of, 266
Grid Herpes simplex encephalitis (HSE), 251 Hypoxia, cerebral
of a vacuum tube, 22 EEG characteristics of, 250 EEG pattern following, 249
Grid input of amplifier EEG features of, 183 Hypoxic encephalopathy, 249
definition of, 23 periodic complexes in, 183 Hypsarrhythmia, 160,245,246
Ground Hertz (Hz), 3 clinical presentation of, 246
as an electrical conductor, 55 Hertz, H.R., 3
as an electrical reference, 23 High frequency filter, 7-8, 29, 31-32 I
current flow to via patient and muscle-activity artifact, 35-36 Ictal patterns in the EEG, 169-175
dangers of, 57 asymptote plot of frequency absence, 169
sources, 57 response of, 33 absence status, 169
definition of, 54-55 circuit of, 33 characteristics of, 169-173
in relation to electrical safety, 54-56 frequency response of, 32-33 tonic-clonic seizures, 170-172
296 Index

Iliac crest, 215-216 Instrumental phase reversal input signal level, 28

Imaging techniques definition of, 87-88, 90 output signal level, 28
definition of, 243 use of in localization, 90 IRIG input jack
Impedance Insulated gate FET, 27 on EEG machines, 28
characteristics of, 19 Insulators use of, 28
computational example of, 19 properties of, 11-12 IRIG output, 206
definition of, 18-19 Intensive care unit (ICU) IRIG output jack
formula for, 19 EEG recording in, 57-59, 248-249 on EEG machines, 28
of electrodes, 49-51 risks of EEG recording in, 57, 58 use of, 28
of patient and electrical safety, Interictal patterns in the EEG, 153-169 Isoground
57-58 Intermittent photic stimulation (IPS), see isolated ground
Incus, 212 194-201 Isolated ground
Inductance, 14-15 abnormal photic driving, 197 and ground lead impedance, 59
Infantile spasms, 168,246 absence of photic driving during, 197 as a current-limiting device, 58
Infarct normal response to, 194-196 definition of, 58
and cr scan, 243 photic driving, 194-197 problems of, 59
EEG in, 251 photo myogenic response, 198-199 use of in patient safety, 58
Infectious disease(s) photoparoxysmal response, 194, Isopotentiallines, 89
EEG recording in patients with, 199-201
282-283 procedural details for EEG technolo- J
factors contributing to transmission gists, 194 Jackson, H., 247
of, 282 use of stroboscope in, 194 Jacksonian march, 247
major risks of in the EEG laboratory, Intermittent rhythmic delta activity Jakob-Creutzfeldt's disease (JCD),
282 (IRDA), 145-147 282
procedures to avoid transmission of in characteristics of, 145-146 EEG abnormalities in, 250, 251
the EEG laboratory, 282-283 Internal capsule, 267 EEG features of, 181-182
transmission of in the EEG labora- Interneurons mode of transmission, 282
tory, 282 definition of, 68 periodic complexes in, 181-182
Infectious encephalopathies, 250 Interpolation precautions in EEG recording with
herpes simplex encephalitis (HSE), methods of in topographic analysis, known cases of, 282
250 223 Jakob-Creutzfeldt's disease virus
Jakob-Creutzfeldt disease, 250, 251 test of reliability of, 223 inactivation of, 282
subacute sclerosing pan encephalitis Intra-axial tumor Jasper, H., 2, 77
(SSPE),250 BAEP in, 214 J unction field-effect transistor (JFET),
Inferior colliculus, 212 Intracellular fluid 27
Infinite series, 4 composition of, 69, 70
Inhibitory postsynaptic potential(s) Intracranial hemorrhage, 252 K
(IPSP),266 Intracranial tumor K complex
definition of, 72 EEG in, 251 and sensory stimulation, 116
generation of, 72-73 Intractable seizures, 165 characteristics of, 116-117
Inhibitory synapse Ionic channels definition of, 116
model of. 7.5 active, 69 distribution of, 116-117
Inion definition of, 69 occurrence of, 116
location of, 271 passive, 69
use of in 10-20 System of electrode lon(s) L
placement, 78, 271 as current-carrying particles, 12 Lacunar infarct, 251
Inking concept of, 46 Lambda activity, 241
methods of used in EEG machines, definition of, 46 Lambda wave(s)
39 formation of, 46 characteristics of, 110-111
problems with, 39-40 properties of, 46-47 comparison with POSTS, III
Inking system(s) IRDA definition of, 110
blockage of, 39 and diffuse encephalopathies, 146 occurrence of, 11 0
maintenance of, 39-40 and mass lesions, 147 Laplace, P.S., 43, 204
operation of, 39 and mental status, 147 Laplacian reference, 242
types of, 39 clinical correlation of, 146-147 Lateral fissure
In-phase signal during deep sleep, 145 see Sylvian fissure
definition of, 25 during drowsiness, 145 Lateral geniculate body, 210
Input box during hyperventilation, 145 Lateral lemniscus, 212
see electrode board during REM sleep, 145 Lateralized activity
Input impedance in focal lesions, 147 definition of, 96
as an amplifier characteristic, 27 interpretation of, 146-147 Lateralized multi spike and wave dis-
of a differential amplifier, 27 localization value of, 146 charges. 166-167
requirements of for EEG amplifiers, IRIG Lead plug-in box
27 definition of, 28 see electrode board
Index 297

