Neonate EEG

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EEG of Newborn

and Infants

Ki Joong Kim MD PhD

Pediatric Neurology

Seoul National University Childrens Hospital

Seoul, Korea


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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 1st 3 months of life

EEG patterns during 1st6 months closely correlate withconceptual age (CA)


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Neonatal EEG

Function of actual age of brain CA = gestational age + legal (chronological) age

A number ofage-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


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T3 C3 Cz C4 T4

O1 O2

Pz

Fz

Fp3 Fp4

Fp1 Fp2

F3 F4 F8F7

T5 P3 P4 T6

CH1

CH2

CH3

CH4

CH5 CH7

CH6 CH8

CH9 CH10 CH11 CH12

Neonatal montage


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Developmental EEG Characteristics of premature and term baby

CA

(wk)

Continuity of

Background Activity

Synchrony of

Background ActivityEEG

Difference

between

Arousal and

Sleep

Appearance and Disappearance of

Specific Waveforms and Patterns

AwakeQuiet

sleep

Active

sleepAwake

Quiet

sleep

Active

sleep

27-28 - D D - ++++ ++++ No

29-30 D D D 0 0 0 No

1. Temporal theta bursts

2. Beta-delta complexes in central region

3. Occipital very slow activity

31-33 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

34-35 C D C +++ + +++ No

1. Frontal sharp transients

2. Extremely high voltage beta activity during

beta-delta complexes

3. Temporal alpha bursts disappear

36-37 C D C ++++ ++ ++++ Yes

1. Continuous bioccipital delta activity with

superimposed 12-15Hz activity during active

sleep

2. Central beta-delta complexes disappear

38-40 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


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Less than 29 wksTrac discontinu(continuously discontinuous and bilaterally synchronous)

Delta brush emerge at 26 weeks

29-31 weeksGreater periods of continuous activity, suppression periods les than 30 sec

Frequent delta brushes, temporal theta burst pattern

32-34 weeks

EEG reactivity to stimulation established

Periods of diffuse attenuation less than 15 sec

Abundant multifocal sharp transients and delta brushes

34-37 weeks

Delta brushes appear less often and multifocal sharp transients less frequent

Frontal sharp transients appear

Trac discontinu pattern is replaced by trac 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

Trac alternant (TA) in quiet sleep

Fisch BJ EEG Primer 1999

EEG change in newborn


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Continuity Discontinuous, long flat stretches

Interhemispheric synchrony Short bursts in synchrony

Differentiation of waking and sleeping Undifferentiated

Posterior basic alpha rhythm None

Slow activity (awake) Very slow high voltage bursts

Temporal theta burst Present and increasing

Occipital theta Prominent

Fast activity (awake) Very little beta activity

Low voltage Long flat stretches

Trac alternant None

Spindles None

Vertex waves and K complexes None

Positive occipital sharp transients None

Slow and fast activity in sleep Slow activity of high voltage, little slow activity

REM sleep Undifferentiated

EEG of Premature ( GA 24-27 Weeks)

Niedermeyer E Electroencephalography 1999

(trac discontinu)


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M / GA 26 wk Trac discontinu


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Continuity Discontinuous

Interhemispheric synchrony Mostly asynchronous

Differentiation of waking and sleeping Undifferentiated


Slow activity (awake) Very slow activity predominant

Temporal theta burst Prominent (temporal sawtooth waves)

Occipital theta Decreasing

Fast activity (awake) Frequent ripples or brushes around 16/sec (delta brushes)

Low voltage Flat stretches, mainly asynchronous

Trac alternant None

Spindles None (but ripples present)



Slow and fast activity in sleep Much slow activity, more irregular, little fast activity

REM sleep Undifferentiated

EEG of Premature (28-31 Weeks)


(trac discontinu)


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F / GA 29 wk Temporal theta


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F / GA 29 wk Delta brush


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M / GA 30 wk Ripples including delta brush


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M / GA 31 wk Ripples


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Continuity Continuous in waking and REM, discontinuous in NREM

Interhemispheric synchrony Partly synchronous, especially in occipital leads

Differentiation of waking and sleeping Waking distinguished from sleep early in the period


Slow activity (awake) Slow (delta) with occipital maximum

Temporal theta burst Decreasing and disappearing

Occipital theta Decreasing

Fast activity (awake) Frequent ripples or brushes (16-20/sec)

Low voltage Low voltage records suspect of serious cerebral pathology

Trac alternant Present in NREM (quite) sleep

Spindles None (but ripples present)



Slow and fast activity in sleep Irregular slow activity of occipital predominance

REM sleep Continuous slow activity

EEG of Premature (32-35 Weeks)



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M / GA 32 wk Discontinuity


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M / GA 32 wk Asymmetry and asynchrony


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M / GA 32 wk Continuity


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F / GA 33 wk Continuity


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F / GA 33 wk Asynchrony


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M / GA 34 wk Status change


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F / GA 34 wk Ripples and frontal sharp transient


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F / GA 35 wk Continuity


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F / GA 35 wk Trace alternant


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Continuity Continuous except for trac alternant in NREM (quiet) sleep

