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April 14, 2015; 84 (15) Resident and Fellow Section

Teaching NeuroImages: A broadly distributed ictal rhythm easily missed on bipolar montage

“Now you see it…”

Rup K. Sainju, Jeremy J. Moeller, Lawrence J. Hirsch
First published April 13, 2015, DOI: https://doi.org/10.1212/WNL.0000000000001463
Rup K. Sainju
From the Comprehensive Epilepsy Program (R.K.S.), Department of Neurology, University of Iowa College of Medicine, Iowa City; and the Yale Comprehensive Epilepsy Center (J.J.M., L.J.H.), Department of Neurology, Yale University School of Medicine, New Haven, CT.
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Jeremy J. Moeller
From the Comprehensive Epilepsy Program (R.K.S.), Department of Neurology, University of Iowa College of Medicine, Iowa City; and the Yale Comprehensive Epilepsy Center (J.J.M., L.J.H.), Department of Neurology, Yale University School of Medicine, New Haven, CT.
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Lawrence J. Hirsch
From the Comprehensive Epilepsy Program (R.K.S.), Department of Neurology, University of Iowa College of Medicine, Iowa City; and the Yale Comprehensive Epilepsy Center (J.J.M., L.J.H.), Department of Neurology, Yale University School of Medicine, New Haven, CT.
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Citation
Teaching NeuroImages: A broadly distributed ictal rhythm easily missed on bipolar montage
“Now you see it…”
Rup K. Sainju, Jeremy J. Moeller, Lawrence J. Hirsch
Neurology Apr 2015, 84 (15) e115-e116; DOI: 10.1212/WNL.0000000000001463

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A 23-year-old woman was admitted for brief, recurrent spells of intense fear and visual hallucinations. During video-EEG study, one of the spells showed no definite ictal EEG changes on longitudinal bipolar montage for 26 seconds while evolving rhythmic discharges were readily visible on Cz reference. Because the pattern was evenly distributed in the temporal region at onset (figure), it “canceled out” in the bipolar montage.1 It is conceivable that a shorter seizure would have been missed if reviewed only in bipolar montage. Hence, this case is a reminder of why EEG should be reviewed in bipolar and referential montages before concluding that a spell has no EEG correlate.

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Figure EEG findings

Onset of evolving rhythmic discharges (red arrows) in Cz reference (A) and in anteroposterior bipolar (B) montages.

AUTHOR CONTRIBUTIONS

Rup K. Sainju: collection of data, interpretation of data, and drafting manuscript. Jeremy Moeller: interpretation of data and revision of the manuscript. Lawrence J. Hirsch: conceptualization of the study, interpretation of data, and revision of the manuscript.

STUDY FUNDING

No targeted funding reported.

DISCLOSURE

R. Sainju reports no disclosures relevant to the manuscript. J. Moeller reports speaker fees from UCB-Pharma and Serono and royalties from UpToDate, Inc. L. Hirsch reports research support for investigator-initiated studies from UCB-Pharma, Upsher-Smith, and Lundbeck; consultation fees for advising from Lundbeck, Upsher-Smith, Neuropace, Natus, and Allergan; and royalties for authoring chapters for UpToDate Neurology and for coauthoring Atlas of EEG in Critical Care, by Hirsch and Brenner, 2010. Go to Neurology.org for full disclosures.

Footnotes

  • Download teaching slides: Neurology.org

  • © 2015 American Academy of Neurology

REFERENCE

  1. 1.↵
    1. Scherg M,
    2. Ille N,
    3. Bornfleth H,
    4. et al
    . Advanced tools for digital EEG review: virtual source montages, whole-head mapping, correlation and phase analysis, J Clin Neurophysiol 1999;19:91–112.
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