Artifacts Variants and Epileptiform Activity Sanjeev V. Kothare, MD, DCH, FAAP,
Artifacts Variants and Epileptiform Activity Observed on PSG in Children Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Conflicts of Interest Artifacts Variants & Epileptiform Activity Observed on PSG in Children • National Institute of Health 1 Sanjeev V. Kothare, Kothare, MD, DCH, FAAP, FAASM Interim Medical Director Center For Pediatric Sleep Disorders Boston Children’ Children’s Hospital Associate Professor, Harvard Medical School RC1 HL099749HL099749-01 (R21) (2009(2009-12) (2010(2010-14) (2010(2010-14) 1R21 NS076859NS076859-01 (2011(2011-13) RFARFA-HLHL-0909-001 • Harvard Catalyst (2010(2010-11) Educational Goals Content • Normal developmental maturation of EEG • Recognize normal variants on the EEGs of Sleep Studies • Recognize artifacts that can mimic pathologic EEG abnormalities on Sleep Studies • Recognize seizure patterns & epileptiform • Developmental Maturation of EEG • Variants • Artifacts • Seizures & Epileptiform Activity activity on EEG of Sleep Studies Total Sleep Time & REM/Non-REM Distribution Over Ages Neonates & Infants: Normal EEG Patterns Copyright (c) 2012 Boston Children's Hospital 1 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Sanjeev V. Kothare, MD, DCH, FAAP, FAASM EEG Wave-forms From 7 Months Gestational Age to 2 Months Post-term Summary Tracé Discontinu • EEG rhythm after 20 weeks of gestation. Tracé Discontinu • Bursts of high amplitude ( (200 200V) activity interspersed with relative quiescence (amplitude 25 25V). • InterInter-burstsbursts-interval (IBI) lasts on an average 8 seconds with more synchrony before 30 weeks, then becoming more asynchronous, evolving into Tracé Tracé Alternans by 34 weeks. Tracé Discontinu Tracé Alternans: Quiet Sleep • EEG rhythm during quiet sleep starting 34 weeks. • Bursts of high amplitude ( (200 200V) activity interspersed with relative quiescence (amplitude ≥25 25V). • InterInter-burstsbursts-interval (IBI) lasts on an average 2-4 seconds with more synchrony with conceptional age (70% at 34 weeks to 100% at 40 weeks). • Evolves into mature continuous slow waves by 2 months. Trace Alternans: Quiet Sleep Prolonged Tracé Alternans Delta brushes Copyright (c) 2012 Boston Children's Hospital 2 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Central Sharp Waves in the Newborn Frequency of Sharp Transients by Conceptual Age Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Positive Sharp Waves in the Newborn Delta Brushes (ripples of prematurity) • Delta wave with superimposed burst of 8-20 Hz activity. • Occur in wakefulness & quiet sleep. • Occur in rolandic, occipital & temporal region, rare to never in frontal regions. • Develop at 34 weeks & disappear by 44 weeks of gestation. Clancy R. J Child Neurol 1989 Active Sleep Delta Brushes • Continuous record of 4-7 Hz thetatheta-delta activity of 2525-50 V amplitude (similar to wakefulness). • Neonates enter into active sleep from wakefulness. • First cycle has more delta activity of higher amplitude with frontal sharp waves. • Subsequent cycles have more theta activity of lower amplitude. Copyright (c) 2012 Boston Children's Hospital 3 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Active Sleep Frontal Sharp waves (Encoches frontales) frontales) • High amplitude (≥ (≥150 V), symmetrically occurring, of broad biphasic morphology. • Maximum at the transition from active to quiet sleep. • Appear from 34 weeks, disappear by 48 weeks. Frontal Sharp Waves: Encoches Frontales Asymmetrical (abnormal) Frontal Sharp Waves: Encoches Frontales Classification of EEG Background Activity Infancy, Childhood & Adolescence Clancy R. J Child Neurol 1989 Copyright (c) 2012 Boston Children's Hospital 4 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Evolution From Quiet Sleep (Trace) to Continuous SWS Evolution to Mature Sleep Patterns • The transition from wakefulness to nonnonREM (quiet) sleep occurs by 22-3 months. • Infants now transit from wakefulness to nonnon-REM & then REM sleep (active sleep). • Mature nonnon-REM sleep stages (N1(N1-3) occur by 44-6 months. Clancy R. J Child Neurol 1989 Sleep Architecture in Children vs Adults Spindles • Present by 6 weeks. weeks. • 1212-14 Hz in central region. • Frontal spindles are slower at 1010-12 