EEG of Newborn and Infants. Ki Joong Kim MD PhD Pediatric Neurology Seoul National University Children s Hospital Seoul, Korea

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1 EEG of Newborn and Infants Ki Joong Kim MD PhD Pediatric Neurology Seoul National University Children s Hospital Seoul, Korea

2 Maturation of EEG Maturation of EEG patterns parallels brain development Anatomical and physiological development of brain Development of age-specific waking and sleep patterns Most dramatic EEG changes occur between premature age and 1 st 3 months of life EEG patterns during 1 st 6 months closely correlate with conceptual age (CA)

3 Neonatal EEG Function of actual age of brain CA = gestational age + legal (chronological) age A number of age-specific normal EEG features for only several weeks at a time Different clinical implication when seen at later ages Persistence or reappearance of patterns with immature features (dysmaturity) means cerebral dysfunction More mature EEG pattern than expected is usually due to underestimated CA

4 Neonatal montage Fp1 Fp3 Fp2 Fp4 F7 CH3 F3 Fz F4 F8 CH1 CH5 CH7 T3 C3 Cz C4 T4 CH9 CH10 CH11 CH12 T5 P3 Pz P4 T6 CH4 CH2 CH6 CH8 O1 O2

5 Developmental EEG Characteristics of premature and term baby CA (wk) Continuity of Background Activity Awake Quiet sleep Active sleep Synchrony of Background Activity Awake Quiet sleep Active sleep EEG Difference between Arousal and Sleep Appearance and Disappearance of Specific Waveforms and Patterns D D No D D D No 1. Temporal theta bursts 2. Beta-delta complexes in central region 3. Occipital very slow activity D D C No 1. Beta-delta complexes in TO region 2. Rhythmic 1.5Hz activity in frontal leads in transitional sleep 3. Temporal alpha bursts replace 4-5 Hz bursts C D C No 1. Frontal sharp transients 2. Extremely high voltage beta activity during beta-delta complexes 3. Temporal alpha bursts disappear C D C Yes 1. Continuous bioccipital delta activity with superimposed 12-15Hz activity during active sleep 2. Central beta-delta complexes disappear C C C Yes 1. Occipital beta-delta complexes decrease and disappear by 39wk 2. Trace alternant pattern (NREM sleep) Mizrahi EM et al Atlas of Neonatal EEG 2004

6 EEG change in newborn Less than 29 wks Tracé discontinu (continuously discontinuous and bilaterally synchronous) Delta brush emerge at 26 weeks weeks Greater periods of continuous activity, suppression periods les than 30 sec Frequent delta brushes, temporal theta burst pattern weeks EEG reactivity to stimulation established Periods of diffuse attenuation less than 15 sec Abundant multifocal sharp transients and delta brushes weeks Delta brushes appear less often and multifocal sharp transients less frequent Frontal sharp transients appear Tracé discontinu pattern is replaced by tracé alternant After 38 weeks Low voltage irregular (LVI) in waking and active sleep Mixed voltage (MV) pattern in waking, transitional and active sleep High voltage slow (HVS) in quiet sleep Tracé alternant (TA) in quiet sleep Fisch BJ EEG Primer 1999

7 EEG of Premature ( GA Weeks) Continuity Interhemispheric synchrony Differentiation of waking and sleeping Posterior basic alpha rhythm Slow activity (awake) Temporal theta burst Occipital theta Fast activity (awake) Low voltage Tracé alternant Spindles Vertex waves and K complexes Positive occipital sharp transients Discontinuous, long flat stretches Short bursts in synchrony Undifferentiated None Very slow high voltage bursts Present and increasing Prominent Very little beta activity Long flat stretches None None None None (tracé discontinu) Slow and fast activity in sleep REM sleep Slow activity of high voltage, little slow activity Undifferentiated Niedermeyer E Electroencephalography 1999

8 M / GA 26 wk Tracé discontinu

9 M / GA 27 wk Tracé discontinu

10 EEG of Premature (28-31 Weeks) Continuity Interhemispheric synchrony Differentiation of waking and sleeping Posterior basic alpha rhythm Slow activity (awake) Temporal theta burst Occipital theta Discontinuous Mostly asynchronous Undifferentiated None Very slow activity predominant Prominent (temporal sawtooth waves) Decreasing (tracé discontinu) Fast activity (awake) Low voltage Tracé alternant Spindles Vertex waves and K complexes Positive occipital sharp transients Slow and fast activity in sleep REM sleep Frequent ripples or brushes around 16/sec (delta brushes) Flat stretches, mainly asynchronous None None (but ripples present) None None Much slow activity, more irregular, little fast activity Undifferentiated Niedermeyer E Electroencephalography 1999

