Electroencephalogram (2024)

Continuing Education Activity

An electroencephalogram (EEG) is an essential tool that studies the brain's electrical activity. Despite the development of more advanced imaging techniques, EEG remains an essential paraclinical tool for seizure evaluation. This activity represents an overview of the electroencephalogram (EEG) testing, including the techniques, indication, contraindication, and clinical significance. It also highlights the role of the interprofessional team in evaluating and performing EEG.

Objectives:

• Identify the indications of the electroencephalogram.

• Describe the technique of electroencephalogram.

• Outline the clinical significance of the electroencephalogram.

• Review the role of the interprofessional team in evaluating and performing electroencephalogram.

Access free multiple choice questions on this topic.

Introduction

An electroencephalogram (EEG) is anessentialtool that studies the brain's electrical activity.Despitethedevelopment of more advanced imaging techniques, EEG remains the essential paraclinical tool for seizure evaluation. It is primarily used to assess seizures and conditions that may mimic seizures. It is also useful to classify seizure types, assess comatose patients in the intensive care unit, and evaluate encephalopathies, among other indications. The electrical properties of the brain were first discovered by an English scientist, Richard Caton, in 1875, and about 50 years later, the first human EEG was recorded by the German psychiatrist, Hans Berger.[1][2]

Anatomy and Physiology

The electroencephalogramrecording electrodesare placed over the scalp. They measure the absolute electrical potentials generated by the neurons of the underlying cerebral cortex. An estimated cortical area of 10 cm2 discharging synchronously is required to generate a deflection on scalp EEG.[3]The pyramidal cell bodies are mostly present in layers 3 and 5 of the cerebral cortex.[4]Following the release of neurotransmitters at the endplate, excitatory or inhibitory postsynaptic potentials (EPSP/IPSP) are generatedsecondary toneuronal depolarization (in the case of EPSP with intracellular sodium influx resulting in extracellular negativity) or hyperpolarization (in the case of IPSP intracellular negativity). The summation of EPSPs and IPSPs over a selected cortical region with synchronous discharge creates an electrical field with positive and negative ends (dipole).The dipole is typically parallel to the pyramidal cell orientation. This summation is measured by the EEG.[5][6]

The cortical neurons and the subcortical structures are systematically connectedthrough well-developed feedback linkages.[7]During the resting or relaxed state, the EEG records a sinusoidal rhythmic activitycalled the posterior dominant rhythm (PDR) that is believed to be due to oscillatory interaction between the cortex (visual cortex in this instance) and subcortical structures (thalamus).[8][9]During activation, the cortical activity desynchronizes, and the oscillatory activity is replaced with lower amplitude and faster frequency activity. In the event of a seizure, a large super-synchronous neuronal discharge is created from an abnormal brain network. EEG evaluation provides important information about the localization and the spread of such discharges.

The commonly encountered waveform frequencies in EEGs are alpha (8to 12 Hz), beta (13to 30 Hz), theta (4to 7 Hz), and delta (less than 4 Hz). The predominance of waveforms in an EEG varies based on the age and state of wakefulness of the individual. The EEG waveforms start with discontinuous backgrounds during the prenatal phase and mature to be continuous at a later age. The normal adult resting PDR of 8.5 Hz in the posterior head regions is noted after eight years of age. The slower waveforms are less during the wakeful state and dominate during later stages of sleep. There is also an anterior-to-posterior distribution of waveforms with faster frequencies present in the anterior and slower frequencies in the posterior head regions.

Other notable components/waveforms that appear during the first year of life and are useful to differentiate sleep stages are sleep spindles and K-complexes. There are also several benign EEG variants and artifacts that one should learn in order to avoid reporting a false-positive test.[10]

Indications

There are several indications for an electroencephalogram.[11][12][13]A brief list of various indications includes:

1. To classify the type of seizure andlocalize the onset of seizures[14][10]

2. Sodium amobarbital or Wada test to determine the hemisphere dominance for language and memory[15]

3. Management of status epilepticus and inducing therapeutic coma[16][17][16]

4. Patients with altered mental status from various etiologies like toxic metabolic encephalopathies[18][19]

5. Encephalopathic patients with unexplained etiologies to assess the degree of encephalopathy[20]

6. Syncope or symptoms of loss of consciousness with a negative cardiac workup[21]

7. Comatose patients in the intensive care unit with impaired or persistent confusion or decreased responsiveness[22][23]

