Electroencephalography

Electroencephalography, or EEG, is a neurological test that involves attaching electrodes to

the head of a person to measure and record electrical activity in the brain over time.
Purpose
The EEG, also known as a brain wave test, is a key tool in the diagnosis and management of
epilepsy and other seizure disorders. It is also used to assist in the diagnosis of brain
damage and diseases such as strokes, tumors, encephalitis, mental retardation, and sleep
disorders. The results of the test can distinguish psychiatric conditions such as
schizophrenia, paranoia, and depression from degenerative mental disorders such as
Alzheimer's and Parkinson's diseases. An EEG may also be used to monitor brain activity
during surgery to assess the effects of anesthesia. Additionally, it is used to determine brain
status and brain death.
Precautions
There are few adverse conditions associated with an EEG test. Persons with seizure
disorders may experience seizures during the test in reaction to flashing lights or by deep
breathing.
Description
Before an EEG begins, a nurse or technologist attaches approximately 1621 electrodes to a
person's scalp using an electrically conductive, washable paste. The electrodes are placed
on the head in a standard pattern based on head circumference measurements. Depending
on the purpose for the EEG, implantable, or invasive, electrodes are occasionally used.
Implantable electrodes include sphenoidal electrodes, which are fine wires inserted under
the zygomatic arch, or cheekbone. Depth electrodes, or subdural strip electrodes, are
surgically implanted into the brain and are used to localize a seizure focus in preparation for
epilepsy surgery. Once in place, even implantable electrodes do not cause pain. The
electrodes are used to measure the electrical activity in various regions of the brain over the
course of the test period.
For the test, a person lies on a bed, padded table, or comfortable chair and is asked to relax
and remain still while measurements are being taken. An EEG usually takes no more than
one hour, although long-term monitoring is often used for diagnosis of seizure disorders.
During the test procedure, a person may be asked to breathe slowly or quickly. Visual
stimuli such as flashing lights or a patterned board may be used to stimulate certain types
of brain activity. Throughout the procedure, the electroencephalography unit makes a
continuous graphic record of the person's brain activity, or brain waves, on a long strip of
recording paper or computer screen. This graphic record is called an electroencephalogram.
If the display is computerized, the test may be called a digital EEG, or dEEG.
The sleep EEG uses the same equipment and procedures as a regular EEG. Persons
undergoing a sleep EEG are encouraged to fall asleep completely rather than just relax.
They are typically provided a bed and a quiet room conducive to sleep. A sleep EEG lasts up
to three hours, or up to eight or nine hours if it is a night's sleep.
In an ambulatory EEG, individuals are hooked up to a portable cassette recorder. They then
go about normal activities and take normal rest and sleep for a period of up to 24 hours.
During this period, individuals and their family members record any symptoms or abnormal
behaviors, which can later be correlated with the EEG to see if they represent seizures.
An extension of the EEG technique, called quantitative EEG (qEEG), involves manipulating
the EEG signals with a computer using the fast Fourier transform algorithm. The result is

