Andy White for their critical review and proofreading. Symmetry is best measured in referential montage to avoid phase cancellation. Immediately after eye closure, alpha frequency may be accelerated for 0. Therefore, alpha frequency assessment should not be done during this period.
Paradoxical AR is seen in drowsiness and sedation. Usually alternates with AR. Rhythmic sinusoidal, notched theta, or delta activities that have a harmonic relationship with the AR one-third or, more commonly, one-half the frequency.
Duration is — msec except in 1—3 years that can be up to msec. Most common during the middle years of childhood. They are always accompanied by the AR, attenuated with eye opening, disappear with the AR during drowsiness and light sleep, and may be accentuated by hyperventilation and stress. Rarely present only on one side. Frequency is more variable and can be elicited by alerting stimuli.
The 14 Hz component is more commonly seen than 6 Hz. They usually are isolated or occur in brief runs, alone or in combination with anterior slow dysrhythmia, symmetrically, bilaterally, and synchronously.
They occur in transition from active to early quiet sleep. Although the premature form which is polyphasic and very high amplitude may appear very early at 26—31 weeks CA, the typical biphasic FST are maximally expressed at 35—36 weeks, are diminished in number and voltage after 44 weeks CA, are rarely seen during sleep after 46 weeks CA, and are absent at 48 weeks CA.
Eye Movement Artifact. A week CA infant with apnea. EEG shows biphasic sharp theta activity in bilateral prefrontal regions that simulate frontal sharp transients. A 40 weeks CA infant with apnea and cyanosis. Anterior slow dysrhythmia is usually admixed with frontal sharp transients. It occurs most prominently during transitional sleep. It is a normal developmental EEG pattern. However, when it is abundant, persistently asymmetric, and high in amplitude or dysmorphic, it may be considered abnormal.
A week CA baby girl with mild hypoxic ischemic encephalopathy and clinically suspected seizures. EEG shows bilateral synchronous, rhythmic 1. Repetitive frontal sharp transients and anterior slow dysrhythmia is considered a normal, developmental EEG pattern. A 2-day-old full-term infant with intraventricular hemorrhage associated with congenital CMV infection and cardiomyopathy. In the same recording not shown , the patient also has focal electrographic seizures in the right frontal region.
Rhythmic Midline Central Theta Bursts. A week CA infant with jitteriness. The rest of the EEG recording was unremarkable. Note an electrode artifact at F7. It can be either a normal variant or can occur in association with other abnormalities, especially central sharp waves, in patients with various CNS insults. A week CA newborn with recurrent apneic episodes associated with cyanosis. The neurologic examination was normal.
Head CT was unremarkable. A routine EEG during slow sleep shows intermittent attenuation of background activity over the left hemisphere lasting for 1—2 min. The asymmetry is transient, lasting from 1 to 5 min less than 1. It occurs at the beginning of quiet sleep. The EEG activity before and after the asymmetry is almost always normal. The latter is usually shorter in duration, occurs in all states, and is associated with other EEG abnormalities such as sharp waves or delta slowing.
A routine EEG during slow sleep shows intermittent attenuation of background activity over the left hemisphere lasting for 1—2 minutes.
EEG shows a nonreactive burst suppression pattern. The burst of activity contains sharp waves and spikes intermixed with delta and faster frequencies. The interburst interval IBI is of very low amplitude. The patient died 1 day after this EEG. During the burst, activity contains intermixed components of poorly organized delta and theta frequencies, at times, with spikes or sharp waves. The IBI contains very low-voltage ictal pattern.
Transient phenomenon disappear within days to weeks. Related to an acute or subacute focal brain lesion involving gray matter. PLEDs were more periodic when they were associated with acute viral encephalitis than with other etiologies.
Aggressive treatment of patients may not be warranted when these EEG patterns are seen after anoxic brain injury.
Alpha- and theta-pattern coma. Aggressive treatment 6 of patients may not be warranted when these EEG patterns are seen after anoxic brain injury. CJD has been reported in children. In the normal setting, the cortex inhibits thalamocortical bursting. In cortical dysfunction, disruption of this inhibitory feedback on the thalamus by cortical projections causes rhythmic activity. This activity can be focal or generalized, and is usually nonconvulsive.
