Atlas of Neonatal Electroencephalography, 3rd Edition

Chapter 5

Patterns of Uncertain Diagnostic Significance

A number of waveforms and patterns have not been reported to occur in normal infants, do not fit criteria of normality, and are not associated with well-defined abnormal clinical correlates. These patterns are of questionable or uncertain diagnostic significance.

FOCAL SHARP WAVES

Currently, little understanding exists of the significance of focal sharp waves in premature and term infants. Various definitions of “normal” spikes and sharp waves have been proposed. For example, spikes or sharp waves occurring two or three times in an hour-long recording have no significance in the newborn. To be considered normal, spikes and sharp waves occurring more frequently than this must be truly random and without persistent focality (Monod et al., 1972) and may arise from any scalp location (Engel, 1975; Hagne, 1972;Schulte, 1970). However, no stringent criteria have been developed to separate, unambiguously, abnormal from normal sharp-wave activity in the newborn.

Sharp waves or sharp-and-slow-wave complexes are commonly recorded from the midtemporal region during sleep in apparently normal premature and term infants. The features our group uses to differentiate between normal and abnormal temporal sharp waves are as follows:

Amplitude and Duration

In general, as the amplitude and duration of sharp waves increase, so does the likelihood that they are abnormal. For example, in a premature or term infant, random midtemporal sharp waves having a voltage of less than 75 µV, a duration of less than 100 milliseconds, and occurring only rarely during sleep would be considered normal (Fig. 5-1). Conversely, midtemporal sharp waves with a voltage exceeding 150 µV and a duration greater than 150 milliseconds would be considered abnormal. Unfortunately, numerous temporal sharp waves fall in a “gray zone” between these criteria. The most controversial is that of amplitude, because some sharp waves of greater than 100 µV may be considered normal if they are normal by all other parameters. However, other features, discussed in this section, often aid the neurophysiologist in determining the probability of normality or abnormality.

Incidence and Persistence

Temporal sharp waves that are considered normal occur randomly. They usually occur bilaterally but asynchronously and may be symmetrical or asymmetrical (Fig. 5-2). Generally these sharp waves appear infrequently; thus temporal sharp waves occurring in quick succession or long runs and sharp waves occurring on only one side are more likely to be considered abnormal (Figs. 5-3, 5-4 and 5-5).

Morphology and Complexity of Waveforms

Temporal sharp waves classified as normal are usually mono- or diphasic. The morphology of abnormal temporal sharp waves is more variable. Although they are sometimes mono- or diphasic, abnormal sharp waves more often are polyphasic and followed by an extremely high voltage slow wave (Figs. 5-6, 5-7, 5-8 and 5-9).

Polarity

The initial component of a normal temporal sharp wave is surface negative. Temporal sharp waves with an initial or prominent surface-positive component are abnormal (Fig. 5-9).

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Features Associated with Changes in Wake/Sleep States

In the premature infant, normal temporal sharp waves occur in any state. In the term infant, however, normal temporal sharp waves are more common during transitional sleep. If temporal sharp waves appear in the waking record of term infants, they probably are abnormal, regardless of other characteristics (Fig. 5-10). Midtemporal sharp waves satisfying the above criteria of normality occur in some healthy term newborns during sleep. These sharp waves disappear rapidly during the first month of life and are seen in fewer than 5% of healthy newborns after 6 weeks postterm. Even temporal sharp waves considered clearly abnormal often do not persist beyond this age.

FOCAL RHYTHMIC ACTIVITY

Midline Frontal Rhythmic Theta and Alpha Activity

Bursts of rhythmic 50- to 200-µV, 5- to 9-Hz activity may occur in the midline frontal regions of neurologically normal infants between 38 and 42 weeks CA (Hayakawa et al., 1987). The waves may have a sharp appearance, may occur in brief bursts usually lasting less than 1.5 seconds, and may occur in transitional or non-rapid eye movement (NREM) sleep, although typically not in REM sleep. They have been reported to occur in 55% of neurologically normal term infants, only rarely occur in infants with abnormal outcomes (4% of abnormal infants), and are not present in infants with moderate to severely depressed background activity (Hayakawa et al., 1987).

