METHOD OF TRACE INTERPRETATION

I. IMPEDANCE
II. BACKGROUND
III. PRESENCE OF SEIZURE

I. IMPEDANCE (aEEG) evaluation of the quality of the EEG trace

- Measured in OHMS
- Reflects how well head leads are receiving the brain voltage meas.
- Affected by : poor scalp prep, poorly adhesive leads, scalp edema etc
- As resistance meas. , accuracy of trace .

GOOD IMPEDANCE consistent value with very resistance (<5 ohms).

- Displayed as very flat line as close to 0 ohms as possible
- Displayed on white background
- Impedance <5 ohms best standard in NICU

WORSENING IMPEDANCE as impedance , quality of trace meas. .

- On CFM, impedance graph may show wandering line upwards that may or
may not show vertical spikes (muscle artifact or lead isturbances)
- Displayed on colored background
- Impeadance 5-10 ohms considered acceptable.
- Impedance >10 ohms very poor and is unreliable for aEEG background
and seizure interpretation may require maintenance or changing by the
operator
- Yellow impedance 5-10 ohms
- Red >10 ohms

II. BACKGROUND refers to compressed, global, summary of a raw EEG meas. over a period
of
hours.
- Cerebral Fxn Monitoring (CFM) uses 3 leads and produces one aEEG for
the entire brain.
- Brainz monitoring 5 leads and produces 2 aEEG

5 Backgrounds:
II.a. Continuous Normal Voltage (CNV)
II.b. Discontinuous Normal Voltage (DNV)
II.c Continuously Extremely Low Voltage (CLV)
II.d. Burst Suppression (BS)
II.e. Isoelectric or Flat

Sleep Wake Cycling (SWC) characteristic of normal, brain activity.

- Appear in both CNV and DNV backgrounds
- HIE return of SWC good prognostic outcome for neurological recovery

A. Continuous Normal Voltage (CNV) assoc. with normal brain fxn

-SWC often observed in this background
- shows voltage variability up and down and that
overall amplitude (ht) is reasonably narrow
- 5-10 rule minimum voltages of the lower and
upper margins of the trace
- lower margin will remain above 5 microvolts and
upper margin will remain above 10 micro volts.
 B. Discontinuous Normal Voltage (DNV) assoc with moderately abnormal
electrophysiological
brain fxn.
- SWC absent in background
- key feature: aEEG band is a large amplitude (ht) that is
quite wide
- the lower margin will remain below 5 micro volts and the
upper
margin will remain above 10micro volts.
-Anticonvulsant can transform CNV into a DNV in early hrs
of admin

C. Continuous Low Voltage (CLV) assoc with severely abnormal

electrophysiological brain fxn
-SWC absent
- key feature: tiny amplitude (ht) that is very narrow aEEG
- lower margin <5microvolts; upper margin
<10microvolts

D. Burst Suppression (BS) assoc. with severe abnormal electrophysiological brain

fxn
-SWC absent
- key feature: aEEG band short, large amplitude bursts of
electrical activity (>25 uV)
- lower margin below 10microvolts
- severity of BS is characterized by the number of bursts
per hour.
- lower # of bursts (<150 bursts/hr) more severe
comprared to large number of bursts (>150 bursts/hr)

E. FLAT or ISOELECTRIC worst background

- absent brain acivity; flat line

III. SEIZURE TYPES

- Early seizure detection in pts clinical course can go a long way towards early tx and
early prognosis and outcome
- Note characteristic of seizure:
- presence
- frequency
- duration
- size
- coupling with clinical sx ( in VS, apnea, desat, etc)
- Seizure types: Single, Repetitive, Status Epilepticus, Unilateral

A. SINGLE SEIZURES
- Linked to variety of pathologies
- May appear on CFM from 10secs to in excess of an hr

B. REPETITIVE SEIZURES
- Linked to several neuro pathologies
- Ranges in freq, duration and coupling with clinical sx

C. STATUS EPILEPTICUS
 - Linked to HIE, electrolyte imbalance, hypoglycemia or inborn errors of
metabolism
- Sawtooth pattern on aEEG trace

D. UNILATERAL SEIZURES
- In 5 leads aEEG (Brainz), seizure may occur on one side of the brain only
(ie. IVH)

FINDING SEIZURES
1. FINDING AN AREA OF INTEREST
- Look for key features: sudden in the lower margin, accompanied by
corresponding in upper margin
- Ie. In single large sz, where a wide amplitude aEEG is apparent, this is easily
identifiable.
Ie. Several small sz, that are close together in proximity, and in more suppressed
aEEG band more difficult to to identify