Leads Magnetic resonance imaging (MRI referential with earlobes, 81

see electrode( s) scan),226, 244,247, 248 reformatting of, 82
Leakage current(s), 56 advantages of in eNS disorders, 244 transverse bipolar, 81
effects of on safety of patient and in suspected intracranial tumor, 251 types of, 79-82
technician, 270 primary uses of, 244 Montage switch, 6
limits for EEG machines, 56 theory of operation, 244 Morrison, R., 59
measurement of, 56 Malleus, 212 Motor-evoked potentials, 267
problem of, 56 Marker pen(s), 40-41 Moyamoya disease, 252
sources of, 56, 270 inking problems in, 41 Multifocal spikes
Lennox-Gastaut syndrome, 165, 166, uses of as a time marker, 40 definition of, 162
169,245,246 uses of in photic stimulation, 41 Multiple sclerosis
clinical presentation in, 246 uses of in seizure monitoring, 41 and cr scan, 243
diagnosis of, 246 Master electrode selector BAEP in, 214
EEG pattern in, 246 see montage switch SSEP in, 217
petit mal variant in, 246 Master gain switch, 7 visual evoked potentials in, 212
Lentiform nucleus, 267 Master writer switch Multiple sleep latency test, 248
Lindsley, D,8., 2 malfunction of, 67 Multispikes
Linear conductor(s), 84 purpose of, 67 see polyspikes
definition of, 84 Matthews, B,H,C., 1,24 Mu rhythm, 3, 104-107
Linearity Maturation abnormalities in, 142
assessment of, 43 EEG in relation to, 124-132 asymmetry in, 142
of EEG channels, 43 Medial geniculate body, 212 asynchrony in, 142
Lipid bilayer Medial lemniscus, 215, 216 attenuation of, 3
in neuronal membrane, 72 lesion of, 216 comparison with alpha rhythm,
Lipids Medial malleous, 268 104-106
in neuronal membrane, 69 Median nerve, 268 definition of, 104
Living tissue abnormal SSEp, 216 lateralized differences in, 142
electrical characteristics of, 1, 15 normal SSEP, 216 location of, 104
Load resistor site for electrical stimulation of, 215 resemblance of breach rhvthm to, 179
in vacuum tube circuit, 22 SSEP to stimulation of, 216 response of to activity of the motor
Localization in EEG, 84-93 Medulla, 215, 216 system, 107
active ear, 88 Medulla oblongata, 262, 267 Muscle spike artifact
importance of differential amplifier, Membrane potential, 68 in the EEG, 278
85 fluctuations in and the EEG, 72-73 Myelin sheath
in bipolar recording, 86-89, Metabolic encephalopathies function of, 68
91-92 EEG findings in, 249-250
in referential recording, 91 Metal-electrolyte interface, 46, 47, 51 N
principles of, 86-89 Metrazole, 202 Narcolepsy, 124, 143, 248
theorv of, 85 Microshock and the multiple sleep latency test,
Localiz~d activity dangers of, 54 248
definition of, 96 definition of, 54 Nasion
Localizing patterns Midbrain, 212, 262, 267 location of, 271
commonly seen examples, 91, 92 Migraine use of in 10-20 System of electrode
with contaminated contralateral or EEG in, 251 placement, 78
ipsilaterial ear as reference, Mirror focus Nasopharyngeal electrode(s), 6, 157,
92 definition of, 202 265, 282
Locked-in syndrome, 249 Monaural stimulation artifacts from in the EEG, 280
Locus ceruleus masking of contralateral ear, 213 Needle electrodes, 282
lesions of, 267 Monophasic wave Nernst, W, 70
Low-frequency filter(s), 7-8, 29, 30-31, definition of, 95 Nernst equation
43 Monorhythmic application of, 70
and sweating artifacts, 279 definition of, 95 formulas for, 70
asymptote plot of response of, 31 Montage(s) Nernst potential
circuit for, 30 bipolar see equilibrium potential
cutoff frequency of, 31 see bipolar montages, 81 Nervous system
frequency response of, 31 commonly-used referential, 81 subdivisions, 262
impedance of, 30 commonly-used types, 81-82 Neuroanatomy, 262-268
Low-pass filter(s), 7-8 coronal, 81 Neurologic disorders
Lumbosacral plexus, 215 definition of, 6, 79 techniques for diagnosis of, 243
"double banana;' 81 averaged evoked potentials,
M guidelines for, 79 211-212,214,216-217,243,
Macroshock longitudinal bipolar, 81 244
definition of, 54 referential brain electrical activity mapping,
Macula, 210 see referential montage(s) 222-237,243,244
298 Index

