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Definition and Classification of Periodic and Rhythmic Patterns

Maciel, Carolina, B.*,†; Hirsch, Lawrence, J.*

Journal of Clinical Neurophysiology: May 2018 - Volume 35 - Issue 3 - p 179–188
doi: 10.1097/WNP.0000000000000462
Invited Review

Summary: The growing use of continuous video-EEG recording in the inpatient setting, in particular in patients with varying degrees of encephalopathy, has yielded a window to the brain with an excellent temporal resolution. This increasingly available tool has become more than an instrument to detect nonconvulsive seizures (its primary use), and clinical indications span from ischemia detection in acute brain injuries, neuroprognostication of comatose patients, to monitoring the degree of encephalopathy. In this context, abnormal findings such as periodic discharges and rhythmic delta activity were increasingly recognized; however, significant subjectivity remained in the interpretation of these findings pertaining to key features regarding their spatial involvement, prevalence of occurrence, duration, associated morphologic features, and behavior. In 2005, the American Clinical Neurophysiology Society proposed standardized definitions and classification of electroencephalographic rhythmic and periodic patterns. This was subsequently revised in 2011 and in 2012 and is now being used by centers worldwide, with the final version published in early 2013 as an official guideline of the ACNS. The resulting uniform terminology has allowed for significant advances in the understanding of the pathophysiology, epileptogenic potential, and overall clinical implication of these patterns. Investigators across multiple institutions are now able to collaborate while exploring diagnostic and therapeutic algorithms to these patterns, an effort that may soon provide definitive evidence guiding treating clinicians on the management of these patients.

*Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A.; and

Department of Neurology, Division of Neurocritical Care, University of Florida College of Medicine, Gainesville, Florida, U.S.A.

Address correspondence and reprint requests to Carolina B. Maciel, MD, Department of Neurology, Division of Neurocritical Care, McKnight Brain Institute, University of Florida College of Medicine, 1149 Newell Dr/L3-185, Gainesville, FL 32610, U.S.A.; e-mail:

L. J. Hirsch has received research support from Yale University for investigator-initiated studies from Eisai and Upsher–Smith, consultation fees for advising from Ceribell, Eisai, Monteris, Sun Pharma, and Engage Therapeutics, royalties for authoring chapters for UpToDate-Neurology, chapters for Medlink—Neurology, and from Wiley for coauthoring the book “Atlas of EEG in Critical Care,” by L. J. Hirsch and Brenner, and honoraria for speaking from Neuropace. C. B. Maciel has no funding or conflicts of interest to disclose.

© 2018 by the American Clinical Neurophysiology Society