8. Prognostication after cardiac arrest[24]

9. Identify delayed ischemic changes after subarachnoid and intracranial hemorrhage[25][26]

10. Anesthetic procedures to monitor the depth of anesthesia[27]

11. Brain death determination[28][29]

Contraindications

There are no clear contraindications to performing an electroencephalogram. However, electrode placement could be challenging following a craniotomy, and in case of breaches in the skull or open wounds. The EEG should be performed after a detailed history and if there are concerns for seizures or epilepsy. Activation procedures should be omitted in individuals with certain underlying conditions. For example, hyperventilation is a relative contraindication in patients with a history ofstrokes, myocardial infarction, surgeries (transplants), acute respiratory distress syndrome, asthma, Moyamoya disease, and sickle cell anemia.[30][31]

Equipment

The basic equipmentincludes electrodes (silver/silver-chloride electrodes are the most widely used), an amplifier, and an EEG system (monitor and processor). Previously, mechanical pen and paper recording devices were used for plotting the EEG recordings (analog recording). In current clinical practice, a standard EEG system has the capacity to obtain information from at least 128 channels, with a greater than 10 kHz sampling rate from all the channels along with a 24-bit resolution at each of the amplifiers.[5]

Other important components of the electrode placement are the gel and salts that are applied to improve the scalp conductivity and thereby record waveforms. Nowadays,‘dry electrodes’ are also used that have improved and hastened scalp preparation.[32]

Personnel

The electroencephalogramis performed by the EEG technician/technologist, whois a trained professional with appropriate under-grad education and training. They undergo rigorous training and certification process. Once a study is completed, the recordings are reviewed, and a report is generated by the clinical neurophysiologist, who is typically a board-certified/eligible neurologist who undergoes additional subspecialty training in EEG/epilepsy.[33]

The EEG performancein the ICU and the epilepsy monitoring units require the participation of additional trained staff (nurses, support staff, monitor techs. and others) in order to provide proper and safe evaluation and care of all patients.[34]

Preparation

When the electroencephalogramis performed in an outpatient setting, clear instructions are provided to the patients prior to their EEG appointment. They are recommended not to use conditioners or other substancesthat mightaffect the quality ofthe recording (electrodeimpedance). The scalp is usually cleaned well to obtain proper recording with low impedance.[35]Typically, the impedance should be lower than 5 kohm. For ICU patients, several measures are typically taken to reduce the disturbances from various medical instruments, devices, and lines used. Mechanical restraints and not chemical restraints might be necessary at times and ensure a proper EEG recording.

Technique or Treatment

A routine electroencephalogramis performed in a quiet room with controllable lighting levels. The test should be performed by an EEG technician with appropriate and relevant training. The 10to 20 international system is most widely used for scalp electrodes placement.[36]Typically at least 21 electrodes are placed on an adult scalp, including a reference and ground electrodes. Once the electrodes are placed, the impedance of all electrodes should be measured and ensured that it is less than 5 kohms. Calibration should be performed prior to beginning the study. These include recording a square wave signal and biological calibration. During the recording, various activation procedures are performed in order to trigger epileptiform abnormalities and other EEG changes. Theseinclude eye-opening and closure, hyperventilation, and photic stimulation. Therecordings of drowsiness and sleep are important components of any EEG procedure. Sleep deprivation is also used as a provocative technique.[37]

The EEG channels are displayed following different montages, and each channel records the electrical potential difference between the two components (electrodes) of each channel. EEGs should be reviewed using different types of montages (mainly bipolar and referential montages)in orderto accurately isolate and localize abnormal discharges.[38]The digitalization of EEG has significantly improved the ease of reformatting and re-montaging per the electroencephalographer's requirements for interpretation purposes.[39]

Commonly used montages are:[40][41]

• Referential montages (ex. ear reference, average reference)

• Bipolar montages (longitudinal and transverse)

• Laplacian montages

Referential Montages

The channels display the potential difference between the recording/active electrode and a preselected reference (another electrode over a body area or the average of a certain number of selected electrodes).

