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EEGs and the brain: insights from Syed Shabbir, MD
In our latest podcast episode, we delve into the fascinating world of brain waves and neurological diagnostics with Dr. Syed Shabbir, Director of Epilepsy and Medical Director of the EEG Lab at Medstar Franklin Square Medical Center. Hosted by Debra Schindler, this episode sheds light on the complexities of the human brain and the critical role of electroencephalograms (EEGs) in diagnosing and treating neurological disorders.
The human brain is an intricate organ, constantly firing neurons and generating electrical activity known as brain waves. These brain waves can be measured using EEGs, a non-invasive method that records macroscopic electroactivity in the brain. Dr. Shabbir explains that EEGs are essential for diagnosing conditions like epilepsy, where abnormal electrical activity can lead to seizures.
Dr. Shabbir shares his expertise on how EEGs are conducted, the importance of sleep in detecting abnormalities, and the difference between epileptic and non-epileptic seizures. This episode is a must-listen for anyone interested in neurology and brain health.
To schedule an appointment with Dr. Shabbir or another member of MedStar Franklin Square’s neurology team, call 443-777-7320.
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
Comprehensive, relevant, and insightful conversations about health and medicine happen here on MedStar health doc talk. You're listening to MedStar Health DocTalk real conversations with physician experts from around the largest healthcare system in the Maryland DC region. The human brain is an amazing yet complex organ that is constantly firing neurons of electrical activity. They're called neural oscillations, or brain waves. When awake, the brain can generate enough wattage of electricity to power a small light bulb. But what happens when the electrical activity is not functioning properly? The result could mean a number of conditions, such as epileptic seizures or blackouts. To treat any of these conditions requires an understanding of the brain waves. To evaluate patterns of abnormal electrical activity of the brain, doctors use something called an electroencephalogram, or EEG, to record and measure them. Today on doctalk, we welcome neurologist doctor Syed to learn how the EEG is conducted, how the information is used, and who might need one. I'm your host, Debra Schindler. Doctor Shabbir thank you for being here.
>> Dr. Syed Shabbir:Thank you for inviting me.
>> Debra Schindler:Doctor Shabbir is the director of epilepsy and medical director of the EEG lab at MedStar Franklin Square Medical center in Baltimore. Let's talk about the EEG. It's described as a non invasive method of recording macroscopic electro activity in the brain. Who comes to you and needs an EEG?
>> Dr. Syed Shabbir:So there might be a lot of different reasons why patients are referred to us for an EEG. The most obvious one is if somebody is concerned that they're having seizures or epilepsy, and then they might be referred. But we also do a lot of eegs, in the hospital, in the icus, and in different settings. So, in the outpatient setting, the EEG, would be a test that we use to see if somebody is having abnormal electrical activity or abnormal short circuiting, because that would be diagnostic of a seizure disorder, of epilepsy on the inpatient setting, we might be using them. When people are in the hospital, they're confused, and the doctors are trying to figure out what is the cause of this confusion. Is it something systemic? Is it because of seizures in the icus? We might be using them. If somebody has had some kind of, devastating, unfortunate, brain injury, and they, again, want to know they're suffering seizures, non convulsive seizures that we can't physically see, or is there any other condition that's going on? So it helps. It's a diagnostic tool that can help, the clinician who's asking that question, help them answer that question.
>> Debra Schindler:So, obviously, the scenarios that you just presented are all different, and the patients would be in very different conditions, outpatient versus inpatient versus ICU, maybe unconscious. How is the EEG performed or conducted? And are there different kinds of EEG tests?
>> Dr. Syed Shabbir:Yes, definitely. And they definitely perform differently. So talking about the outpatient setting, what we would typically, that's more of a scheduled appointment. We have, patients that come in at their scheduled time. We might tell them to make sure that their hair is washed, that they don't have any kind of gel or oil, because it can affect our ability to put the EEG leads on. otherwise, we tell them to, try and be a little bit sleep deprived. What that means is try to limit sleep about four to 5 hours, for the night prior to the EEG.
>> Debra Schindler:Why is that important?
