Neurol. praxi. 2025;26(2):147-153 | DOI: 10.36290/neu.2024.056

Biting the bullet: Errors in electroencephalography (EEG)

doc. MUDr. Zdeněk Vojtěch, Ph.D.
Neurologické oddělení, Nemocnice Na Homolce, Praha

In this article, we want to highlight the causes of the most frequent mistakes in indications and descriptions of EEG findings, both generally and specifically in seizure disorders and encephalopathies. We refer to the mistakes in descriptions and interpretations we most frequently see in our practice. We want to open the discussion about how to minimalize these mistakes in Czech environment.

Keywords: electroencephalography, epilepsy, encephalopathy.

Received: June 28, 2024; Revised: June 28, 2024; Accepted: August 29, 2024; Prepublished online: August 29, 2024; Published: May 5, 2025  Show citation

ACS AIP APA ASA Harvard Chicago Chicago Notes IEEE ISO690 MLA NLM Turabian Vancouver
Vojtěch Z. Biting the bullet: Errors in electroencephalography (EEG). Neurol. praxi. 2025;26(2):147-153. doi: 10.36290/neu.2024.056.
Download citation

References

  1. Amin U, Benbadis SR. The role of EEG in the erroneous diagnosis of epilepsy. J Clin Neurophysiol. 2019;36:294-7. doi: 10.1097/WNP.0000000000000572. Go to original source... Go to PubMed...
  2. Benbadis SR, Heriaud L, O'Neill E, et al. Outcome of prolonged EEG-video monitoring at a typical referral epilepsy center. Epilepsia. 2004;45:1150-3. doi: 10.1111/j.0013-9580.2004.14504.x. Go to original source... Go to PubMed...
  3. Benbadis SR, Kaplan PW. The dangers of over-reading an EEG. J Clin Neurophysiol. 2019;36:249. doi: 10.1097/WNP.0000000000000598. Go to original source... Go to PubMed...
  4. Benbadis SR, Lin K. Errors in EEG interpretation and misdiagnosis of epilepsy. Which EEG patterns are overread? Eur Neurol. 2008;59:267-71. doi: 10.1159/000115641. Go to original source... Go to PubMed...
  5. Beniczky S, Aurlien H, Brøgger JC, et al. Standardized computer-based organized reporting of EEG: SCORE - Second version. Clin Neurophysiol. 2017;128:2334-46. doi: 10.1016/j.clinph.2017.07.418. Go to original source... Go to PubMed...
  6. Binnie CD. EEG audit: increasing cost efficiency of investigations in epilepsy. Electroencephalogr Clin Neurophysiol. 1990;76:29P.
  7. Bridgers SL. Epileptiform abnormalities discovered on electroencephalographic screening of psychiatric in-patients. Arch Neurol. 1987;44:312-16. doi: 10.1001/archneur.1987.00520150056022. Go to original source... Go to PubMed...
  8. Doležalová I, et al. EEG v intenzivní medicíně. Maxdorf, 2024.
  9. Engel J Jr. A practical guide for routine EEG studies in epilepsy. J Clin Neurophysiol. 1984;1:109-42. doi: 10.1097/00004691-198404000-00001. Go to original source... Go to PubMed...
  10. Faigle R, Sutter R, Kaplan PW. Electroencephalography of encephalopathy in patients with endocrine and metabolic disorders. J Clin Neurophysiol. 2013;30:505-16. doi: 10.1097/WNP.0b013e3182a73db9. Go to original source... Go to PubMed...
  11. Gloor P. The EEG in the differential diagnosis of epilepsy. In: Van Duyn H, Donker DNJ, Van Huffelen AC, eds. Current Concepts in Clinical Neurophysiology. The Hague: Drukker Trio, 1977:9-21.
  12. Halford JJ, Arain A, Kalamangalam GP, et al. Characteristics of EEG Interpreters Associated With Higher Interrater Agreement. J Clin Neurophysiol. 2017;34:168-73. doi: 10.1097/WNP.0000000000000344. Go to original source... Go to PubMed...
  13. Halford JJ, Westover MB, LaRoche SM, et al. Interictal Epileptiform Discharge Detection in EEG in Different Practice Settings. J Clin Neurophysiol. 2018;35:375-80. doi: 10.1097/WNP.0000000000000492. Go to original source... Go to PubMed...
  14. Hasan TF, Tatum WO. When should we obtain a routine EEG while managing people with epilepsy? Epilepsy Behav Rep. 2021;16:100454. doi: 10.1016/j.ebr.2021.100454. Go to original source... Go to PubMed...
  15. Hoppe M, Wennberg R, Tai P, et al. EEG in epilepsy. In: Lozano AM, Gildenberg PL, Tasker RR, eds. Textbook of Stereotactic and Functional Neurosurgery. Berlin Heidelberg: Springer. 2009:2575-85. Go to original source...
  16. Chadwick D, Smith D. The misdiagnosis of epilepsy. BMJ. 2002;324:495-6. doi: 10.1136/bmj.324.7336.495. Go to original source... Go to PubMed...
  17. Jing J, Herlopian A, Karakis I, et al. Interrater reliability of experts in identifying interictal epileptiform discharges in electroencephalograms. JAMA Neurol. 2020;77:49. doi: 10.1001/jamaneurol.2019.3531. Go to original source... Go to PubMed...
