Electroencephalography (EEG) - A Detailed Overview

1. History and Basic Concept

• Adams and Victor's Principles of Neurology, 12th Ed.
• Eric Kandel - Principles of Neural Science, 6th Ed.

2. Technical Setup

Electrodes

• Silver or silver-silver chloride discs, ~0.5 cm in diameter, placed on the scalp with a conductive medium
• Modern EEG machines: 8 to 32+ amplifying channels recording simultaneously
• Frequency range displayed: 0.5 to 30 Hz at standard paper speed of 3 cm/s
• Amplitude range: 20 to 100 µV typically
• Signal displayed as voltage-versus-time; negative voltage deflects upward, positive downward by convention

The International 10-20 System

• Fp - frontopolar
• F - frontal
• C - central
• P - parietal
• O - occipital
• T - temporal
• z suffix - midline electrodes (Fz, Cz, Pz)
• Odd numbers = left hemisphere; even numbers = right hemisphere

Montages

1. Bipolar montage: each channel records the voltage difference between two adjacent electrodes - helps localize focal abnormalities
2. Referential (common reference) montage: each electrode is compared to a common reference point - better for amplitude comparison across the scalp

3. Normal EEG Patterns

The Four Core Rhythms

• Most intense in the occipital region
• Waxes and wanes spontaneously
• Attenuated or suppressed by eye opening or mental effort ("alpha blocking")
• Frequency is almost invariant for a given individual, though it slows with aging
• Benzodiazepines and sedating drugs increase beta-frequency activity prominently
• Guyton and Hall Textbook of Medical Physiology
• Adams and Victor's Principles of Neurology, 12th Ed.

4. Sleep EEG

• Kaplan & Sadock's Synopsis of Psychiatry
• Costanzo Physiology, 7th Ed.

5. Activating Procedures

1. Hyperventilation: 20 breaths/min for 3 minutes - lowers pCO₂, causes cerebral vasoconstriction, enhances absence seizure patterns (3 Hz spike-and-wave). Normal children may show "buildup" (delta) activity during HV, which stops after.
2. Photic stimulation (intermittent phased light): flashing strobe at various frequencies (1-30 Hz). A photic driving response is normal. Abnormal responses include:
   • Photomyoclonic response: myoclonic jerks during stimulation
   • Photoparoxysmal response: epileptiform discharges that outlast the stimulus
   • Photoconvulsive response: full seizure triggered; seen in alcohol/sedative withdrawal
3. Sleep deprivation: 24 hours of deprivation can activate paroxysmal discharges in susceptible patients
4. Sleep (natural or sedated): widens the recording window for epileptiform activity

6. Abnormal EEG Patterns

Focal Slowing

• Delta waves (1-3 Hz, focal): indicate a destructive cortical lesion - tumor, infarct, abscess, subdural hematoma, encephalitis
• Theta waves (4-7 Hz, focal or diffuse): less severe but still pathological when prominent during wakefulness
• Large acute middle cerebral artery infarctions produce large areas of focal slowing; lacunar or brainstem infarcts often leave the surface EEG normal despite clinical deficits

Generalized Slowing

• Metabolic encephalopathies: uremia, hepatic coma, hypoglycemia, anoxia, hypercapnia
• Severity of slowing generally correlates with depth of impaired consciousness
• Triphasic waves (bilaterally synchronous high-amplitude sharp triphasic waves, frontally predominant): characteristic of hepatic encephalopathy (also seen in renal/pulmonary failure, acute hydrocephalus)

Epileptiform Patterns

• Spike: transient high-voltage waveform, pointed peak, duration 20-70 ms
• Sharp wave: similar morphology, duration 70-200 ms
• Spike-and-wave complex: 3 Hz = typical absence epilepsy (petit mal)
• Polyspike-and-wave: myoclonic epilepsy syndromes
• Focal spikes/sharp waves: focal (partial) epilepsy

• In 30% of patients with absence epilepsy and 50% with generalized tonic-clonic epilepsy, a single interictal EEG is normal
• 30-40% of epilepsy patients have nonspecifically abnormal records between seizures
• Antiepileptic drugs can mask interictal abnormalities
• A completely normal EEG during a clinical convulsion strongly suggests psychogenic nonepileptic seizure (PNES)

