EEG

Dr. Ahmed Gaber

Ass. Prof. Neurology

Ain Shams University
Electroencephalography EEG

The EEG plays an important

role in the diagnosis of
diseases that affect the
cerebral hemispheres such as:

❑ Epilepsy
❑ Stroke
❑ Tumors
❑ Infection
❑ Degenerative illnesses
❑ Delirium
❑ Psychiatric Dis
EEG Recordings

Fp2-T4

T4 -O2

Fp2-C4

C4 -O2

Fp1-T3

T3 -O1

Fp1-C3

C3 -O1

Electrodes
10-20 montage Tracing Mapping
Left frontal activity Longitudinal bipolar montage Power spectrum
 10-20 Montage
20%
20% 20%
20%
20% Cz
Cz Fz
C3 C4
Pz
Pz Fpz
20% 20%

20% 10%

Nasion T3 Oz T4
Oz

10% 10%
10% A2
Pg2 A1 A2
Inion
10%

20% Pg1 Pg2

Nasion 25% Nasion

Fp1 Fp2 Fp1 Fp2

F7 Fz F8 20% F7 F8
F3 Fz F4
25%
A1 A2 A1 A2
T3 C3 Cz C4 T4 T3 C3 Cz C4 T4
Left Right Left Right

Pz 25% P3 Pz P4
T5 T6 20% T5 T6

O1 O2 O1 O2
25%
Inion Inion
20%

10%
 Electrodes & Conductive Paste
Paste Surface Electrodes
9013S0501 Length 100cm
9015B4712 10 pcs

Conductive
Adhesive Paste 9013C0181 Length
228 g. 10 pcs
100cm
Flat Bristle
Disposable EEG Cups Diam 10mm
Nuprep

9015B4772 Flat Bristle

Skin Prepping 30pcs 9013S0511 9013S0531
Gel - 114 g. 500pcs 9013S0521 9013S0541

Needle Electrodes
Disposable Needle
9013R0312 Box of 40 pcs
Lgth 10mm D.0.3
9013P0782 Length 80cm
8 pcs
 Connections to Patient
Use Nuprep gel to prepare the skin before placing electrodes
Use Ten20 conductive and adhesive paste to fix surface electrode
Pg1 Pg2

Fp2-Ref
Nasion
Imp.
Fp1 Fp2 Fp2
X Poly
F4-Ref
Fp1 Fp2
F7
F3 Fz F4
F8
F4 1 1
F7 F3 F4 F8
Fz
A1 T3 C3 Cz C4 T4 A2
2 2 C4-Ref
A1
T3 C3 Cz C4 T4
A2
C4
P3 Pz P4
T5 T6 3 3
Left Right

O1 O2

T5
P3 Pz P4
T6
P4 P4-Ref

O1 O2

Ground
Inion

Reference Reference
Ground
Electrode impedance must be < 5 KΩ
 Montages
Pg1 Pg2 Pg1 Pg2

Bipolar Longitudinal Nasion Nasion Bipolar Transversal

For comparison of Fp1 Fp2 Fp1 Fp2
For comparison of
left-right differences F7 F3 Fz F4 F8 F7 F3 Fz F4 F8 left-right differences
A1 A2 A1 A2
T3 C3 Cz C4 T4 T3 C3 Cz C4 T4
Left Right Left Right

P3 Pz P4 P3 Pz P4
T5 T6 T5 T6

O1 O2 O1 O2

Inion Inion

Common Reference Pg1 Pg2 Pg1 Pg2 Linked Ear Reference

To estimate actual Nasion
Nasion To estimate actual
voltages Fp1 Fp2 Fp1 Fp2
voltages and analyze
F7 F3 Fz F4 F8 F7 F3 Fz F4 F8 temporobasal activities
A1 A2 A1 A2
T3 C3 Cz C4 T4 T3 C3 Cz C4 T4
Left Right
Left Right

P3 Pz P4 P3 Pz P4
T5 T6 T5 T6

O1 O2 O1 O2

Inion
Inion
EEG Interpretation

 Visual Analysis (Qualitative)

 Quantitative EEG
Amplitude Mapping
Power Spectrum & Frequency Mappin

Power Spectrum Frequency Mapping

Signals versus Montages

ipsilateral ear common average source bipolar

derivation
 Normal EEG

Left to themselves, things tend to go from bad to worse

Electroencephalogram (EEG)