Neurologic disorders (cont.) Notch filter(s), 8, 29, 34 Parietal lobe

computerized tomography (Cf), definition of, 34 location of, 264
243-244 frequency response of, 35 Paroxysmal activity
magnetic resonance imaging definition of, 95, 151
(MRI), 243, 244 o Paroxysmal epileptogenic abnormalities,
neurosonography, 243, 244 Occipital intermittent rhythmic delta 151-181
positron emission tomography activity (OIRDA), 145-146 Partial complex status epilepticus, 248
(PET), 243, 244 in aqueduct stenosis, 146 Partial (focal) epilepsy, 247-248
Neuron(s) in metabolic encephalopathies, 250 and newly-occurring seizures, 248
bipolar, 68 occurrence of, 145 complex partial seizures, 247
communication between, 71 Occipital lobe focal motor seizures, 248
definition of, 68 location of, 264 in childhood, 247-248
function of, 71 medial portion of, 265 Rolandic epilepsy, 247-248
multipolar, 68 Offner, E, 24 role of EEC in, 247-248
parts of, 68-69 Ohm, G.S., 12 simple partial seizures, 247
relay neurons, 68 Ohm(s) symptoms of, 247
role of different types of in genera- as a measure of electrical resistance, Patient safety
tion of the EEC, 73 12 EEC technician's role in, 58
structure of, 68, 69 Ohm's law, 16-17,30,58 Pattern-reversal stimuli
three types of in cerebral cortex, 73 and grounding problems, 59 parameters of, 210
unipolar, 68 application of, 52 luminance, 210
varieties of, 68 application of in voltage divider, 26 pattern-reversal rate, 210
Neuronal membrane application to vacuum tube circuit, visual angle, 210
abnormalities of and epileptiform 22 technique of, 210
activity, 152-153 computational formula, 13 Penis)
definition of, 68 definition, 13 clearing of blockage, 39-40
depolarization of, 71 in circuits containing impedance, 18 clogging of, 39
equivalent circuit of, 72 use of, 49 construction of, 38
functions of, 69 use of in analysis of R-C circuit, 20 replacement of, 40
hyperpolarization of, 71 use of in analysis of series circuit, 14 skipping of, 40
permeability of, 69 OIRDA Penmotor(s), 8-9
polarization of, 69 see occipital intermittent rhythmic construction of, 38
repolarization of, 71 delta activitv frequency response of, 37-38
voltage regulated channels within, Olivary nucleus (s~perior olivary function of, 37
69 nucleus),212 operation of, 37-38
Neurophysiology, 68-76 Omni-Prep@, 49 Pen mounts, 38
Neurosonography,244 Optic chiasm, 210 Pen pressure
theory of operation, 244 Optic nerve, 210 adjustment of, 38
uses of, 244 Optic nerve demyelination measurement of, 38
Neurotransmitters in multiple sclerosis patients and Periodic activity
acetylcholine, 72 YEP abnormalities, 212 definition of, 95
excitatorv, 72 Optic nerve lesions Periodic Lateralized Epileptiform Dis-
Cama-a~inobutyric acid (CABA), 72 visual evoked potentials in, 211 charges (PLEDS), 251
inhibitory, 72 Optic neuropathies characteristics of, 188
Nodes of Ranvier, 68 visual evoked potentials in, 212 in glioma, 189
Noise Optic radiation, 210 in infarcts, 188
as random voltage fluctuation, 26 Organ of Corti, 212 in infectious encephalopathies, 188
externally generated, 45 Organic anions Periodic paroxysmal patterns
in amplifiers, 26-27 and the concentration gradient, 69 general, 181-187
in EEC machines, 45 Out-of-phase signal in Herpes simplex encephalitis, 183
internally generated, 45 definition of, 25 in Jakob-Creutzfeldt disease,
maximum recommended levels in Oval window, 212 181-182
EEC amplifiers, 26 in SSPE, 181
sources of in EEC machines, 26-27 p lateralized, 188-189
Noise level, 42 Pacemaker PLEDS, 188-189
assessment of, 45 concept of as source of EEC rhyth- suppression burst pattern, 184-185
standards for in EEC, 45 micity,74 triphasic waves, 186-187
Noncephalic reference electrode(s), 80 Palmaris longus, 268 Peripheral nerves
Non-convulsive status epilepticus Paradoxical alpha anatomv of, 215
(NCSE), 246, 248, 249 see paradoxical effect Peripheral nervous system, 268
Normal pressure hydrocephalis, 251 Paradoxical effect Peroneal nerve
Normal somatosensory evoked poten- definition of, 99 site for electrical stimulation of, 215
tial,216 example of, 101 Petit mal variant, 165,246
Normal visual evoked potential, 211 Parallel circuits, 13-14 Phantom spike and wave, 152
Index 299

