ARTICLES

EEG in Convulsive and Nonconvulsive Status Epilepticus

Richard P. Brenner

Abstract: Seizures and status epilepticus (SE) are serious compli-

of most types of SE in adults. For a comprehensive review of
cations in intensive care unit (ICU) patients. SE is often divided into SE, including clinical features, etiologies, treatment, and
convulsive and nonconvulsive types, based on clinical features. The prognosis in children and adults, see Shorvon (1994).
EEG is helpful in further dividing SE into those that are generalized
from onset, or have a partial onset, because this may be difficult to CONVULSIVE STATUS EPILEPTICUS
do clinically. This is particularly true in patients with tonic-clonic
Convulsive status epilepticus (CSE) is the most serious,
seizures, which may be generalized from onset, or secondarily
frequent, and most easily recognized type of SE. It may occur
generalized. Rarely in the ICU, although not infrequently in epilepsy
monitoring units, the EEG may indicate that the event is nonepilep- in either primary generalized epilepsy or be secondarily
tic, such as pseudostatus epilepticus. Nonconvulsive SE is often generalized. It is characterized by a loss of consciousness and
difficult to diagnose, be it partial or generalized, and the diagnosis is recurrent or continuous convulsions. CSE is a medical emer-
usually delayed. Furthermore, although an EEG is required to verify gency and is associated with high morbidity and mortality.
the diagnosis, there are not widely accepted criteria to diagnose this Initially, in primary generalized epilepsy seizures begin with
entity, particularly in obtunded/comatose patients. For example, it is a flattening of the background rhythms, followed by low-
controversial whether several EEG patterns, such as periodic later- voltage fast activity that subsequently increases in amplitude
alized and generalized periodic epileptiforms, are ictal or interictal. and decreases in frequency. The tonic phase is obscured by
This article reviews EEG findings in different types of SE in adults muscle artifact and is followed by a checkerboard-type pat-
and provides numerous examples.
tern that is the clonic phase, with repetitive muscle artifact
Key Words: Status epilepticus, EEG, Convulsive, Nonconvulsive. often obscuring underlying cerebral activity; postictally, there
(J Clin Neurophysiol 2004;21: 319 –331) is suppression (Fig. 1). As outlined by Treiman and col-
leagues (1990), there are five identifiable EEG patterns that
the authors thought occurred in a predictable sequence during
Just as there are numerous seizure types, any type of seizure the course of secondarily generalized CSE. These are:
may manifest as status epilepticus (SE) (Gastaut, 1983). SE is
1. EEG changes of discrete seizures with interictal slowing
usually defined as more than 30 minutes of (1) continuous
2. Merging seizures with waxing and waning ictal discharges
seizure activity, or (2) two or more sequential seizures with-
3. Continuous ictal discharges
out full recovery of consciousness between seizures (Work-
4. Continuous ictal discharges with “flat” periods
ing Group on Status Epilepticus, 1993). A more recent
5. Periodic epileptiform discharges on a “flat” background
operational definition of generalized, convulsive SE in adults
and older children refers to at least 5 minutes of (a) contin- However, a number of investigators have not found this
uous seizures, or (b) two or more discrete seizures between sequential EEG pattern (Garzon et al., 2001; Lowenstein and
which there is incomplete recovery of consciousness (Lowen- Aminoff, 1992; Nei et al., 1999; So et al., 1995). Clinically,
stein et al., 1999). initially there are generalized tonic-clonic movements. This
Status epilepticus is often divided into convulsive and has been termed “overt” status epilepticus (Treiman, 1995).
nonconvulsive types. The EEG, which demonstrates ongoing In later stages, there may be electroclinical dissociation,
ictal activity, can be used to further subdivide SE into either termed “subtle” status epilepticus (Treiman et al., 1984).
generalized or partial (Table 1). I will discuss EEG features During these times, the patient may have slight twitching of
the limbs, facial muscles, or jerking eye movements. Often
there is coma without signs of seizures, and many consider
Departments of Neurology and Psychiatry, University of Pittsburgh, Pitts- this a form of nonconvulsive status epilepticus (NCSE), as I
burgh, Pennsylvania, U.S.A.
do, and it will be covered in that section. Primary generalized
Address correspondence and reprint requests to Dr. Richard P. Brenner,
WPIC, 3811 O’Hara Street, Room 111, Pittsburgh, PA 15213, U.S.A. CSE (PGCSE) is less common than secondarily generalized
Copyright © 2004 by Lippincott Williams & Wilkins CSE (SGCSE) and reportedly does not undergo the sequence
ISSN: 0736-0258/04/2105-0319 of clinical and EEG changes seen in prolonged SGCSE