Bipolar Montages

The channels, arranged in a longitudinal or transverse manner, display the potential difference between two contiguous electrodes.These montageseasily detect asymmetry between the two brain hemispheres.

Laplacian Montages

In this montage, the reference is a combined weighted average of the potentials surrounding a particular electrode or region of interest. It is typically useful to study or assess focal discharges that have a minimal field.[42]

Complications

Unexpected complications can occur if due diligence is not performed while screening patients before performing the activation or provocative procedures like hyperventilation in certain individuals as mentioned previously. Long-term EEG monitoring in epilepsy monitoring units and the intensive care units is associated with skin injury and appropriate care needs to be provided.[43]

Clinical Significance

Electroencephalogram is an important tool to investigate central nervous system pathologies associated with seizures and altered mental status in routine practice. It is a complementary test to the more advanced imaging studies. EEG is widely used in the evaluation of epilepsy patients, altered mental status or altered consciousness, parasomnias, encephalopathies secondary to various metabolic and toxic derangements, dementias, and strokes presenting as seizures. EEG is also useful to assess for prognostication in patients with anoxic brain injury, traumatic brain injuries, determining brain death, and drug toxicities. EEG is fundamentally a universal tool to assess any interictal brain wave activity and to better understand the underlying progress in an unresponsive or comatose individual. It is also useful to assess patients with behavioral or psychogenic spells that appear to be similar to seizures.[11][12][13]

The activation procedures help or facilitate capturing abnormal discharges that are useful to classify the areas of the brain involved in focal epilepsies or determine if the individual has a genetic or primary type of epilepsy. Long-term EEGs with video are useful to capture seizures and characterize their semiology. From a diagnostic and treatment standpoint, this information would be useful for presurgical work with curative intent if the patient's seizures tend to be medically intractable. The more invasive form of EEGs using the grid and depth electrodes isapplied to assess the brain's electrical activity from the surface of the cortex and subcortical white matter, respectively.[44][45]

Enhancing Healthcare Team Outcomes

An interprofessionalteam is essential for the management of patients who require a diagnostic electroencephalogram. A team of well-trained EEG technicians, nurses, clinical neurophysiologists, and neurologists are required to appropriately screen the patients, ensure a proper test is performed in a safe manner and interpreted correctly based on guidelines, thus facilitating the best treatment decision to be made by the treating providers.[46]The EEG interpreting physicians should be board certified and follow the guidelines provided by the appropriate clinical neurophysiology society for EEG reporting.[47][48]

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

References

1.

Haas LF. Hans Berger (1873-1941), Richard Caton (1842-1926), and electroencephalography. J Neurol Neurosurg Psychiatry. 2003 Jan;74(1):9. [PMC free article: PMC1738204] [PubMed: 12486257]

2.

Tudor M, Tudor L, Tudor KI. [Hans Berger (1873-1941)--the history of electroencephalography]. Acta Med Croatica. 2005;59(4):307-13. [PubMed: 16334737]

3.

COOPER R, WINTER AL, CROW HJ, WALTER WG. COMPARISON OF SUBCORTICAL, CORTICAL AND SCALP ACTIVITY USING CHRONICALLY INDWELLING ELECTRODES IN MAN. Electroencephalogr Clin Neurophysiol. 1965 Feb;18:217-28. [PubMed: 14255050]

4.

DeFelipe J, Fariñas I. The pyramidal neuron of the cerebral cortex: morphological and chemical characteristics of the synaptic inputs. Prog Neurobiol. 1992 Dec;39(6):563-607. [PubMed: 1410442]

5.

Biasiucci A, Franceschiello B, Murray MM. Electroencephalography. Curr Biol. 2019 Feb 04;29(3):R80-R85. [PubMed: 30721678]

6.

Kirschstein T, Köhling R. What is the source of the EEG? Clin EEG Neurosci. 2009 Jul;40(3):146-9. [PubMed: 19715175]

7.