Phantom spike and wave discharge Polymorphic delta activity (PDA), 3, Power supply voltages
see 6 Hz spike and wave, 179 251, 252 measurement of, 67
Pharmacological activation and localization of lesions, 149 Preauricular point(s)
barbiturates, 202 characteristics of, 148-149 location of. 271
Bemegride, 202 definition of, 148 use of in 10-20 System of electrode
Brevital, 202 focal, 149-151 placement. 78
drugs used to induce epileptiform genesis of, 149 Precalibration (precal). 9
activity, 202 in focal lesions of subcortical white definition of. 45
Metrazole, 202 matter, 251 Presenile dementia
Thiopental, 202 in glioma, 149-150 case of. 226, 231-232
Phase reversal Polyphasic wave use of brain electrical activity map-
definition of, 87-88 definition of, 95 ping in, 226
interpretation of, 90-91 Polyrhythmic Primary generalized epilepsy. 246-247
types of, 90 definition of, 95 Projected rhythm, 147
Phencvclidine intoxication Polysomnography, 40, 129,248 Protein pores
gen~ralized periodic complexes in, use of in documenting sleep apnea, in neuronal membrane. 69
183 248 Protons, 11
Phenylketonuria, 246 Polyspike(s), 152, 164, 166-167 Pseudodementia. 250
Photic driving characteristics of, 152 Pseudoepileptiform abnormalities.
abnormal, 197-200 Pons, 212, 262, 267 177-181
and unilateral destructive structural Popliteal fossa, 215 Pseudotumor cerebri
lesions, 197 Positive OCCipital sharp transients of EEC in. 251
and unilateral irritative lesions, sleep (POSTS), 111, 117 Psychogenic coma
197 characteristics of, 120 EEC pattern in. 249
at flash rate of stroboscope, 195 definition of, 120 Psychogenic stupor. 249
at sub-harmonics of flash rate, 196 distribution of, 120 Psychomotor variant. 180
definition of, 194 illustrations of, 117, 118, 1'20, 121 Pulse artifact
normal,194-196 Positive Rolandic spikes in the EEC, 280
Photic stimulation, 96 in infant intraventricular hemorrhage, Purkinje cell
photomyogenic response to, 250 152 definition of. 68
photoparoxysmal response to, 250 Positive spikes, 152, 178 Push-pull amplifier, 24
Photic stimulator Positron emission tomography (PET Pyramidal neurons. 73
see stroboscope scan), 244
Photoconvulsive response as a measure of cerebral glucose
see photoparoxysmal response metabolism, 244 Q
Quantified electroencephalography
Photoelectric electrode artifacts, theory of operation, 244
precautions necessary in. 224-226
200-201 use of in studies of neurological dis-
Photomyogenic response orders, 244
clinical significance of, 199 Postcalibration (postcal), 9 R
contrasted with photoparoxysmal definition of, 45 Raphe nuclei
response, 198-199 Posterior cranial fossa, 262, 267 lesions of, 267
definition of, 198 contents of, 267 Rapid eye movement (REM) sleep, 267
features of, 198 Posterior-dominant rhvthm, 3, 99-103 Rarefaction click
Photoparoxysmal response in children, 124-125 definition of. 213
clinical significance of, 199-200 Posterior slow waves of youth R-C circuit
compared with photomyogenic characteristics of, 126 impedance of, 29
response, 198-200 definition of, 126 Recording electrode(s), 46-53
definition of, 199 distribution of, 126 see also e1ectrode(s)
features of, 199 Postictal slowing, 247 Rectilinear recording. 38
in diffuse encephalopathies, 200 POSTS Reference electrode(s)
in drug and alcohol withdrawal, see positive OCCipital sharp transients average potential reference. 80-81
200 of sleep disadvantages of using ear as. 79-80
in patients with absence seizures, Post-traumatic epilepsy, 252 extracerebral electrodes as. 80
200-201 Potassium channels noncephalic electrode as, 80
Plexus(es), 268 in neuronal membrane, 71 selection of. 79-81
brachial, 268 Potential difference use of ear as. 79
lumbosacral, 268 definition. 12 use of linked ears as. 80
Pneumoencephalogram, 243 Power Referential montage(s), 79-81
Polarity, 84-93 definition of. 6 advantages of. 79
determination of in EEC recording, Power amplifier. 6 and common reference electrodes,
89-90 Power spectral analysis, 3-5 79
problems of, 8,5-86 Power spectrum(s). 4 and localization of discharges. 79
Polarization Power supply. 9 definition of, 79
of electrodes, 47 function of. 9 disadvantages of. 79-80
300 Index