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R. P. Brenner Journal of Clinical Neurophysiology • Volume 21, Number 5, October 2004

TABLE 1. Status epilepticus

ing techniques, including inappropriate sensitivity and filter
settings, could confuse the situation and lead to an incorrect
EEG Convulsive Nonconvulsive conclusion.
Generalized Tonic-clonic (primary Absence (ambulatory) Myoclonic Status Epilepticus
generalized) Nonconvulsive This type, although rare, can occur in waking patients
Myoclonic (obtunded/coma)
Myoclonic (coma)
with primary generalized epilepsy, such as juvenile myo-
Partial Tonic-clonic Complex partial
clonic epilepsy (Badhwar et al., 2002), and the EEG shows
(secondarily (ambulatory) bursts of generalized spike and polyspike and wave dis-
generalized) Nonconvulsive charges associated with the movements (Fig. 2). Conscious-
(obtunded/coma) ness is usually preserved. Myoclonic status epilepticus is a
Simple partial Simple partial well-recognized complication of cardiorespiratory arrest
Somatomotor Aphasic (Walker, 2003). In these comatose patients, the EEG often
(epilepsia partialis Somatosensory
continua) Psychic
shows the jerks to be associated with generalized repetitive
Autonomic spikes, sharp waves, or triphasic waves (TWs) occurring at
approximately 1-second intervals with periods of suppression
between the intervals (Fig. 3), or a burst-suppression pattern
(Jumao-as and Brenner, 1990). This entity, which has gone
(Treiman, 1995). On EEG, SGCSE initially has focal seizure under a variety of terms including myoclonic status epilepti-
activity. However, if the status is not recorded early in its cus (Jumao-as and Brenner 1990), status myoclonus (Krum-
course it may be difficult to distinguish between primary and holz et al., 1988), generalized status myoclonicus (Celesia et
secondarily generalized CSE. al., 1988), and generalized myoclonic status epilepticus
One form of status that may be confused with CSE is (Rothner and Morris, 1988), is usually associated with a fatal
pseudostatus epilepticus (PSE). In pseudostatus the record is outcome (Young et al., 1990; Wijdicks et al., 1994). Some
often obscured by muscle and movement artifact. Unlike patients, described as subtle generalized convulsive status
patients with CSE who always have EEG changes (at least epilepticus by Treiman and colleagues (1984), have had
postictally; earlier stages may be obscured by artifact), pa- similar clinical and EEG findings.
tients with PSE do not exhibit EEG changes, aside from
artifact. They often appear comatose but may have a well- Simple Partial Status Epilepticus
developed alpha rhythm, which can be tested by passive eye One form of simple partial status epilepticus (SPSE)
opening and eye closure. Furthermore, the muscle artifact associated with motor movements is somatomotor SE (Figs.
usually does not have the repetitive characteristics seen in 4A and 4B), such as epilepsia partialis continua. The EEG of
epileptic convulsions and during the course of the “seizure” SPSE resembles that of simple partial seizures. However,
there is often waxing and waning of the event, rather than a there are patients who clinically appear to be in partial motor
complete cessation and postictal EEG suppression. Particu- status and are treated despite lack of seizure activity on EEG
larly before the widespread use of digital EEG, poor record- (Drislane et al., 1999). The scalp EEG can be normal if the

FIGURE 1. Generalized spike and

wave, best seen in the midline elec-
trodes, with prominent superimposed
repetitive muscle artifact during the
clonic phase, followed by postictal
suppression in a 22-year-old woman
with a primary generalized tonic-
clonic seizure.

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Journal of Clinical Neurophysiology • Volume 21, Number 5, October 2004 EEG in Status Epilepticus

FIGURE 2. Frequent repetitive myo-

clonic jerks, associated with general-
ized spike and wave, in a 22-year-old
woman with juvenile myoclonic epi-
lepsy.