Hz. • Duration: Duration: may be as long as 66-8 seconds in young infants, then decrease to 11-3 seconds in children, & 0.50.5-1.5 seconds in adults. • Frequency: 4-6/minute (range 11-10) • InterInter-hemispheric asynchrony is seen until 2 years, after which largely synchronous. • Indicates N2 sleep Clancy R. J Child Neurol 1989 Long Spindles During Infancy Copyright (c) 2012 Boston Children's Hospital Asynchronous Spindles 5 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Vertex waves Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Vertex Sharp Waves • Earliest forms seen at 33-4 months. • Well developed at 5 months. • Maximum at 33-4 years. • High voltage, 250 mm-second in duration, of biphasic morphology. • May occur in frequent runs. • Shifting asymmetry seen commonly, without pathological significance. K Complexes K-complex • Seen after age 5 months. • Triphasic morphology, morphology, broad field. • 500 mm-second in duration. • Followed by an overover-riding spindle like activity. • Indicates N2 sleep. Epileptic K Complex Hypnogogic Hypersynchrony • Dominant rhythm from 6 months to 5 yrs. • 2-7 Hz activity. • May be notched. • Uncommon after age 10 years (2%). Copyright (c) 2012 Boston Children's Hospital 6 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Hypnogogic Hypersynchrony Waking rhythms Voltage: • Adults: 1515-45 V. • Children: 5050-75 V, 9% >100 V. Posterior Dominant Rhythm (Hz) Age 3mo 6mo 12mo 3yr 5yr 8yr Freq (LL) 3 4 5 6 7 8 Slow Alpha Variant Neonatal Seizures Copyright (c) 2012 Boston Children's Hospital 7 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Video withheld. Video withheld. Benign Sleep Myoclonus Video withheld. Video withheld. Copyright (c) 2012 Boston Children's Hospital 8 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Rhythmic MidMid-Temporal Theta of Drowsiness (RMTD) EEG Variants • 5-7 Hz, sharply contoured, with flattened upper contour. • Unilateral, bilateral or shifting laterality. • In drowsiness. Rhythmic Mid-Temporal Theta of Drowsiness (RMTD) Wicket Waves (temporal alpha activity) Rhythmic Mid-Temporal Theta of Drowsiness (RMTD) Wicket Waves (temporal alpha activity) • Intermittent trains of arciform waveforms. • 6-11 Hz frequency. frequency. • During drowsiness & sleep. • Temporal region with shifting laterality. • 1% of adults over 30 years. Copyright (c) 2012 Boston Children's Hospital 9 Artifacts Variants and Epileptiform Activity Observed on PSG in Children 14 & 6 Spikes (Ctenoids) Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Fourteen & Six Positive Spikes • Seen in drowsiness and light sleep. • Peak incidence in midmid-adolescence. • Comb shaped, in posterior temporal rhythm. • Best seen in long (especially interinterhemispheric) interinter-electrode distance montages. Fourteen & Six Positive Spikes Benign Epileptiform Transients of Sleep Small Spikes of Sleep (BETS, SSS) Fourteen & Six Positive Spikes Benign Epileptiform Transients of Sleep Small Spikes of Sleep (BETS, SSS) • Low voltage ( ( 50 V) biphasic fast spike without a significant slow wave. • NonNon-repetitive. • Occur in light sleep in temporal leads with shifting laterality. • 2020-25% of adults. Copyright (c) 2012 Boston Children's Hospital 10 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Phantom SpikeSpike-Wave 6 Hz SpikeSpike-Wave Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Phantom Spike-Wave (6Hz Spike-Wave) • 5-6 Hz evanescent spike & wave pattern. • Adolescents & adults. • 0.50.5-1% of EEG recordings. • Two patterns FOLD: FOLD: female, occipital, low amp, drowsy. waking, high amp, anterior, male. WHAM: WHAM: 12 year old girl: FOLD Phantom Spike-Wave (6Hz Spike-Wave) Slow Rhythmic Epileptiform Discharges of Adults (SREDA) • Occurs during drowsiness. • In adults > 50 years. • Rhythmic evolving thetatheta-delta activity over posterior temporaltemporal-parietal regions. • Bilaterally synchronous or focal. • Lasts 20 seconds to a minute. 