Version No - PDF document

1 Version No.: 1.0; Effective from :
Version No.: 1.0; Effective from : 26 November 2 012 Page 1 of 15 Printed copies are uncontrolled Document Number # QH - GDL - 388:2 012 Routine Electroencephalography (EEG) Clinical Neurophysiology 1. Purpose This guideline provides recommendations regarding best practice to support high quality electroencephalography (EEG) practice throughout Queensland Health facilities . 2. Scope This guideline provides information for all clinical measurement practitioners who perform routine EEG. This guideline provides the minimum requirements for recording a routine EEG. Refer to the Queensland Health Guidel ine for non - routine EEG for neonates, infants, recordings in critical care units, and for electro - cerebral silence. 3. Related documents Policy and Standard/s: Informed Decision - making in Healthcare (QH - P OL - 346:2011) 1 Procedures, Guidelines, Protocols Australian Guidelines for the prevention and control of infection in healthcare (CD33:2010) 2 Forms and templates Consent to clinical digital images (Appendix 1) 4. Guideline for perform ing routine 4.1. Emergency Protocol F ollow local Hospital and Health Service protocols i n the event of a seizure. Custodian/Review Officer: Chief Allied Health Officer Version no: 1.0 Applicable To: Clinical measurement practitioners Approval Date: 26 / 11 / 2012 Effective Date: 26 No vember 2012 Next Review Date: 26 November 2012 Authority: Chair – State - wide clinical measurements network. Approving Officer Chief Allied Health Officer New document Key Words: Electroencephalography, EEG, Routine EEG, Neurophysiolog y, Photic Stimulation, Hyperventilation. Accreditation References: EQuIP and other criteria and standards Queensland Health: Routine Electroencephalography (EEG)

2 Version No.: 1.0 ; Effective from
Version No.: 1.0 ; Effective from 26 November 2012 Page 2 of 15 Printed copies are uncontrolled Follow relevant Hospital and Health Service protocols in the event of an emergency. 4.2. Infection Control Procedures Inte rnational Organisation of Societies for Electrophysiological Technology (OSET) Guidelines for Infection Control in the Clinical Neurophysiology Department 1999. http://www.oset.org/guide.htm 3 Australian Guidelines for the prevention and control of infection in healthcare (2010) http://www.nhmrc.gov.au/node/30290 2 4.3. Gaining Consent Gain consent in accordance with Queensland Health’s Informed Decision - making In Healthcare Policy 1 Epilepsy and photosensitive seizure disorders are not considered a contraindication for photic stimulation; however the patient should be made aware that there is a slight risk of provoking a se izure during Intermittent Photic Stimulation ( IPS ) 4 , 5 Signed consent is required from the patient (or their legal guardian/carer) to record their digital image during the EEG. This signed document shall be filed in the patient’s medical record (see example in A ppendix 1). 4.4. Identifying Ind ications/Contraindications Contraindications for activations procedures are listed in the body of the document. Please refer to suggested readings for a list of possible indications for EEG. 4.5. Facilities and equipment Perform t he routine EEG within a quiet, temperate room with controllable light levels. Sit or recline t he patient comfortably for the duration of the set up and recording. 4.6. Training requirements Relevant training include s : Undergraduate courses offered at Central Queensland University and Charle s Sturt University. G raduate C ertificate in Clinical Neurophysiology offered at Charles Sturt University. American Society of Electroneurod

3 iagnostic Technology www.aset.org . 4
iagnostic Technology www.aset.org . 4.7. Test Procedure 4.7.1. Electrodes Electrode Placement Place the electrodes in accordance with the International 10/20 System of Electrode Placement (Appendix 2). Use a minimum of 21 electrodes , as well as reference and ground electrodes where applicable 6 . Queensland Health: Routine Electroencephalography (EEG) Version No.: 1.0 ; Effective from 26 November 2012 Page 3 of 15 Printed copies are uncontrolled Electrode Choice To record a routine EEG, use e lectrodes that allow undistorted recordings of no less than a frequency range of 0.5 – 70Hz. The electrodes used are to be of the same material - preferably silver/silver chloride (Ag/AgCl) or gold cup 7 . Electrode Impedance Measure e lectrode impedance prior to each recording and at any time during the EEG when an electrode is altered or adjusted. Measure the i mpedances of all electrodes to ensure the impedance is 5Kohms or be low and of similar value, i.e. within 3kohm range of each other 3 . 4.7.2. Pre - test checks Calibration Record a square wave calibration signal of known input for a minimum of 10 seconds prior to the EEG recording and store this with the EEG. This square wave ca libration recording documents the machine parameters (filters and sensitivity settings) used during the EEG recording 4 . Biological Calibration Record, w he re possible , a biological calibration of no less than 10 seconds and store this with the EEG 7 . All Electrode Check Perform an electrode check by recording a period of no less than 10 seconds w ith the primary reference montage (digital EEG recording systems) displaying all recording electrodes . Perform this at the beginning of the EEG recording and store with the EEG 4 . 4.7.3. Recording Patient Information Document patient information including:

4 patient name, h ospital reference (U
patient name, h ospital reference (UR) number, date of birth , recording date, referring doctor, recording technologists (clinical measurement practitioner’s) initi als, recording time, clinical details (last seizure, handedness, last meal, and behavioural state) current medications and any sedation given prior to the test. Include n otation of any skull defects or sites of previous surgery within the factual report or within information supplied to the reporting medical officer 8 . Annotations Make regular annotations to mark any changes in the EEG or the patient’s state and behaviour t hroughout the recording. This includes any movement of the patient, any external stimuli, artefact s, instructions given etc. Montages Use a selection of recording montages during the baseline EEG. Use a minimum of anterior - posterior bipolar and transverse bipolar montages 4 . Incorporate a reference montage (common, average and source) into the routine EEG. Represent all recording electrodes on the montages, at some time during the recording 4 , 9 . Queensland Health: Routine Electroencephalography (EEG) Version No.: 1.0 ; Effective from 26 November 2012 Page 4 of 15 Printed copies are uncontrolled Length of Recording Record no less than 20 mi nutes of technically satisfactory, artefact free baseline recording including activation procedures (where applicable) 7 . Machine Settings - Display Record within the range of the following para meters: Sensitivity – 5 - 10µV/mm of trace deflection 10 Low Frequency Filter – No higher than 1Hz (TC 0.16s) 10 High Frequency Filter – No lower than 70Hz Notch filter – N ot be used in the routine setting and only to be used when all technical means have been employed to reduce 50Hz interference 10 Paper speed – 30mm/sec or 10 seconds per page/screen

5 10 4.7.4. Polygraphic recording Du
10 4.7.4. Polygraphic recording During the routine EEG it may be necessary to record from additional polygraphic channels generally with the purpose of distinguishing artefact from cerebral potentials. ECG – Electrocardiogram (heart beat) shall always be recorded in conjunction with the EEG and displayed on all recording pages. In certain cases the following additional electrodes are required as minimum standards to the Routine EEG: EOG – Electro - oculogram (eye movement) 11 EMG – Surface Electromyogram (muscle activity) 8 4.7.5. Activations Performing additional activation procedures (e.g. reading) is guided by the avail able clinical information and question i.e. possible causative factor for the events. Eyes opening and closure Record a period of no less than 10 seconds with eyes open and a period no less than 10 seconds with eyes closed , during the recording . The usual procedure for a compliant patient is to record most of the baseline EEG with eyes closed and to include two or three 10 second periods of eyes open. For a less compliant patient such as a small child the baseline EEG may be performed with a majority of t he recording with eyes open and two or three 5 - 10 second periods of eye closure (passive or with assistance) 7 . Hyperventilation Perform h yperventilation by asking the patient to breathe deep ly in and out through their mouth ensuring as much air is expelled during expiration as possible. The desired respiratory rate i s approximately 1 breath every three seconds 12 . Perform h yperventilation for a m inimum of three minutes and extend to five minutes if absence seizures are suspected. Continue t he post h yperventilat ion EEG recording for at least two minutes after cessation of hyperventilation 4 , 7 . Allow a minimum period of three minutes separating the performance of hyperventilation