Burst-Suppression

• Alternating periods of EEG activity (bursts of sharp/irregular delta) and flat isoelectric periods
• Seen with severe anoxic brain injury, deep anesthesia, severe metabolic derangement

Electrocerebral Silence (Isoelectric EEG)

• Complete absence of EEG activity
• Component of the diagnosis of brain death, but must be interpreted carefully:
  • Can be mimicked by deep sedation with barbiturates, profound hypothermia, or hypothyroid coma
  • Not sufficient alone for brain death determination - clinical criteria must also be met

Periodic Discharges

• Periodic sharp wave complexes at 1-3/second in temporal regions: strongly suggest herpes simplex encephalitis
• Periodic bisynchronous sharp wave bursts: almost pathognomonic of Creutzfeldt-Jakob (prion) disease
• SSPE (subacute sclerosing panencephalitis): also shows periodic high-amplitude sharp wave bursts

Alpha Coma

• EEG shows apparent 8-12 Hz alpha-like activity distributed broadly (not just posteriorly)
• Different from normal alpha - slightly variable in frequency
• Usually a transitional pattern after global anoxia, or with large acute pontine lesions; carries poor prognosis

Breach Rhythm

• Focal fast (beta) activity over a skull defect (bone acts as a high-frequency filter; its absence allows abundant cortical fast activity to pass through)
• Adams and Victor's Principles of Neurology, 12th Ed.
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry

7. Clinical Applications

Epilepsy

Encephalopathy Assessment

• Quantifies severity and tracks progression of metabolic, toxic, and inflammatory brain diseases
• Useful in distinguishing delirium from psychiatric disease (normal EEG in functional/psychiatric states)

Coma Evaluation

• Differentiates nonconvulsive status epilepticus (NCSE) from other causes of impaired consciousness
• Grading of coma severity
• Prognostication after cardiac arrest (burst suppression or flat EEG = poor prognosis)

Sleep Medicine

• Polysomnography uses EEG together with EOG, EMG, and respiratory sensors to characterize sleep architecture
• Diagnoses REM sleep behavior disorder, narcolepsy, nocturnal epilepsy

Intraoperative Monitoring

• Monitors cerebral perfusion during carotid endarterectomy and cardiac surgery
• Processed EEG (bispectral index [BIS], others) used to assess depth of anesthesia

Specific Diseases

• Herpes simplex encephalitis: periodic temporal sharp waves at 1-3/second - supports early treatment decision
• Creutzfeldt-Jakob disease: periodic bisynchronous sharp wave complexes - important adjunctive test
• Hepatic encephalopathy: triphasic waves
• Brain death determination: isoelectric EEG as ancillary test

EEG-Based Brain-Computer Interfaces (BCI)

8. Limitations

• Spatial resolution is poor: scalp EEG averages activity from millions of neurons and cannot record from deep structures (hippocampus, amygdala, thalamus, brainstem) directly
• Deep foci (medial temporal, orbital frontal) may produce seizures without visible scalp EEG changes
• Temporal resolution is excellent (millisecond scale)
• A normal interictal EEG does not exclude epilepsy - up to 50% of grand mal epilepsy patients have a normal single EEG
• Interpretation requires significant expertise; artifacts (movement, ECG, eye blink) can mimic pathology
• EEG has largely been replaced by MRI/CT for structural lesion localization

9. Variants and Extended Techniques

10. EEG in Relation to Drug Effects

• Kaplan & Sadock's Synopsis of Psychiatry

Stages of the Sleep Cycle

1. Overview and Measurement

1. EEG (electroencephalogram) - brain wave patterns
2. EOG (electro-oculogram) - eye movement activity
3. EMG (electromyogram, surface chin/leg electrodes) - muscle tone

• Adams and Victor's Principles of Neurology, 12th Ed.
• Harrison's Principles of Internal Medicine, 22nd Ed.

