Normal Variants Are Commonly Overread as

Interictal Epileptiform Abnormalities

Joon Y. Kang* and Gregory L. Krauss* (J Clin Neurophysiol 2019;36: 257–263)

Presented by
dr. Rizka Aprilia Syahputri
dr. Daniel Mahendra

Supervised by
dr. Hj. Sri Handayani, SpS(K)
INTRODUCTION
One of the most challenging aspects of
interpreting EEGs is distinguishing
between pathologic activity and “benign
variants.”

Benign variants appear in small

fragments with sharp morphology, the
normal patterns can easily be
misinterpreted as epileptiform
discharges.

Benign variants include wicket

spikes/rhythms, benign epileptiform
transients of sleep (small sharp spikes),
and rhythmic mid-temporal theta bursts
of drowsiness
Wicket Spikes and Wicket Rhythms

monophasic wave
bursts that usually
medium to high theta to alpha range brief (0.5–1 second)
evolve from the
voltage (60–210 mV), (6–11 Hz) rhythmic discharges
background as
arcuate-shaped

Auditory stimulation
unilaterally or
most commonly in maximal over the and arousal can
bilaterally with
drowsiness temporal regions attenuate wicket
shifting asymmetry
patterns

drowsiness or light seen in adults older

sleep and rapid eye than 30 years and
movement sleep can are used to be
activate wicket believed to be more
spikes frequent in patients
Distiguish from AED

wicket spikes do not disturb the

background activity

do not have an after-going slow

wave
Small Sharp Spikes

usually seen in
appear almost
adults (2.9%
exclusively
electronegative between 30 and
during
small amplitude brief (50 ms), spikes in the 40 years of age)
drowsiness or
(<50 mV), broad temporal and are almost
light non-rapid
region never seen in
eye movement
children younger
sleep
than 10 years
Distiguish from AED

SSS tend to appear as single, sporadic transients and,

when repeated, are often separated by more than 10
second

Interictal epileptiform discharges often occur in

repetitive clusters and may be associated with
accompanying focal slowing with disruption of
background rhythms
RMTD
occur unilaterally
paroxysmal, or bilaterally in
medium- to an independent
highvoltage (50– and synchronous
200 mV), fashion

theta (4–7 Hz) occur unilaterally

rhythmic bursts or bilaterally in
that are maximal an independent
over the mid- and synchronous
temporal region fashion
General Indicators of Benign Variants

The IEDs represent Interictal

a paroxysmal epileptiform SSS and RMTDs do
surface-negative The IEDs often discharges may not cause a
spike/sharp have a spiky/sharp also be paroxysmal
activity with an morphology accompanied by disruption in the
after-going slow focal slowing in background
wave the same region
 Most benign variants,
Benign patterns also
such as SSS and wicket
tend to have broader
spikes, are activated by
topography
drowsiness and light
CONCLUSION

The diagnosis of epilepsy should not be made or ruled out on the basis of a nonspecific finding on a single
outpatient EEG.

Careful history-taking and analysis of clinical events is critical to properly diagnosing epilepsy; the
role of the EEG should be supportive.

Careful history-taking and analysis of clinical events is critical to properly diagnosing epilepsy; the
role of the EEG should be supportive.

When nonspecific transients occur only once during an EEG finding, it may not be possible to
determine whether a transient is an IED or a benign variant.

When this occurs, the finding should be described within the report with a comment that a suspicious
transient was observed and the study should be repeated if possible. It has been reported that repeating
studies can increase the yield of detecting IEDs if the first EEG demonstrates nonspecific findings.
Thank You