6 and intermittent photic stimulation . D
and intermittent photic stimulation . During this period, monitor the background EEG for the persistence of any changes produced by the hyperventilation response 10 . Queensland Health: Routine Electroencephalography (EEG) Version No.: 1.0 ; Effective from 26 November 2012 Page 5 of 15 Printed copies are uncontrolled Note: Ensure hyperventilation is not the last procedure performed during the EEG recording. Use profes sional judgement to ascertain the patient’s ability to perform adequate hyperventilation for the required time. If there are any doubts, seek a medical opinion. Document the results of this in the patient’s notes, the EEG technical notes and as an annotati on on the record. Note: Relative contraindications for hyperventilation include recent: Cerebral Vascular Accidents (CVA) Transient Ischaemic Attacks (TIA) Myocardial Infarction (MI) Acute Respiratory Distress Syndrome (ARDS) Surgery (including transplant s) Patients that have a history or known diagnosis of – — Asthma — Chronic Obstructive Pulmonary Disease (COPD) — Moya Moya disease — Sickle - Cell anaemia. Pregnancy (Third Trimeste�r 24weeks/6months) Increased intracranial pressure On supplemental oxygen Note: A ge alone is not considered a contraindication 4 . Note: The presence of diffuse epileptiform discharges is not an absolute contraindication to the performanc e of hyperventilation. Intermittent Photic Stimulation (IPS) IPS requires the patient to look at a series of flashing lights of varying frequency with periods of eyes open and eyes closed 10 . Place the strobe light approximately 30cm from the patient’s face and decrease the ambient lighting for the duration of IPS. Utilise f lash frequencies from 1 - 50Hz for a minimum of 10 seconds each, with periods of eyes open and eyes close

7 d for each frequency presented. For exa
d for each frequency presented. For example, some texts recommended the use of the following IPS sequence - 1, 2, 3, 4, 6, 8, 10, 12, 14, 16, 18, 20Hz. Immediately followed by 50, 40, 30, 25Hz. Separate each flash frequency with a minimum of sev en seconds 5 , 13 . Note: Relative contraindications to photic stimulation include photophob ia associated with conditions such as migraine, meningitis or encephalitis and inability to perform the procedure (such as with agitated patients or those with intellectual impairment) 11 . Queensland Health: Routine Electroencephalography (EEG) Version No.: 1.0 ; Effective from 26 November 2012 Page 6 of 15 Printed copies are uncontrolled As with h yperventilation, assess the patient’s ability and will ingness to perform IPS to the required standard using professional judgement. Annotate a ny modifications to the IPS procedure on the recording and also within the patient notes. Epilepsy and photosensitive seizure disorders are not considered a contraindi cation for photic stimulation; however make the patient aware of the possible risk of provoking a seizure during IPS 4 , 5 . Stop IPS immediately if generalised photo - paroxysmal activity is seen during a particular train flash frequency. Repeat t his stimulus frequency to demonstrate that the epileptiform discharge is reproducible and therefore a result of the stimulus 11 . Repeat the stimulus frequency to demonstrate that the epileptiform discharge is reproducible and therefore a result of the stimulus 11 . Ascertain the range of photic frequencies assumed to result in a photo - paroxysmal response 13 . This is done by stimulating at the highest frequency available (i.e. 50Hz) then reducing the fr equency used (following the process outline d above (*) in reverse) until evidence of a photo - paroxysmal

8 response is obtained. Document t his r
response is obtained. Document t his range in the technical notes of the EEG report 8 . Drowsiness/Sleep Encourage a period of sleep/drowsiness in all routine EEG recordings, but not to the exclusion of the waking record ing. This can often be obtained in the routine setting without sleep deprivation. E ncourage sleep by performing the EEG in a dimly lit, temperate room with the patient comfortably reclined. Minimal eye opening and interaction with the patient is encourage d to promote drowsiness and light sleep within the time constraints of the routine EEG in clinical practice 4 . Sleep Deprivation Sleep deprivation preparatio ns can vary depending o n the patient’s age and routine. Advise adult patients to : remain awake for 24 hours prior to the Sleep Deprived EEG appointment arrange for transportation to and from the appointment (with a well rested, responsible adult) refrain from any stimulants such as caffeine during the period of sleep deprivation. Note: Partial sleep deprivation can be used in children or in circumstances where it is judged necessary, allowing the patient a brief (one to two hours) period of sleep in the middle of the night 14 . 4.7.6. Post recording checks All electrode c heck Perform a recording of a period of no less than 10 seconds with a primary reference montage (digital EEG recording systems) displaying all recording electrodes . Perform this at the end of the EEG recording and store it with the EEG 4 . Queensland Health: Routine Electroencephalography (EEG) Version No.: 1.0 ; Effective from 26 November 2012 Page 7 of 15 Printed copies are uncontrolled Biological Calibration Where possible , record a biological calibration of no less than 10 seconds and store with the EEG 7 . Calibration Record a square wave calibration signal of known input for a minimum of