2. Stage W - Wakefulness

• Eyes beginning to droop and slow, roving lateral eye movements appearing
• Pupils constricting
• Muscles relaxing progressively
• Alpha waves dropping out and replaced by low-voltage mixed-frequency activity

3. Stage N1 - Light NREM Sleep

• Loss of alpha waves
• Low-voltage, mixed-frequency activity (predominantly theta, 4-7 Hz)
• Vertex sharp waves may appear at central electrode sites (Cz), especially in younger individuals

• Blood pressure begins to fall slightly
• Body temperature begins to decrease
• Heart rate slows slightly

4. Stage N2 - Intermediate NREM Sleep

1. Sleep spindles - bursts of 12-14 Hz waxing-and-waning activity lasting 0.5-2 seconds; maximal over biparietal/central regions; generated by thalamocortical circuits (thalamic reticular nucleus gating)
2. K-complexes - high-amplitude, biphasic (negative sharp wave followed by slow positive deflection) complexes at central-parietal regions; can be triggered by external stimuli or occur spontaneously; thought to represent a cortical response suppressing arousal

• Blood pressure and heart rate progressively lower
• Body temperature drops further
• Sleep bruxism (teeth grinding) and sleep talking can occur in N2
• Most sleepwalking actually originates from N2/N3 transitions

5. Stage N3 - Slow-Wave Sleep (Deep NREM / SWS)

• Delta waves (0.5-2 Hz, >75 µV amplitude) comprising ≥20% of the EEG (some guidelines say ≥20% of a 30-second epoch)
• High-voltage, synchronized slow activity
• Sleep spindles and K-complexes disappear

• Hardest stage to arouse from - stimuli that would easily wake someone from N1 or N2 may fail here
• If aroused from N3, the person typically feels disoriented and groggy for several minutes ("sleep inertia")
• Parasomnias arising from N3: sleepwalking (somnambulism), sleep terrors, confusional arousals, and sleep-related eating disorder - the person is partially awake and partially in deep sleep

• Blood pressure falls 10-20% below daytime values
• Heart rate at its lowest
• Respiratory rate slow and regular
• Basal metabolic rate decreases ~10-30%
• Growth hormone (GH) - the largest secretory pulse of the night occurs in the first N3 episode; SWS is the primary driver of GH release
• Immune restoration - cytokine release and immune function consolidation
• This is the most restorative form of sleep; sleep deprivation causes selective N3 rebound on recovery nights

6. Stage R - REM Sleep (Rapid Eye Movement / Paradoxical Sleep)

• Low-voltage, mixed-frequency, desynchronized - similar to wakefulness or N1
• Sawtooth waves (2-6 Hz notched waves) may appear, often preceding bursts of rapid eye movements
• Called "paradoxical sleep" because the EEG looks awake while the person is behaviorally asleep

1. Active dreaming - complex, narrative, emotionally vivid dreams occur predominantly during REM; subjects awakened during REM recall dreams most consistently
2. Muscle atonia - brainstem-mediated inhibition of spinal motor neurons; serves to prevent acting out dreams (failure = REM sleep behavior disorder)
3. Autonomic instability - heart rate and respiration become irregular, unlike the regularity of NREM
4. Penile/clitoral tumescence occurs in REM; used clinically to distinguish psychogenic from organic erectile dysfunction (nocturnal penile tumescence testing)
5. Brain metabolism increases up to 20% above wakefulness levels in some areas
6. Increased arousal threshold - paradoxically, despite active EEG, REM can be harder to arouse from than NREM
7. Temperature dysregulation - poikilothermy (body temperature follows environmental temperature rather than being actively regulated)

• Memory consolidation - particularly procedural and emotional memories; learning and synaptic plasticity
• Emotional processing - threat simulation theory; amygdala highly active
• Neural development - explains why newborns spend ~50% of sleep in REM (high plasticity period)

7. The Ultradian Sleep Cycle

1. Sleep onset → N1 → N2 → N3 (rapid descent in 45-60 min)
2. First REM episode at ~90 minutes, usually brief (5-10 min)
3. NREM-REM cycle repeats 4-6 times per night with ~90-100 minute periodicity ("ultradian rhythm")
4. Early night is dominated by N3 (deep NREM)
5. Late night is dominated by REM (REM episodes grow longer; N3 may be absent)
6. Brief awakenings from lighter NREM or REM during the night are normal and usually not recalled