>> Dr. Syed Shabbir:Yeah. So it's interesting, and it's a whole topic in itself, but what we do know for a fact is that sleep can, for some reason or another, that we don't completely understand, because there are so many different reasons why it could be, increases our ability to be able to see some electrical abnormalities in the brain. We know that people, when they have epilepsies, when they have seizure disorders, a lot of times theyre more likely to have, seizures or epilepsy, or seizures, out of sleep. And its something about this transition between these different sleep states from wakefulness to light sleep, light sleep to deep sleep, that makes the brain less able to control this abnormal electrical activity. In general, when we are doing an EEG, what we like to do is to be able to capture, to increase the sensitivity of that test, to capture some kind of abnormal activity. And the way we do that, one of the ways we do that is, by trying to capture that sleep. And the only way we can sort of do that is make sure the patients are somewhat sleep deprived. So when we leave them in the dark with no noise, no distractions, more or less, they're able to fall asleep. It's interesting. It's actually the light sleep, where we find that patients generally can have abnormal irritable brain activity. so we really just want them to fall asleep, even if they can go to light sleep or deep sleep, these different stages, because it brings out some of that abnormal activity.
>> Debra Schindler:And do they need to have a seizure for you to really get a.
>> Dr. Syed Shabbir:Read on whether or not, because, you're absolutely right. If you're doing an outpatient AEG, which might be between 20 minutes to 60 minutes, the chances that we're going to capture a seizure, that's low. I mean, depending on how often somebody, is having seizures, can be helpful, but for the most part, what we're relying on is not necessarily to be able to see a seizure, but be able to see some kind of abnormal brain activity. If we see some kind of brain activity that could be these electrical discharges or if we see some kind of slowing on one side of the brain, that could give us a hint, and that's pretty diagnostic for some kind of an underlying seizure disorder. And then there's also people that have, epilepsy syndrome, and they tend to actually have markers, very predictable, very nice to. Very easy to see markers on EEG. See these spike and wave sort of discharges that are happening very frequently, even when they're not physically manifesting something, because it's only when these discharges are going on for a long time, up to 10 seconds, is when the person clinically can have a little bit of a, ah, conscious, ah, lapse, even for a brief second or so. So the eegs are helpful in not only diagnosing somebody with seizure disorders, but also help us to localize where it might be coming from and to tell us what type of an epilepsy or seizure disorder they might have, because it can determine what medicines work for them or what kind of modalities work for them, because there are so many medicines with certain different seizure types that can actually make those seizures worse. So, it's always useful to get an eeg just to make sure we're not missing those very predictable markers that tell us that somebody has a generalized epilepsy syndrome. If we capture something, that's always good, but I always tell my patients that if we don't, that's okay. epilepsy, seizure disorders, it's still very much a clinical diagnosis, so it has to do with what the patients tell us and what we see, and we use all the information we have available. That includes an MRI, but it also includes an EEg, so it's vital, but not necessary. as far as to answer your question, then, do we absolutely need to see a seizure? not necessarily. The one time it is particularly useful. Where we want to capture an episode is what we call studies that are for capture and characterization, where there's a question that the doctors have as to what type of a seizure, what sort of an episode somebody is going through. And, for that instance, we generally do prefer to be able to capture one of these episodes and see what the brainwaves are doing at the time of somebody having one of these episodes? Because then we can tell them, is it truly an epileptic seizure where there's some abnormal brain activity, or is it something else?
>> Debra Schindler:What other kind of seizures are there? If they're not epileptic, what might cause someone to have a seizure? Non epileptic?
>> Dr. Syed Shabbir:Yeah. So, I mean, kind of taking a step back from that. it's important to point out, because a lot of people have a lot of questions about this, and I spent some time kind of discussing this difference between, first of all, a seizure and epilepsy. And then another topic beyond that is, what is the difference between an epileptic seizure versus a non epileptic seizure?
>> Debra Schindler:I have that question, I guess. Please.