Interhemispheric synchrony Minor asynchronies still present

Differentiation of waking and sleeping Good


Slow activity (awake) Slow (delta) mostly of moderate voltage

Temporal theta burst Disappearing or absent

Occipital theta Absent

Fast activity (awake) Decreasing ripples, sparse fast activity

Low voltage Very low voltage records due to serious cerebral pathology

Trac alternant Present in NREM (quite) sleep

Spindles None (but scanty ripples)



Slow and fast activity in sleep Much delta and theta activity, continuous in REM sleep

REM sleep Continuous slow activity

EEG of Full-term Newborn (36-41 Weeks)



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M / GA 36 wk


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F / GA 37 wk


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M / GA 38 wk Trac alternant


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F / GA 39 wk Frontal sharp transient


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F / GA 40 wk


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M / GA 40 wk Anterior dysrhythmia


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M / GA 42 wk


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Appearance and disappearance of developmental EEG landmarks

26 28 30 32 34 36 38 40 42 44 46 48 50 52 54

Beta Delta Complex

Temporal Theta Bursts

Frontal Sharp Transients

Trace Alternant

Temporal

Alpha Bursts

Occipital

Dominant

Alpha Rhythm

Conceptual Age (weeks)

Mizrahi EM et al Atlas of Neonatal EEG 2004

Sleep Spindles

Vertex Transients


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F / GA 38 wk Excessive suppression in HIE


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F / GA 38 wk Rhythmic epileptiform activity in HIE


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F / GA 38 wk Rhythmic epileptiform activity in HIE


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F / GA 41 wk Focal spike discharges


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F / GA 40 wk FST vs. epileptiform spike


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F / GA 40 wk Repetitive spike discharges

F / GA 40 k N l i


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F / GA 40 wk Neonatal seizures

F / GA 40 k N l i


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F / GA 40 k N t l i


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M / GA 33 k N t l i


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M / GA 33 wk Neonatal seizures



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Early Infantile Epileptic Encephalopathy


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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 150-350 V high voltage slow wavesmixed 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

F / 1 mo Burst suppression in EIEE


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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

EEG of Infancy (2-12 Months)


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Continuity Continuous

Interhemispheric synchrony No significant asynchrony


Posterior basic alpha rhythm Starting at 3-4 mos (4/sec) reaching about 6/sec at 12 mos

Slow activity (awake) Considerable

Temporal theta burst None

Occipital theta None

Fast activity (awake) Very moderate

Low voltage Uncommon, usually abnormal

Trac alternant Disappears in 1st(seldom 2nd) mo

Spindles Appear after 2ndmo (12-15/sec, sharp, shifting)

Vertex waves and K complexes Appear mainly at 5 mos, fairly large, blunt


Slow and fast activity in sleep Much diffuse 0.75-3/sec activity with posterior maximum

REM sleep REM portion decreasing

EEG of Infancy (2 12 Months)


M / 1 mo


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M / 3 mo


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M / 5 mo Sleep spindle


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p p

M / 8 mo A-P gradient


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g

W t S d (I f til S )


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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)

M / 6 mo Hypsarrhythmia in IS


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M / 13 mo Hypsarrhythmia in IS


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Changing EEG Patterns from SB through H to SSW


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Awake SB H H SSW SSW

Sleep SB SB H H SSW

F / 2 mo Early phase of IS


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F / 2 mo EEG progression of IS


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Patterns of Atypical Hypsarrhythmia


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Patterns of Atypical Hypsarrhythmia

Asymmetrical or unilateralhypsarrhythmia Hypsarrhythmia with constant focal discharges

Hypsarrhythmia comprising primary, high-voltage,

bilateral asynchronous slow activity with minimalepileptiform potentials

Hypsarrhythmia with partial conservation of basal

rhythm and focal or generalized sharp and slow waves Hypsarrhythmia similar to suppression-bursts

F / 15 mo Asymmetric hypsarrhythmia


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F / 7 mo Hypsarrhythmia with constant focal discharges


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M / 3 mo Hypsarrhythmia with constant focal discharges


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M / 3 mo Hypsarrhythmia with constant focal discharges


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M / 4 yr Hypsarrhythmia with prominent fast activity


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HF 12Hz

M / 16 mo Hypsarrhythmia with rare epileptiform discharges


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M / 7 mo Hypsarrhythmia with prominent slow activity


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F / 4 mo Hypsarrhythmia with conservation of normal BG


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


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F / 2 mo Hypsarrhythmia like burst-suppression


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F / 4 mo Hypsarrhythmia like burst-suppression


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F / 10 mo Electrodecremental event (EDE)


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F / 7 mo Ictal EEG in IS


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C ti it C ti

EEG of Early Childhood (12-36 Months)


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Continuity Continuous

Interhemispheric synchrony No significant asynchrony


Posterior basic alpha rhythm Rising from 5-6/sec to 8/sec

Slow activity (awake) Considerable

Temporal theta burst None

Occipital theta None

Fast activity (awake) Mostly moderate

Low voltage Uncommon, usually abnormal

Trac alternant None

Spindles In 2ndyr sharp and shifting, then symmetrical with vertex max

Vertex waves and K complexes Large, becoming more pointed

Positive occipital sharp transients Poorly defined

Slow and fast activity in sleep Marked posterior maximum of slow activity

REM sleep Mostly slow, starting to become more desynchronized


M / 13 mo Vertex sharp transient


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Summary


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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


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Thank You for Your Attention

Neonate EEG

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