8. Sleep Across the Lifespan

9. Neural Control of Sleep

Process S - Homeostatic Sleep Pressure

• Adenosine accumulates in the basal forebrain during wakefulness and acts as a sleep-promoting substance
• Adenosine levels rise proportionally with waking duration and fall during sleep
• Caffeine works by blocking adenosine receptors (A1 and A2A), thereby preventing the sleepiness signal

Process C - Circadian Timing

• The suprachiasmatic nucleus (SCN) of the anterior hypothalamus is the master pacemaker
• Entrains to light-dark cycle via the retinohypothalamic tract
• Controls nocturnal release of melatonin from the pineal gland (darkness triggers release; light suppresses it)
• Melatonin signals "biological night" and promotes sleep onset

The Flip-Flop Switch

• Locus coeruleus (norepinephrine)
• Dorsal raphe (serotonin)
• Tuberomammillary nucleus (histamine) - explains why antihistamines cause drowsiness
• Pedunculopontine/laterodorsal tegmental nuclei (acetylcholine)

• Ventrolateral preoptic nucleus (VLPO) of the hypothalamus - releases GABA and galanin to inhibit all wake-promoting centers

REM Generation

• Adams and Victor's Principles of Neurology, 12th Ed.
• Guyton and Hall Textbook of Medical Physiology
• Harrison's Principles of Internal Medicine, 22nd Ed.

10. Physiological Summary Table

Chemical Mediators of Sleep

The Big Picture: Two Drives, One Switch

• Process S (Homeostatic): adenosine accumulates during wakefulness, building sleep pressure
• Process C (Circadian): the suprachiasmatic nucleus (SCN) drives a ~24-hour alternating wake/sleep signal modulated by light and melatonin

I. SLEEP-PROMOTING MEDIATORS

1. GABA (gamma-aminobutyric acid)

• During sleep, VLPO GABAergic neurons fire and release GABA + galanin onto all the major wake-promoting nuclei: the tuberomammillary nucleus (TMN), locus coeruleus (LC), dorsal raphe, ventral tegmental area (VTA), pedunculopontine/laterodorsal tegmental nuclei (PPT/LDT), and the basal forebrain
• This inhibition silences the arousal system and allows sleep to proceed
• GABA acts on GABA-A receptors (ionotropic Cl⁻ channels) → neuronal hyperpolarization → suppression of arousal

• Stahl's Essential Psychopharmacology
• Eric Kandel - Principles of Neural Science, 6th Ed.

2. Galanin

• Released alongside GABA from VLPO neurons during sleep
• Acts on galanin receptors (GalR1, GalR2) - inhibitory Gi-coupled GPCRs
• Reinforces the inhibitory silencing of TMN histaminergic neurons
• Also promotes REM sleep suppression mechanisms

3. Adenosine

• Adenosine levels rise proportionally with duration of wakefulness
• Acts on A1 receptors on wake-promoting neurons → direct inhibition (hyperpolarization)
• Acts on A2A receptors on neurons in the nucleus accumbens shell and other regions → indirect disinhibition of VLPO, allowing sleep-promoting circuits to activate
• The resulting VLPO disinhibition promotes GABA release, which then silences arousal systems
• Adenosine levels fall during sleep as they are cleared - representing restoration of homeostatic sleep pressure

• Stahl's Essential Psychopharmacology
• Ganong's Review of Medical Physiology, 26th Ed.

