Avoiding the pitfalls of EEG interpretation in childhood epilepsy

The accurate interpretation of the electroencephalogram (EEG) of infants and children being evaluated for suspected epilepsy is based on the appreciation of normal and expected age-dependent characteristics, an awareness of the significance of both epileptiform and non-epileptiform activity, and the correlation of epileptiform abnormalities with clinical findings. Avoiding the pitfalls of pediatric EEG interpretation include the recognition of such normal EEG features in wakefulness as posterior slow waves of youth, mu rhythm, and lambda waves. In addition, the understanding of age-dependent characteristics of EEG state-changes is essential, such as: monorhythmic and paroxysmal hypnagogic hypersynchrony, special features of vertex transients and sleep spindles, positive occipital sharp transients, initial arousal responses and post-arousal hypersynchrony. The EEG response to activation procedures such as hyperventilation and photic stimulation may also be a source of confusion. Patterns of uncertain diagnostic significance also may be present in children, including 14- and 6-Hz bursts and rhythmic temporal theta bursts of drowsiness (the so-called psychomotor variant). Some nonepileptiform EEG abnormalities may also be misinterpreted as epileptiform. The determination of the clinical significance of spike foci and generalized abortive spike-and-wave may pose more of a problem as a potential pitfall than the identification by visual analysis of these interictal discharges. Another problem posed to the electroencephalographer is the determination of the EEG response to antiepileptic drug therapy including effect on spike foci, generalized spike-and-wave and electrical seizure activity, and effect on background activity. The recognition of the differences between the EEG of children and adults will provide the basis for more accurate interpretation and assist the electroencephalographer in avoiding the identification of normal, age-dependent features as epileptiform.