FIGURE 3. Myoclonic status epilepti-

cus in a 65-year-old comatose man
who suffered an anoxic event 48
hours before the recording. The EEG
shows generalized polyspikes occur-
ring approximately every second.

size of the seizure focus is small, or show nonspecific abnor- serious medical conditions. However, some investigators
malities. If there is an ictal pattern, it can contain any have used NCSE to include all the above-described patients,
frequency. Evolution of the discharge is common; the dis- ranging from those with barely detectable mental status
charges may wax and wane. At other times the EEG may changes to those in coma. I prefer to subdivide NCSE based
show repetitive spikes or spike and wave activity. Noncon- on clinical features, such as degree of impairment of con-
vulsive forms of SPSE will be discussed later. sciousness (Kaplan, 1999). Initially, ambulatory forms of
NCSE will be reviewed.
NONCONVULSIVE STATUS EPILEPTICUS
Nonconvulsive status epilepticus is a more heteroge- Ambulatory Patients
neous and controversial entity than is CSE. Within this group, Nonconvulsive status epilepticus is defined as an epi-
the term absence status or petit mal status is usually used for leptic state lasting more than 30 minutes with some clinically
those patients with generalized EEG findings who are ambu- evident change in mental status or behavior from baseline and
latory and may appear confused, with repetitive automatisms, ictal activity on EEG. There are two major categories of
while those with a partial EEG onset have been described as NCSE based on EEG: generalized and partial. Numerous
complex partial status epilepticus (CPSE). The term NCSE is terms have been used to describe generalized NCSE in
more often applied to patients who are severely obtunded or patients who are often confused but ambulatory (Shorvon,
comatose with minimal or no motor movements, often with 1994); absence status is the most widely used. The EEG is

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FIGURE 4. (A) Simple partial status

epilepticus in a 79-year-old woman
after a right subdural hematoma evac-
uation 3 days before this recording.
Repetitive right central sharp waves
unassociated with clinical changes at
this point. (B) The sharp waves subse-
quently were associated with left-
sided facial movements.

extremely useful in the identification of NCSE, particularly focal discharge that may characterize complex partial sei-
when the cause of this acute confusional state is not clinically zures can range from the delta to beta frequency (Figs.
apparent. A variety of EEG patterns have been described in 6A– 6C). The EEG findings may show recurrent focal sei-
generalized NCSE. Most commonly, the EEG shows more or zures or a more continuous cycling with alterations of unre-
less continuous, or frequently recurring, generalized, bilater- sponsiveness and partially responsive phases. Rarely, aphasia
ally synchronous, symmetric spike and wave, which may be may be the sole manifestation of partial SE (Kirshner et al.,
at a frequency of 3 Hz, but is often less (Agathonikou et al., 1995). It can be difficult to determine if there is an alteration
1998; Baykan et al., 2002; Gastaut and Tassinari, 1975; of consciousness in such patients. If consciousness is not
Granner and Lee, 1994; Shneker and Fountain, 2003), or impaired, then aphasic SE can be included with SPSE, rather
generalized polyspike and wave discharges. Figures 5A and than with CPSE.
5B demonstrate a twilight state (absence status) in a young At times NCSE can be difficult to classify (generalized
man. versus. partial), even with ictal EEG recordings. In particular,
In contrast to absence status, in CPSE the EEG abnor- frontal seizures may show a generalized pattern on EEG
malities usually are focal, most often affecting the temporal (Thomas et al., 1999). Guberman et al. (1986) hypothesized
area, although they can become generalized. The focal EEG that transitional cases of NCSE exist with lateralizing EEG
abnormalities may not be appreciated, particularly if the features and that some cases are probably due to secondary
recording begins after the onset of the status. The rhythmic generalization from a temporal or frontal focus. Tomson and

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Journal of Clinical Neurophysiology • Volume 21, Number 5, October 2004 EEG in Status Epilepticus

FIGURE 5. (A) The EEG in a 20-year-

old ambulatory, confused man with a
history of absence seizures since child-
hood. (B) The EEG pattern resolved
and the patient was more alert after
treatment with intravenous loraz-
epam, confirming the diagnosis of ab-
sence status.