Referential recording, 79-82 Scala media, 212 Sharp wave

and amplitude comparisons between Scalp edema, 136,251 characteristics of, 151-152
the hemispheres, 91 Scrubbing definition of, 95, 151
definition of, 91 in electrode application, 49 epileptogenicity of, 152
localization in, 91 Secondary bilateral synchrony, 176 Sharp wave discharges, 151-152
Reformatting montages, 82 clues to detection of, 176 Shielded rooms
Relative polarity EEG pattern in, 176 use of to screen out 60 Hz fields, 57
definition of, 86 Sedation Signal averaging
REM sleep, 124, 143 use of in EEG practice, 202 instrumentation for, 206-207
distinguishing features of, 124 Seizure(s) principle of, 204
Renal disorders absence (petit mal), 246-247 sampling rate, 204
EEG in, 249, 250 akinetic, 169 use of digital computers in, 204
Report of the Committee on Infectious e1ectrographic, 173-175 use of to enhance evoked electrical
Diseases of the American EEG febrile, 246 activity, 204
Society, 282 focal, 173-175 Signal averaging system(s)
Residual potential(s) and postictal slowing, 173-179 artifact rejection feature, 208-209
definition of, 48 characteristics of, 173 comparison of different types,
elimination or reduction of, 48 generalized tonic-clonic, 170, 247 206-207
factors responsible for, 48 grand mal, 170, 247 component-type
Resistance, 14-20 infantile spasms, 246 software-controlled averager,
definition of, 12 tonic-clonic (grand mal), 170, 247 206-207
measurement of, 12 Seizure disorders computer controlled high-speed
Resistor( s) use of EEG in the evaluation of, 245 printers, 207
connected in parallel, 13-14 Seizure-like phenomena, 245 display methods, 207
connected in series, 13-14 Seizure monitoring, 218-220 hard-copy methods, 207
transient response of, 15-16 disadvantages of, 220 hard-wired
Respiration artifact electrode application, 219 fixed-program averager, 206
in the EEG, 278 electrodes used in, 219 printers, 207
Resting membrane potential (RMP) importance of EEG technician's role types of, 206
definition of, 69 in, 220 x-v plotters, 207
maintenance of, 70-71 instrumentation used in, 218 Signal-to-noise ratio
normal value of, 69 interpretation of data, 220 as a factor in the detection of evoked
preservation of by sodium-potassium synchronizing analog data with video brain electrical activity, 204
pump, 71 data, 219-220 definition of, 204
Retina, 210 techniques employed in, 218-219 ways of increasing, 203-204
Retrochiasmal lesions time synchronization of data, Significance probability mapping
visual evoked potentials in, 211 219-220 (SPM), 223-224, 230
Reye's syndrome, 178, 250 use of split-half TV screen, 218 application of, 226, 227, 232-233
Rhythmic activity use of video cassette recorder in, 218 development of method of, 223-224
classification of, 95 Seizure monitoring systems limitations of, 225
Rhythmic midtemporal theta of drowsi- alarm button, 219 use of, 223
ness (RMTD), 180 analog tape recorder in, 219 use of in delineation of regional
Rhythmic temporal bursts of drowsi- basic components of, 218 abnormalities, 223, 230
ness, 180 cable telemetrv, 219 use of Student's t-test in, 223-224, 230
Rise time identifying tim'e of seizure during Z transform, 223, 230
and chart speed differences, 44 recording, 219 Simple partial seizures, 247
Rolandic epilepsy, 247-248 operation of, 219 Single-ended amplifier
benign of childhood, 154 patient hook-ups, 218-219 definition of, 23
clinical manifestations of, 247 cable telemetry, 219 problems with artifacts, 23-24
EEG pattern in, 247-248 using an EEG machine, 218-219 problems with in EEG work, 23-24
Rolandic fissure, 263-264 wireless telemetry, 219 Six Hz spike and wave, 179
and placement of electrodes for using a standard EEG machine, characteristics of, 179
SSEP, 264 218-219 distribution of, 179
Rolandic spikes, 154-156 varieties of, 218-219 incidence of, 179
in benign Rolandic epilepsy of child- video cassette recorder, 218 potential of for epileptogenicity, 179
hood, 154-155 video cassette recorders in, 219 significance of, 179
in patient with old infarct, 156 wireless telemetry, 219 Six Hz spike and wave discharge, 152
Rolando, L., 264 Semiconductor Sixty-Hz filter(s)
definition of, 23 see notch filter(s), 29
S Sensitivity Skull
Salt bridge, 49, 50 of amplifiers, 26 anatomy of, 262, 263
Sampling rate Sensory homonculus, 203 hones of, 262
definition of, 204 Series circuits, 13-14 Skull bones
effect of on average evoked potential, Series R-C circuit topographic relationship to underly-
204 transient response of, 16-17 ing brain areas, 262
Index 301

