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Abnormal EEG in Infants and Children
Terence S. Edgar MD. FAAP. FAANEM.
Child Neurologist
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Disclosure
Relevant Financial Relationships
• None
Off Label Use
• None
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Learning Objectives
Review patterns of abnormal EEGs in
infants and children and potential
etiologies
Discuss epileptiform EEG patterns in
infants and children and the
accompanying seizure types
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Mild EEG Abnormalities
Immature pattern for age
Excessive multifocal sharp transients
(neonates)
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Excessive Multifocal Sharp Waves
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Significant EEG Abnormalities
Positive Rolandic Sharp Waves
(preterm)
Persistent asymmetry / asynchrony
Suppression
Epileptiform discharges
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Positive Rolandic Sharp Waves
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Intraventricular Hemorrhage
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Asymmetry of EEG in a Neonate
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Neonatal Stroke
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Suppression and Seizure Discharges
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Types of Disorders
Metabolic
Biochemical
Degenerative
Dysgenic
Inflammatory
Tumors
Trauma
Vascular
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Metabolic
Hypoglycemia
Hypocalcemia
Hyponatremia
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Hypoglycemia
Prominent hyperventilation
response
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Effect of Glucose on Hyperventilation Response
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Hypoglycemia
Prominent hyperventilation response
Slowing
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Effect of Hypoglycemia on EEG
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Hypocalcemia
Slowing
Photoparoxysmal response
Epileptiform abnormlaities
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Hypocalcemia
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Photoparoxysmal Response with Hypocalcemia
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Hyponatremia
Diffuse Slowing
Triphasic waves
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Polymorphic Delta Slowing
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Biochemical Disorders
Slowing
Epileptiform abnormalities
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Degenerative Disorders
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Diffuse Disorders
Gray matter
• Epileptiform activity
White matter
• Delta slowing
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Progressive Familial Myoclonic Epilepsy
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Metachromatic Leukodystrophy
150 μV
1 sec
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Dysgenetic Conditions
AKA Neurocutaneous Disorders
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Sturge - Weber
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Recorded Seizure in Patient with Tuberous Sclerosis
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Inflammatory Disorders
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Inflammatory Disorders
Meningitis
Encephalitis
Abscess
SSPE
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Encephalitis
Several-day Hx of fever, headache, and
progressive obtundation
150 μV
1 sec
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Recorded Sz in a Patient with Encephalitis
150 μV
1 secJerking of eyes to the right with
generalized tonic posturing
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Right Frontal Abscess
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Subacute Sclerosing Panencephalitis –(SSPE)
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Tumors
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Tumors
Greater degree of slowing than
adults
Maximum over the posterior head
regions
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Posterior Fossa Tumor with Posterior Rhythmic slowing
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Head Trauma
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Head Trauma
Slowing
Asymmetry
Epileptiform abnormalities
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Posterior Slowing After Head Trauma
1 sec
50 μV
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Severe Head Injury with Recovery
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Vascular Disorders
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Vascular Disorders
Infarcts
Hemorrhage
Vascular Malformations
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PLEDS in a Young Child Associated with Clonic Movements of the Right Arm
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Summary
Abnormal EEG. Is
this a …?
• Grey matter disorder
• White matter disorder
• Vascular disorder
• Structural disorder
• Metabolic disorder
Watch for:
• Asymmetry
• Slowing
• Suppression
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Which Type of Degenerative Disorder is More Commonly Associated with Epileptiform Activity on the EEG?