9 10 seconds at the end of the EEG record
10 seconds at the end of the EEG recording and store with the EEG. The square wave calibration represent s the machine parameters (filters and sensitivity settings) used during the EEG recording 4 . 4.8. Quality Control Procedures For calibration techniques and machines checks for digital EEG machines, please refer to: Binnie. C, Cooper. R, Mau guiere. F, Osselton. J, Prior. P, Tedman. B (2003) Clinical Neurophysiology: EEG, Paediatric Neurophysiology, Special Techniques and Applications. Volume 2; Chapter 4, EEG Technology, Digital Calibration, pg 73 - 76, Elsevier 5. Definition of Terms Definitions of key terms are provided below. Abbreviation Term Definition / Explanation / Details Montage Refers to the pattern of systemic linkage of the scalp electrodes designed to obtain a logical display of the electrical activity 14 . Impedance The apparent resistance of a circuit to the flow of an alternating electric current 15 . Calibration T o standardise (as a measuring instrument) by determining the deviation from a standard so as to ascertain the proper correction factors 16 . IPS Intermittent Photic Stimulation Queensland Health: Routine Electroencephalography (EEG) Version No.: 1.0 ; Effective from 26 November 2012 Page 8 of 15 Printed copies are uncontrolled 6. Consultation Key stakeholders (position and business area) who reviewed this version are: Queensland Health Clinical Neurophysiology Working Party (Emma Fetherston, Fred Tremayne, Jo Wex, Carolin Healion, Annett Koenig, Kane Curtis, Susan Koklas) Clinical Measurements Advisory Group (CMAG) for Clinical Education and Training State - wide Clinical Measurements Network (SWCMN) Association of Neurophysiological Technolog ists Australia Inc (ANTA) Dr Alice - Ann Sullivan – Staff Specialist Neurology Dr Sophie Calve

10 rt - Staff Specialist in Paediatric N
rt - Staff Specialist in Paediatric Neurology Dr Kate Rinney - Consultant Paediatric Neurologist & Epileptologist Queensland Health Neurophysiology Laboratory Manag ers (as of 18/02/2011) 7. Guideline Revision and Approval History Version No. Modified by Approved by 1.0 Megan Harbourne Dane Enkera - Chair State - wide Clinical Measurements Network Brett Duce - Chair Clinical Measurements Advisory Group (for clinical ed ucation) Queensland Health: Routine Electroencephalography (EEG) Version No.: 1.0 ; Effective from 26 November 2012 Page 9 of 15 Printed copies are uncontrolled 8. Appendices APPENDIX 1 – Consent to Clinical Digital Images Queensland Health: Routine Electroencephalography (EEG) Version No.: 1.0 ; Effective from 26 November 2012 Page 10 of 15 Printed copies are uncontrolled APPENDIX 2 - International 10/20 System of Electrode Placement 14 1. Locate the skull landmarks: inion, nasion and pre - auricular points. It is often helpfu l to mark the inion in one colour and all other positions in another colour. Corrections can then be done in the first colour. 2. Measure the distance along the midline between the nasion and the inion with the centimetre tape. The value for this example is 30cm. a. Determine half (50%) of this distance, e.g., 15cm, place the mark for Cz. b. Determine 10% of the total inion - nasion distance, e.g., 3cm. Mark 3cm (10%) posterior from the nasion along the midline. This is reference point Fpz. c. Determine 20% of the to tal distance. From Fpz reference (not the nasion) measure 6cm (20%) back along the midline. This is the location of Fz. d. Measure 20% of the total distance (6cm) back from Cz. This is the location for Pz. e. Locate Oz which is 20% (6cm) back along the midline f rom Pz. f. Verify that Oz is 10% above t

11 he inion. 3. Measure the distance
he inion. 3. Measure the distance between the right and left pre - auricular points making sure that the tape goes through Cz, for example 35cm. a. Determine half (50%) of this distance, e.g. 17.5cm, place a second mark for Cz . This completes the two marks for the Cz position. b. Keeping the tape in place through Cz, measure up 10% (3.5cm) from the right pre - auricular point and mark. This is one mark for T4. c. Place the mark for electrode position C4 halfway between T4 and Cz. This represent s 20% (7cm) of the entire distance. d. Follow the same procedure on the left side of the head for C3 and T3 . 4. Measure the circumference of the head making sure that the tape goes through the frontal pole (Fpz), the occipital (Oz) reference point and T3(T7) and T4(T8) (mid temporal). Divide the circumference of the head into two halves. For example : If the circumference is 54cm, each half circumference will be 27cm. 10% = 2.7cm; 20% = 5.4cm. These distances will be used for the following measurement s . Queensland Health: Routine Electroencephalography (EEG) Version No.: 1.0 ; Effective from 26 November 2012 Page 11 of 15 Printed copies are uncontrolled a. Position the tape measure so that it straddles the midline at the level of Fpz. Make a vertical mark for each F p 1 and F p 2 . The right mark is the first for the Fp2 (10%) position and the left mark the first for the Fp1 (10%) position. b. From Fp2 put the t ape measure along the circumference line. The next point becomes the vertical mark for F8 (20%). ( Fp 2  20% =F8) c. From F8, continue posterior along the circumference line and make a vertical mark through the previous mark for T4 (T8) (+20%). NOT E: This position may not be directly above the pre - auricular point. d. Continue with the tape measure posterior along the circumference from T4