Midline Central Rhythmic Theta and Alpha Activity

Rhythmic activity similar to the frontal midline activity described earlier also may be present in the midline central region in an otherwise normal EEG (Hrachovy et al., 1990) (Figs. 5-11, 5-12 and 5-13). This activity also may accompany other EEG features that are considered abnormal, particularly central sharp waves, in infants who have experienced various central nervous system (CNS) insults.

Occipital Rhythmic Theta Activity

In the term infant's EEG, an uncommon finding is the occurrence of brief runs of rhythmic 4- to 6-Hz, 50- to 100-µV activity in the occipital regions with a duration of less than 1 second. This activity appears in wakefulness or sleep and usually occurs asynchronously on the two sides. In some infants, this activity may be unilateral. Occipital rhythmic theta activity can occur as an isolated feature in an otherwise normal EEG, but usually it accompanies other abnormalities such as sharp waves or an abnormal background (Fig. 5-14).

TRANSIENT UNILATERAL ATTENUATION OF BACKGROUND ACTIVITY DURING SLEEP

Transient unilateral attenuation of background EEG activity occurring during slow-wave sleep is an unusual finding reported to occur in about 3% to 4% of all newborns (Challamal et al., 1984; O'Brien et al., 1987) (Fig. 5-15). The attenuation episodes usually last about 1 minute and begin and end abruptly. The background EEG activity is normal in many infants. In our experience, these episodes usually occur only once during a recording session and usually within minutes of the time the infant first enters NREM sleep.

The significance of this finding, which occurs in apparently normal as well as in abnormal infants, has not been determined. Such episodes of unilateral attenuation of background activity should not be confused with the more common finding of marked generalized and/or lateralized voltage attenuation seen in the EEGs of infants who have experienced a variety of CNS insults. The latter attenuation episodes are short in duration (2-15 seconds), occur repeatedly during the recording session, and may be present in all states. The isolated transient unilateral attenuation episodes seen in slow-wave sleep and the generalized and/or lateralized attenuation episodes associated with various CNS insults also must be distinguished from the generalized attenuation of background EEG activity that is seen when transient arousal occurs during NREM sleep.

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LIST OF FIGURES

Focal Sharp Waves

Fig. 5-1. Randomly occurring right temporal sharp wave

Fig. 5-2. Independent, symmetrical, bitemporal sharp waves

Fig. 5-3. Repetitive left temporal sharp waves

Fig. 5-4. Repetitive right temporal sharp waves

Fig. 5-5. Repetitive, independent, bilateral temporal sharp waves

Fig. 5-6. Sharp- and slow-wave morphology

Fig. 5-7. Complex morphology of left temporal sharp waves

Fig. 5-8. Complex and variable morphology in bilateral, independent temporal sharp waves

Fig. 5-9. Complex morphology and varying polarity of temporal sharp waves

Fig. 5-10. Influence of wake/sleep state on the occurrence of temporal sharp waves: activation of sharp waves during sleep

Focal Rhythmic Activity

Fig. 5-11. Brief burst of rhythmic theta activity in the midline central region

Fig. 5-12. Sustained burst of rhythmic theta activity in the midline central region

Fig. 5-13. Rhythmic midline central theta bursts and midline central sharp waves

Fig. 5-14. Brief, rhythmic occipital theta activity on the left and right.

Transient Unilateral Attenuation of Background Activity during Sleep

Fig. 5-15. Transient unilateral attenuation of background activity during sleep

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FIG. 5-1. Randomly occurring right temporal sharp wave. An isolated diphasic sharp wave is present in the right temporal region with features that suggest it is a normal phenomenon. The background EEG of this sleeping 40-week CA infant is normal.

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FIG. 5-2. Independent, symmetrical, bilateral temporal sharp waves. Sharp waves in the left and right temporal regions appear asynchronously, but symmetrically. The bilateral and asynchronous nature of the sharp waves is a normal finding. However, their amplitudes are near or greater than 150 µV, and their duration are relatively long, suggesting abnormality. The background activity is normal in this 40-week CA infant.

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FIG. 5-3. Repetitive left temporal sharp waves. Recurring sharp waves are present in the left temporal region in this 40-week CA infant with normal EEG background activity. Only two sharp waves are present in this sample; thus, although repetitive, the degree of repetition is marginal. Additional sharp waves occurring in the recording would have to be analyzed before making a final determination of normality.