Skull defect, 179 Snellen chart, 211 tibial nerve stimulation, 215
Sleep Sodium channels ulnar nerve stimulation, 215
abnormal EEG patterns in, 143-144 in neuronal membrane, 71 Somatosensory-evoked response, 224
as an activation procedure, 201 Sodium hypochlorite see also somatosensory evoked poten-
augmenting effects of on epileptiform use of in disinfecting EEG elec- tial( s)
EEG discharges, 201-202 trodes, 282 Somatosensory pathways, 267
disorders of, 248 Sodium-potassium pump, 71 anatomyof,215
EEG features of benign Rolandic Somatosensory evoked potential(s) Somatosensory system
epilepsy during, 201 (SSEP), 71, 214-217, 224, 267 topographic features of, 203
REM, 124 abnormal waveforms, 216-217 Spatial summation
Stage 1,111-113 median nerve stimulation, 216 definition of, 72
Stage II, 114-120 tibial nerve stimulation, 217 Special Report on Infection Control for
Stage III, 120, 122 anatomical basis of, 215 Patients with AIDS, 282
Stage IV, 123 and detection of subclinical demye- Spectra data
Sleep apnea syndrome, 248 linating lesions, 217 analysis of, 223, 230
Sleep deprivation and needle stimulating electrodes, Spectral analysis, 3-5
as an activation procedure, 202 215 Sphenoidal electrode, 157, 248, 265
augmenting effects of on epileptiform and surface stimulating electrodes, Spike(s)
EEG discharges, 202 215 anterior temporal, 157-158
technique followed in EEG practice, clinical correlates of, 217 central and midtemporal, 247
202 commonly tested nerves, 215 centroparietal, 154
use of in EEG practice, 202 electrical stimulation of nerve fibers, characteristics of, 151
Sleep disorders, 248 215 confusion of with beta and muscle
Sleep recording in determination of brain death, 217 activity, 109, 151
in patients with seizure disorders, in head trauma, 217 confusion with ECG artifact, 152-153
201-202 in lesions of brachial plexuses, 217 confusion with normal transients, 152
use of sedation, 202 in lesions of lumbosacral plexuses, definition of, 95, 151
Sleep spindle(s) 217 detection of, 152-153
amplitude asymmetry of, 143 in multiple sclerosis, 217 effects of high frequency filter on,
and skull defects, 143-144 in spinal cord lesions, 217 109,151
and Stage II sleep, 118-119 in spinal surgery, 217 frontal lobe, 158
and Stage III sleep, 122 location of stimulating electrodes, identification of, 151-153
characteristics of, 118-119 215 inferior frontal, 157-158
characteristics of in adults, 118 median nerve localization of, 86-92, 152-153
characteristics of in children, 130 abnormal waveform, 216 location of and correlation with sei-
definition of, 118 cortical response, 216 zure disorder, 152
distribution of, 118 normal waveform, 216 mesiotemporal, 157
in children, 130 origin of components of, 216 method of distinguishing from elec-
in Stage III sleep, 122 median nerve stimulation, 215 trode artifact, 152-153
suppression of, 251 normal waveforms, 216 midline, 160-161
Sleep spindle activity median nerve, 216 confusion with vertex waves, 152
asymmetry of, 35 tibial nerve, 216-217 resemblance to vertex waves, 160
Slow activity pathways for in the spinal cord, brain multifocal, 162
abnormal, 144-151 stem, and brain, 215 occipital, 159
focal and lateralized intermittent, peroneal nerve stimulation, 215 problems of identification, 159
147-151 recording parameters of, 215-216 occipital and parieto-occipital, 248
causes of, 147 analysis time, 216 polarity of in the EEG, 90
in subcortical infarct, 148 electrode placement, 215-216 positive, 152, 178
in temporal lobe glioma, 147 epoch duration, 216 Rolandic, 154-156
generalized and persistent filter settings, 216 small sharp, 177
in viral encephalitis, 149 montages, 215-216 Sylvian, 154
generalized intermittent, 145-147 number of trials, 216 Spike and wave complex(es), 152, 158,
FIRDA, 145-146 recording site for median nerve SSEP, 163-166, 169, 172
OIRDA, 145-146 264 characteristics of, 152
normal, 144 recording site for tibial nerve SSEp, forms of, 152
persistent, 148-151 264 Spike discharges, 151-162
monomorphic rhythmic, 148 stimulus parameters of, 215 Spike generation
polymorphic arrhythmic, 148 stimulus duration, 215 pathophysiology of, 152-153
polymorphic delta activity (PDA), stimulus intensity, 215 Spinal cord, 267
148-151 stimulus rate, 215 central canal, 267
Slow-wave sleep, 120 tibial nerve gray matter, 267
Small sharp spike(s) (SSS), 152, 158, 177 abnormal waveform, 217 location of, 267
characteristics of, 177 cortical response, 216 structures of, 267
distribution of, 177 lumbar potential, 216 tracts of, 267
resemblance to muscle spikes, 177 normal waveform, 217 white matter, 267
302 Index