>> Dr. Syed Shabbir:Yeah. So, the seizure is an episode. An episode where there's electrical short circuiting in the brain, electrical discharges, and depending on what part of the brain is involved, it can cause abnormal movements, it can cause, lapses in consciousness. It can cause confusion. And then when we think about a typical seizure, that's typically a generalized autonic clonic seizure, which is a typical expectation when somebody has of thinking of a seizure, is when they pass out, they lose consciousness. They're having a full body shaking, convulsions. Maybe, they bite their tongue. Maybe they lose control of the bowels, bladder. So these are all, different types of seizures. It's only that one episode. We call that a seizure. Now, if somebody is predisposed to having seizures that are not caused by anything, then we would call it a seizure disorder or epilepsy. So one way to think about this is, let's say somebody has their first seizure of their life, and they come to the emergency room. Obviously, they're concerned. What if we find that their sugar levels are really low, or they're really high, or some sort of another electrolyte in the bloodstream that's really low or really high, or maybe they have an infection or they're really sick. all of those things can predispose somebody to having a seizure, but that doesn't necessarily mean they're going to have. And they're going to continue to have seizures forever. So we would typically try to control whatever that abnormality is, whatever thing it is that provoke them to have a seizure. If it's an infection, treat the infection. If it's some electrolyte abnormality, we treat that. If we find that they had diabetes they never knew about, well, then we treat the diabetes. So we try to figure it out. we might also get some imaging, God forbid, did they have a stroke or a bleed, and that's what ended up, causing them to have a seizure. So we try to figure that out and we treat it, but once it's taken care of, we don't necessarily expect that people are going to continue to have seizures recurrently. Now, if somebody is at risk of that happening, if they're at risk for having seizures again and again, which, in our field, we try to think of as somebody having a risk of, 50% or greater risk of having. Having recurrent seizures, once we feel that somebody is there, what would make you feel that?
>> Debra Schindler:What would increase their risk for seizures?
>> Dr. Syed Shabbir:Yeah. So there's different ways we can get there. one of the ways we can get there is if somebody has had two unprovoked seizures, meaning somebody has had two seizures at separate times, not on the same day, not right after one after the next, but they've had it at different times and they're not. We don't have a cause for it. We are not able to give them a reason as to why it might happen or might have happened. Now, if somebody's had two seizures, now there's a higher likelihood that they're going to have a third seizure and a fourth seizure and a fifth seizure. And at that stage, we say you have a seizure disorder, you have epilepsy. We need to have you on an anti seizure medicine to prevent that from happening. Now, if somebody's had two seizures, but in each scenario, we knew that they were not uncontrolled diabetes or they had a bad infection, or maybe they overdosed on some kind of a medicine accidentally. well, we wouldn't necessarily call it an epilepsy because in either case, there, was a cause for it. another way we can kind of get there to that diagnosis is, let's say, somebody who's only had the one seizure, but then we get an EEg, and the EEG shows that they have this epilepsy syndrome. Now, that it's pretty definitive in telling us that we don't necessarily have to wait for that second seizure to give them that diagnosis. We know they have an epilepsy syndrome, and at that stage, we don't have to wait. We will put them on an anti seizure medicine. Or if somebody had that one seizure and then we again get an EEg, and it shows again that there's some kind of, abnormality. We see some electrical short circuiting, some discharges, some of that irritable brain activity, then that's pretty sufficient for me to say that the chances that now you're going to have a second one and a third one is a lot higher, and so people try to treat it with an anti seizure medicine.
>> Debra Schindler:So someone who is epileptic and is not having a seizure gets an eeg, and you can still tell that they have epilepsy. How does that show up? How does that reveal itself? Or do we need to go back to walking through the process of getting an eeg test?
>> Dr. Syed Shabbir:Right. Yeah, we've gone through a couple of different tangents. but, yeah, to answer your question, we may or may not see something on an EEg and depends on how long that EEG is. Well, so, a typical eeg that's done in an outpatient setting might be anywhere from 20 to 60 minutes. The sensitivity of that test is not the best. I think between 20% to 30%. But the specificity, meaning if we see something, it definitely can change the diagnosis, it can definitely change our management. So what we generally see with the brainwaves is some electrical short circuiting, because a seizure, in essence, an epileptic seizure, is when there's electrical surges. The brain cells, the neurons, they're always communicating with each other. They're firing, electrical signals. That's how they communicate, and that's how they should be. So it should be more of a buzz. But all of a sudden, if all the neurons, or at least neurons in a certain part of the brain altogether start discharging, start firing together, that's abnormal. That's what a seizure is. So on an EEG, what we see is we see, occasional intermittent short circuiting signals. We see the brain waves all firing kind of together and then stopping. And then in the middle, they might do that again. If it shows us that pattern, that's pretty definitive in telling us that there is an underlying irritable focus, any underlying irritable activity that's happening.
