(EEG) Faculty: M. Kabiraj, M. Fiol, D. MacDonald, M. Mikati

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1 (EEG) Moderator: N. Biary Faculty: M. Kabiraj, M. Fiol, D. MacDonald, M. Mikati Neurosciences 2003; Vol. 8 Supplement 2 S145

2 S146 Neurosciences 2003; Vol. 8 Supplement 2

3 Mohammad Kabiraj, Nabil Biary Department of Neurosciences, Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia A 57-year-old lady, admitted to the Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia (KSA) on 27th July, 2002 with history of fever (one day duration), sense of breathlessness, pain and swelling in the back of the left thigh for few days, computerized tomography (CT) revealed a large hematoma extending from the groin to the knee (hematoma was evacuated surgically). On 28th August 2002, the hematoma started again, increasing in size with drop of hemoglobin (Hb) of 8.2%; drop of blood pressure (BP) of 90/50 mm Hg; drowsiness and confusion. An electroencephalography (EEG) was requested. Question 1) What does the EEG demonstrate? Question 2) What is the clinical significance? Question 3) What is the differential diagnosis? Neurosciences 2003; Vol. 8 Supplement 2 S147

EEG 1 - Ten second records. This is a 57-year-old lady.

EEG 3 - Subsequent 10 seconds longitudinal bipolar montage.

EEG 2 - Subsequent 10 seconds transverse montage.

4 EEG 1 - Ten second records. This is a 57-year-old lady. Transvervebipolar montage. Note the morphology and voltage of the potential. EEG 3 - Subsequent 10 seconds longitudinal bipolar montage. Note that the patient moved to one side. EEG 2 - Subsequent 10 seconds transverse montage. Note that patient moved as shown by muscle artifacts. EEG 4 - Subsequent 10 seconds longitudinal bipolar montage. EEG changes is due to painful stimulus. S148 Neurosciences 2003; Vol. 8 Supplement 2

5 Mohammad Kabiraj, Nabil Biary Department of Neurosciences, Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia A 24-year-old man with history of one generalized tonic clonic seizure. His EEG and magnetic resonance (MR) of the brain were normal. Subsequently, he started to have cognitive deterioration and myoclonic jerks. This EEG was carried out 6 weeks after the first normal EEG. Question 1. What is the likely diagnosis? Neurosciences 2003; Vol. 8 Supplement 2 S149

6 EEG 1 - Double banana montage. Note the paroxysmal discharges are associated with jerks. EEG 2 - Double banana montage. EEG 3 - Double banana montage. S150 Neurosciences 2003; Vol. 8 Supplement 2

7 Mohammad Kabiraj, Nabil Biary Department of Neurosciences, Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia A 12-year-old Saudi girl, a known case of end stage renal failure presented at A&E on 17th October 2002 with the following complaints: fever, vomiting, poor feeding, and generalized weakness (duration 2 days). During the examination she was ill looking, dehydrated, sunken eyes, weak pulse, BP 60/32 mm Hg, urine analysis was 10,000 white blood cell. The clinical impression was chronic renal failure with septic shock. The patient was admitted to the Pediatric General Intensive Care Unit (PGICU) where she developed seizures. Serial portable EEGs were carried out: First EEG was on the 25th September Question 1) What is the EEG abnormality? Question 2) What is the EEG classification? The second, third and fourth EEG (28th September 2002) shows the effect of diazepam. Question: What are the EEG changes and why? On 21st October 2002, the patient came with peritoneal shunt infection. She was given intravenous Ceftriaxone. She developed confusional state with the marked deterioration of the cognitive functions. On the fifth EEG: Question 1) What does the EEG demonstrate? Question 2) What is the possible diagnosis? Question 3) What would be the effect of diazepam? On 23rd October 2002, ceftriaxone administration was stopped. On the sixth EEG: Question 1) What is the EEG abnormality? Question 2) How do you correlate these EEG changes with the clinical status of the patient? Neurosciences 2003; Vol. 8 Supplement 2 S151

EEG 1 - The EEG of the 12-year-old Saudi girl on 25th September 2002 (10 second epoke). Longitudinal bipolar montage.

