Overview

The electroencephalogram (EEG) is the depiction of the electrical activity occurring at the
surface of the brain. This activity appears on the screen of the EEG machine as waveforms of
varying frequency and amplitude measured in voltage (specifically microvoltages).

EEG waveforms are generally classified according to their frequency, amplitude, and shape, as
well as the sites on the scalp at which they are recorded. The most familiar classification uses
EEG waveform frequency (eg, alpha, beta, theta, and delta). [1, 2, 3]

Examples of alpha, beta, theta, and

delta electroencephalography frequencies.
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Information about waveform frequency and shape is combined with the age of the patient, state
of alertness or sleep, and location on the scalp to determine significance.

Normal EEG waveforms, like many kinds of waveforms, are defined and described by their
frequency, amplitude, and location. [4]

 Frequency (Hertz, Hz) is a key characteristic used to define normal or abnormal EEG
rhythms.
 Most waves of 8 Hz and higher frequencies are normal findings in the EEG of an awake
adult. Waves with a frequency of 7 Hz or less often are classified as abnormal in awake
adults, although they normally can be seen in children or in adults who are asleep. In
certain situations, EEG waveforms of an appropriate frequency for age and state of
alertness are considered abnormal because they occur at an inappropriate scalp location
or demonstrate irregularities in rhythmicity or amplitude. [5]
 Some waves are recognized by their shape, scalp location or distribution, and symmetry.
Certain patterns are normal at specific ages or states of alertness and sleep.
 The morphology of a wave may resemble specific shapes, such as vertex (V) waves seen
over the vertex of the scalp in stage 2 sleep or triphasic waves that occur in the setting of
various encephalopathies.
Frequency
The frequencies most brain waves range from are 0.5-500 Hz. However, the following categories
of frequencies are the most clinically relevant:

 Alpha waves - 8-13 Hz

 Beta waves - Greater than 13 Hz
 Theta waves - 3.5-7.5 Hz
 Delta waves - 3 Hz or less

Examples of alpha, beta, theta,

and delta electroencephalography frequencies.

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Alpha waves

See the list below:

 Alpha waves generally are seen in all age groups but are most common in adults. They occur
rhythmically on both sides of the head but are often slightly higher in amplitude on the
nondominant side, especially in right-handed individuals. A normal alpha variant is noted when
a harmonic of alpha frequency occurs in the posterior head regions. They tend to be present
posteriorly more than anteriorly and are especially prominent with closed eyes and with
relaxation.
 Alpha activity disappears normally with attention (eg, mental arithmetic, stress, opening eyes).
In most instances, it is regarded as a normal waveform.
 An abnormal exception is alpha coma, most often caused by hypoxic-ischemic encephalopathy
of destructive processes in the pons (eg, intracerebral hemorrhage). In alpha coma, alpha waves
are distributed uniformly both anteriorly and posteriorly in patients who are unresponsive to
stimuli.
Beta waves

See the list below:

 Beta waves are observed in all age groups.

 They tend to be small in amplitude and usually are symmetric and more evident anteriorly.
 Drugs, such as barbiturates and benzodiazepines, augment beta waves.

Theta waves

See the list below:

 Theta waves normally are seen in sleep at any age. In awake adults, these waves are abnormal if
they occur in excess.
 Theta and delta waves are known collectively as slow waves.

Delta waves

See the list below:

 These slow waves have a frequency of 3 Hz or less.

 They normally are seen in deep sleep in adults as well as in infants and children.
 Delta waves are abnormal in the awake adult.
 Often, they have the largest amplitude of all waves.
 Delta waves can be focal (local pathology) or diffuse (generalized dysfunction).

Morphology
This section identifies some normal waveforms, including K complex, V waves, lambda waves,
positive occipital sharp transients of sleep (POSTS), spindles, mu rhythm, spikes, sharp waves,
and certain delta waves (polyphasic and monophasic shapes).

These waves are recognized by their shape and form and secondarily by their frequency. They
include waves that may be normal in some settings and abnormal in others (eg, spikes, sharp
waves).
K complex

Example of a K complex.

See the list below:

 K complex waves are large-amplitude delta frequency waves, sometimes with a sharp apex.
 They can occur throughout the brain and usually are higher in amplitude and more prominent in
the bifrontal regions.
 Usually symmetric, they occur each time the patient is aroused partially from sleep.
 Semiarousal often follows brief noises; with longer sounds, repeated K complexes can occur.
 K complexes sometimes are followed by runs of generalized rhythmic theta waves; the whole
complex is termed an arousal burst.

V waves

See the list below:

 V waves are sharp waves that occur during sleep. They are largest and most evident at the
vertex bilaterally and usually symmetrically.
 They show phase reversal at the vertex.
 V waves tend to occur especially during stage 2 sleep and may be multiple.
 Often, they occur after sleep disturbances (eg, brief sounds) and, like K complexes, may occur
during brief semiarousals.
 V waves are easy to recognize.
Lambda waves

Example of either lambda or positive

occipital sharp transients of sleep (POSTS).

See the list below:

 Lambda waves occur in the occipital regions bilaterally as positive (upgoing) waves.
 They are triangular in shape and generally symmetric.
 They occur in the awake patient and are said to be most evident when the subject stares at a
blank, uniform surface.
 Lambda waves occur when reading and occasionally when watching TV.
 Morphologically, they are similar to POSTS both in form and in occipital distribution.

Positive occipital sharp transients of sleep

Example of either lambda or positive

occipital sharp transients of sleep (POSTS).