>> Debra Schindler:But what you're looking at in that case is not necessarily a seizure. It's just abnormal.
>> Dr. Syed Shabbir:Correct.
>> Debra Schindler:I got it.
>> Dr. Syed Shabbir:So most of the time when we're getting an EEG on the outpatient setting, it's not because we expect that somebody's going to have a seizure in those 20 to 60 minutes. it happens sometimes, but not all the time. Most of the time, what we're looking for is either those markers of an epilepsy syndrome that somebody is born with, or we're looking for these electrical short circuits, which a lot of times we're able to see. Sometimes we're not. And the longer that EEG is, the more likely it makes us, be able to see something.
>> Debra Schindler:Okay, so let's get back to how this test takes place. The patient comes in, are they lying down or are they sitting? Is it invasive?
>> Dr. Syed Shabbir:Yeah. The EEG, compared to a lot of other studies and tests, is very harmless, very safe. It's not invasive. There's no pain whatsoever. So what the patients can expect is they walk into what looks like very much a clinic room with a, with a hospital bed or a stretcher, and we have them lie down. We have, EEG technicians that would then measure, different places on your head. They'll just do some other measurements, and they'll put these metal electrodes that are not very dissimilar to the electrodes a lot of people are kind of familiar with is the one that's, kind of put on their chest maybe when they come into the emergency room hospital in their primary care doctor's office to.
>> Debra Schindler:Measure EKG or an ekG.
>> Dr. Syed Shabbir:Correct.
>> Debra Schindler:Got it.
>> Dr. Syed Shabbir:So those. It's very similar to that. And we place about 21 of those with some kind of a gel that's a conductive gel that helps the electrical activity get to the electrode without kind of, getting disappeared or interfered with. There's wires that are connected from those electrodes, and they all kind of go to the, EEG machine. That's a specialized machine that amplifies that electrical activity. As you can imagine, the brainwaves, they're very subtle, and so it's very important for us to be able to amplify them, isolate them from the background noise, and then, put them in a manner that's interpretable. And it's tricky, and that's why not everybody can read eegs. It takes a fellowship, ideally, for you to be able to spend maybe a year or two years looking at eegs and nothing else, to develop that capacity, to be able to interpret them. And so that typically involves an epileptologist who has this background, training in neurology and epilepsy to be able to read them, interpret them, and, the reports generated. So, from the patient's perspective, they're coming in, except for making sure there's nothing in the hair and making sure that they have had some level of sleep deprivation. All they can expect to do is come in, let the eeg text, do the measurements, put the eeg leads on, and relax. they'll have you do some sort of exercises like eye opening, eye closures, because we want to see what the brain waves are doing when you're doing that, they might do what we call activation procedures. These are procedures that increase likelihood for us to see some kind of abnormal activity, to increase that, the yield of that test. and then sleep. We put them in the dark room and we have them relax and go to sleep that entire time the brain waves are being recorded. There's a video recording at the same time to see if we see something abnormal on an EEG. What is that person doing at that very time?
>> Debra Schindler:Are you watching the results in real time, or do you look at something later, like many of the scans that we get medically?