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FIG. 5-4. Repetitive right temporal sharp waves. The temporal sharp waves on the right are repetitive and high in amplitude. These features suggest abnormality. The background EEG activity is normal in this 40-week CA infant (low-frequency filter, 1.0 Hz).

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FIG. 5-5. Repetitive, independent, bilateral temporal sharp waves. Runs of sharp waves are present in the left and right temporal regions, more prominently on the left where the sharp waves are more frequent and higher in amplitude than those on the right. The repetitive occurrence and the high amplitude of some of the waves and their association with slow waves on the left suggest abnormality. Note the frontal sharp transients in the early portion of the sample; their occurrence is a normal phenomenon at this CA. This sleeping infant is 40 weeks CA, and normal background EEG activity is present.

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FIG. 5-6. Sharp- and slow-wave morphology. A temporal sharp wave on the left is normal in morphology and marginal in amplitude. However, the high-voltage slow wave that follows the sharp wave (creating a sharp- and slow-wave complex) suggests that this is an abnormal finding. This 42-week CA infant is in non-rapid eye movement (quiet) sleep. The background activity is normal.

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FIG. 5-7. Complex morphology of left temporal sharp waves. The morphology of the sharp-wave activity in the left temporal region is relatively complex, with slow and fast components and some waveforms that are sharper than others, suggesting abnormality. The background EEG activity is normal in this 38-week CA infant.

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FIG. 5-8. Complex and variable morphology in bilateral, independent temporal sharp waves. Repetitive temporal sharp waves appear independently in the left and right temporal regions with complex morphology, including spike-like waveforms. These features suggest that these temporal sharp waves are abnormal. The background EEG activity is abnormal with brief episodes of generalized voltage attenuation in this 40-week CA infant.

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FIG. 5-9. Complex morphology and varying polarity of temporal sharp waves. The sharp wave activity appears independently in the left and right temporal regions. Variable and complex morphology is present in both regions, with waveform components that are both surface negative and surface positive in polarity. The EEG background is abnormal, with brief periods of voltage attenuation in this 40-week CA infant.

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FIG. 5-10. Influence of wake/sleep state on the occurrence of temporal sharp waves: activation of sharp waves during sleep. A: The awake recording in this 40-week CA infant is normal with continuous polyfrequency activity and no sharp waves. B: In non-rapid eye movement (quiet) sleep, independent, bilateral temporal sharp waves are found with variable and complex morphology. The background activity is characterized by abnormal periods of generalized voltage attenuation. This recording is from the same infant shown in Fig. 5-9.

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FIG. 5-10. (Continued)

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FIG. 5-11. Brief burst of rhythmic theta activity in the midline central region. A brief burst of rhythmic theta activity is seen in the midline central (Cz) region in this sample from a 40-week CA infant with normal background EEG activity.

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FIG. 5-12. Sustained burst of rhythmic theta activity in the midline central region. A sustained burst of rhythmic theta activity is present in the midline central (Cz) region. Normal frontal sharp transients are present. The background EEG activity is normal in this 40-week CA infant.

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FIG. 5-13. Rhythmic midline central theta bursts and midline central sharp waves. A brief run of rhythmic theta activity occurs in the midline central region in the middle portion of this sample. Earlier and later, sharp waves or spikes in the same region are more abnormal features. Frontal sharp transients, normal waveforms, are present, and the EEG background activity is normal in this 40-week CA infant.

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FIG. 5-14. Brief, rhythmic occipital theta activity on the left and right. Brief bursts of rhythmic theta activity in the left (A) and right (B) occipital regions appear on two samples from one EEG recording in this 34-week CA infant.

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FIG. 5-15. Transient unilateral attenuation of background activity during sleep. Selected segments are shown of an episode of transient unilateral attenuation of background activity during sleep, lasting 70 seconds. A: Initially voltage attenuation of activity occurs in leads from the left hemisphere. B: The attenuation persists for several seconds. C:Gradual resolution of the attenuation. D: The EEG eventually returns to baseline. The background EEG activity is normal in this 40-week CA infant.

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FIG. 5-15. (Continued)

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FIG. 5-15. (Continued)

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FIG. 5-15. (Continued)

FIG. 4-31. (Continued)