then best displayed using a colored gray scale transposed onto a schematic map of the head
to form a topographic image. The brain map produced in this technique is a vivid illustration
of electrical activity of the brain. This technique also has the ability to compare the similarity
of the signals between different electrodes, a measurement known as spectral coherence.
Studies have shown the value of this measurement in diagnosis of Alzheimer's disease and
mild closed-head injuries. The technique can also identify areas of the brain having
abnormally slow activity when the data are both mapped and compared to known normal
values. The result is then known as a statistical or significance probability map (SPM). This
allows differentiation between early dementia (increased slowing) or otherwise
uncomplicated depression (no slowing).
Preparation
An EEG is generally performed as one test in a series of neurological evaluations. Rarely
does the EEG form the sole basis for a particular diagnosis.
Full instructions should be given to individuals receiving an EEG when they schedule their
test. Typically, individuals taking medications that affect the central nervous system, such as
anticonvulsants, stimulants, or antidepressants, are told to discontinue their prescription for
a short time prior to the test (usually one or two days). However, such requests should be
cleared with the treating physician. EEG test candidates may be asked to avoid food and
beverages that contain caffeine, a central nervous system stimulant. They may also be
asked to arrive for the test with clean hair that is free of spray or other styling products to
make attachment of the electrodes easier.
Individuals undergoing a sleep EEG may be asked to remain awake the night before their
test. They may be given a sedative prior to the test to induce sleep.
Aftercare
If an individual has suspended regular medication for the test, the EEG nurse or technician
should advise as to when to begin taking it again.
Risks
Being off certain medications for one to two days may trigger seizures. Certain procedures
used during EEG may trigger seizures in persons with epilepsy. Those procedures include
flashing lights and deep breathing. If the EEG is being used as a diagnostic tool for epilepsy
(i.e., to determine the type of seizures an individual is experiencing), this may be a desired
effect, although the person needs to be monitored closely so that the seizure can be aborted
if necessary. This type of test is known as an ictal EEG.
Normal results
In reading and interpreting brain wave patterns, a neurologist or other physician will
evaluate the type of brain waves and the symmetry, location, and consistency of brain wave
patterns. Brain wave response to certain stimuli presented during the EEG test (such as
flashing lights or noise) will also be evaluated.
The four basic types of brain waves are alpha, beta, theta, and delta, with the type
distinguished by frequency. Alpha waves fall between 8 and 13 Hertz (Hz), beta are above
13 Hz, theta between 4 and 7 Hz, and delta are less than 4 Hz. Alpha waves are usually the
dominant rhythm seen in the posterior region of the brain in older children and adults, when
they are awake and relaxed. Beta waves are normal in sleep, particularly for infants and
young children. Theta waves are normally found during drowsiness and sleep and are
normal in wakefulness in children, while delta waves are the most prominent feature of the
sleeping EEG. Spikes and sharp waves are generally abnormal; however, they are common
in the EEG of normal newborns.

Different types of brain waves are seen as abnormal only in the context of the location of
the waves, a person's age, and one's state of consciousness. In general, disease typically
increases slow activity such as theta or delta waves, but decreases fast activity such as
alpha and beta waves.
Not all decreases in wave activity are abnormal. The normal alpha waves seen in the
posterior region of the brain are suppressed merely if a person is tense. Sometimes the
addition of a wave is abnormal. For example, althms seen in a newborn can signify seizure
activity. Finally, the area where the rhythm is seen can be telling. The alpha coma is
characterized by alpha rhythms produced diffusely, or, in other words, by all regions of the
brain.
Some abnormal beta rhythms include frontal beta waves that are induced by sedative
drugs. Marked asymmetry in beta rhythms suggests a structural lesion on the side lacking
the beta waves. Beta waves are also commonly measured over skull lesions such as
fractures or burr holes, in an activity known as a breach rhythm.
Usually seen only during sleep in adults, the presence of theta waves in the temporal region
of awake, older adults has been tentatively correlated with vascular disease. Another
rhythm normal in sleep, delta rhythms, may be recorded in a wakeful state over localized
regions of cerebral damage. Intermittent delta rhythms are also an indication of damage of
the relays between the deep gray matter and the cortex of the brain. In adults, this
intermittent activity is found in the frontal region, whereas in children it is in the occipital
region.
The EEG readings of persons with epilepsy or other seizure disorders display bursts, or
spikes, of electrical activity. In focal epilepsy, spikes are restricted to one hemisphere of the
brain. If spikes are generalized to both hemispheres of the brain, multifocal epilepsy may be
present. The EEG can be used to localize the region of the brain where the abnormal
electrical activity is occurring. This is most easily accomplished using a recording method, or
montage, called an average reference montage. With this type of recording, the signal from
each electrode is compared to the average signal from all the electrodes. The negative
amplitude (an upward movement) of the spike is observed for the different channels, or
inputs, from the various electrodes. The negative deflection will be greatest as recorded by
the electrode that is closest in location to the origin of the abnormal activity. The spike will
be present but of reduced amplitude as the electrodes move farther away from the site
producing the spike. Electrodes distant from the site will not record the spike occurrence.
A final variety of abnormal result is the presence of slower-than-normal wave activity, which
can either be a slow background rhythm or slow waves superimposed on a normal
background. A posterior dominant rhythm of 7 Hz or less in an adult is abnormal and
consistent with encephalopathy (brain disease). In contrast, localized theta or delta rhythms
found in conjunction with normal background rhythms suggest a structural lesion.