 Recording of electrical activity occurring at

the surface of the brain.
 Appears as waveforms of varying frequency
and amplitude measured in voltage.
 EEG waveforms are classified according to:
 Frequency
 Amplitude Age and state of alertness are important
 Shape information that should be combined with
wave form description
 Sites on the scalp
 The frequencies most brain waves range from

Frequency Bands
are 0.5-500 Hz. However, the following
categories of frequencies are the most clinically
relevant

14

Fast Beta
waves
Beta +

Alpha 13

Alpha

Alpha 8

Theta
Theta
4

Slow
waves 3
Delta
Delta
1 sec. 0
Normality and Frequency

 Frequency (Hertz, Hz) is a key characteristic used to

define normal or abnormal EEG rhythms.
 Waves = or>7.5 Hz– N awake adult.
 Waves =or< 7 Hz --
 abnormal in awake adults
 N in children or in adults who are asleep.
 Appropriate frequency for age and state of alertness
-- abnormal ---inappropriate scalp location or
demonstrate irregularities in rhythmicity or
amplitude.
Other Parameters

 Distribution
 Rhythmicity
 Regularity
 Symmetry
 Amplitude
 Shape
 Some waves are recognized by their shape, scalp location or
distribution, and symmetry. Certain patterns are normal at specific
ages or states of alertness and sleep.
 The morphology of a wave may resemble specific shapes, such as
vertex (V) waves seen over the vertex of the scalp in stage 2 sleep
or triphasic waves that occur in the setting of various
encephalopathies.
 Alpha waves
 Alpha waves generally are seen in all age groups but are most
common in adults.
 Rhythmically on both sides of the head
 Often slightly higher in amplitude on the nondominant side,
especially in right-handed individuals.
 Posteriorly more than anteriorly and are especially prominent with
closed eyes and with relaxation.
 Alpha activity disappears normally with attention (eg, mental
arithmetic, stress, opening eyes). In most instances, it is regarded as
a normal waveform.
 An abnormal exception is alpha coma, most often caused by hypoxic-
ischemic encephalopathy of destructive processes in the pons (eg,
intracerebral hemorrhage). In alpha coma, alpha waves are
distributed uniformly both anteriorly and posteriorly in patients who
are unresponsive to stimuli.
Alpha Rhythm
Sinusoidal alpha
Eyes Open
Alpha Blocking
Hyper Ventilation
Photic Stimulation
Beta waves

 Beta waves are observed in all age groups.

 They tend to be small in amplitude and
usually are symmetric and more evident
anteriorly.
 Many drugs, such as barbiturates and
benzodiazepines, augment beta waves.
G beta
Medazolam induced beta
Tense Then Relaxes
Theta waves

 Theta waves normally are seen in sleep at

any age. In awake adults, these waves are
abnormal if they occur in excess.
 Theta and delta waves are known
collectively as slow waves.
Alpha theta
Theta
Sleep transition
Psychomotor variant
Slow Alpha Variant
Alpha variant + Beta
Delta waves

 These slow waves have a frequency of 3 Hz or less.

 They normally are seen in deep sleep in adults as
well as in infants and children.
 Delta waves are abnormal in the awake adult.
 Often, they have the largest amplitude of all waves.
 Delta waves can be focal (local pathology) or diffuse
(generalized dysfunction).
Theta Delta
Slow wave sleep
K complex

 K complex waves are large-amplitude delta frequency waves,

sometimes with a sharp apex.
 They can occur throughout the brain and usually are higher in
amplitude and more prominent in the bifrontal regions.
 Usually symmetric, they occur each time the patient is
aroused partially from sleep.
 Semiarousal often follows brief noises; with longer sounds,
repeated K complexes can occur.
 K complexes sometimes are followed by runs of generalized
rhythmic theta waves; the whole complex is termed an
arousal burst.
 V waves
 V waves are sharp waves that occur during sleep.
They are largest and most evident at the vertex
bilaterally and usually symmetrically.
 They show phase reversal at the vertex.
 V waves tend to occur especially during stage 2
sleep and may be multiple.
 Often, they occur after sleep disturbances (eg,
brief sounds) and, like K complexes, may occur
during brief semiarousals.
Abnormal Sharp waves in sleep
Sleep spindles

 Spindles are groups of waves that occur during many

sleep stages but especially in stage 2.
 They have frequencies in the upper levels of alpha or
lower levels of beta.
 Lasting for a second or less, they increase in
amplitude initially and then decrease slowly. The
waveform resembles a spindle.
 They usually are symmetric and are most obvious in
the parasagittal regions.
Lambda waves

