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• W2172905572 abstract "Free AccessCPAPAn Unexpected Abnormality on the EEG Clodagh M. Ryan, M.D., Brian J. Murray, M.D. Clodagh M. Ryan, M.D. Address correspondence to: Clodagh M. Ryan, 9N-967 Toronto General Hospital, 585 University Ave., M5G 2N2, Toronto, Canada(416) 340-4719(416) 340-4197 E-mail Address: [email protected] Sleep Research Laboratory of Toronto Rehabilitation Institute, University of Toronto, Toronto, Canada Search for more papers by this author , Brian J. Murray, M.D. Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada Search for more papers by this author Published Online:December 15, 2010https://doi.org/10.5664/jcsm.27998Cited by:4SectionsPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutINTRODUCTIONA 59-year-old male was referred for a sleep study because of observed hypersomnolence during a medical evaluation for kidney transplant.His past medical history was significant for a 30-year history of insulin dependent diabetes. He was known to have many secondary macrovascular and microvascular complications. These included a history of myocardial infarction, microangiopathic disease, symptomatic peripheral vascular disease, and proliferative retinopathy. He also had end-stage renal disease, treated with intermittent hemodialysis 3 times per week for the past 5 years.He had a 10-year history of obstructive sleep apnea and was on CPAP at 10 cm H20. However, he had not had a formal reevaluation of the efficacy of his CPAP therapy in over 6 years. There was also a history of daytime hypersomnolence, for which the patient was on modafinil. Other medications included diltiazem, atorvastatin, aspirin, atenolol, ramipril, omeprazole, and insulin.On physical examination he had a body mass index of 33.6 and Mallampati score of 3 on oropharyngeal examination. Neurological examination was unremarkable.What does the EEG tracing (Figure 1) show?Figure 1 A 30-second epoch tracing of polysomnography recorded during wakeDownload FigureA: Frontal intermittent rhythmic delta activity (FIRDA)Frontal intermittent rhythmic delta activity (FIRDA) was originally described by Cobb in 1945.1 However, it was Van der Drift and Magnus who coined the term FIRDA in 1959.2FIRDA is a rhythmic 2 to 3 Hz delta frequency activity with an amplitude of 50–100 mv that predominates in the bilateral frontal regions of the waking adult electroencephalogram (EEG). The waves are usually regular with a sinusoidal pattern. FIRDA usually occurs in short bursts lasting 2 to 6 seconds and must be differentiated from slow eye blink artifact Figure 2. The electrooculogram (EOG) electrodes can aid in the differentiation of the two. FIRDA, unlike eye blink artifact, may have posterior field extension. It is attenuated by alerting or eye opening and accentuated by eye closure, hyperventilation, drowsiness, and stage N1 sleep. It disappears with the onset of Stage N2 sleep but may reappear during REM sleep. If diagnostic uncertainty is present, a full EEG montage should be used and the EEG recording should include 20 minutes during wakefulness, followed by 3 minutes of hyperventilation and standard intermittent light stimulation to adequately document FIRDA.Figure 2 10-second epoch tracing of polysomnography recorded during wake demonstrates intermittent rhythmic delta activityDownload FigureThe exact neurophysiological basis of the FIRDA rhythm is unclear. When first described, it was attributed to deep midline and posterior fossa pathology.3,4 Subsequently Fariello et al. demonstrated that hemispheric brain tumors, ischemic brain injury, or metabolic derangements were the most likely culprits.5As a variety of pathological processes result in FIRDA, it is a nonspecific finding. In particular, increased intracranial pressure of any cause, tumors, and systemic toxic and metabolic disorders including hyperglycemia, and renal and hepatic failure may be responsible. There is no association between FIRDA and seizures.In patients with chronic renal disease, FIRDA was initially described in those with progressive dialytic encephalopathy. Due to the elimination of aluminium-containing dialysate, dialysate encephalopathy is now rare. However, cognitive impairment occurs in up to 70% of individuals over the age of 55 years with chronic renal failure. This is frequently associated with cerebrovascular disease.6 Furthermore, encephalopathy due to uremia, fluid and electrolyte disturbances, hypertension, or drug toxicity is common.7 Presentations may vary from mild sensorial clouding to delirium and coma. Radiological studies of correlates of FIRDA have demonstrated that periventricular white matter disease and cortical atrophy were the most prevalent findings.8 Furthermore, a recent retrospective study of patients in whom FIRDA was found on the EEG tracings showed that 50% had acute renal failure on admission to hospital and 33% had hyperglycemia.8Although, usually described in adults, Watenberg et al. have shown FIRDA to be present in 1.3% of pediatric EEGs.9 In contrast to the