EEG 4 - The EEG on the 28th September 2002 with the same montage (next 10 second record). Note the changes after administration.

Note the interdischarge interval and subsequent flattening following diazepam administration.

The patient was confused. Note the EEG abnormality. EEG 3 - Double banana montage.

8 EEG 1 - The EEG of the 12-year-old Saudi girl on 25th September 2002 (10 second epoke). Longitudinal bipolar montage. Note the pattern of epilptiform discharges lasting for more that 30 minutes. EEG 4 - The EEG on the 28th September 2002 with the same montage (next 10 second record). Note the changes after administration. EEG 2 - This is a 12-year-old Saudi girl: The EEG on the 25th September 2002 (10 seconds epoke). Note the interdischarge interval and subsequent flattening following diazepam administration. EEG 5 - The EEG on the 21st October A 10 second epoke of an hour record in the second admission transverse bipolar montage. The patient was confused. Note the EEG abnormality. EEG 3 - Double banana montage. The EEG on the 25th September 2002 with the same montage. Subsequent 10 seconds record. Note the EEG changes following diazepam. EEG 6 - The EEG on the 23rd October Ten seconds epocke. Bipolar longitudinal montage. Note this EEG was carried out prior to discharge and after taking ceftriaxone. S152 Neurosciences 2003; Vol. 8 Supplement 2

9 Is it generalized convulsive status epilepticus? It has been seen that the patient with generalized convulsive status is kept untreated, the motor manifestations become increasing subtle. Electroencephalography shows discreted electrographic seizure with waxing and wanning ictal pattern without muscle artifacts. Eventually, these continuous ictal EEG discharges are punctuated by periods of relative flattening. Could it be a myoclonic status? Myoclonic status begins insidiously in course of generalized epilepsy with myoclonus and absence components. The parents notice progressive deterioration of consciousness. Our patient developed seizure in PGICU and the EEG was requested. Both the clinical and electrographic seizures improved by administration of diazepham and phenobarbitone + on CAPD II. The patient was loaded with anti-epileptic drugs and was subsequently transfer to the ward and discharged. A month later, the patient had a second admission due to the infection of the intraperitoneal drainage. The patient developed cognitive deterioration following the intravenous administration of ceftriaxone. Electroencephalography was requested and it showed nearly continuous runs of triphasic waves bilaterally. This could be due to metabolic encephalopathy. CAPD II was discontinued every 6 hourly in the form of 560 per cycle and ceftriaxone was stopped. Subsequent EEG showed drowsy to sleep state without any signs of lateralizing or focalizing features. Patient was discharge and given appointment in the renal clinic. Neurosciences 2003; Vol. 8 Supplement 2 S153

Mohammad Kabiraj, Nabil Biary Department of Neurosciences, Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia The patient is a 12-year-old boy with the following EEG.

10 Mohammad Kabiraj, Nabil Biary Department of Neurosciences, Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia The patient is a 12-year-old boy with the following EEG. Question 1) What is the possible diagnosis of the patient? EEG 1 - A 52-year-old man. A 10 second record. Double banana montage. S154 Neurosciences 2003; Vol. 8 Supplement 2

possible diagnosis? EEG 1 - A 14-year-old boy. Double banana montage. EEG 2 - A 10 second record.

11 Mohammad Kabiraj, Nabil Biary Department of Neurosciences, Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia The patient is a 14-year-old boy with the following EEG: Question 1) What is the possible diagnosis? EEG 1 - A 14-year-old boy. Double banana montage. EEG 2 - A 10 second record. Longitudinal bipolar montage with an additional zygomatic electrode. Neurosciences 2003; Vol. 8 Supplement 2 S155

12 S156 Neurosciences 2003; Vol. 8 Supplement 2

Electroencephalography. Role of EEG in NCSE. Continuous EEG in ICU 25/05/59. EEG pattern in status epilepticus

Electroencephalography. Role of EEG in NCSE. Continuous EEG in ICU 25/05/59. EEG pattern in status epilepticus EEG: ICU monitoring & 2 interesting cases Electroencephalography Techniques Paper EEG digital video electroencephalography Dr. Pasiri Sithinamsuwan PMK Hospital Routine EEG long term monitoring Continuous