Electrodecremental periods following EEG complexes. Paroxysm of bisynchronous spike-wave activity. Random spikes over frontal regions. Focal abnormalities, such as spike- and slowwave foci. It may also be caused by acute brain stem lesions. Sequential EEG recordings are required to detect the evolution of rhythmic coma patterns during childhood. EEG reactivity in subsequent patterns is relatively favorable, while a B-S pattern without reactivity is unfavorable in anoxic-ischemic encephalopathy.
All patients with HIE bilateral basal ganglia involvement have developmental delay. Shorter duration of suppressive therapy, ultimately with the same outcome and possibly with fewer complications, was recommended. Neuronal cell loss in HS occurs as the result of prolonged severe seizure activity in humans. Rarely reported below the age of 20 years.
Bursts of moderate- to high-amplitude complexes, usually at 1. A year-old girl with microscopic polyangiitis and chronic renal failure developed visual hallucinations, lethargy, and new-onset seizures.
She was on cyclophosphamide. After the visual hallucination, she was found to have elevation of her blood pressure. The patient recovered after cyclophosphamide was stopped, and the blood pressure was well controlled. Polymorphic delta comas are due to structural abnormalities involving subcortical white matter or profound metabolic coma.
Same patient as in Figure The patient developed a new-onset seizure described as head and eyes deviating to the right side, associated with unconsciousness lasting for approximately 3 minutes. EEG shows ictal activity arising from the left occipital lobe during the seizure.
Occipital lobe seizures have been described as a major clinical manifestation of PRES. Seizure focus was parieto-occipital in four patients and temporal in two.
A 7-year-old comatose girl with severe TBI causing intraparenchymal hemorrhage required brain decompression. Note a persistent focal suppression of the left fronto-temporal region. Bilateral but lateralized PDA is characteristic of frontal lobe lesions. Functionally or structurally abnormal thalamocortical interactions, especially involving the dorsal medial nucleus of the thalamus, play a major role in IRDA.
However, the same combination of patterns can also be seen in patients with focal structural lesions and coexistent toxic or metabolic encephalopathies. Same patient as in Figure The patient developed signs of cerebral herniation. He underwent another cerebral decompression with resection of necrotic tissues in the left fronto-temporal region. EEG performed after the surgery shows continuous high-voltage polymorphic delta activity PDA in the left hemisphere, caused by the surgery.
Unfortunately, despite subsequent treatment with pentobarbital coma, the patient deteriorated and died 4 days after the surgery. Same patient as in Figure and The EEG shows electrocerebral inactivity before the cardiorespiratory support was discontinued. Note rhythmic delta activity, mainly at F3, time-locked with ECG indicating pulse artifact. Paradoxical Activation. There is a period of background attenuation more severe delta slowing following stimulation.
Paradoxical activation is a period of more severe delta slowing following painful stimulation. It is seen less commonly than a typical response to stimuli but is associated with a milder degree of encephalopathy compared to the invariant EEG. There is a period of background attenuation without delta slowing following stimulation. A 2-year-old boy with bilateral parietal strokes, maximal in the right hemisphere arrow occurring after cardiac transplantation.
He developed frequent seizures described as head and eyes deviating to the left side, followed by generalized tonic-clonic seizures. MRI shows bilateral watershed infarctions in the frontal parietal regions, much greater in the right hemisphere. EEG shows periodic lateralized epileptiform discharges PLEDs in the right parietal temporal region and polymorphic delta slowing in parietal temporal regions, greater on the right, corresponding to the strokes.
Note pacemaker rhythm in the ECG channel. He developed a new-onset seizure described as left arm and facial clonic jerking with head and eyes deviating to the left side, followed by a generalized tonic clinic seizure. EEG shows periodic lateralized epileptiform discharges in the right centrotemporal region. It is sometimes associated with EPC. A 2-month-old boy with anoxic encephalopathy due to SIDS. He had multifocal clonic seizures.
MRI shows bilateral watershed infarction arrows as typically seen in anoxic encephalopathy. EEG shows quasiperiodic spikes and sharp waves the Cz electrode. This activity has the same characteristics as periodic lateralized epileptiform discharges PLEDs except for its location in midline vertex. All patients had sustained a cerebrovascular insult, either old or new. The PEDIM and seizures suggested an origin from the watershed area between the anterior, middle, and posterior cerebral arteries, involving predominantly the parasagittal region of the cerebral hemisphere.
A 9-month-old boy with fever, left facial twitching, and then generalized tonic clonic seizure. MRI showed bilateral watershed infarction in the mesial frontal regions arrows. All patients had strokes. The PEDIM and seizures suggested an origin from the watershed area, involving predominantly the parasagittal, midline parietal, or midline central areas. The seizures and PEDIM resolved after initiation of treatment with antiepileptic drugs and treatment of the underlying disorder.