12 (20% 5.4cm) to make the vertical mark fo
(20% 5.4cm) to make the vertical mark for T6 (P8). e. Continue posterior from T6 (P8) (20% 5.4cm) to make the first mark for O2. f. Repeat this procedure for the left side of the head, working posterior from the Fp1 mark previously made. Establish o ne mark for F7, T5 (P7) and O1 during this step and the T3 (T7) location is completed. g. With the tape measure, verify that the distance between O1and O2 is 20% (5.4cm) as well. (O1  10%  Oz  10%  O2) NOTE: Ensure the Fp1 and Fp 2 are equidistant from the midline at the front of the head and O1 and O2 are equidistant from the midline at the back of the head. Ensure T3 (T7) and T 4 (T8) are in the same position with respect to the ear on each side of the head. 5. To determine the second coordinate for each of the positions identified in the previous step (commonly referred to as the temporal or lateral chain of electrodes) extend the 4 horizontal marks for Fpz, Oz, T3 (T7) and T4 (T8) to intersect with the vertical marks just made for Fp1, F7, T5 (P7), O1 and on the right Fp2, F8, T6 (P8) and O2. For example, place one end of the tape measure at Fpz and the other at T3 (T7). Place a h orizontal mark through Fp1 and F7 along the straight edge of the tape. Repeat this between T3 (T7) and Oz, Oz and T4 (T8), and T4 and Fpz. 6. Measure the distance from Fp1 to O1 going through C3 (100%; 22cm). At one half of this distance, make the intersecti ng mark that completes electrode position C3 (50% = 11cm). a. Locate F3 (25%; 5.5cm) halfway between Fp1 and C3. b. P3 (25%; 5.5cm) is halfway C3 and O1. Queensland Health: Routine Electroencephalography (EEG) Version No.: 1.0 ; Effective from 26 November 2012 Page 12 of 15 Printed copies are uncontrolled 7. Repeat this procedure on the right hemisphere (100%). At one half of the distance from Fp2 to O2 through C4 (50

13 %), complete the mark for the C4 positio
%), complete the mark for the C4 position. a. Halfway between Fp2 and C4, make one mark for the F4 (25%) location. b. Halfway between C4 and O2, make one mark for the P4 (25%) location. 8. With the tape, measure the distance from F7 to F8 through Fz (100% 12cm ). Determine one half (50%) of this distance and mark. This becomes the final mark for Fz (6cm). a. The final mark for F3 (25%; 6cm) is placed halfway between Fz and F7. b. Similarly, the final mark for F4 (25%; 6cm) is halfway between F8 and Fz. 9. Measure the di stance from T5 (P7) to T6 (P8) through Pz (100% 18cm). Mark one half (50%) of this distance. This mark completes the Pz location. a. One half of the Pz to T5 (P7) distance is the final mark for P3 (25% 4.5cm). b. One half of the distance from Pz to T6 (P8) is th e final mark for P4 (25% 4.5cm). Note: T wo coordinates are required for each of the 19 standard electrode positions on the scalp. Ear electrodes, A1 and A2, make a full complement of 21 electrodes. Queensland Health: Routine Electroencephalography (EEG) Version No.: 1.0 ; Effective from 26 November 2012 Page 13 of 15 Printed copies are uncontrolled Figure 1: International 10/20 System of Elec trode Placement Teplan, M. 2002, Fundamentals of EEG measurement, Measurement Science Review, Volume 2, Institute of Measurement Science, Slovak Academy of Sciences, Dúbravská cesta 9, 841 04 Bratislava, Slovakia Left pre - auricular point Right pre - auricular point Queensland Health: Routine Electroencephalography (EEG) Version No.: 1.0 ; Effective from 26 November 2012 Page 14 of 15 Printed copies are uncontrolled 9. References and Sugge sted Reading 9.1. References 1. Queensland Health. Informed decision making in health care2012: Available from: http://www.health.