  18. Juarez-Garcia A, Stokes T, Shaw B, et al. The costs of epilepsy misdiagnosis in England and Wales. Seizure. 2006;15:598-605. doi: 10.1016/j.seizure.2006.08.005. Go to original source... Go to PubMed...
  19. Kane N, Acharya J, Beniczky S, et al. A revised glossary of terms most commonly used by clinical electroencephalographers and updated proposal for the report format of the EEG findings: revision 2017. Clin Neurophysiol Pract. 2017;2:170-85. doi: 10.1016/j.cnp.2017.07.002. Go to original source... Go to PubMed...
  20. Kang JY, Krauss GL. Normal Variants Are Commonly Overread as Interictal Epileptiform Abnormalities. J Clin Neurophysiol. 2019;36:257-63. doi: 10.1097/WNP.0000000000000613. Go to original source... Go to PubMed...
  21. Kemp B, Värri A, Rosa AC, et al. A simple format for exchange of digitized polygraphic recordings. Electroencephalogr Clin Neurophysiol. 1992; 82:391-3. doi: 10.1016/0013-4694(92)90009-7. Go to original source... Go to PubMed...
  22. Klatt J, Feldwisch-Drentrup H, Ihle M, et al. The EPILEPSIAE database: an extensive electroencephalography database of epilepsy patients. Epilepsia. 2012;53:1669-76. doi: 10.1111/j.1528-1167.2012.03564.x. Go to original source... Go to PubMed...
  23. Lafrance WC Jr, Benbadis SR. Avoiding the costs of unrecognized psychological nonepileptic seizures. Neurology. 2006;13:1620-1. doi: 10.1212/01.wnl.0000224953.94807.be. Go to original source... Go to PubMed...
  24. Lee CH, Lim SN, Lien F, et al. Duration of electroencephalographic recordings in patients with epilepsy. Seizure. 2013;22:438-42. doi: 10.1016/j.seizure.2013.02.016. Go to original source... Go to PubMed...
  25. Lodder SS, van Putten MJ. Quantification of the adult EEG background pattern. Clin Neurophysiol. 2013;124:228-37. doi: 10.1016/j.clinph.2012.07.007. Go to original source... Go to PubMed...
  26. Lourenço ES, Kowacs DP, Gavvala JR,et al. EEG education in Brazil: a national survey of adult neurology residents. Arq Neuropsiquiatr. 2022;80:43-7. doi: 10.1590/0004-282X-ANP-2021-0150. Go to original source... Go to PubMed...
  27. Luders HO, Noachtar S. Atlas and Classification of Electroencephalography. WB Saunders Company: Philadelphia, 2000.
  28. Mahajan A, Cahill C, Scharf E, et al. Neurology residency training in 2017. A survey of preparation, perspectives, and plans. Neurology. 2019;92:76-83. doi: 10.1212/WNL.0000000000006739. Go to original source... Go to PubMed...
  29. Miller JW, Henry JC. Solving the dilemma of EEG misinterpretation. Neurology. 2013;80:13-4. doi: 10.1212/WNL.0b013e318279755f. Go to original source... Go to PubMed...
  30. Nascimento FA, Gavvala JR. Education Research: Neurology Resident EEG Education: A Survey of US Neurology Residency Program Directors. Neurology. 2021;96:821-4. doi: 10.1212/WNL.0000000000011354. Go to original source... Go to PubMed...
  31. Nascimento FA, Gavvala JR, Tankisi H, et al. Neurology resident EEG training in Europe. Clin Neurophysiol Pract. 2022;7:252-9. doi: 10.1016/j.cnp.2022.08.001. Go to original source... Go to PubMed...
  32. Nascimento FA, Jing J, Beniczky S, et al. One EEG, one read- a manifesto towards reducing interrater variability among experts. Clin Neurophysiol. 2022;133:68-70. doi: 10.1016/j.clinph.2021.10.007. Go to original source... Go to PubMed...
  33. Ng MC, Gaspard N, Cole AJ, et al. The standardization debate: A conflation trap in critical care electroencephalography. Seizure. 2015;24:52-8. doi: 10.1016/j.seizure.2014.09.017. Go to original source... Go to PubMed...
  34. NICE: The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care. Clinical guideline, National Institute for Clinical Excellence, London;2004:201-73.
  35. NICE: The epilepsies: Evidence Update February 2014: A summary of selected new evidence relevant to NICE clinical guideline 137 'The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care' (2012) [Internet]. London: National Institute for Health and Care Excellence (NICE); 2014.
  36. Nicolaides P, Appleton RE, Beirne EM. EEG requests in paediatrics: an audit. Arch Dis Child. 1995;72:522-3. doi: 10.1136/adc.72.6.522. Go to original source... Go to PubMed...
  37. Oh DA, Kim H, Bae EK. Electroencephalographic Abnormalities in the Screening for Pilot Applicants in Korea. J Clin Neurol. 2018;14:212-14. doi: 10.3988/jcn.2018.14.2.212. Go to original source... Go to PubMed...
  38. Oto M, Russell AJ, McGonigal A, et al. Misdiagnosis of epilepsy in patients prescribed anticonvulsant drugs for other reasons. BMJ. 2003;326:326-7. doi: 10.1136/bmj.326.7384.326. Go to original source... Go to PubMed...
