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In severe encephalopathy
First, high-amplitude irregular delta Lower amplitude below 20 V, invariant delta activity Suppression-burst pattern Electrocerebral inactivity (ECI)
Alternating pattern
Cyclic alteration of low-voltage irregular & high-voltage slow waves in coma with Cheyne-Stokes respiration Induce high-voltage slowing with stimulus during lowvoltage period, more aroused during slow-wave period May be due to pacemaker function of arousal system, temporarily released by cortical inhibition, or blood gas changes from respiratory center itself
Periodic spiking
Single or multiple spikes on a flat background activity, closely related to suppression-burst activity, but with higher repetition rate and less prominent or lacking slow waves Periodic spikes accompanied by myoclonic jerks, but no definite one-to-one relation to spikes
Burst-Suppression Pattern
Suppression-Burst Pattern
Monorhythmic Activity
Monorhythmic activity in coma patients
Normal-looking rhythmical activities in alpha range in deep coma Encountered in unresponsive conditions after brainstem lesions and in severe anoxic encephalopathy
Anoxic Encephalopathy
EEG in anoxic encephalopathy
EEG should be obtained at least 5 or 6 hours after cardiopulmonary resuscitation after stabilization To assess the severity of cerebral insult and for prognosis Normal or almost normal EEG after a short episode of cerebral anoxia
Hyperglycemia
EEG with mixed slow and fast frequency In advanced diabetic coma, pronounced slowing, indistinguishable from hypoglycemic state Focal epileptic seizures are more common in non-ketotic hyperglycemia, but possible in ketotic hyperglycemia
Triphasic Waves
Typical triphasic waves;
Medium- to high-voltage triphasic waves in rhythmical trains at 1.5 to 2.5 cycles/sec with sharp transients, bilaterally synchronous and symmetrical over both hemispheres Anterior-posterior time delay as an important criterion but observed with referential or transverse montages
Fairly characteristic of hepatic coma, but not specific Continuous triphasic waves considered a type of nonconvulsive status epilepticus in hepatic coma Also in hypoxic states, intoxication, other metabolic or sepsis-associated encephalopathy, subdural hematoma/brainstem infarction, cerebral carcinomatosis, preserved consciousness in Alzheimers disease, prion disease, unspecified demented states Confused with sharp and slow waves with absence status of Lennox-Gastaut syndrome
Triphasic Waves
Lennox-Gastaut Syndrome
Epileptic conditions
Prolonged coma in convulsive status epilepticus, in postictal states with lingering subclinical paroxysmal activity, in typical and atypical absence status, other types of nonconvulsive status epilepticus Prominent seizure activity, but EEG without spikes does not exclude epileptic nature and complicated by interspersed epileptic seizures in many coma patients
Creutzfeldt-Jakob Disease
Effect of stimulation
Good information about coma depth Blocking type of response is replaced by alerting type, and finally unreactive EEG even to repeated stimulation
Pathophysiology
Crucial mechanism is elevation of intracranial pressure, common final pathway, whatever the cause of coma Intensity of pathological changes depends on development of intracranial circulatory arrest
Absent spontaneous respiration, no respiration movements after removal from the respirator Apnea testing is necessary to confirm Absent spinal reflexes by Harvard criteria, but simple or complex spinal reflexes after initial phase of spinal shock due to total brain infarction down to C1 level Obscured EEG by very-low-amplitude fast activity due to sustained contraction of scalp muscles should be ruled out by giving a short-acting neuromuscular blocking agent (succinylcholine 20-40 mg IV)
FP2-T4
Cz-Oz