 Lambda waves occur in the occipital regions

bilaterally as positive (upgoing) waves.
 They are triangular in shape and generally
symmetric.
 They occur in the awake patient and are said to be
most evident when the subject stares at a blank,
uniform surface.
 Lambda waves occur when reading and occasionally
when watching TV.
 Morphologically, they are similar to POSTS both in
form and in occipital distribution.
Positive occipital sharp transients
of sleep
 POSTS are triangular waves that occur in the
bilateral occipital regions as positive (upgoing)
waves.
 They can be multiple and usually are symmetric.
 POSTS occur in sleeping patients and are said to be
most evident in stage 2 of sleep, although they are
not uncommon in stage 1.
 POSTS are similar if not identical to lambda waves
both morphologically and in the occipital distribution.
Normal EEG Variants

The light at the end of the tunnel is ALWAYS a train

"electroencephalogram (EEG) variant
waves"
 They refer to waves that are rare or unusual but not
generally abnormal.
 They may be unusual in shape or in distribution.
 They include artifacts or electrical disturbances from
structures that are not in or part of the brain and do
not affect the brain or its function but appear in the
EEG tracing; and complex wave mixtures that can
appear unusual and can confuse the casual reader
(eg, wave harmonics).
Slow Alpha Variant
Alpha Variant
Slow alpha
Psychomotor variant (rhythmic harmonic
theta)
 This is an unusual form that occurs as asymmetrical runs of
theta or delta activity primarily in the temporal regions,
lasting for a few seconds or as long as 30-45 seconds
 This waveform is clearly a harmonic of 2 or more rhythms. The
waves often have a bifid appearance.
 It starts suddenly on 1 side and lasts for several seconds
before terminating suddenly. This behavior resembles a
seizure discharge, hence the name "psychomotor variant."
 Generally considered benign, this waveform does not correlate
with seizure disorder. It is best seen on a prolonged EEG and
tends to be more common in children and young people.
Mu waves - Wicket rhythm or
rhythm en arceau
 Mu waves are runs of rhythmic activity that have a specific shape.
They are rounded in one direction with a sharp side in the other
direction.
 Frequency is one half of the fast (beta) activity OR in the alpha range
frequency.
 The most classical feature of mu waveform is that it blocks with motor
activity of the contralateral body (or the thought of such movement).
 Unlike alpha activity, they are not blocked by eye opening.
 It becomes obvious when the alpha disappears (ie, alpha blocking).
 They often are asymmetric.
 Mu waves are seen best when the cortex is exposed or if bone defects
(eg, postsurgical) are present in the skull.
 They tend to be more evident over the motor cortex and in the
parasagittal (central) regions.
 They have no pathological significance
14- and 6-Hz waves

 In these waves, the 2 frequencies are

intimately intertwined and the complexes
occur in bursts.
 They generally are thought to be clinically
insignificant.
 They occur in healthy children and
adolescents. Some claim that they are best
seen in referential recordings during sleep.
Spikes and sharp waves

 These are recognized by their height, their sharp top, and

their narrow base.
 Spikes and sharp waves usually are abnormal.
 They can be normal in the following settings:
 V waves of sleep in the parasagittal regions in stage 2 sleep can be
normal.
 Small, sharp spikes of sleep or benign epileptiform transients of
sleep (BETS) are nonpathologic. They occur in the temporal
regions, often switching from side to side. They do not have slow-
following waves as do most of the pathologic spikes of epilepsy.
 Numerous artifacts resemble spikes, but they are distinguished by
other waves that may be present, by observation of the patient
while they are occurring, and by experience.
 POSTS can have a sharp contour yet be quite normal. They occur in
the occipital regions bilaterally during sleep.
Spikes & Sharp Waves
(Abnormal)
Spike

Sharp Wave
Benign epileptic transients of sleep (BETS)
Small sharp spikes of sleep (SSS)