  39. Pearce KM, Cock HR. An audit of electroencephalography requests: use and misuse. Seizure. 2006;15:184-9. doi: 10.1016/j.seizure.2006.01.003. Go to original source... Go to PubMed...
  40. Petkar S, Jackson M, Fitzpatrick A. Management of blackouts and misdiagnosis of epilepsy and falls. Clin Med (Lond). 2005;5:514-20. doi: 10.7861/clinmedicine.5-5-514. Go to original source... Go to PubMed...
  41. Rathore C, Prakash S, Rana K, et al. Prevalence of benign epileptiform variants from an EEG laboratory in India and frequency of their misinterpretation. Epilepsy Res. 2021;170:106539. doi: 10.1016/j.eplepsyres.2020.106539. Go to original source... Go to PubMed...
  42. SIGN 143. Diagnosis and management of epilepsy in adults A national clinical guideline Evidence May 2015. Revised 2018
  43. Scottish Intercollegiate Guidelines Network. Diagnosis and management of epilepsy in adults. A national clinical guideline. Scottish Intercollegiate Guidelines Network, Edinburgh;2003:70.
  44. Seidel S, Pablik E, Aull-Watschinger S, et al. Incidental epileptiform discharges in patients of a tertiary centre. Clin Neurophysiol. 2016;127:102-7. doi: 10.1016/j.clinph.2015.02.056. Go to original source... Go to PubMed...
  45. Schomer DL, Lopes da Silva FH. Niedermeyer´s Electroencephalography: Basic Principles, Clinical Applications, and Related Fields. Lippincott Williams & Wilkins; 2010.
  46. Smith D, Bartolo R, Pickles RM, et al. Requests for electroencephalography in a district general hospital: retrospective and prospective audit. BMJ. 2001;322:954-7. doi: 10.1136/bmj.322.7292.954. Go to original source... Go to PubMed...
  47. Smith D, Defalla B A, Chadwick D W. The misdiagnosis of epilepsy and the management of refractory epilepsy in a specialist clinic. QJM. 1999;92:15-23. doi: 10.1093/qjmed/92.1.15. Go to original source... Go to PubMed...
  48. Smith SJM. EEG in neurological conditions other than epilepsy: when does it help, what does it add? J Neurol Neurosurg Psychiatry. 2005;76 (Suppl.2):ii8-ii12. doi: 10.1136/jnnp.2005.068486. Go to original source... Go to PubMed...
  49. Stone J, Smyth R, Carson A, et al. Systematic review of misdiagnosis of conversion symptoms and "hysteria". BMJ. 2005;331:989. doi: 10.1136/bmj.38628.466898.55. Go to original source... Go to PubMed...
  50. Tatum WO. Normal "suspicious" EEG. Neurology. 2013;80(1 Suppl 1):S4-11. doi: 10.1212/WNL.0b013e31827974df. Go to original source... Go to PubMed...
  51. Vojtěch Z. Atlas elektroencefalografie dospělých, 3. díl. Triton, 2024.
  52. Walczak TS, Scheuer ML, Resor S, et al. Prevalence and features of epilepsy without interictal epileptiform discharges. Neurology. 1993;43(suppl):287-8.
  53. Walzl D, Carson AJ, Stone J. The misdiagnosis of functional disorders as other neurological conditions. J Neurol. 2019;266:2018-26. doi: 10.1007/s00415-019-09356-3. Go to original source... Go to PubMed...
  54. Witlox J, Eurelings LS, de Jonghe JF, et al. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA. 2010;304:443-51. doi: 10.1001/jama.2010.1013. Go to original source... Go to PubMed...
  55. Zaidi A, Clough P, Cooper P, et al. Misdiagnosis of epilepsy: many seizure-like attacks have a cardiovascular cause. J Am Coll Cardiol. 2000;36:181-4. doi: 10.1016/s0735-1097(00)00700-2. Go to original source... Go to PubMed...




Neurology for Practice

Madam, Sir,
please be aware that the website on which you intend to enter, not the general public because it contains technical information about medicines, including advertisements relating to medicinal products. This information and communication professionals are solely under §2 of the Act n.40/1995 Coll. Is active persons authorized to prescribe or supply (hereinafter expert).
Take note that if you are not an expert, you run the risk of danger to their health or the health of other persons, if you the obtained information improperly understood or interpreted, and especially advertising which may be part of this site, or whether you used it for self-diagnosis or medical treatment, whether in relation to each other in person or in relation to others.

I declare:

  1. that I have met the above instruction
  2. I'm an expert within the meaning of the Act n.40/1995 Coll. the regulation of advertising, as amended, and I am aware of the risks that would be a person other than the expert input to these sites exhibited


No

Yes

If your statement is not true, please be aware
that brings the risk of danger to their health or the health of others.