Babiloni C, Binetti G, Cassarino A, Dal Forno G, Del Percio C, Ferreri F, Ferri R, Frisoni G, Galderisi S, Hirata K, Lanuzza B, Miniussi C, Mucci A, Nobili F, Rodriguez G, Luca Romani G, Rossini PM. Sources of cortical rhythms in adults during physiological aging: a multicentric EEG study. Hum Brain Mapp. 2006 Feb;27(2):162-72. [PMC free article: PMC6871339] [PubMed: 16108018]

8.

Goldman RI, Stern JM, Engel J, Cohen MS. Simultaneous EEG and fMRI of the alpha rhythm. Neuroreport. 2002 Dec 20;13(18):2487-92. [PMC free article: PMC3351136] [PubMed: 12499854]

9.

Sauseng P, Klimesch W, Stadler W, Schabus M, Doppelmayr M, Hanslmayr S, Gruber WR, Birbaumer N. A shift of visual spatial attention is selectively associated with human EEG alpha activity. Eur J Neurosci. 2005 Dec;22(11):2917-26. [PubMed: 16324126]

10.

Ramakrishnan S, Rayi A. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 24, 2023. EEG Localization Related Epilepsies. [PubMed: 32491577]

11.

Herman ST, Abend NS, Bleck TP, Chapman KE, Drislane FW, Emerson RG, Gerard EE, Hahn CD, Husain AM, Kaplan PW, LaRoche SM, Nuwer MR, Quigg M, Riviello JJ, Schmitt SE, Simmons LA, Tsuchida TN, Hirsch LJ., Critical Care Continuous EEG Task Force of the American Clinical Neurophysiology Society. Consensus statement on continuous EEG in critically ill adults and children, part I: indications. J Clin Neurophysiol. 2015 Apr;32(2):87-95. [PMC free article: PMC4435533] [PubMed: 25626778]

12.

Primavera A, Audenino D, Cocito L. Emergent EEG: Indications and diagnostic yield. Neurology. 2004 Mar 23;62(6):1029; author reply 1029. [PubMed: 15037727]

13.

Varelas PN, Spanaki MV, Hacein-Bey L, Hether T, Terranova B. Emergent EEG: indications and diagnostic yield. Neurology. 2003 Sep 09;61(5):702-4. [PubMed: 12963769]

14.

Modur PN, Rigdon B. Diagnostic yield of sequential routine EEG and extended outpatient video-EEG monitoring. Clin Neurophysiol. 2008 Jan;119(1):190-6. [PubMed: 18042424]

15.

Gotman J, Bouwer MS, Jones-Gotman M. Intracranial EEG study of brain structures affected by internal carotid injection of amobarbital. Neurology. 1992 Nov;42(11):2136-43. [PubMed: 1436524]

16.

Privitera M, Hoffman M, Moore JL, Jester D. EEG detection of nontonic-clonic status epilepticus in patients with altered consciousness. Epilepsy Res. 1994 Jun;18(2):155-66. [PubMed: 7957038]

17.

Claassen J, Hirsch LJ, Emerson RG, Bates JE, Thompson TB, Mayer SA. Continuous EEG monitoring and midazolam infusion for refractory nonconvulsive status epilepticus. Neurology. 2001 Sep 25;57(6):1036-42. [PubMed: 11571331]

18.

Kaplan PW, Rossetti AO. EEG patterns and imaging correlations in encephalopathy: encephalopathy part II. J Clin Neurophysiol. 2011 Jun;28(3):233-51. [PubMed: 21633250]

19.

Malhotra K, Rayi A. Gyriform Infarction in Cerebral Air Embolism: Imaging Mimicker of Status Epilepticus. Ann Indian Acad Neurol. 2017 Jul-Sep;20(3):313-315. [PMC free article: PMC5586131] [PubMed: 28904468]

20.

Kaplan PW. The EEG in metabolic encephalopathy and coma. J Clin Neurophysiol. 2004 Sep-Oct;21(5):307-18. [PubMed: 15592005]

21.

Brenner RP. Electroencephalography in syncope. J Clin Neurophysiol. 1997 May;14(3):197-209. [PubMed: 9244159]

22.