4. Melatonin

• Secretion is triggered by darkness and suppressed by light (especially blue-spectrum, 480 nm)
• Light input travels via the retinohypothalamic tract → SCN → superior cervical ganglion (sympathetic) → pineal gland
• In humans, melatonin rises sharply ~2 hours before habitual bedtime ("dim-light melatonin onset", DLMO), peaks in the middle of the night, and falls before morning awakening

• Acts on MT1 and MT2 receptors (Gi-coupled GPCRs) in the SCN and other brain regions
• MT1 activation: inhibits SCN neuronal firing → reduces the wake-promoting circadian signal
• MT2 activation: phase-shifts the circadian clock, mediating the entraining effects of light/dark cycles
• Does not directly cause sleep but lowers the threshold for sleep onset by suppressing circadian wakefulness promotion

• Exogenous melatonin is used for jet lag, shift-work disorder, and delayed sleep phase syndrome
• Ramelteon (MT1/MT2 agonist) is an FDA-approved hypnotic that targets this system
• Tasimelteon used for non-24-hour sleep-wake disorder in blind individuals

5. Melanin-Concentrating Hormone (MCH)

• Produced by neurons in the lateral hypothalamus and zona incerta
• Inhibitory neuropeptide that promotes sleep, particularly REM sleep
• MCH neurons are active during sleep and nearly silent during wakefulness
• Work alongside VLPO to suppress arousal; MCH neuron ablation reduces REM sleep in animal models

6. Prostaglandin D₂ (PGD₂)

• A prostaglandin produced in the brain, particularly in the subarachnoid space overlying the basal forebrain
• Levels rise during prolonged wakefulness and fever
• Acts on DP1 receptors on leptomeningeal cells, triggering adenosine release → secondary sleep promotion
• Explains the somnolence associated with infection/inflammation; also the mechanism by which aspirin/NSAIDs (PG synthesis inhibitors) can mildly impair sleep in some individuals

7. Cytokines (IL-1β and TNF-α)

• Interleukin-1β and tumor necrosis factor-α are somnogenic - they promote NREM/slow-wave sleep
• Released during immune activation (explaining sickness-induced sleepiness)
• Levels show circadian variation, peaking during sleep onset
• Promote N3 (slow-wave) sleep via direct effects on the VLPO and adjacent circuits
• Part of the brain's mechanism linking immune status to sleep-wake behavior

II. WAKE-PROMOTING MEDIATORS

8. Orexin / Hypocretin

• Orexin A (33 amino acids) - binds both OX1R and OX2R
• Orexin B (28 amino acids) - binds selectively to OX2R

• OX1R: coupled to intracellular Ca²⁺ increase + Na⁺/Ca²⁺ exchanger activation
• OX2R: increases NMDA glutamate receptor expression + inactivates GIRK channels

• Stimulates acetylcholine release from basal forebrain (→ cortical arousal) and PPT/LDT (→ thalamic activation)
• Drives dopamine release from VTA (→ motivation, reward, wakefulness)
• Promotes norepinephrine release from locus coeruleus (→ arousal, attention)
• Increases serotonin release from raphe nuclei (→ wakefulness)
• Increases histamine release from TMN (→ cortical/thalamic arousal)
• Together these create robust, stable wakefulness

• Fragmented, unstable wakefulness → excessive daytime sleepiness
• Intrusion of REM components into wakefulness:
  • Cataplexy (sudden muscle atonia triggered by strong emotion)
  • Sleep paralysis (REM atonia persisting into awakening)
  • Hypnagogic/hypnopompic hallucinations (dream imagery at sleep onset/offset)
• CSF orexin A levels <110 pg/mL are diagnostic

• Stahl's Essential Psychopharmacology
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry

9. Histamine

• TMN neurons are maximally active during wakefulness, slow during NREM, and nearly silent during REM
• Histamine projects to the prefrontal cortex, basal forebrain, thalamus, and all brainstem arousal centers
• Acts on H1 receptors (Gq) → depolarization of thalamic and cortical neurons → maintained wakefulness
• H1 antagonism (first-generation antihistamines: diphenhydramine, doxylamine) causes marked sedation - explaining their use as OTC sleep aids
• H3 receptors are autoreceptors on TMN neurons: H3 agonism reduces histamine release (used in treatment of narcolepsy/hypersomnia, e.g., pitolisant is an H3 inverse agonist)

10. Norepinephrine (Noradrenaline)

• LC neurons fire at highest rates during active wakefulness (especially during novelty, stress, attention)
• Firing decreases during quiet wakefulness and NREM sleep
• Nearly completely silent during REM sleep - a defining feature