11 M / GA 28 wk Tracé discontinu

12 F / GA 29 wk Temporal theta

13 F / GA 29 wk Delta brush

14 M / GA 30 wk Ripples including delta brush

15 M / GA 31 wk Ripples

16 EEG of Premature (32-35 Weeks) Continuity Interhemispheric synchrony Differentiation of waking and sleeping Posterior basic alpha rhythm Slow activity (awake) Temporal theta burst Occipital theta Fast activity (awake) Low voltage Tracé alternant Spindles Vertex waves and K complexes Positive occipital sharp transients Slow and fast activity in sleep REM sleep Continuous in waking and REM, discontinuous in NREM Partly synchronous, especially in occipital leads Waking distinguished from sleep early in the period None Slow (delta) with occipital maximum Decreasing and disappearing Decreasing Frequent ripples or brushes (16-20/sec) Low voltage records suspect of serious cerebral pathology Present in NREM (quite) sleep None (but ripples present) None None Irregular slow activity of occipital predominance Continuous slow activity Niedermeyer E Electroencephalography 1999

17 M / GA 32 wk Discontinuity

18 M / GA 32 wk Asymmetry and asynchrony

19 M / GA 32 wk Continuity

20 F / GA 33 wk Continuity

21 F / GA 33 wk Asynchrony

22 M / GA 34 wk Status change

23 F / GA 34 wk Ripples and frontal sharp transient

24 F / GA 35 wk Continuity

25 F / GA 35 wk Trace alternant

26 EEG of Full-term Newborn (36-41 Weeks) Continuity Interhemispheric synchrony Differentiation of waking and sleeping Posterior basic alpha rhythm Slow activity (awake) Temporal theta burst Occipital theta Fast activity (awake) Low voltage Tracé alternant Spindles Vertex waves and K complexes Positive occipital sharp transients Slow and fast activity in sleep REM sleep Continuous except for tracé alternant in NREM (quiet) sleep Minor asynchronies still present Good None Slow (delta) mostly of moderate voltage Disappearing or absent Absent Decreasing ripples, sparse fast activity Very low voltage records due to serious cerebral pathology Present in NREM (quite) sleep None (but scanty ripples) None None Much delta and theta activity, continuous in REM sleep Continuous slow activity Niedermeyer E Electroencephalography 1999

27 M / GA 36 wk

28 F / GA 37 wk

29 M / GA 38 wk Tracé alternant

30 F / GA 39 wk Frontal sharp transient

31 F / GA 40 wk

32 M / GA 40 wk Anterior dysrhythmia

33 M / GA 42 wk

34 Appearance and disappearance of developmental EEG landmarks Trace Alternant Frontal Sharp Transients Temporal Alpha Bursts Occipital Dominant Alpha Rhythm Temporal Theta Bursts Vertex Transients Beta Delta Complex Sleep Spindles Conceptual Age (weeks) Mizrahi EM et al Atlas of Neonatal EEG 2004

35 F / GA 38 wk Excessive suppression in HIE

36 F / GA 38 wk Rhythmic epileptiform activity in HIE

37 F / GA 38 wk Rhythmic epileptiform activity in HIE

38 F / GA 41 wk Focal spike discharges

39 F / GA 40 wk FST vs. epileptiform spike

40 F / GA 40 wk Repetitive spike discharges

41 F / GA 40 wk Neonatal seizures

42 F / GA 40 wk Neonatal seizures

43 F / GA 40 wk Neonatal seizures

44 M / GA 33 wk Neonatal seizures

45 M / GA 33 wk Neonatal seizures

46 M / GA 33 wk Neonatal seizures

47 Early Infantile Epileptic Encephalopathy with Suppression-bursts (EIEE) Pseudoperiodical suppression-bursts pattern High amplitude bursts alternating with and nearly flat suppression phases Bursts of irregular µv high voltage slow waves mixed with spikes for 1-3 seconds Suppression phase for 3-4 seconds Burst-burst interval 5-10 seconds Appearance regardless of waking and sleep states