colleagues (1992) concluded that most cases of NCSE rep- (Treiman et al., 1984), electrographic SE (Simon and
resent CPSE. However, Granner and Lee (1994), in a large Aminoff, 1986), SE in comatose patients (Lowenstein and
series of patients with NCSE (85 ictal episodes in 78 pa- Aminoff, 1992), generalized electrographic SE (Drislane
tients), found that 69% of the episodes were generalized on and Schomer, 1994), nontonic-clonic SE (Privitera et al.,
EEG, 18% were generalized with focal predominance, and 1994), subclinical SE (So et al., 1995), and NCSE (De-
13% were focal. The difficulty in distinguishing absence Lorenzo et al., 1998; Kaplan, 1999; Litt et al., 1998;
status from CPSE may, in part, explain the differences in Towne et al., 2000). Sometimes the same term has been
interpretation of NCSE after metrizamide myelography, used when describing different disorders, whereas differ-
which has been described as either generalized (Obeid et al., ent terms are often applied to the same clinical entity.
1988) or complex partial status epilepticus (Elian and Fen- These cases are often difficult to diagnose and the diag-
wick, 1985). nosis is usually delayed. Patients may display subtle,
Obtunded/Comatose Patients intermittent, focal, or multifocal rhythmic movements sug-
Patients may be encephalopathic because of ongoing gestive of seizures (Treiman, 1995). Hussain et al. (2003)
epileptic activity with minimal or no motor movements. noted that certain clinical features were more likely to be
This entity, NCSE, is difficult to diagnose in obtunded/ present in patients with NCSE compared with other types
comatose patients (Brenner, 2002; Lawn and Wijdicks, of encephalopathy. These included either remote history of
2002; Walker, 2001). A variety of terms have been used to seizures or ocular movement abnormalities. NCSE can
describe these patients, including subtle generalized SE occur in a variety of disorders, including hypoxia, meta-

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FIGURE 6. (A) Beginning of a partial

(left frontal temporal) seizure in a 60-
year-old man in complex partial status
epilepticus due to vasculitis. (B) Thirty
seconds after seizure onset. (C) The
seizure ends with repetitive left frontal
temporal sharp waves after 2 minutes
and 7 seconds.

bolic disturbances (Drislane and Schomer, 1994; Lowen- periodic epileptiform discharges (PEDs), which can be either
stein and Aminoff, 1992; Simon and Aminoff, 1986), and focal or generalized, and generalized TWs.
after convulsive seizures (Treiman et al., 1990). Periodic lateralized epileptiform discharges (Fig. 7A) oc-
cur in a variety of disorders, most often acute unilateral lesions,
EEG PATTERNS such as infarcts or tumors. They may also be seen in patients
A number of EEG patterns have been described in NCSE, with chronic seizure disorders or old static lesions, especially
and many of these are controversial, particularly as to whether when associated with recent seizures, alcohol withdrawal, or a
they are ictal. These include periodic lateralized epileptiform toxic-metabolic disorder. Chatrian et al. (1964) described
discharges (PLEDs), bilateral independent PLEDs (BIPLEDs), PLEDs as consisting of lateralized complexes usually recurring

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Journal of Clinical Neurophysiology • Volume 21, Number 5, October 2004 EEG in Status Epilepticus

FIGURE 7. (A) Left-sided PLEDs in a

74-year-old woman after evacuation
of a left subdural hematoma 4 days
earlier. (B) Left-sided ictal discharge in
the same patient.