Singh J, Thakur G, Alexander J, Rayi A, Peng J, Bell W, Britton J. Predictors of Nonconvulsive Seizure and Their Effect on Short-term Outcome. J Clin Neurophysiol. 2021 May 01;38(3):221-225. [PubMed: 32141985]

23.

Sutter R, Fuhr P, Grize L, Marsch S, Rüegg S. Continuous video-EEG monitoring increases detection rate of nonconvulsive status epilepticus in the ICU. Epilepsia. 2011 Mar;52(3):453-7. [PubMed: 21204818]

24.

Sivaraju A, Gilmore EJ, Wira CR, Stevens A, Rampal N, Moeller JJ, Greer DM, Hirsch LJ, Gaspard N. Prognostication of post-cardiac arrest coma: early clinical and electroencephalographic predictors of outcome. Intensive Care Med. 2015 Jul;41(7):1264-72. [PubMed: 25940963]

25.

Vespa PM, Nuwer MR, Juhász C, Alexander M, Nenov V, Martin N, Becker DP. Early detection of vasospasm after acute subarachnoid hemorrhage using continuous EEG ICU monitoring. Electroencephalogr Clin Neurophysiol. 1997 Dec;103(6):607-15. [PubMed: 9546487]

26.

Claassen J, Hirsch LJ, Kreiter KT, Du EY, Connolly ES, Emerson RG, Mayer SA. Quantitative continuous EEG for detecting delayed cerebral ischemia in patients with poor-grade subarachnoid hemorrhage. Clin Neurophysiol. 2004 Dec;115(12):2699-710. [PubMed: 15546778]

27.

Zhang XS, Roy RJ, Jensen EW. EEG complexity as a measure of depth of anesthesia for patients. IEEE Trans Biomed Eng. 2001 Dec;48(12):1424-33. [PubMed: 11759923]

28.

Kompanje EJ, Epker JL, de Groot Y, Wijdicks EF, van der Jagt M. [Determination of brain death in organ donation: is EEG required?]. Ned Tijdschr Geneeskd. 2013;157(42):A6444. [PubMed: 24128600]

29.

Young GB, Shemie SD, Doig CJ, Teitelbaum J. Brief review: the role of ancillary tests in the neurological determination of death. Can J Anaesth. 2006 Jun;53(6):620-7. [PubMed: 16738299]

30.

Kane N, Grocott L, Kandler R, Lawrence S, Pang C. Hyperventilation during electroencephalography: safety and efficacy. Seizure. 2014 Feb;23(2):129-34. [PubMed: 24252807]

31.

Matheja P, Weckesser M, Debus O, Franzius Ch, Löttgen J, Schober O, Kurlemann G. Moyamoya syndrome: impaired hemodynamics on ECD SPECT after EEG controlled hyperventilation. Nuklearmedizin. 2002 Feb;41(1):42-6. [PubMed: 11917348]

32.

Lopez-Gordo MA, Sanchez-Morillo D, Pelayo Valle F. Dry EEG electrodes. Sensors (Basel). 2014 Jul 18;14(7):12847-70. [PMC free article: PMC4168519] [PubMed: 25046013]

33.

Herman ST, Abend NS, Bleck TP, Chapman KE, Drislane FW, Emerson RG, Gerard EE, Hahn CD, Husain AM, Kaplan PW, LaRoche SM, Nuwer MR, Quigg M, Riviello JJ, Schmitt SE, Simmons LA, Tsuchida TN, Hirsch LJ., Critical Care Continuous EEG Task Force of the American Clinical Neurophysiology Society. Consensus statement on continuous EEG in critically ill adults and children, part II: personnel, technical specifications, and clinical practice. J Clin Neurophysiol. 2015 Apr;32(2):96-108. [PMC free article: PMC4434600] [PubMed: 25626777]

34.

Shafer PO, Buelow JM, Noe K, Shinnar R, Dewar S, Levisohn PM, Dean P, Ficker D, Pugh MJ, Barkley GL. A consensus-based approach to patient safety in epilepsy monitoring units: recommendations for preferred practices. Epilepsy Behav. 2012 Nov;25(3):449-56. [PubMed: 22999858]

35.