A previously healthy 4-year-old girl who presented with high fever, lethargy, vomiting, and a new-onset seizure described as head and eyes deviating to the right side, followed by cyanosis. Brain biopsy was performed over the left occipital region. B Axial T1-weighted image with GAD shows increased enhancement in the left parieto-occipital regions double arrows.
At the last follow-up 1 year later, the patient had moderate global developmental delay, visual anogsia, and well-controlled seizures. A 5-month-old boy with pneumococcal meningitis who was in a comatose state and developed seizures.
EEG performed 4 hours after the seizure described as tonic posturing and nystagmus shows bilateral independent pseudoperiodic polymorphic sharp waves and spikes in the left temporal and right parieto-temporal regions. The patient subsequently developed NCSE. At 7 months of age, he started having infantile spasms. At a month follow-up, he had severe developmental delay, microcephaly, intractable CPS, and left hemiparesis.
A 9-yearold boy with dilated cardiomyopathy caused by viral myocarditis. Examination and CXR were compatible with congestive heart failure. EEG shows bilateral independent pseudoperiodic spikes and polymorphic sharp waves, maximum over the posterior head regions, consistent with BiPLEDs.
There was no evolving pattern as seen in his electrographic seizures. A 4-month-old boy with a prolonged generalized tonic-clonic seizures due to nonaccidental trauma. EEG during the comatose stage shows bilateral independent periodic lateralized epileptiform discharges in the bitemporal regions BiPLEDS arrow and asterisk. This EEG pattern is commonly seen in patients with coma due to anoxic encephalopathy, strokes, epileptic seizure disorders, especially complex partial status epilepticus, and encephalitis.
A 6-year-old boy with hypoplastic left ventricle with cardiac transplantation who developed anoxic encephalopathy due to near drowning. MRI shows a bilateral watershed infarction. Thus aggressive treatment of patients may not be warranted when these EEG patterns are seen after anoxic brain injury. A 3-year-old boy with high fever, prolonged left hemiconvulsion, eye and head deviation to the left, and lethargy. EEG shows continuous ictal activity in the right hemisphere, maximally expressed in the fronto-central region.
At times, the sharp waves are time-locked with the clonic jerks on the left side. He underwent surgical decompression and, subsequently, removal of necrotic tissue over the right hemisphere.
The patient survived but was left with permanent left hemiparesis and intractable epilepsy. HHE is a rare sequence comprising a sudden and prolonged hemiclonic seizure during febrile illness in an otherwise normal child, followed by permanent ipsilateral hemiplegia and focal epilepsy.
Ictal EEG shows high-voltage rhythmic slow waves intermingled with spikes, sharp waves, spike-wave complexes, or low-voltage fast activity. Note muscle artifact, maximum in the left temporal region during the left facial twitching open arrow. The ictal EEG is characterized by bilaterally rhythmic slow waves, with higher amplitude on the hemisphere contralateral to the clinical seizure. The spike-wave complexes are periodically interrupted by a 1- to 2-sec background attenuation.
A 4-year-old boy with cardiac arrest after rupture of coarctation of the aorta. Head CT shows bilateral massive cerebral edema. CXR shows congestive heart failure. Generalized periodic epileptiform discharges GPEDs are periodic complexes that occur throughout the brain in a symmetric and synchronized manner. Other characteristics that favor a more optimistic outlook include younger age, higher level of alertness at the time of the EEG, history of seizures in the current illness, and higher inter-GPED amplitude.
A 9-year-old boy with refractory status epilepticus RSE of unknown etiology who was treated with pentobarbital coma but developed cardiorespiratory complications. He developed clinical seizures described as facial twitching and nystagmus while his pentobarbital dosage was decreased. Atlas of Pediatric Emergency Medicine, Third Edition is written to assist the busy clinician in the evaluation, management, and disposition of acutely ill or injured pediatric patients.
Enhanced by more than 2, photographs and nearly line illustrations, this unique visual resource has been acclaimed as the finest collection of pediatric emergency medicine images available anywhere.
The Atlas features a clear, consistent format, with concise text detailing Clinical Summary, Emergency Department Treatment and Disposition, and Pearls. Positioned next to this easy-to-read text is a wealth of images that illustrate how these clinical problems actually present in a real-life emergency setting.
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