• Activates α1-adrenergic receptors (excitatory) and β-receptors on cortical neurons → promotes arousal and cognitive alertness
• Inhibits VLPO neurons via α2-adrenergic autoreceptors (negative feedback)
• Drives orexin release during active states

• Atomoxetine (NE reuptake inhibitor): promotes wakefulness; used in narcolepsy
• Clonidine (α2 agonist): reduces LC firing → sedation, used for ADHD/anxiety
• Antidepressants (TCAs, SNRIs) that increase NE → suppress REM sleep (explaining reduced REM% in patients on these drugs)

11. Serotonin (5-HT)

• Most active during wakefulness
• Reduced during NREM
• Nearly silent during REM sleep (like LC)

• Serotonin promotes wakefulness via 5-HT2A receptors on cortical neurons
• Simultaneously inhibits REM-generating cholinergic neurons in the PPT/LDT
• Activates wake-promoting basal forebrain cholinergic neurons (different population from REM-ACh)
• Orexin drives serotonin release to maintain daytime wakefulness

• SSRIs and SNRIs increase serotonin → suppress REM sleep, reduce REM% (causing REM rebound on discontinuation)
• Trazodone (5-HT2A antagonist/SRI): promotes sleep, widely used as a hypnotic at low doses
• Mirtazapine (5-HT2A/5-HT3 + H1 antagonist): promotes deep NREM sleep, increases appetite

12. Dopamine

• Dopamine reuptake transporter (DAT) blockade by modafinil and armodafinil is one mechanism behind their wake-promoting effects (though their full mechanism includes multiple targets)
• Amphetamines promote wakefulness partly via massive dopamine (and NE) release
• Dopamine D2 agonists (used in Parkinson's) can cause sudden sleep attacks

13. Acetylcholine (ACh)

1. Pedunculopontine nucleus (PPT) and laterodorsal tegmental nucleus (LDT) - pontine cholinergic cells - primarily drive REM sleep
2. Basal forebrain cholinergic neurons (nucleus basalis of Meynert, medial septal nucleus) - primarily drive cortical arousal (wakefulness and REM)

• As monoaminergic (NE + serotonin) firing ceases at the NREM-REM transition, the cholinergic "REM-on" neurons in PPT/LDT become disinhibited
• ACh is released in the pontine reticular formation → generates the pontine-geniculate-occipital (PGO) waves that precede and accompany REM
• ACh from PPT/LDT activates thalamic relay neurons → desynchronized EEG (paradoxical wakefulness pattern)
• Descending ACh projections activate the REM atonia circuit via glutamatergic neurons in the sublaterodorsal area → inhibitory interneurons in the medulla/spinal cord hyperpolarize motor neurons

• Cholinergic agonists (physostigmine, pilocarpine): promote REM sleep; can trigger REM-onset nightmares
• Cholinergic antagonists (scopolamine, atropine): suppress REM sleep
• REM sleep behavior disorder (RBD): failure of REM atonia (loss of sublaterodorsal neurons) → patients physically act out vivid dreams; early marker of Lewy body disease/Parkinson's

III. SUMMARY TABLE

IV. The Homeostatic-Circadian Interaction

1. Adenosine accumulates in the basal forebrain → progressive disinhibition of VLPO
2. The SCN's circadian wake-promoting signal (partly orexin-driven) counteracts adenosine during the day - explaining afternoon alertness despite hours awake
3. In the early evening, SCN wake-promotion wanes, and unmasked adenosine tips the balance toward sleep
4. Melatonin is released ~2 hours before bedtime, suppressing SCN firing and facilitating the transition
5. VLPO fires → GABA floods all wake centers → sleep begins
6. During sleep, adenosine clears → homeostatic debt repaid
7. Near morning, circadian promotion of sleep occurs (prevents premature awakening), then light suppresses melatonin and SCN ramps up wakefulness signals → awakening

• Stahl's Essential Psychopharmacology
• Ganong's Review of Medical Physiology, 26th Ed.
• Eric Kandel - Principles of Neural Science, 6th Ed.
• Adams and Victor's Principles of Neurology, 12th Ed.

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