Ferree TC, Luu P, Russell GS, Tucker DM. Scalp electrode impedance, infection risk, and EEG data quality. Clin Neurophysiol. 2001 Mar;112(3):536-44. [PubMed: 11222977]

36.

Homan RW, Herman J, Purdy P. Cerebral location of international 10-20 system electrode placement. Electroencephalogr Clin Neurophysiol. 1987 Apr;66(4):376-82. [PubMed: 2435517]

37.

Sinha SR, Sullivan L, Sabau D, San-Juan D, Dombrowski KE, Halford JJ, Hani AJ, Drislane FW, Stecker MM. American Clinical Neurophysiology Society Guideline 1: Minimum Technical Requirements for Performing Clinical Electroencephalography. J Clin Neurophysiol. 2016 Aug;33(4):303-7. [PubMed: 27482788]

38.

Foldvary N, Caruso AC, Mascha E, Perry M, Klem G, McCarthy V, Qureshi F, Dinner D. Identifying montages that best detect electrographic seizure activity during polysomnography. Sleep. 2000 Mar 15;23(2):221-9. [PubMed: 10737339]

39.

Halford JJ, Sabau D, Drislane FW, Tsuchida TN, Sinha SR. American Clinical Neurophysiology Society Guideline 4: Recording Clinical EEG on Digital Media. Neurodiagn J. 2016;56(4):261-265. [PubMed: 28436799]

40.

Acharya JN, Hani AJ, Thirumala P, Tsuchida TN. American Clinical Neurophysiology Society Guideline 3: A Proposal for Standard Montages to Be Used in Clinical EEG. Neurodiagn J. 2016;56(4):253-260. [PubMed: 28436788]

41.

Acharya JN, Hani AJ, Thirumala PD, Tsuchida TN. American Clinical Neurophysiology Society Guideline 3: A Proposal for Standard Montages to Be Used in Clinical EEG. J Clin Neurophysiol. 2016 Aug;33(4):312-6. [PubMed: 27482795]

42.

Gordon R, Rzempoluck EJ. Introduction to Laplacian montages. Am J Electroneurodiagnostic Technol. 2004 Jun;44(2):98-102. [PubMed: 15328706]

43.

Drees C, Makic MB, Case K, Mancuso MP, Hill A, Walczak P, Limon S, Biesecker K, Frey L. Skin Irritation during Video-EEG Monitoring. Neurodiagn J. 2016;56(3):139-150. [PubMed: 28436772]

44.

Behrens E, Zentner J, van Roost D, Hufnagel A, Elger CE, Schramm J. Subdural and depth electrodes in the presurgical evaluation of epilepsy. Acta Neurochir (Wien). 1994;128(1-4):84-7. [PubMed: 7847148]

45.

Wellmer J, von der Groeben F, Klarmann U, Weber C, Elger CE, Urbach H, Clusmann H, von Lehe M. Risks and benefits of invasive epilepsy surgery workup with implanted subdural and depth electrodes. Epilepsia. 2012 Aug;53(8):1322-32. [PubMed: 22708979]

46.

Tsuchida TN, Acharya JN, Halford JJ, Kuratani JD, Sinha SR, Stecker MM, Tatum WO, Drislane FW. American Clinical Neurophysiology Society: EEG Guidelines Introduction. Neurodiagn J. 2016;56(4):231-234. [PubMed: 28436786]

47.

Tatum WO, Olga S, Ochoa JG, Munger Clary H, Cheek J, Drislane F, Tsuchida TN. American Clinical Neurophysiology Society Guideline 7: Guidelines for EEG Reporting. J Clin Neurophysiol. 2016 Aug;33(4):328-32. [PubMed: 27482790]

48.

Kane N, Acharya J, Benickzy S, Caboclo L, Finnigan S, Kaplan PW, Shibasaki H, Pressler R, van Putten MJAM. A revised glossary of terms most commonly used by clinical electroencephalographers and updated proposal for the report format of the EEG findings. Revision 2017. Clin Neurophysiol Pract. 2017;2:170-185. [PMC free article: PMC6123891] [PubMed: 30214992]

Disclosure: Appaji Rayi declares no relevant financial relationships with ineligible companies.

Disclosure: Najib Murr declares no relevant financial relationships with ineligible companies.