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    Eeg Coma PDF

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    Desi Suryani Dewi

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    CHAPTER @45 Electrodiagnostic . Studies of Nervous” System Disorders: EEG, Evoked Potentials, and EMG Michael J. Aminoff ‘The electrical activity of the brain {the clectoencephalogzam (E5G)} se easly recorded from electrodes placed om the scalp. The potential difference Between pars of electrodes on the salp (bipolar dezivation) or between individual scalp elecuodes and a relatively inactive common reference point (referential derivation) is ampli- fed and displayed on a computer monitor, esciloscope, o pape. “The charactristice ofthe normal EEG depend on the patient's age and level of arousal. The shythmic activity normally recorded repr sents the postsynaptic potential of vertically oriented pyramidal Eyes open calls of the cerebral cortex and is characterized by its frequency In normal awake adults lying quietly with the eyes closed, an 8 to 13-Hie alpha shythm is seen posteriorly in the BEG, ‘mixed with a variable amount of Fos-ra race Face eneraized faster (beta) activity Gap (G13 Ho): the alpha rhythm is SPP attenuated when the eyes are opened (Hig. 045-1). During 4 drowsiness, the alpha rhythm ig also attenuated: with light FAI sleep, slower activity in the theta yay (4-7 Ha) and delta (<4 He) ranges ‘becomes more conspicuous road Digital syteme are now widely OT-AT used for recording the EEG. aaa “They allow the BEG to be recon: structed and displayed with any desired format and manipulated PAZ for more detailed analysis, and o2-A2 also permit computerized tech-—g rigues to be used to detect certain abnormalities. Acivating proce: dures are generally undertaken hile the EEG is recorded in an attempt to provoke abnormal ties. Such procedures commonly include hyperventilation (lor 3 or 4 min), photic stimulation, sleep, and seep deprivation on the night prior to the recording Figure 045-1 828 ee inter F264 Hlectroencephalography is relatively inexpensive and may aid clinical management in several diferent contexts INTHE EEG AND EPILEPSY ‘The BEG is most useful in evaluating patients with suspected epilepsy. The presence of electrographic seizure activty—ie, of abnormal, repetitive, shyzhmic activity having an abrupt onset and termination and a characteristic evlution—clearly establishes the ‘diagnosis. The absence of such clectocerebral accompaniment ‘dors not exclude a seizure disorder, however, because there may be ho change inthe sealp-recorded EEG during certain focal seizures. ‘With generalized tonic-clonic seizure, the BEG i alwaye abnormal during the episode. It is often not possible to obtain an EEG during clinical events that may represent seizures, especially when such ‘events occur unpredictably or infrequently. Continuous monitoring {or prolonged periods in video-EEG telemetry units has made it cssier to capture the clectrocerebral accompaniments of euch ‘linical episodes, Monitoring by these means is sometimes helpfal ‘in confirming thal seinures are occuzting, characterizing the nature of clinically equivocal episodes, and determining the frequency of epileptic events, ‘The BEG findings may also be helpfal in the interictal period by showing certain abnormalities that are strongly supportive of diagnosis of eplepey. Such spileptiform activity consists of burst fof abnormal discharges containing spikes or sharp waves, The presence of epileptiform activity ie not speci for epilepsy, but it Fees yA poy apa Vn ye Paar I yy Mh fens coe Yay \ Ay pace Vy Vi Tez ye ZTE AWD Dye > ‘A Normal EE6 showing a postrony situated 6-He apna thm that aterutes with ye ‘pening. B. Abnormal EEG shoving menuarcifuse show activity in an obtuned patent with encephas C. trogulr slow activity inthe righ central rein, on a usely slowed background na patent with 2 ight ital lora.D. Parle composes occuring anc ovr second ina paint with Creutltlakob soso. Hocsonal calibration: 1s: vertical calttion: 200 pW in A. 300 pV in ober panels. (Fem Md Amit, et tsctdlagnsisn Clea! Newoogy, 5th et. New York. Church Lingstne, 2005) nth and the folowing figure, lecrde placaments2eindcaed at helt ofeach pana ar accord with he near 10:20 stm 1 eatbe; Cerra, anal: Fp, otal pol P part temporal, octal Rigid lacarents are Indctad by ven numbers, let-sided placaments by odd urbe, and mine placement Oy Z. ‘IN Pue ‘sjenuelog peyong "933 :siepuosig WalsAg snoweN Jo salpmyg oysoUdeponveg MERE LTB) 45-1 rae: CI siopiosig a6ojaney 45-2 bar a much greater prevalence in eplepic patients than in normal individuals. However, even in an individual epulepay, the sital routine soterictal FEG may be normal up to 608% he tie. Thus, the EEG cannot establish the diagnosis of epilepsy The EEG findings have been weed in classifying seizure disor and selecting appropriate anticonvulsant medication fr individual patient (Tig. e15-2), The