>> Dr. Syed Shabbir:Yeah. So it's a little bit of both. It depends, again, on, what that setting is. If somebody is, getting this outpatient, we know it's not urgent. We don't necessarily expect to see anything concerning. Now, if I do get a call from the EEG tech and they're concerned about something they're seeing, or, God forbid, somebody had a seizure, an episode we're concerned about, then, yes, we can remotely log in and actually take a look at it that very second. but typically what we do is we record the EEG for about, again, those 20 minutes to 60 minutes it gets recorded. And typically within the day or the following day, one of the epileptologists will read it and they'll generate the report, which is not so dissimilar to when somebody might get an MRI or some other kind of a study. Now, if somebody's in the hospital, we necessarily don't. We can do these shorter eegs that we call routine eegs, but we can also do, something that we call long term monitoring or continuous eegs. So especially in the critical care setting where the EEG is kind of used, pretty frequently. Well, what happens is the EEG machine is brought bedside, and the EEG technicians, they are able to put the leads on and wrap it up in a manner so it does not easily come off. And patients can be wearing it for days, for weeks. These might be patients, like I mentioned, who are, in their comatose. They're in a vegetative state, and we're trying to figure out, well, what's going on. Are they having these seizures we can't see? So they might be wearing that for about a couple of days or so. These might be patients that are in status epilepticus, meaning they're having seizures that are refractory to medicines and we're trying to control them, and they might be on, these eegs, these EEG study for, maybe sometimes weeks, as long as it takes to control it. Or it might be because somebody, again, is comatose and they've had some devastating brain injury. And we're wondering what the prognosis is. What, are the chances that they're going to wake up from this, ah, devastating, injury to the brain? And so it can help us diagnose that as well. So it depends on what the cause is, what the indication is for us to get that EEG and how often we read those eegs and how soon we see them. And, it's determined by that as well. So if somebody gets that EEG in the hospital, we don't have anybody that's looking at them all the time, but we look at it two to three times a day to catch up on whatever's happened. And in that meantime, if the critical care doctors or the hospitals, the hospital, they're concerned about any kind of activity, if they're concerned somebody's had a seizure, then they give us a call and we can look at it at that very minute. And that's the great thing about that EEG, because it is an instant test. We can have bedside kind of, determinations that can be made, which is not necessarily true for a lot of other kind of testing, which is testing for that moment. And then you have to wait for the results to be interpreted and come back. But if something sees in the meantime, there's nothing you can do about that.
>> Debra Schindler:So there are four ways to conduct an EEG. You talked about some of them. Is the ambulatory EEG different from what you just described? I'm going to make sure that I'm calling it the right thing.
>> Dr. Syed Shabbir:Yes, you are. So, it is somewhat different. It is an outpatient version of this long term monitoring. So we talked about this routine EEG, which is 20 to 60 minutes. It could be outpatient, it could be in the hospital. Then we have the continuous eegs. Those are the ones that may be running for days to weeks. Again, depends on the reason for them. And then we have ambulatory EEG. So that's the outpatient extension of this long term EEG. And it's been around for a while, ever since we've had the ability to have EEG machines through the recording portably. So it's a portable version. It's been a little bit on the rise since COVID because with COVID obviously, it was a pandemic. Nobody knew what was going on or how bad the infection was going to be, people were, obviously avoiding the hospitals. People were avoiding unnecessary elective kind of testing. And so we started using these ambulatory eegs. What that involves is the technician comes to the patient's house, and they put on these leads just how they would anywhere else, and they wrap it up so that they don't become dislodged easily, and then they leave. They maybe put a camera in one of the rooms because we want to capture any kind of abnormal activity. And then the patients, they're not tied on to anything. They can go about their business. We don't, prefer that they leave the house because obviously, it looks a little bit, weird to have these leads on and these wrapping. but then also the leads can also become dislodged. So primarily, they're stuck at home. And they could potentially vary for maybe three days, four days. During that entire time, the brainwaves are being recorded. And at the end of that, we look at all the brainwaves, look at the video recording, we see what it shows. Now, this is a very useful test. First of all, it's in the convenience of someone's home. So rather than, having to come to the hospital or being admitted to the epilepsy monitoring unit, where, things are a little bit more artificial, well, it's in their homes, they can have certain stressors or triggers that might not exist anywhere else. I've had instances where I've had somebody on ambulatory EEG, and their loved ones are trying to provoke some kind of a stress by picking a fight with them, just to see if it triggers something that we can capture and kind of give some an explanation for. Obviously, that's not the sort of thing you can do elsewhere. It is a longer study, so it increases that yield of that eeg we were talking about. and it is a study that is running when the person's awake. It's running when the person's asleep. So we capture all these different states, including sleep, which is so important for us to be able to see something abnormal. so Disney and age, post Covid especially, we have started using ambulatory eegs quite a lot.
>> Debra Schindler:So millisecond by millisecond, you can see changes in the brain activity in real time with an eeg. And it differs from activity to activity. If the person is having a migraine, it shows differently. Is that correct? I've seen videos of the EEG results. It looks like an audio wave or up and down lines, maybe a polygraph. If people can picture a polygraph result, right, the up and down lines that occur. I mean, how would you describe what the results look like and how do they differ from one condition to the next?