11 year old boy: WHAM Slow Rhythmic Epileptiform Discharges of Adults (SREDA) Copyright (c) 2012 Boston Children's Hospital Midline Theta Rhythm 11 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Reactive Rhythm Rhythms • 8-10 Hz rhythm of the sensorisensori-motor cortex. • 1717-19% of young adults, only 5% of children <4yrs. • Blocked by movement in opposite hand. • May be asymmetrical for prolonged periods. Reactive Rhythm Breach Rhythm • High voltage faster frequency “arciform” arciform” activity that occurs in the region of a skull defect. • Is not considered abnormal per se. • Most prominent over central or temporal regions. • Caution regarding interpreting ‘spikes’ spikes’ in same area. Breach Rhythm Posterior Slow Waves of Youth (Youth Waves; Mittens) • Superimposition of a slow wave on the background rhythm. • Maximum prevalence between 88-14yrs. • Occur in 15% of teenagers, rare after 21yrs. • Blocks with eye opening & disappears in drowsiness. • May not be synchronous or symmetrical. Copyright (c) 2012 Boston Children's Hospital 12 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Posterior Slow Waves of Youth Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Lambda Waves • Sharply contoured occipital transients, time locked to saccadic eye movements associated with looking at patterned or visually complex stimuli (scanning). • Positive polarity, bi or triphasic & triangular morphology. • Blocked by darkness, eye closure, looking at blank screen/paper. • Most prevalent at 33-12 years, declining in frequency with age. Lambda Waves Reactive Lambda waves EC Asymmetric Lambda EO Positive Occipital Sharp Transients of Sleep (POSTS) • Surface positive sharp transients, singly or in trains. • From 4yrs to 50 yrs, most common in young adults. • Are synchronous, but may be asymmetrical. Copyright (c) 2012 Boston Children's Hospital 13 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Positive Occipital Sharp Transients of Sleep Positive Occipital Sharp Transients of Sleep (POSTS) (POSTS) Patting Artifact Artifacts Patting Artifact Video withheld. Copyright (c) 2012 Boston Children's Hospital 14 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Patting Artifact Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Patting Artifact Neonatal Seizure Rocking Artifact Sobbing Artifact Hiccough Artifact Copyright (c) 2012 Boston Children's Hospital 15 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Lateral Eye Movements Unilateral Eye Blink Lateral Rectus Spikes Copyright (c) 2012 Boston Children's Hospital Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Eye Blinking Artifact Lateral Rectus Spikes Hyperekplexia 16 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Chewing Artifact Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Glossokinetic Artifact La La La Pacifier Artifact Bruxism Artifact High-frequency Ventilator Artifact Telephone Artifact Copyright (c) 2012 Boston Children's Hospital 17 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Phone Ringing Electrode-box Unplugged from Computer: Mistaken for Status Epilepticus in ICU Popping Artifact 60 Hz Artifact Pulse Artifact Respiratory Artifact Copyright (c) 2012 Boston Children's Hospital 18 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Cardio-ballistic (EKG) Artifact Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Salt Bridge Artifact Sweat Artifact Epileptiform Activity Hypsarrhythmia Copyright (c) 2012 Boston Children's Hospital Hypsarrhythmia: Tonic Seizure 19 Artifacts Variants and Epileptiform Activity Observed on PSG in Children Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Hypsarrhythmia: Burst Suppression in Sleep Hypsarrhythmia: Electro-decremental Response Centro-Temporal Spikes; BREC Video withheld. Benign Epilepsy of Childhood with Occipital Paroxysms Childhood Absence Epilepsy: 3 Hz Spike-Wave Discharges Fp1-F3 F3-C3 C3-P3 P3-O1 Fp2-F4 F4-C4 C4-P4 P4-O2 Fz-Cz Cz-Pz Fp1-F7 F7-T3 T3-T5 T5-O1 Fp2-F8 F8-T4 T4-T6 T6-O2 *Photic Sens 30 uv/mm Copyright (c) 2012 Boston Children's Hospital staring vm 20 Artifacts Variants and Epileptiform Activity Observed on PSG in Children 3 Hz Spike Wave Discharge Sanjeev V. Kothare, MD, DCH, FAAP, FAASM Slow Spike Wave Discharge PSG: 120 seconds epoch Tonic Seizure Video withheld. Continuous Generalized Spike Wave Discharges Copyright (c) 2012 Boston Children's Hospital 21 Artifacts Variants and Epileptiform Activity Observed on PSG in Children 2012 Copyright (c) 2012 Boston Children's Hospital Sanjeev V. Kothare, MD, DCH, FAAP, FAASM “The eyes do not see what the mind does not know” know” William Osler 22
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