epizodi generalized spike-wave activity that occurs during and between seizures in patients with typical absence epilepsy contrasts with focal interictal epileptiform Aseharges or fetal paterns found in patients with focal seizures, A reco. ——~ Pso1 Face ——~ cops ee PA02 ~~ vail ath sfanlalee soz 2h A " * FPYET inne FITS meme almatn inna TRS ewan Atiarenentnt® T5-01 “warner niananininnnaront FOR enter FTE emer TATE Swern Avimal 6.02 sunaa\ amntnarrenvatannnsttty bath hemispheres. B. Bust of repetive spikes occuring wih sucdon nso the gh empaal regan ting a cecal spall harctecad by ‘ransint impairment of extemal enareness.C Genetazad 3-H soke-nave actity occuring synchronously ovr both hempheres ding an absence pt mab attack Horiztal carat: 1s; vote albaton: 400 niin ‘4.200 min B, and 780 min (Fam MY Ait, eo: lectrotagnosis in nea Newey, Sth ed. New York, Church Lingstone, 2005) These later seizures may have no corrates i the scalp-recorded EEG or may be astocisted with abnormal rhythmic activity of varlable feequency, a localized or generalized distribution, and a stereotyped paler that varies with the patient. Focal or lleralized epleptogenic lesions are important to recognize, especialy if surgi- cal treatment is contemplated, Intensive long-term monitoring of linea behavior and the EG is required for operative candidates, however, and this generally also involves recording from intra- cranially placed electrodes (which may be subdural, extradural, or intracerebral in location ‘The findings inthe routine salp-recorded EEG may indicate the prognosis of seizure disorders: In general, a normal EEG implies a better prognosis than otherwise, wherese an abnormal background tr profuse epileptiform activity suggest a poor outlook. The EEG sings are not helpfl in determining which patients with head injuries, stroke, or brain tumors will go on to develop seizures, because in such cicumutancesepilepilorm activity is commonly encountered regardless of whether seizures occur. The FEG find ings are sometimes used to determine whether anticonvulsant medication can be discontinued in epileptic patients whe have Been seinute-fte for several years, but the findings provide only general ulde to prognosis Further tizures may oceur after withdrawal of anticonvulsant medication despite a normal EEG or, conversely, may not occur despite a continuing EEG abnormality. The deci- sion to discontinue anticonvulsant medication is made on clinica rounds, and the BEG does not have a useful role in this context xcept for providing guidance when there i clinical ambiguity or the patent requires reassurance about aparticalar course of action, “The BEG has no role in the management of tonic-clonic status epilepticus except when there is clinical uncertainty whether seinures are continwing in a comatose patent. In patients treated by pentobarbital-nduced coma for refeactory status epilepticus, the FEG findings ate useful in indicating the level of anethessa and wocther seizures are occurring, Dunng status epilepticus, the BEG shows repeated electrographic seizures or continuous spike-wave discharges. In nonconvulsive status epilepticus, a disorder that ray not he recognized unless an FEG is performed, the BEG may also show continuous spke-wave activity (spike-wave stupor”) or, less commonly, repetitive electrographic seizures (focal status epilepicu). THE EEG AND COMA Inpatients with an altered mental state or ome degree of obtunds- tion, the EEG tends to become slower ae consciousness i depresced, regardless ofthe underlying cause (Fg. e45-1), Other findings may also be present and may suggest diagnostic possiblities, as when clectrographic seizures are found or there ia focal abnormality indicating a structural lesion, The EEG generally slows in mets- bolic encephalopathies, and triphasic waver may be present. The findings do not permit differentiation ofthe underiying metabolic disturbance bt help to exclude other encephlopathi processes by indicating the diffuse extent of cerebral dysfunction, The response ofthe FEG to external stimulation i helpful prognostialy because clectrocercbral responsiveness implies a lighter level of coma than a nonreactive BEG, Serial records provide a better guide to prognotie than a single record and supplement the clinical examination in following the course of evens. As the depth of coma increas, the EEG becomes nonreactive and may show a burst-suppression pat- tern, with Burts of mixed-lrequency activity separated by intervale of relative cerebral inactivity. In other instances there i reduction in amplitude of the BEG unt eventeally atvty cannot be detected Such eletrocerebrl silence doesnot necessarily rellec iereversble brain damage, because st may occur in hypothermic patients of wath drug overdose, The prognosis of electzocerebrl silence, when recorded using an adequate technique, depends upon the clinical context in which it is found. In patients with severe cerebral