 These sharp, usually small waves occur on one or

both sides (usually asynchronously), especially in the
temporal and frontal regions.
 BETS are rare in children but are more frequent in
adults and elderly persons.
 Although they can occur in epileptic patients, BETS
often are seen in individuals without epilepsy and
can be regarded as a probable normal variant.
6-Hz spike and wave (phantom spike and
wave)
 These occur as bursts of miniature spike and wave
complexes or runs of such complexes at 6 Hz rather
than the usual 2-4 Hz.
 Their significance is debated, but generally those
occurring in the posterior head regions are regarded
as benign.
 Seen at all ages (but especially in adults) they often
are confused with 14- and 6-Hz waves and may
merge into them.
 The anterior variety are regarded by some as
consistent with epilepsy, but further studies are
needed to confirm this.
Wicket spikes

 Wicket spikes are another waveform that is without

pathological significance.
 They are thought to be due to harmonics of 2 or more
waveforms that combine to form pseudospikes .
 Like wicket rhythm, they have rounded aspects to 1 side and
sharp points to the other, giving the appearance of spikes or
sharp waves.
 When these are especially large, they may appear similar to
pathological spikes. However, they generally can be
distinguished by their morphology and at times by their
defined background rhythms, which are harmonizing.
Subclinical rhythmic EEG discharges in
adults (SREDA)
 The typical pattern of SREDA consists of theta rhythm occurring in a
widespread manner, maximal over the parietal and posterior temporal
regions, and lasting for a few seconds to a minute without clinical signs
or symptoms. It is described as "not evolving" and appears quite stable
for its duration.
 Another unusual variant is made up of predominantly delta frequencies
as well as notched waveforms with a frontal distribution and a more
prolonged duration that even includes sleep.
 No significant clinical differences have been found between groups
that had the atypical pattern and those with the typical pattern.
 Although the mechanism of SREDA is not understood, it appears to
represent a benign EEG phenomenon that should be distinguished
from seizure discharges.
Rhythmic midline theta

 This is a focal rhythm maximal at the midline, most

prominently at Cz, which occasionally may spread to
adjacent electrodes.
 It has a frequency of 5-7 Hz and typically has an
arciform, spiky, mulike appearance.
 It waxes and wanes, can appear during wakefulness
or drowsiness, and is usually reactive to eye opening
or limb movement.
 Although initially described in association with
temporal lobe epilepsy, it probably represents a
normal variant.
ARTIFACTS

Dr. Ahmed Gaber

MD Neurology
Artifacts

 These waveforms are produced by an

electrical alteration of the recorded brain
wave due to factors outside the skull.
 Their recognition is important because they
can distort the recording of brain waves.
 Patient Artifacts
electrode
F1 Artery
ECG interferences pulses artery

F2
F2

ECG ECG

Fp1

Eye movement Fp1

Fp2

F3 Sweat
Fp2
F4
Electrodes Artifacts

Electrode movement

Defective scalp
contact

Bad connection to
electrode clip

Bad connection
to input socket
ECG and Pulse artifacts

 ECG produces small  Pulse artifacts occur with

spikes that are recurrent motion of
electrodes sitting over a
recurrent and are bounding pulse, which
especially evident in the alters the contact with
monopolar montages. the skin. This causes a
rhythmic disturbance
that is synchronous with
the heart but rounded
rather than sharp in
form.
Electrode Pops and Sweat Artifacts

 Electrode pops or  Sweating produces very

movements can produce slow waves, because the
sudden, recurrent, or salt solution shorts out
continuous electrical pairs of adjacent
waves. electrodes.
Sweating artifacts
Electrical Artifacts

 60 Hz artifacts  Electrical fields result

from electrical devices
and televisions.
Chewing artifact and Ms artifacts

 Chewing produces
spurious spike and wave
runs in the frontal and
temporal regions from
the temporalis muscles.
Eye Movement and Tongue Artifact

 Eye movements occur with blinking and result

from the electrical charge of the eye itself. They
are frontal. Nystagmus also produces artifactual
waves.
Tongue movement
Eye movement
Other Artifacts

 Tremor and movement of the head or body

may cause electrodes to move.
 ICU special waveforms may result from
respirator-induced movements, intravenous
drips and drip pumps, electrical fields, or
cautery (eg, Bovie) in the operating room or
emergency department.
Movement / Cough artifacts
Harmonics

 EEG is a complex summation of many frequencies.

 Different frequencies sometimes add to or cancel
each other, creating odd waveforms or fluctuations
of waveforms.
 Pseudospikes or pseudoslow waves may be seen
with intermixing of waves.
 Many fascinating patterns have been generated by
mixing artificially created computer-generated
frequencies. These waveforms have the significance
of the basic waveforms that underlie the patterns.
 nk s !
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