adult patients, no acute encephalopathy was evident clinically in these subjects. However, 50% of the children were cognitively impaired and 50% had epilepsy. Their EEGs had concomitant epileptiform discharges in 55%.Less commonly, intermittent rhythmic delta activity may also occur in other EEG locations, namely occipital and temporal. Occipital intermittent rhythmic delta activity (OIRDA) was originally considered an equivalent of FIRDA in children. The difference in location was considered a result of maturational and developmental factors. However, more recent reviews suggest that unlike FIRDA, OIRDA is strongly associated with seizures in children and not with encephalopathy.10Temporal intermittent rhythmic delta activity (TIRDA) raises concern for temporal lobe epilepsy and is usually unilateral. It differs markedly from both OIRDA and FIRDA in that it necessarily implies a focal rather than global lesion.11Although the exact pathophysiological significance of FIRDA is uncertain, in otherwise normal individuals a search for underlying pathology should be undertaken.In this patient, the presence of FIRDA was probably multifactorial. He had known microangiopathic disease, renal failure, and inadequately controlled diabetes mellitus and obstructive sleep apnea at the time of the study. On a subsequent titration study with CPAP no further episodes of FIRDA were observed. There are no cases of FIRDA in association with OSA in the literature; in view of this patient's multiple comorbidities, it is unlikely that the FIRDA is a result of this.CLINICAL PEARLS FOR FIRDAIt is a rhythmic high voltage delta activity at 2–3 HzThe rhythm is intermittent and occurs in bursts lasting 2 to 6 secondsOccurs in the waking and drowsy adult EEG in the frontal regionsMay occur withMetabolic encephalopathiesToxic encephalopathiesIncreased intracranial pressureDeep structural abnormalitiesPathophysiological significance uncertainDISCLOSURE STATEMENTThe authors have indicated no financial conflicts of interest.REFERENCES1 Cobb WRhythmic slow discharges in the electroencephalogramJ Neurol Neurosurg Psychiatry1945865, 20984308CrossrefGoogle Scholar2 Van der Drift JMagnus OThe value of the EEG in the differential diagnosis of cases with cerebral lesionElectroencephalogr Clin Neurophysiol19591173346, 13811933Google Scholar3 Daly DWhelan JLBickford RG, et al.The electroencephalogram in cases of tumors of the posterior fossa and third ventricleElectroencephalogr Clin Neurophysiol1953520316, 13052069CrossrefGoogle Scholar4 Bagchi BKKooi KAElectroencephalography and brain tumorsMed Bull (Ann Arbor)1961275060, 13685842Google Scholar5 Fariello RGOrrison WBlanco G, et al.Neuroradiological correlates of frontally predominant intermittent rhythmic delta activity (FIRDA)Electroencephalogr Clin Neurophysiol198254194202, 6179744CrossrefGoogle Scholar6 Murray AMCognitive impairment in the aging dialysis and chronic kidney disease populations: an occult burdenAdv Chronic Kidney Dis20081512332, 18334236CrossrefGoogle Scholar7 Brouns RDe Deyn PPNeurological complications in renal failure: a reviewClin Neurol Neurosurg2004107116, 15567546CrossrefGoogle Scholar8 Watemberg NAlehan FDabby R, et al.Clinical and radiologic correlates of frontal intermittent rhythmic delta activityJ Clin Neurophysiol2002195359, 12488784CrossrefGoogle Scholar9 Watemberg NGandelman RNeufeld MY, et al.Clinical correlates of frontal intermittent rhythmic delta activity in childrenJ Child Neurol2003185259, 13677577CrossrefGoogle Scholar10 Gullapalli DFountain NBClinical correlation of occipital intermittent rhythmic delta activityJ Clin Neurophysiol2003203541, 12684556CrossrefGoogle Scholar11 Gambardella AGotman JCendes F, et al.Focal intermittent delta activity in patients with mesiotemporal atrophy: a reliable marker of the epileptogenic focusEpilepsia1995361229, 7821268CrossrefGoogle Scholar Previous article Next article FiguresReferencesRelatedDetailsCited by EEG in WNV Neuroinvasive DiseaseParsons A, Grill M, Feyissa A, Britton J, Hocker S and Crepeau A Journal of Clinical Neurophysiology, 10.1097/WNP.0000000000000558, Vol. 36, No. 2, (135-140), Online publication date: 1-Mar-2019. Sazgar M and Young M Encephalopathies, Brain Death, and EEG Absolute Epilepsy and EEG Rotation Review, 10.1007/978-3-030-03511-2_10, (183-198), . Electroencephalography and delirium in the postoperative periodPalanca B, Wildes T, Ju Y, Ching S and Avidan M British Journal of Anaesthesia, 10.1093/bja/aew475, Vol. 119, No. 2, (294-307), Online publication date: 1-Aug-2017. EEG Derived Neuronal Dynamics during Meditation: Progress and ChallengesKaur C and Singh P Advances in Preventive Medicine, 10.1155/2015/614723, Vol. 2015, , (1-10), . Volume 06 • Issue 06 • December 15, 2010ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationApril 1, 2010Submitted in final revised formJune 1, 2010Accepted for publicationJune 1, 2010Published onlineDecember 15, 2010 Information© 2010 American Academy of Sleep MedicinePDF download" @default.
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