every 1 to 2 seconds. The complexes often consist of sharp lesser degree over homologous areas in the contralateral
waves or spikes that may be followed by a slow wave. The hemisphere. In contrast, in patients with BIPLEDs, the com-
clinical picture associated with PLEDs is usually obtundation, plexes are asynchronous, usually differing in morphology,
focal seizures, and focal neurologic signs (Garcia-Morales et al., amplitude, rate of repetition, and site of maximal involvement
2002). The majority of patients with PLEDs will have seizures (Fig. 8). De la Paz and Brenner (1981) reported clinical
during the acute stage of illness and the PLEDs usually will be findings in 18 patients whose EEGs showed this pattern. The
transiently replaced by a new pattern, often consisting of faster most common cause of BIPLEDs was hypoxic encephalop-
rhythmic activity (Fig. 7B). For this reason PLEDs are usually athy (five), central nervous system (CNS) infection (enceph-
considered an interictal pattern, although not all agree (Assal et alitis or meningitis) (five) and chronic seizure disorders
al., 2001; Garzon et al., 2001; Handforth et al., 1994). In several (four). When compared with patients with PLEDs, those with
studies of NCSE, PLEDs alone were not considered an ictal BIPLEDs were more likely to be comatose (72% versus 24%)
pattern (Claassen et al., 2001; Jordan, 1999; Jaitly et al., 1997). and had a higher mortality rate (61% versus 29%), but focal
Pohlmann-Eden et al. (1996) viewed PLEDs as an electro- neurologic deficits and focal seizures were less common.
graphic signature of a dynamic pathophysiological state in Generalized periodic bisynchronous sharp complexes,
which unstable neurobiological processes create an ictal-interic- often with a triphasic configuration, have been described in a
tal continuum. variety of drug-related disorders, metabolic encephalopathies
Periodic lateralized epileptiform discharges are lateral- (Yemisci et al., 2003), after anoxia-ischemia (Brenner and
ized; however, they are often reflected synchronously to a Schaul, 1990), and in convulsive status epilepticus (Treiman

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R. P. Brenner Journal of Clinical Neurophysiology • Volume 21, Number 5, October 2004

FIGURE 8. Bilateral independent

PLEDs in a 72-year-old woman after
anoxia.

FIGURE 9. Generalized PEDs (maximal

right) in a 33-year-old man after anoxia
secondary to a motor vehicle accident.
Initially he had eyelid twitching. This
EEG pattern was present after the ad-
ministration of lorazepam and phenyt-
oin and was unassociated with clinical
changes.

FIGURE 10. Triphasic waves in a 74-

year-old man in renal failure.

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Journal of Clinical Neurophysiology • Volume 21, Number 5, October 2004 EEG in Status Epilepticus

FIGURE 11. Beginning (A) and end

(B) of a brief (16 second) left-sided
electrographic seizure in a 56-year-old
comatose woman in partial NCSE
with hepatic and renal failure.

et al., 1990). A similar pattern may be seen with degenerative fronto-occipital lag may be present. The initial negative compo-
diseases, such as Creutzfeldt-Jakob disease. As noted earlier, nent is the sharpest, whereas the following positive portion of the
Treiman and colleagues (1990) described a progressive se- complex is the largest and is subsequently followed by another
quence of EEG changes during generalized CSE. Whether the negative wave (Fig. 10). TWs may increase with stimulation;
final pattern of this proposed sequence, namely PEDs with a this is also true of PLEDs and generalized PEDs (Hirsch et al.,
“flat” background (Fig. 9), should be considered ictal is 2004).
debatable (Brenner and Schaul, 1990; Garzon et al., 2001; When electroencephalographers use the term triphasic
Hirsch et al., 2004; Husain et al., 1999; Nei et al., 1999). waves, they are usually implying a pattern seen with a variety
Furthermore, although some authors have stated that PEDs of encephalopathies, particularly hepatic or renal dysfunction.
may represent NCSE, others view it as an encephalopathy However, the term triphasic can also be used to describe the
where spikes and sharp waves may not impair clinical func- morphology of the waveform in that sharp and slow wave
tion, but rather reflect damage from severe brain injury complexes usually have three phases; hence, they are TWs. It
(Krumholz, 1999; Niedermeyer and Ribeiro, 2000). can be difficult to distinguish TWs due to a toxic-metabolic
Another pattern described by some as consistent with encephalopathy from epileptiform sharp and slow waves
NCSE is TWs. These consist of bursts of moderate- to high- complexes, which may or may not be ictal. This is apparent
amplitude (100 to 300 uV) activity, usually of 1.5 to 2.5 Hz, when reviewing reports of patients who became confused
often occurring in clusters. Although frequently predominant in after treatment with baclofen (Hormes et al., 1988; Zak et al.,
the frontal regions, occasionally they are maximal posteriorly. A 1994) or postmetrizamide myelography (Drake, 1984; Elian

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R. P. Brenner Journal of Clinical Neurophysiology • Volume 21, Number 5, October 2004

FIGURE 12. Generalized NCSE in a

comatose 74-year-old woman after
anoxia (A) and after intravenous loraz-
epam treatment (B). The EEG is mark-
edly improved; however, there were
no clinical changes.