>> Dr. Syed Shabbir:There's somebody that's done research on this to see, if the eeg patterns somewhat change as a result of somebody having migraines. But it's not something that we routinely do in clinical practice, and I'm not sure if there's any kind of clinical utility to doing that. So it's not something that we've ever done or I've heard of.
>> Debra Schindler:How would the patterns look differently, then in an epileptic patient, for example, and a non epileptic seizure patient?
>> Dr. Syed Shabbir:What would be different between an epileptic patient and a non epileptic seizure patient? So I think what you're kind of referring to is somebody, that might have a seizure disorder, but it's not from an underlying abnormal electrical activity, is that right?
>> Debra Schindler:Yes. Correct.
>> Dr. Syed Shabbir:Seizures can be epileptic seizures, which refers to the fact that there's some electrical short circuiting that's happening. But then seizures can also be nonepileptic. And that's what we're referring to when we have, people that have outwardly episodes that look very much like seizures. And especially to the entrained eye, they would look very much like seizures. So we might see somebody that's losing consciousness. We might see somebody that's having, these extravagant kind of movements. We can see somebody that can even bite their tongue, lose control, bowel splatter. But there's no associated abnormal electrical activity that's happening at that time.
>> Debra Schindler:So nothing is appearing on the EEG?
>> Dr. Syed Shabbir:That's correct. If anything, what we tend to see is just normal, restful kind of backgrounds, on the eeG. To speak to the broader question that you had is, what do we really see on eegs? Well, what we're seeing are wavelengths. We're seeing electrical activity that we kind of differentiate into different frequencies. And at one stage or another, they're sort of all happening together.
>> Debra Schindler:What are the four basic eeg patterns?
>> Dr. Syed Shabbir:Yeah, so the four important eeg patterns, and there are certainly more where what we're referring to are the different frequencies of the brain waves. We have the beta waves, we have the alpha waves, we have the theta waves, and we have the delta waves. And they all kind of refer to the frequencies. Some are lower frequency, some are higher frequency. So when we're reading someone's eeg, we see all those frequencies, but the predominance of one frequency over the other is what tells us what state they're in. So, the beta waves, for instance, that's something that we generally tend to see if somebody is more actively thinking or they're anxious. The alpha waveforms, they're the ones that we tend to see a little bit more when somebody is awake, but they're resting, so it's more of a resting state. We, have the theta waveforms, which, in someone, we might see more often if they're going into light drowsiness and light sleep. And then we have the delta waves, which is something that we see in deep sleep. Now, if somebody has a predominance of one or the other one, it can tell you something's wrong. So, let's say if I see somebody and they have, instead of more of the alphas and betas during, wakefulness, they have more of the thetas and deltas. But that tells us there's some kind of a cerebral dysfunction, some kind of slowing in their brains. It could be because they're, overdosed on some medicine that's a sedative. It could be, because they have dementia. It could be because, they, just had a seizure and they're recurring from it, and their brain's in a rebooting state. So it tells us something about what's going on, especially if they're awake now. If they're sleeping, then that's a what it's from. If we see a lot of excess beta frequencies, there are certain medicines that can make you more likely to have those. So I wonder if somebody's taking those medicines. So, depending on the context that we're seeing in, it can give you more information. What side of the brain we're seeing it in, if it's asymmetric, can tell you something, too. So, let's say if I see a lot of these slower waveforms over on the one side, but I'm not seeing them as much over on the other side, that tells me that it's not a diffuse kind of dysfunction that's going on. Nothing systemic in their system that's happening, but maybe there's some kind of a focality on the one side of the brain. And I would wonder if, again, there's something going on on that side. Do they have a tumor? Do they have some kind of a lesion? Did they have a bleed on that side? Did they have a stroke on that side? Or did they just have a seizure on that side? And now the brain is in this rebooting kind of state, so it gives us minute by minute, a little bit of information as to what's going on, and you still have to put it in the context of what else is going on. So any test is just as good as a question that's being asked. If we ask the right questions, the EEG can give you very useful information.
>> Debra Schindler:But it just gives you a snapshot. I suppose you would still need additional scans, MRI, perhaps?