anoxia, for example, clecrocerebral silence in a technically stiefactory record implies that useful cognitive ecovery will ot occur. In patients with clinically suspected brain death, an EEG, when recorded wsing appropriate technical standards, may be confirma- tory by shoving electrocerebal silence. However, complicating disorders that may produce a similar but reversible EEG appear ance (eg. hypothermia or drug intoxication) must be excluded The presence of residual EEG activity in suspected brain death fas to confirm the diagnosis but does not exclude i, The EEG is usually normal im patients with locked-in syndrome and helps ia thie disorder from the comatoze state with which it fused clinically. (THE EEG IN OTHER NEUROLOGIC DISORDERS In the developed countries, CT scanning and MRI have taken place of EEG as 2 noninvasive means of sereening for focal steuctural abnormalities of the brain, such as tumors, infarcts, of hematomas (Fig, 15-1). Nonetheless, the BEG ts still used for thie purpose in many parts of the world, although infratentorial oF slowly expanding lesions may fll cause any abnormalities. Focal slow-wave disturbances, a localized loss of eletzocerebral sctiv~ 4ty, oF more generalized electrocerebeal disturbances are common, findings but provide no reliable indication about the nature of the uunderiying pathology Tn patients with an acute encephalopathy, focal or laterlzed periodic slow-wave complexes, cometimes with a sharpened outline, suggest 2 diagnosis of herpes simplex encephalitis, and periodic latealzing epileptiform discharges (PLEDs) are commonly found wath acute hemtipherse pathology such asa hematoma, abscess, of rapidly expanding tumor. The EEG Sndings in dementia are usi- ally nonspecific and do not dstnguich between the diferent causee of cognitive decline except in raze instances when, for example, the presence of complexes occuring with a regular repetition rate (o-called periodic complexes) supports a diagnosis of Creutzeld- Jakob disease (Fig. 5-1) or subacute selerosing panencephalitis. most patents with dementias, the EEG is normal or difely slowed, and the EEG findings alone cannot indicate whether a patient is demented or distinguish between dementia and pseudodementia, 1m CONTINUOUS EEG MONITORING “The brief EEG obtained routinely in the laboratory often fuls to reveal abnormalities that are transient and infrequent, Continuous ‘monitoring over 12 oF 24 hours of longer may detect sbaormalites tor capture clinical events that would otherwise be missed. The EEG Isoften recorded contiswousy in cecal ill patient to detect easy changes in nestologe status, whichis parsicularly sie when the clinical examination is limited. Continuous EEG recording in th context has been uted to detect acute event such as nonconvulsive seinutes or developing cerebral ischemia, to monitor cerebral func {won inpatients with metabolic disorders such alive failure and to _manage th level of anesthesia in pharmacologicallyinduced coma lecrodes for clecrophysiologic monitoring. MEG has aso been ‘used for mapping brain tumors, identifying the central fsure pre ‘operatively, and localizing functionally eloquent coral areas such as those concerned with language IM SENSORY EVOKED POTENTIALS. ‘The noninvasive recording of spinal or cerebral potentials elicited by stimlation of specific aferent pathways isan important means ‘of monitoring the functional integrity of these pathways but does ‘not indicate the pathologic basis of lesions involving them. Such ‘evoked potentials (EPs) are so mall compared to the background EEG activity thatthe responses to a number of stimuli have to be recorded and averaged with a computer in order to permit their recognition and definition. The background EEG activity, which thas no fted temporal relationship to the stimulus, is averaged out Dy tis procedure Visual evoked potentials (VEPs) are ected by monoclar stim: Jasion with a reversing checkerboatd pater and ate recorded Som, the occipital region inthe midline and on either side of the salp. ‘The component of major clinical importance is the so-called P100 "response, a positive peak having alatency of approximately 100 ms. Ite presence, latency, and symnetry over the ta sides ofthe salp are noted, Amplitude may als be measured, but changes in sie are ‘muh less helpful fr the recognition of pathology. VEPs are most ‘useful in detecting dysfunction of the visual pathways anterior to the optic chiasm. In patients with acute severe optic neuritis, the 100 ts fequently lox or grossly attenuated: as cinieal recovery ‘occurs and visual acuity improves, the P100 is restored but with fan increased latency that generally remains abnormally prolonged. indefinitely. The VEP findings ave therefore helpful in indicating previous or subrlinical optic neuritis. They may also be abnormal swith ocslar abnormalities and with other causes of optic nerve

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