FIGURE 13. Bihemispheric NCSE in a

72-year-old woman after resection of
a bifrontal-parietal meningioma.

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Journal of Clinical Neurophysiology • Volume 21, Number 5, October 2004 EEG in Status Epilepticus

FIGURE 14. (A) Beginning of a partial

seizure (right posterior head region)
in a 31-year-old man with a left-sided
homonymous hemianopsia having
frequent, repetitive seizures (10 to 15
per hour). There is left-beating nys-
tagmus. (B) Forty seconds after onset,
the discharge has increased in ampli-
tude and decreased in frequency. (C)
At the end of seizure, 1 minute and 45
seconds after onset.

and Fenwick, 1985; Obeid et al., 1988). Some authors con- may straddle the borders between epilepsy and encephalop-
cluded that these patterns represented NCSE, whereas others athy and that the distinction between NCSE and encephalop-
viewed it as an encephalopathy that resolved with discontinu- athy can be difficult, whereas Litt et al. (1998) claimed that
ing the offending agent. Kaplan (1999) reported that TWs monorhythmic TWs could be distinguished from ictal pat-

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R. P. Brenner Journal of Clinical Neurophysiology • Volume 21, Number 5, October 2004

terns. Clearly there are times when this distinction can be ments. An EEG is the only way to verify the diagnosis, although,
difficult; hence, the terms “triphasic-like waves” and nonepi- as has been emphasized, interpretation can be difficult. An EEG
leptiform “true TWs” (Husain et al., 1999). This topic is is also helpful in monitoring patients who are being treated for
further reviewed in this issue (Kaplan, 2004). SE, particularly because the neurologic examination is affected
Nonconvulsive status epilepticus consists of EEG-ictal by the administration of drugs, such as lorazepam, midazolam,
episodes, which are continuous or recurrent for greater than 30 propofol, pentobarbital, or neuromuscular blocking agents.
minutes without improvement in clinical state or return to Jaitly et al. (1997) emphasized the prognostic value of
preictal EEG pattern between seizures (Young et al., 1996). EEG monitoring after CSE and described patterns with a poor
There are no agreed-on criteria to diagnose NCSE in obtunded/ prognosis after CSE, including PLEDs, burst-suppression, and
comatose patients (Kaplan, 2003). Litt et al. (1998) described after-SE ictal discharges. Patients whose records normalized did
three EEG patterns of electrographic SE: focal (Fig. 11), gener- well. Nei et al. (1999) found that PEDs were associated with a
alized (Figs. 12A and 12B), and bihemispheric (Fig. 13). It is poor outcome independent of etiology. The investigators were
relatively easy to diagnose NCSE when there are frequent uncertain if this was an ictal pattern and concluded that it was
electrographic seizures, particularly when they are focal. The unclear whether PEDs required aggressive treatment.
problem is greater with generalized spike and wave and sharp
and slow wave complexes. The latter usually should not be Simple Partial Status Epilepticus
invariant, nor should changes, if present, be only state related. There are several different types of SPSE, in which, by
For proposed criteria of nonconvulsive seizures, which, in turn, definition, consciousness is preserved. These include convul-
help define NCSE, see Young et al. (1996). sive types (e.g., somatomotor, as discussed previously) and
The effects of medications, such as benzodiazepines, and nonconvulsive types (e.g., somatosensory), as well as psychic
their role in diagnosis are also debated. For example, a test dose and autonomic status and some cases of and aphasic SE.
of lorazepam may complicate matters because most EEG pat- Somatosensory symptoms may include visual hallucinations,
terns may resolve if the patient is given an adequate dose, field cuts, or ictal blindness (Figs. 14A–14C). Both psychic
including TWs due to a metabolic encephalopathy (Fountain and SE, the most common symptom of which is ictal fear (Shro-
Waldman, 2001). This can be attributed to a state change if the von, 1994), and autonomic SE, which may consist of pro-
pattern recurs after painful stimulation. Improvement in the EEG longed abdominal sensations (Gastaut, 1983; Manford and
after treatment does not prove that the discharges were ictal and Shorvon, 1992), are rare.
responsible for the patient’s decreased responsiveness. Clearly
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