2. REFFERING TO EEG STRIP

- Review raw EEG strip at that point in time
- Ensure EEG trace is available on screen and tap the aEEG strip on the area of
interest, you can use the direction arrows

3. SCROLLING FOR REPITITIVE PATTERN

- Sz appear as repitiive form; not all look exactly the same
- Sometimes will transform from one distinct pattern to another distinctive pattern
to another distinct pattern over the course of one large seizure
- Key: repetition

4. ADJUSTING THE EEG SCALES

- In case of low amplitude sz in CVL backgrounds, it may be helpful to adjust the
(time) scale of the EEG voltage, or speed, to enhance repeating pattern.

ARTEFACTS
- Can appear as seizure
- Artefacts from: ECG, pulse artefact, HFV

A. ECG
- To differentiate ECG vs aEEG: match the HR on VS monitor
- Seizure repeitions are usually a lot slower and the waveforms are a lot wider than
QRS complexes
- Amplitude of sz waves are often a lot larger than their QRS counterparts.
- There is no sharp in the lower margin that is typical of a seizure

B. Pulse Artefact
- Arterial pulses in the head may appear on the raw EEG as another form of
repetitive wave
- There is no sharp in the lower margin that would be indicative of a regular
seizure event

C. HFV
- High frequency ventilation can produce vibration of the head in a pt with a
profound shake.
- On EEG, shaking will produce a fine, repetitive pattern too fast to be seizures
- Determine the set frequency of the HFO or HFJV being used
 Aeeg NAVIGATION

I. NAVIGATING THE SCREENS

-CFM and Brainz monitors are very similar in their fxn, capabilities and display

BRAINZ
Patient ID number
Signal Indicator gives summary of impedance level for the leads;
- Help Yellow impedance 5-10ohms
- Red- impedance >10 ohms
- Confirms that the machine is actively recording data
Time display designate to show present time on Brainz
EEG strip there are 2 raw EEGs on the Brainz that represent the left and right
hemisphere of the brains electrical activity.
EEG voltage scale 2 buttons that allow the user to change the voltage scale (y
axis) of the Brainz EEG strip.
aEEG strips 2 aEEGs that represent the left and right hemispheres of the brains
electrical activity
Time Axis along the X-axis of Brainz display. You can view 3 hours of time along
the length of the aEEG strip at any single moment
Check Signal used to troubleshoot the lead impedance on the Brainz
- Green- lowes and most accurate impedance range at 0-5 ohms
- Yellow - slightly higher impedance and has more marginal accuracy range
at 5-10 ohms
- Red indicates very poor quality trace with high impedance >10ohms
and requires lead maintenance by the user
Change Display allows the user to toggle between different main screen
appearances on the Brainz
- The CFM only displays the aEEG trace along with one of the impedance or
EEG strips

Tools allows the user to complete some advanced fxns such as file management
Record Toggle both starts and stops the active aEEG recording on the Brainz
Help Menu quick guide

CFM
Prin Button allows access to the print fxn menus and operations on the CFM
- Brainz does not have printing capability

Demographic Data Label pts name, ID number, date of birth

Recording Indicator will be present when aEEG is actively recording on the cfm.
- If green signal not present no recording is being done.
Date/Time
aEEG strip single aEEG strip shown on the CFM display
 Time Axis along the x-axis of the CFM display; shows 3 hours of aEEG trace at any
single moment
Scroll Bar and arrows CFM does not have a specific review assessment mode.
- Scroll bar and arrows positioned in between the 2 strips allow the user
to review the aEEG strip, impedance and EEG strip at any point during
the recording from the main screen
- Arrows located below the EEG strip allow for reviewing of the EEG strip
- Playbackyellow-not present, live recording
Impedance Strip - CFM uses a single impedance strip that tells user about the
quality of the aEEG strip located above it in the display; does not use color indicator
system (Brainz-green,yellow,red)
Record Toggle starts and stop the active aEEG recording
Markers button triggers the marking fxn allowing the user to place descriptive tags
on aEEG trace
- Can be chosen from pick list or typed in on an input line
II. REVIEWING aEEG and EEG STRIPS