Spinal cord lesions technique of, 204 Temporal summation

SSEP in, 217 use of in radar systems, 204 definition of, 72
Spinal gray matter, 267 use of to detect evoked potentials in Tentorium, 262, 263
Spinal surgery noisy background, 204-205 Tentorium cerebelli, 262, 263
SSEP in, 217 Suppression Ten-Twenty International System, 5, 6,
Spindle neurons, 73 definition of, 95 264, 265
Stage I sleep, 111-113 Suppression burst pattern, 184-185 commonly-used additions to, 82
Stage II sleep characteristics of, 184 definition of electrode placements,
features of in adults, 113-121 in post-anoxic tracings, 184 271
features of in children, 130-131 significance of, 184 development of, 77
Stage III sleep, 121-122 Supratentorial compartment, 262 electrode locations in, 78-79
delta activity in, 122 Supratentorial tumor, 251 extension of, 82
sleep spindles in, 122 Swallowing artifact in evoked potential recording, 207
Stage IV sleep, 123 in the EEG, 277 landmarks used for placing elec-
Stapes, 212 Sweating artifact trodes,271
Steady-state response in the EEG, 279 location of ground electrode, 273
definition of, 15 Switch contact( s) location of scalp electrodes, 272
Stellate neurons, 73 cleaning of, 66 relationship of to cerebral cortical
Step function Switches areas, 79
definition of, 15 "soft touch;' 67 skull landmarks of, 78
Stimulus intensitv "touch-screen;' 67 step-by-step procedure for techni-
scales for defi~ing, 213 Sylvian epilepsy, 247 cians, 271-273
Stimulus intensity scales Sylvian fissure, 263, 264 steps to correctly locate positions of
hearing level (HL), 213 Sylvian seizure syndrome scalp electrodes, 271-273
sensation level (SL), 213 case of, 227 Ten-Twenty System
Stimulus repetition rate use of brain electrical activity map- see Ten-Twenty International System
and control of 60 Hz artifact, 208 ping in, 227, 234-235 Thalamic neurons
factors determining selection of, 209 Sylvian spike(s), 154 and EEG waveform rhythmicity, 266
Stray capacitance, 56 Symmetry Thalamic pacemaker
Stroboscope definition of, 96 concept of, 74, 76
description of, 194 Synapse(s) Thalamocortical fibers, 215
use of in photic stimulation, 194 abnormalities of and epileptiform Thalamus, 215
Sturge-Weber syndrome, 143 activity, 153 anatomy of, 266
Subacute sclerosing pan encephalitis definition of, 71 functio~ of, 266
(SSPE) Synaptic potentials, 71-72 role of in etiology of the EEG, 74,
EEG abnormalities in, 250 as fluctuations.in membrane poten- 76
EEG features of, 181 tial, 72-73 stimulation of, 266
value·of EEG in diagnosis of, 181 as source of EEG waveforms, 73 topographic relationship to cerebral
Subarachnoid hemorrhage, 251 duration of, 73, 74 cortex, 266
and cr scan, 243 Synaptic terminals Theta activity, 3-4, 95
Subclinical electroencephalographic formation of, 68 definition of, 110
discharge of adults (SEDA), 180 Synaptic transmission, 71-72 distinction between normal and
characteristics of, 180 Svnchrony abnormal, 144
occurrence of, 180 , definiti~n of, 96 in coma, 249
Subdur.al hematoona, 136,251 .sy.ncope, 245 in drowsiness, 111-112
and cr scan, 243 in Stage I sleep, 111-112
aOO sleep spindles, 143 T in waking record, 110
Substitution Tarchanoff effect, 98 Theta band, 3-4
pitfalls of method, 61 Telemetry Thiopental
principle of in trouble§hooting, cable telemetry, 219 use of in identifying a mirror focus,
60-61 wireless telem~trv, 219 202
use of to locate source of fault in Temporallobe ' Thompson, J.J., 21
single channel of EEG machine, location of, 264 Three Hz spike and wave discharges,
60-61 Temporal lobe cortex 163
Subvigil beta, 113 and seizure-genesis, 265 asynchronous onset, 163
Sulcus Temporal lobe epilepsy characteristics of, 163
definition of, 263 case of, 227 in absence seizures, 163
Summation, 25 use of brain electrical activity map- resemblance to other EEG patterns,
definition of, 90 ping in, 232-233 163
examples of, 90 Temporal slow activity Tibial nerve, 268
in EEG recording, 89-90 characteristics of, 132-134 abnormal SSEp, 217
principles of, 90 distribution of, 132 normal SSEp, 216-217
Superimposition in old age, 132-134 site for electrical stimulation of, 215
practical methods of, 204 interpretation of, 132 SSEP to stimulation of, 216-217
Index 303