See the list below:

 POSTS are triangular waves that occur in the bilateral occipital regions as positive (upgoing)
waves.
 They can be multiple and usually are symmetric.
 POSTS occur in sleeping patients and are said to be most evident in stage 2 of sleep, although
they are not uncommon in stage 1.
 POSTS are similar if not identical to lambda waves both morphologically and in the occipital
distribution.
Sleep spindles

See the list below:

 Spindles are groups of waves that occur during many sleep stages but especially in stage 2.
 They have frequencies in the upper levels of alpha or lower levels of beta.
 Lasting for a second or less, they increase in amplitude initially and then decrease slowly. The
waveform resembles a spindle.
 They usually are symmetric and are most obvious in the parasagittal regions.

Mu waves - Wicket rhythm or rhythm en arceau

Example of mu waveforms.

See the list below:

 Mu waves are runs of rhythmic activity that have a specific shape. They are rounded in one
direction with a sharp side in the other direction.
 Frequency is one half of the fast (beta) activity.
 Mu waves disappear with motor acts of the contralateral hand or arm.
 Unlike alpha activity, they are not blocked by eye opening.
 They often are asymmetric.
 Mu waves are seen best when the cortex is exposed or if bone defects (eg, postsurgical) are
present in the skull.
 They tend to be more evident over the motor cortex and in the parasagittal regions.

Spikes and sharp waves

See the list below:

 These are recognized by their height, their sharp top, and their narrow base.
 Spikes and sharp waves usually are abnormal.
 They can be normal in the following settings:
o V waves of sleep in the parasagittal regions in stage 2 sleep can be normal.
o Small, sharp spikes of sleep or benign epileptiform transients of sleep (BETS) are
nonpathologic. They occur in the temporal regions, often switching from side to side.
They do not have slow-following waves as do most of the pathologic spikes of epilepsy.
 o Numerous artifacts resemble spikes, but they are distinguished by other waves that may
be present, by observation of the patient while they are occurring, and by experience.
o POSTS can have a sharp contour yet be quite normal. They occur in the occipital regions
bilaterally during sleep.

Benign epileptic transients of sleep

Example of small sharp spikes, also

known as benign epileptiform transients of sleep (BETS).

See the list below:

 These sharp, usually small waves occur on one or both sides (usually asynchronously), especially
in the temporal and frontal regions.
 BETS are rare in children but are more frequent in adults and elderly persons.
 Although they can occur in epileptic patients, BETS often are seen in individuals without epilepsy
and can be regarded as a probable normal variant.

This section gives a brief introduction to how EEG electrodes are set up, what they mean and
what the doctors can learn from reading an EEG.

How are the electrodes arranged?

An EEG technicial places the electrodes in specific areas, according to internationally agreed-
upon criteria.

 To find where to put the electrodes, first the technician marks four points on your head -
the nasion (indentation between the forehead and the nose), the inion (ridge that can be
felt in the middle of the back of the skull, over the occipital area), and the preauricular
points on both sides of the head (indentations above the outer part of the ear openings).
 The electrode are then placed in many areas on the head, at specific locations and
distances from these landmarks or points listed above.
  Sometimes other electrodes (sphenoidal and suboccipital, for instance) are placed to
increase the chance of recording EEG waves from areas that may be too small or too deep
to be recorded by the usual electrodes.
 Often an electrode is placed on the chest to record the EKG (electrocardiogram) which is
a a record of the heartbeat.

What do the letters and numbers mean?

The names of the electrode sites use alphabetical abbreviations that identify the lobe or area of
the brain which each electrode records from:

 F = frontal
 Fp = frontopolar
 T = temporal
 C = central
 P = parietal
 O = occipital
 A = auricular (ear electrode)

The localization of the brain waves within the brain regions or lobes is further narrowed by
adding electrodes, which are given numbers such as T3, T4, P3, P4. Even numbers identify
electrode positions on the right side of the head, and odd numbers refer to the left side. The label
"z" points to electrode sites in the midline of the head. For example, Cz refers to the midline
central region of the head.

How are the electrodes related to each other?

The EEG records brain waves using equipment called amplifiers and by looking at the
information from the electrodes in different combinations. These combinations of electrodes are
called 'montages'.

 In bipolar montages, consecutive pairs of electrodes are linked by connecting the

electrode input 2 of one channel to input 1 of the subsequent channel, so that adjacent
channels have one electrode in common. The bipolar chains of electrodes may be
connected going from front to back (longitudinal) or from left to right (transverse).
 Another type of montage is the referential montage. In this type, various electrodes are
connected to input 1 of each amplifier and a reference electrode is connected to input 2 of
each amplifier. Ideally, inactive electrodes (ones that are uninvolved in the electrical field
being studied) are chosen as references.

What does the doctor learn from looking at the EEG?

Being able to locate the origin of electrical activity ("localization") is critical to being able to
interpret the EEG tracings meaningfully.
 Localizing normal or abnormal brain waves in bipolar montages is usually accomplished
by identifying "phase reversal," a deflection of the two channels within a chain pointing
to opposite directions.
 In a referential montage, all channels may show deflections or movements in the same
direction. If the electrical activity at the active electrodes is positive when compared to
the activity at the reference electrode, the deflection will be downward. Electrodes where
the electrical activity is the same as at the reference electrode will not show any
deflection. In general, the electrode with the largest upward deflection represents the
maximum negative activity in a referential montage.