48 F / 1 mo Burst suppression in EIEE

49 F / 1 mo Burst suppression in EIEE

50 Normal EEG in Infancy Delta and theta equally prominent Transient asymmetries Central rhythms develop during the 1st year Posterior rhythms equivalent to alpha of older age during eye closure V waves of higher voltage and briefer than in adults (spike-like) begins at 3-4 months Spindles of more numerous and longer than later expressed at 3-4 months

51 EEG of Infancy (2-12 Months) Continuity Interhemispheric synchrony Differentiation of waking and sleeping Posterior basic alpha rhythm Slow activity (awake) Temporal theta burst Occipital theta Fast activity (awake) Low voltage Tracé alternant Spindles Vertex waves and K complexes Positive occipital sharp transients Slow and fast activity in sleep REM sleep Continuous No significant asynchrony Good Starting at 3-4 mos (4/sec) reaching about 6/sec at 12 mos Considerable None None Very moderate Uncommon, usually abnormal Disappears in 1 st (seldom 2 nd ) mo Appear after 2 nd mo (12-15/sec, sharp, shifting) Appear mainly at 5 mos, fairly large, blunt None Much diffuse /sec activity with posterior maximum REM portion decreasing Niedermeyer E Electroencephalography 1999

52 M / 1 mo

53 M / 3 mo

54 M / 5 mo Sleep spindle

55 M / 8 mo A-P gradient

56 West Syndrome (Infantile Spasms) Hypsarrhythmia Disorganized and chaotic background activity Irregular high amplitude 1-3 Hz slow waves with multifocal asynchronous spikes or sharp waves Appear during awake and light sleep states Modified or atypical hypsarrhythmia possible Electrodecremental event (EDE)

57 M / 6 mo Hypsarrhythmia in IS

58 M / 13 mo Hypsarrhythmia in IS

59 Changing EEG Patterns from SB through H to SSW Awake SB H H SSW SSW Sleep SB SB H H SSW

60 F / 2 mo Early phase of IS

61 F / 2 mo EEG progression of IS

62 Patterns of Atypical Hypsarrhythmia Asymmetrical or unilateral hypsarrhythmia Hypsarrhythmia with constant focal discharges Hypsarrhythmia comprising primary, high-voltage, bilateral asynchronous slow activity with minimal epileptiform potentials Hypsarrhythmia with partial conservation of basal rhythm and focal or generalized sharp and slow waves Hypsarrhythmia similar to suppression-bursts

63 F / 15 mo Asymmetric hypsarrhythmia

64 F / 7 mo Hypsarrhythmia with constant focal discharges

65 M / 3 mo Hypsarrhythmia with constant focal discharges

66 M / 3 mo Hypsarrhythmia with constant focal discharges

67 M / 4 yr Hypsarrhythmia with prominent fast activity HF 12Hz

68 M / 16 mo Hypsarrhythmia with rare epileptiform discharges

69 M / 7 mo Hypsarrhythmia with prominent slow activity

70 F / 4 mo Hypsarrhythmia with conservation of normal BG

71 F / 10 mo Hypsarrhythmia with normal BG due to status change

72 F / 2 mo Hypsarrhythmia like burst-suppression

73 F / 4 mo Hypsarrhythmia like burst-suppression

74 F / 10 mo Electrodecremental event (EDE)

75 F / 7 mo Ictal EEG in IS

76 EEG of Early Childhood (12-36 Months) Continuity Interhemispheric synchrony Differentiation of waking and sleeping Posterior basic alpha rhythm Slow activity (awake) Temporal theta burst Occipital theta Fast activity (awake) Low voltage Tracé alternant Spindles Vertex waves and K complexes Positive occipital sharp transients Slow and fast activity in sleep REM sleep Continuous No significant asynchrony Good Rising from 5-6/sec to 8/sec Considerable None None Mostly moderate Uncommon, usually abnormal None In 2 nd yr sharp and shifting, then symmetrical with vertex max Large, becoming more pointed Poorly defined Marked posterior maximum of slow activity Mostly slow, starting to become more desynchronized Niedermeyer E Electroencephalography 1999

77 M / 13 mo Vertex sharp transient

78 Summary Within broad normal limits of variability for age Marginal patterns should be interpreted in a prudent manner Rash link between brain and psyche do more harm Deviation from normal, immaturity or structural insult? Careful correlation with clinical status for significance

79 Thank You for Your Attention

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