>> Dr. Syed Shabbir:In what context? What kind of,
>> Debra Schindler:Well, you said it could be a brain bleed or it could be a brain tumor. So really, to get a full picture, that is just the beginning, correct?
>> Dr. Syed Shabbir:That is right. So it kind of is one of the tools that we have. And certainly, if that's what I was concerned about, then absolutely, I would get an MRI, and I would see, If we can see something on an MRI that needs to be treated, that might explain this abnormality on the EEG.
>> Debra Schindler:one thing I wanted to ask you about, when you said patients come in, I did read that they should wear loose fitting clothing because some heart monitoring may be going on. Is that. Is that not true?
>> Dr. Syed Shabbir:So, that is true to some degree, yes. We do have, as part of the EEG, we also have at least one lead. It's not the typical multiple leads that you might be doing for an EKG, but we do have one lead on so that we can monitor the heart rhythms at the same time, because that can also be helpful in some ways. We use it so that if the heart rhythm is, sometimes it can cause a shadow, an artifact on the EEG pattern. So we'll be able to know, oh, it's the heart rhythm rather than anything else. If somebody is having a seizure and the heart rhythms are going up or down, that could be helpful. There's been instances where somebody, actually really has a cardiac issue, a heart issue, rather than an epilepsy issue, and their heart is stopping, or they are having conduction abnormalities and their heart stopping, and that's what's causing them to have seizures. Well, then it's important for us to know that, as well. Sometimes there's, some seizure disorders that can cause the heart rhythms to stop as well. And so if that's the case, then we would. Then we become very, very concerned, because that's obviously very risky, and so we try to treat it a little bit more aggressively, and we might ask our cardiology colleagues to help us with those cases as well.
>> Debra Schindler:Is there something about eegs that when your patients come in, they misunderstand, or is there any confusions that patients may have or misunderstandings about getting an EEG that we might be able to clarify for them today.
>> Dr. Syed Shabbir:Yeah, I think the important ones are some of the basic misconceptions is the EEG is not stimulating any brain waves. The EEG is, we cannot read someone's thoughts. it's primarily the electrical activity, just like how you can have that electrical activity of the heart, with those heartbeats. That's all it's telling you. The EEG is kind of doing the same. It is picking up on the brain waves, and, it's giving us some information. the one misconception I get a lot of times is about the thing that I wanted to emphasize is the difference between having a seizure and having epilepsy. That's the typical misconception. sometimes people feel that their EEG is normal. That means they don't have epilepsy, which is not the case. It's one of those tests that if it shows you something, it can add a lot of value and it can give us a lot of information. But if it doesn't show us anything, if it's normal, you have to remember. It's just that snapshot. It's only telling you what's happening for those 20 to 60 minutes or longer. If we do it for longer, if we see some electrical short circuiting, which we expect to with a longer enough study, then it's very helpful. but if not, we still make a clinical judgment. If somebody's having these clinical episodes, they sound like they're seizures. It's very reasonable for us. Even if the EEG is normal, even if the MRIs is normal, and often they are, to treat them as a seizure disorder, as an epileptic seizure disorder, and to see what the response is.
>> Debra Schindler:A young woman who I know was in a Home Depot holding onto the cart with both hands and had a seizure. She never lost consciousness. It was the first time it happened. And of course, an ambulance was called, didn't know what was happening. And that was the first of many seizures that was later diagnosed to be a post traumatic stress related seizure. Do you treat patients with PTSD related seizures, and how do you treat, I mean, how is that different in treating.
