osce for DNB

1. EEG
DR MANDAR HAVAL

2. • EEG is about pattern recognition
• ECG is about precision

3. EEG – systematic approach
• Minimal technical requirements
• 16 channels
• Atleast 3 montages
• Longitudinal bipolar, horizontal bipolar, referential
• Atleast 20 min recording and in neonates 1 hour

4. International 10-20 system of Electrode
placement

5. Montages
Bipolar: the potential
difference between 2
active electrodes
Referential: potential
difference between 1
active and 1 inactive
electrode

6. EEG- what to look at?
• Background
• Activity – rhythmic, arhythmic, periodic
• Evolution of the rhythm

7. EEG- describing the waves
• Frequency :delta(0-4hz), theta(4-8hz), alpha(8-13hz), beta(>13 hz)
• Amplitude: low(<25 uv), moderate(25-75uv),
high(>75uv)
• Location
• Symmetry
• Synchrony
• Reactivity
• Rhythmic, periodic, arhythmic
• Morphology (spike, sharp, biphasic, triphasic)

8. Normal EEG in a child

9. Normal EEG in adult

11. Spike and wave complex

12. Case 1
• 10 year old girl
• Developmentally normal
• Slight deterioration in school performance last
2 months
• Multiple episodes of brief staring 5 -10 sec
• No loss of tone
• Examination normal

13. EEG

14. Absence seizure
• Onset 4-10 yrs
• Hundreds per day; 4-20 secs
• Eyes open, voluntary activity stops
• EEG – 3per sec spike wave activity. Ppt by
hyperventilation
• Drug of choice – ethosuxamide/ valproate/
lamotrigine

15. Case 2
• 5 month male
• HIE stage 2 at birth
• Clusters of sudden tonic flexion of entire body
several times in a day, especially on awakening
- 2 weeks

16. Diagnosis?

17. West syndrome
• Infantile spasms with hypsarrythmia
• EEG – chaotic
• High amplitude, multifocal spikes and
polyspikes, asynchronous, arrrhythmic
• Drugs of choice- ACTH/ steroids

18. Case 4
• 7 year old boy
• Nocturnal seizure, jerky movements of the
lips, eyes wide open, unable to sleep,
hypersalivation

20. BECTS- benign childhood epilepsy with centro-temporal
spikes (Rolandic epilepsy)
• Onset 1-14 yrs
• Unilateral facial sensorimotor seizures
• Hypersalivation
• Speech arrest
• Oropharyngeal manifestations
• Prognosis- most remit in 2-4 yrs
• Treatment- nil/ CMZ/LVT

21. Case 4
• 8 year old boy
• h/o delayed milestones – walking 2 yrs,
speech 3 years
• Multiple types of seizures several times a day
– 2 months
• Tonic seizures, atonic falls, myoclonic seizures
• Regression of milestones

22. EEG

23. EEG of Lennox Gastaut Syndrome
• Background – slow and disorganised
• Slow generalized spike wave ( < 2.5 cps)
• Multiple independent spike foci
• Very fast ( 10-20 cps) paroxysmal activity s/o
tonic seizures

24. Management of LGS
• Multiple anti epileptic drugs
• Poor response
• Non AED’s- IVIG, steroids, ketogenic diet
• Surgery – corpus callosotomy

25. Case 5
• 4 year old girl
• Fever & recurrent focal seizures – 2 days
• Comes in status epilepticus
• Seizures stop after lorazepam and phenytoin
• Patient remains comatose > 24 hours after all
motor seizures have stopped.

26. EEG

27. EEG of NCSE (non convulsive status epilepticus)
• Spikes, waves, rhythmic activity
• Focal or partial features, discrete or
continuous
• Cyclic or recurrent patterns
• May correlate with changes in behaviour and
responsiveness
• Significant improvement in discharges and
sensorium on giving IV anti epileptics

28. Case 7
• 11 year old boy
• Cognitive decline last 6 months
• Repetitive extensor myoclonus last 1 month
• Stopped walking, speaking, swallowing last 15
days
• Past h/o measles at 3 years

29. EEG

30. SSPE
• EEG: stereotyped, generalized and
synchronous high amplitude periodic
complexes
• Diagnosis: Elevated CSF anti measles
antibodies
• Prognosis: grim

55. • 8 mts old female child with delayed development milestones
flexor spasm EEG done.
• Describe characteristic EEG findings
• What is diagnosis?
• What is T/t?
• Which type having the good prognosis?
10/15/2014 CME,Pune 55

56. • Hppsarrythmia
• Infartile spasms
• ACTH and glucocorticoids
• Cryptogenic infantile spasms
10/15/2014 CME,Pune 56

57. 12.Child with fever , convulsions, altered
sensorium
CSF picture : protein 62,
cells 95 P10 L90,
sugars 45/80,
RBCs 80/ hpf
• Additional 2 investigations of choice
• Treatment with dose

58. • EEG - PLEDS-periodic lateralizing epileptiform
discharges
• HSV PCR,( ? HSV IgG, IgM ), CT scan / MRI
with contrast – bi/ uni temporal
hyperintensities
• Acyclovir 10mg/kg/dose 8 hrly for 14 -21 days

60. 6) What does this EEG show?
• What is the drug of choice?
• Prognosis?
• One OPD procedure to confirm diagnosis

61. • 3 Hz spike and wave activity in Absence
seizure – childhood /Juvenile
• Valproate, Lamotrigine, clobazam
• Good in childhood, slightly less for juvenile
• Hyperventilation

62. Jerk jerk

63. 7) Diagnosis
• Confirmatory test
• 3 therapeutic options

64. • SSPE –burst suppression pattern
• CSF measles IgG
• Ribavarine, interferons, inosiplex,
amantidine

66. 8) Diagnosis
• Commonest etiology
• Drug of choice

67. • PLEDS
• Herpes encephalitis
• Acyclovir

68. 9) 6 yr old male admitted with prolonged
generalised seizures.
• Immediate AEDs –name 2 with dose
• 2nd line AEDs –2 with dose
• 3rd line – name 2

69. • Lorazepam [0.05mg/kg],
• Diazepam [0.3mg/kg],
• midazolam[ 0.2mg/kg]
• Phenytoin[ 20mg/kg],
• phenobarb[20/kg]
• Midazolam drip,
• propofol,
• thiopentol

70. 10) 6 months old child with h/o perinatal
insult comes with regression of social
milestones and clusters of startles on
awakening .
• Diagnosis
• Name 2 investigations you will ask for?

71. • Infantile spasms, West syndrome
• EEG, MRI
• Hypsarrhythmia
• ACTH / steroids, Vigabatrin, Valproate
/Topiramate / Nitrazepam

72. • Station No : A term newborn who required resuscitation at
birth with a 5 minute APGAR of 5 is admitted in NICU. The
neonate had seizures in first 12 hrs of life
• Identify the findings-[1]
• What is the significance of this finding- [1/2]
• Name of the staging system other than Sarnat and Sarnat and
give its component- [1]

73. • EEG of neonate showing Burst Suppression
pattern
• It indicates serious outcome in HIE patients
• Levene’s staging system (Mild, Moderate and
Severe)
– Consciousness
– Tone
– Seizures
– Sucking/Respiration