Eeg in pediatric (DNB PEDIATRIC)

osce for DNB

1. EEG DR MANDAR HAVAL

2. EEG is about pattern recognition ECG is about precision

3. EEG – systematic approach Minimal technical requirements 16 channels Atleast 3 montages Longitudinal bipolar, horizontal bipolar, referential Atleast 20 min recording and in neonates 1 hour

4. International 10-20 system of Electrode placement

5. Montages Bipolar: the potential difference between 2 active electrodes Referential : potential difference between 1 active and 1 inactive electrode

6. EEG- what to look at? Background Activity – rhythmic, arhythmic, periodic Evolution of the rhythm

7. EEG- describing the waves Frequency : delta( 0-4hz ), theta( 4-8hz ), alpha( 8-13hz ), beta (>13 hz) Amplitude: low (<25 uv ), moderate( 25-75uv) , high (>75uv ) Location Symmetry Synchrony Reactivity Rhythmic, periodic, arhythmic Morphology (spike, sharp, biphasic, triphasic)

8. Normal EEG in a child

9. Normal EEG in adult

10. Spike and wave complex

11. Case 1 10 year old girl Developmentally normal Slight deterioration in school performance last 2 months Multiple episodes of brief staring 5 -10 sec No loss of tone Examination normal

12. EEG

13. Absence seizure Onset 4-10 yrs Hundreds per day; 4-20 secs Eyes open, voluntary activity stops EEG – 3per sec spike wave activity. Ppt by hyperventilation Drug of choice – ethosuxamide/ valproate/ lamotrigine

14. Case 2 5 month male HIE stage 2 at birth Clusters of sudden tonic flexion of entire body several times in a day, especially on awakening - 2 weeks

15. Diagnosis?

16. West syndrome Infantile spasms with hypsarrythmia EEG – chaotic High amplitude, multifocal spikes and polyspikes, asynchronous, arrrhythmic Drugs of choice- ACTH/ steroids

17. Case 4 7 year old boy Nocturnal seizure, jerky movements of the lips, eyes wide open, unable to sleep, hypersalivation

18. BECTS- benign childhood epilepsy with centro-temporal spikes (Rolandic epilepsy) Onset 1-14 yrs Unilateral facial sensorimotor seizures Hypersalivation Speech arrest Oropharyngeal manifestations Prognosis- most remit in 2-4 yrs Treatment- nil/ CMZ/LVT

19. Case 4 8 year old boy h/o delayed milestones – walking 2 yrs, speech 3 years Multiple types of seizures several times a day – 2 months Tonic seizures, atonic falls, myoclonic seizures Regression of milestones

20. EEG

21. EEG of Lennox Gastaut Syndrome Background – slow and disorganised Slow generalized spike wave ( < 2.5 cps) Multiple independent spike foci Very fast ( 10-20 cps) paroxysmal activity s/o tonic seizures

22. Management of LGS Multiple anti epileptic drugs Poor response Non AED’s- IVIG, steroids, ketogenic diet Surgery – corpus callosotomy

23. Case 5 4 year old girl Fever & recurrent focal seizures – 2 days Comes in status epilepticus Seizures stop after lorazepam and phenytoin Patient remains comatose > 24 hours after all motor seizures have stopped.

24. EEG

25. EEG of NCSE (non convulsive status epilepticus) Spikes, waves, rhythmic activity Focal or partial features, discrete or continuous Cyclic or recurrent patterns May correlate with changes in behaviour and responsiveness Significant improvement in discharges and sensorium on giving IV anti epileptics

26. Case 7 11 year old boy Cognitive decline last 6 months Repetitive extensor myoclonus last 1 month Stopped walking, speaking, swallowing last 15 days Past h/o measles at 3 years

27. EEG

28. SSPE EEG: stereotyped, generalized and synchronous high amplitude periodic complexes Diagnosis: Elevated CSF anti measles antibodies Prognosis: grim

29. 8 mts old female child with delayed development milestones flexor spasm EEG done. Describe characteristic EEG findings What is diagnosis? What is T/t? Which type having the good prognosis? 10/15/2014 55 CME,Pune

30. Hppsarrythmia Infartile spasms ACTH and glucocorticoids Cryptogenic infantile spasms 10/15/2014 56 CME,Pune

31. 12.Child with fever , convulsions, altered sensorium CSF picture : protein 62, cells 95 P10 L90, sugars 45/80, RBCs 80/ hpf Additional 2 investigations of choice Treatment with dose

32. EEG - PLEDS-periodic lateralizing epileptiform discharges HSV PCR,( ? HSV IgG, IgM ), CT scan / MRI with contrast – bi/ uni temporal hyperintensities Acyclovir 10mg/kg/dose 8 hrly for 14 -21 days

33. 6) What does this EEG show? What is the drug of choice? Prognosis? One OPD procedure to confirm diagnosis

34. 3 Hz spike and wave activity in Absence seizure – childhood /Juvenile Valproate, Lamotrigine, clobazam Good in childhood, slightly less for juvenile Hyperventilation

35. Jerk jerk

36. 7) Diagnosis Confirmatory test 3 therapeutic options

37. SSPE –burst suppression pattern CSF measles IgG Ribavarine, interferons, inosiplex, amantidine

38. 8) Diagnosis Commonest etiology Drug of choice

39. PLEDS Herpes encephalitis Acyclovir

40. 9) 6 yr old male admitted with prolonged generalised seizures. Immediate AEDs –name 2 with dose 2 nd line AEDs –2 with dose 3 rd line – name 2

41. Lorazepam [0.05mg/kg], Diazepam [0.3mg/kg], midazolam[ 0.2mg/kg] Phenytoin[ 20mg/kg], phenobarb[20/kg] Midazolam drip, propofol, thiopentol

42. 10) 6 months old child with h/o perinatal insult comes with regression of social milestones and clusters of startles on awakening . Diagnosis Name 2 investigations you will ask for?

43. Infantile spasms, West syndrome EEG, MRI Hypsarrhythmia ACTH / steroids, Vigabatrin, Valproate /Topiramate / Nitrazepam

44. Station No : A term newborn who required resuscitation at birth with a 5 minute APGAR of 5 is admitted in NICU. The neonate had seizures in first 12 hrs of life Identify the findings-[1] What is the significance of this finding- [1/2] Name of the staging system other than Sarnat and Sarnat and give its component- [1]

45. EEG of neonate showing Burst Suppression pattern It indicates serious outcome in HIE patients Levene’s staging system (Mild, Moderate and Severe) Consciousness Tone Seizures Sucking/Respiration