A: White Matter
B: Gray Matter
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Epileptiform Patterns
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Epileptiform Discharges
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Ictal and Interictal Discharges
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Seizure Discharges in Infnats
Subclinical electrographic discharges
Prolonged
Variable morphology
Rhythmic activity
Focal or multifocal
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Electrographic Seizure Discharge in an Infant
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Bilateral Independent Seizure Discharges in an Infant with Neonatal Seizures
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Neonatal Seizure
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Hypsarrhythmia
High amplitude poorly organized
background
Multifocal epileptiform discharges
Generalized electrodecrements
Epileptic spasms
West syndrome
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Hypsarrhythmia
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Hypsarrhythmia
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Epileptic (Infantile) Spasms
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Generalized Patterns
3 Hz spike and wave
Atypical spike and wave
Slow (2-2,5 Hz) spike and wave
Paroxysmal fast
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3 Hz Spike and Wave
Absence seizures
3 -15 yr of age
Increased with hyperventilation
Background EEG normal
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Atypical Spike and Wave
Multiple generalized seizures
Juvenile Myoclonic Epilepsy
▪ Absence 7-13 yrs (if atyp. Spw higher risk for JME)
▪ Myoclonic jerks 12-18 yrs
▪ Generalized tonic clonic sz. 13-20 yrs
3.5-6 Hz generalized spike and polyspike and
wave – faster frequency
Photoparoxysmal response
Background EEG normal
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Generalized Atypical Spike Wave
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Atypical Spike and Wave Discharges
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Slow Spike and Wave (<2 Hz)
Lennox-Gastaut Syndrome – anterior
dominant
Frequent seizures of multiple types
Mental retardation
2-6 years
Background EEG abnormal
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LGS
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Paroxysmal Fast Discharge
Trains of repetitive spikes
8-20 Hz
Tonic / Atonic seizures
Tonic stiffening / drop attacks
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Paroxysmal Fast Activity with Tonic Seizure
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Focal Epilepsy: BECTS (BRE)
Seizures usually occur out of sleep
• Tingling hand / face
• Motor speech arrest
• Excessive salivation
• Clonic movements of hand / face
• Or secondary generalized TC seizure
3-13 yrs (peak 9-10 yrs)
Dramatic activation of centro-temporal spike
and waves during sleep
90% are otherwise normal
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Centro-temporal Spikes
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Trains of Centro-temporal SPW
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Evolution to a GTC seizure
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Electrical Status Epilepticus During Slow Wave Sleep (ESES)
Nearly continuous activation that
• Began with sleep onset
• Continued throughout the night
• Resolved upon awakening
• No clinical correlate
Normal sleep patterns
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ESES
Patry: SWI 85-100%
• SWI =(minutes of SW abnormalities X 100)
TOTAL MINUTES NREM SLEEP
ILAE: “Significant activation of
epileptiform discharges in sleep”
CSWS vs LKS: potentially treatable
causes of regression in children
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Continuous Spike Wave of Sleep (CSWS)
Age of onset: variable
Global regression: language, temporo-spatial,
memory
• Language: expressive aphasia, poor lexical and
syntactic skills, comprehension spared
Behavior: hyperactivity, aggressiveness
Motor deficits:
80% present with seizures
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CSWS EEG
Awake: focal, multifocal, diffuse
epileptiform discharges
Fronto-temporal or fronto-central
predominance
Dramatic activation in sleep
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CSWS EEG
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Landau Kleffner-Syndrome (LKS)
Epileptic syndrome
Language regression: progressive acquired auditory
agnosia
Behavior: irritability, hyperkinesia, ADD, autistic-like
behavior
Epilepsy: rare, easily treated, nocturnal
Etiology: unknown, development and language is
normal prior to LKS
No abnormalities on neuroimaging
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LKS EEG
Awake: focal, multifocal, diffuse
epileptiform discharges, may be normal
Focal abnormalities, postero-temporal
Sleep: activation of discharges,
maximal centro-temporal with diffuse
spread
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LKS EEG
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Summary
3 Hz: absence seizure: CAE
Atypical SW: generalized seizure, JME
Slow SW & paroxysmal fast:
generalized seizure, LGS
Hypsarrhythmia: epileptic spasms
C-T spikes: BRE
ESES: LKS / CSWS
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What interictal pattern is most likely to be seen with Lennox Gastaut Syndrome
A: 3 Hz spike and wave
B: Slow spike and wave
C: Atypical spike and wave
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Generalized 3 Hz SW is a Typical IctalPattern During what Sz type?
Myoclonic
Generalized Tonic Clonic
Absence
Tonic
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Focal Spikes and Sharp Waves are see over which area in Benign Rolandic Epilepsy
Frontal
Centro – temporal
Parietal
Occipital
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