14 qld.gov.au/consent/default.asp . 2.
qld.gov.au/consent/default.asp . 2. National Health and Medical Research Council. Australian Guidelines for the Prevention and Control of Infection in Healthcare. National Health and Medical Research Council; 2010 [cited 2012 12/09/12]; CD33:[Available from: http://www.nhmrc.gov.au/node/30290 . 3. International Organisation of Societies for Electrophysiological Technology. Guidelines For Infection Control In The Clinical Neurophysiology Department1999: Available from: http://www.oset.org/img/guidelines/Guidesinfectioncontrol.pdf . 4. Association of Neurophysiological Technologists of Australia Inc. Routine EEG Recording Guidelines2009: Available from: http://www.anta.asn.au/forms/Guidelines/EEG%20Guidelines%20Aug%202009.pdf . 5. Kasteleijn - Nolst Trenite DG, Binnie CD, Harding GF, Wilkins A. Photic stimulation: standardization of screening methods. Epilepsia. [Consensus Development Conference Review]. 1999;40 Suppl 4:75 - 9. 6. American Clinical Neurophysiology Society. Guideline 5: Guidelines for Standard Electrode Position Nomenclature2006: Available from: http://www.acns.org/pdfs/ACFDD46.pdf . 7. American Clinical Neurophysiology Society. Guideline 1: Minimum Technical Requirements for Performing Clinical Electroencephalography2006: Available from: http://www.acns.org/pdfs/Guideline%201.pdf . 8. Cooper R, Binnie C, Billings R. Techniques in Clinical Neurophysiology: A Practical Manual: Elsevier, Amsterdam; 2005. 9. American Clinical Neurophysiology Society. Guideline 6: A Proposal for Standard Montages to Be Used in Clinical EEG2006: Available from: http://www.acns.org/pdfs/Guideline%206.pdf . 10. Flink R, Pedersen B, Guekht AB, Malmgren K, Michelucci R, Neville B, et al. G uidelines for the use of EEG methodology in the diagnosis of epilepsy. International League Against Epilepsy: commission report. Commission on European Affairs: Subcommission on European

15 Guidelines. Acta Neurol Scand. 2002 Jul
Guidelines. Acta Neurol Scand. 2002 Jul;106(1):1 - 7. 11. Fisch BJ. Fis ch and Spehlmann’s EEG primer : basic principles of digital and analog EEG. 3rd ed: Amsterdam : Elsevier; 1999. 12. Mendez OE, Brenner RP. Increasing the yield of EEG. J Clin Neurophysiol. [Review]. 2006 Aug;23(4):282 - 93. 13. Rubboli G, Parra J, Seri S, Ta kahashi T, Thomas P. EEG diagnostic procedures and special investigations in the assessment of photosensitivity. Epilepsia. [Review]. 2004;45 Suppl 1:35 - 9. Queensland Health: Routine Electroencephalography (EEG) Version No.: 1.0 ; Effective from 26 November 2012 Page 15 of 15 Printed copies are uncontrolled 14. Rowan AJ, Tolunsky E. Primer of EEG : with a mini - atla: Philadelphia ; [Oxford] : Butterworth - He inemann; 2003. 15. Gennaro AR, Gould GM. Blakiston's Gould medical dictionary : a modern comprehensive dictionary of the terms used in all branches of medicine and allied sciences, with illustrations and tables. New York: McGraw - Hill; 1979. 16. Merriam - Web ster I. Merriam - Webster's medical dictionary. Springfield, Mass.: Merriam - Webster; 2007. 9.2. Suggested readings Guidelines for the use of EEG methodology in the diagnosis of e pilepsy http://cvu.rediris.es/pub/bscw.cgi/d856948/GuidelinesEEG.pdf American Clinical Neurophysiology Society Guidelines http://www.acns.org ‘A glossary of terms most commonly used by clinical electroencephalographers and proposal for the report form for the EEG findings’, S. Noachtar, C. Binnie, S. Ebersole, S. Mauguière, A. Sakamoto, B. Westmoreland. 1999, Recommendations for the Practice of Clinical Neurophysiology; Guidelines of the International Federation of Clinical Physiology (EEG Suppl. 52) International Organisation of Societies for Electrophysiological Technology (OSET) Guidelines for Digital EEG http://www.oset.org/img/guidelines/digitalEE