Time base Tract(s) Ventilator artifact

in an EEG tracing, 9 definition of, 267 in the EEG, 281
Time constant Tragus, 271 Ventricle(s)
check of in an EEG channel, 44 Transducer(s) lateral ventricles, 262, 263, 266,
commonly-used values of in EEG definition of, 8-9 267
machines, 44 electrical-mechanical, 8 third ventricle, 266
definition of, 17-18 examples of, 9 Ventriculogram, 243
relation of to cutoff frequency, 44 mechanical-electrical, 9 Ventriculography, 251
Time-locked alpha, 225, 228 Transient ischemic attack(s) (TIA), 245, Vertex sharp transients
Toennies, J.F., 24 251 see vertex wave( s)
Tonic-clonic (grand mal) seizures, 247 Transient response Vertex wave( s)
Topographic analysis and assessment of high-frequency abnormalities in, 143
and "14 and 6;' 228 filter, 44 and Stage II sleep, 114
and time-locked alpha, 228 contrasted with frequency response, characteristics of, 114-115
application of to clinical practice, 19 definition of, 114
227-228 definition of, 15 distribution of, 114
as a diagnostic aid in clinical diagno- in relation to size of capacitance, 16 forms of, 114-115
sis, 228 of a circuit containing a condenser, Vestibular apparatus, 212
coefficient of variation, 223 15-17 Viral hepatitis B, 282
example of using EP data, 223, 229 of a circuit containing a resistor, mode of transmission, 282
interpolation algorithms, 223 15-16 precautions in EEG recording with
mapping algorithms, 223 of a series R-C circuit, 16-17 known cases of, 282
potential errors in clinical usage of, relationship to frequency response, Visual angle
228, 235-236 43-44 formula for calculation of, 210
recommended standards and prac- Transient wave Visual cortex, 210
tices for, 238-242 definition of, 95 Visual evoked potential(s), 210-212,
skills needed in, 228 Transistor 224,225,226
steps in the evaluation of a topo- definition of, 23 abnormal
graphic study, 225-226 elements of, 22-23 clinical correlations, 212
use of in interpretation of EEG, use of in electronic amplifiers, 22-23 interocular difference in P100
223-224 Trapezoid body, 212 latency, 211
use of in interpretation of EP, Triode prolonged P100 latency, 211
223-224 definition of, 22 abnormal latency values, 211
Topographic mapping, 222 Triphasic wave(s) abnormalities in, 211-212
approaches to clinical application, characteristics of, 186 absence of
238 definition of, 95 and technical problems, 211
artifact-management skills needed in, in EEG of hepatic encephalopathy, significance of, 211
239 249 anatomical basis of: 210
devices used in, 238 in metabolic encephalopathy, 186 detedion of using technique of
familiar example of, 222 in uremic encephalopathy, 249, 250 Stlperimposition., 204-205
general laboratory requirements for, time delay in anterior-posterior distri- effect of pupil size on., 210-211
240 bution of, 186-187 effect of stimulus rate on, 210
patient management skills needed in, Troubleshooting effect of vtsual acuit¥ on, 211
239 methods of, 60-67 effect of visual angl~ on, 210
recommended standards for True phase reversal full-field stimulation, 210
analytic techniques, 241 and referentially-connected elec- half-field stimulation, 210
artifact detection and removal, 241 trodes,91 in chiasmallesions, 211
calibration in, 241 definition of, 90 in cortical blindness, 212
color displays, 241 Tuberose sclerosis, 246 in multiple sclerosis, 212
data storage, 241 in optic nerve lesions, 211
display equipment, 240-241 U in optic neuropathies, 212
electrodes, 240 Ulnar nerve, 268 in retrochiasmallesions, 211
equipment, 240-242 site for electrical stimulation of, 215 normal
interpolation methods, 242 Ultrasound, 244 interocular differences in, 211
norms, 241 Uremic encephalopathy, 249, 250 N75 latency, 211
reference electrode sites, 242 EEG in, 249, 250 peak latencies of major compo-
statistical operations, 241 nents, 211
Topographic maps, 229, 231-236 V P100 latency, 211
Topographical brain mapping, 5 Vacuum tube normal waveforms, 211
Topography analogy to valve, 22 recording parameters of, 211
definition of, 222 development of, 22 stimulus parameters of, 210-211
Tracing(s) elements of, 22 to flash stimuli, 211
curvilinear, 38 Valve indications for use of, 211
rectilinear, 38 definition of, 22 parameters of stimulus, 211
304 Index

Visual evoked potential(s) (cant.) Volume conductor(s), 84 Wicket spikes, 178

to pattern-reversal stimuli, 210 definition of, 84 characteristics of, 178
patient-related factors affecting, distribution of voltages in, 84-85, 86 incidence of, 178
210 V wave(s) occurrence of, 178
stimulus parameters affecting, see vertex waves Wilson, N.F., 80
210 Writer unit, 37-41
types of stimuli used, 210 W function of, 37
Visual evoked potential recording Walter, W. Grey, 2, 24 major units of, 37
analysis time, 211 Wave
electrode placement, 211 diphasic, 95
filter settings, 211 monophasic, 95 x
number of trials, 211 polyphasic, 95 X-Y plotter
Visual-evoked response (VER), 224, triphasic, 95 operation of, 207
225,226 Waveform replication purpose of, 207
minimizing eye blinks to flash stimu- in average evoked potential studies,
lation, 224 209 Y
see also visual evoked potential(s) Waveshape Yawn artifact
Volta, A., 1, 12 definition of, 95 in the EEG, 276
Voltage amplifier, 6 Wave trap, 64
Voltage divider use of to reduce ground noise, 64
definition of, 26 West's syndrome, 246 z
use of, 26 White matter Z transform
Voltaic pile, 48 composition of, 263 in SPM, 223, 230