>> Dr. Syed Shabbir:Right. And that's why, that's the question that comes up quite often. That's the difference we were talking about when we were talking about the epileptic seizures versus the nonepileptic seizures. So these are seizures that we find are associated with electrical discharges, and we would call them epileptic seizures. And these are the seizures that do response to anti seizure medicines. And that's where you would definitely want to see a neurologist, and you would use anti triacetomacids to try and prevent them from happening more often. So in a case where somebody has a non epileptic episode, whether it's triggered by stress or PTSD or something else, the brain waves are actually completely normal. And that is how we determine if somebody is having an epileptic seizure versus a non epileptic seizure. If it is a non epileptic seizure, if it's confirmed to be that way, then the typical medicines that we have for epileptic seizures, they're not going to work, they're not going to help. And so, it's more useful to kind of try and get to the root of what the issue is. And if it is, in fact, the PTSD and the stressors, then it's important to try and treat that and see if that makes it better with a mental health professional. With a mental health professional. And it's reassuring sometimes to know that there's no abnormal brain activity that's happening at that time, that they're not going to have something dangerous happen to them from this prolonged episodes. And sometimes a lot of that reassurance is helpful, and it's helpful for, the patients, other providers to know that as well, because then they can treat it as it should be, because, the anti seizure medicines are not going to help. Now, this thing, this phenomenon of these non epileptic seizures, they're not that uncommon. And when we talk about people who come to the epilepsy monitoring units for evaluation for seizure episodes that they want to confirm as seizure or nonepileptic seizures, anywhere from 20% to 30% of people that come in are having nonepileptic episodes. So it's not that uncommon for us to see. when we first evaluate someone with seizures, that's the first question we're trying to answer is, is it epileptic? Is it non epileptic? And sometimes it's obvious and sometimes it isn't. In general, what we try to do is to treat empirically with anti seizure medicines until we know for sure that these are non epileptic. And some of the ways you would know as well, if you capture some of these episodes and the eeg waveforms are completely normal, it shows normal eeg background. If somebody has had one of these episodes and somebody who sees seizure disorders pretty frequently can tell what kind of patterns we're picking up on in terms of someone's behavioral kind of symptoms, then that could be helpful as well. Now, there's always, that gray area. There's always a little bit of that area where we have to be a little bit more cautious. Some different types of epilepsies, especially that stem from the frontal lobe, can sometimes look nonepileptic and sometimes can have normal eegs because the brain is used and the frontal lobe is. Is a pretty large part of the brain. the EEG might not be able to pick up the small things, but generally people can have episodes that are characterized as having a lot of movements, a lot of shaking. Sometimes it's cycling type movements of the legs and the arms. There's typically no loss of consciousness, which is some of the things we expect to see with a seizure. Typically, they can be vocalizing and maybe even responsive during these episodes. They can last for a typical duration of, a seizure. And then there's typically not a postictal period, which is what we refer to when the brain is rebooting. So if you think there was short circuiting in your computer and you rebooted the computer, it will take a little bit of time for the computer to reboot. So the same thing happens in the brain. If you have a seizure, we typically expect it's going to take a little bit of time for the body to recover. So we expect people to be more confused anywhere between, minutes to sometimes hours. We may not see something like that with these frontal lobe seizures, so there's always a little bit of caution, and it depends on the scenario. And at that stage, something more invasive might be worth considering, if not just treating it empirically as seizures and seeing if the seizure medicines help.
>> Debra Schindler:What's the most surprising thing that you've ever seen doing what you do?
>> Dr. Syed Shabbir:We see stuff that's surprising all the time. and I'm always surprised. And I've learned to have a humility about what we know and what we don't know. There's been times where I feel somebody for certain that I feel that they might have something, and I've been surprised that I'm. That I was wrong. And there's other times when I felt that somebody didn't have seizures, and I've been surprised that they did. So I've learned to have a healthy skepticism and an open mind. And an open mind and to listen carefully to what somebody's saying and to take their word for it, to listen carefully to, what somebody's telling me and to give them the benefit, always. And to treat them as if these might be epileptic. But then always quick to, take the whole picture in point and view as well, and deciding maybe if we made the wrong move to kind of come back and readdress.
>> Debra Schindler:I guess the age of people or patients needing an EEG vary. You probably see all ages. Would that be accurate?
>> Dr. Syed Shabbir:That's absolutely true. So we actually see, infants as soon as they're born, if they're having episodes where they're stopping breathing, if they're having, episodes of shaking on one side or another. Sometimes we get asked to, to read the eegs for babies as well, to help determine if these are seizures or not. We might be asked to read eegs on someone. If somebody is concerned about the development, of their child and whether they're having episodes at school, where the teachers are concerned that maybe they're stopping in their tracks, maybe, or, they're not paying attention, something that we call absence seizures. so that would be one way we might be diagnosing them as well.
>> Debra Schindler:What is an absence?
>> Dr. Syed Shabbir:So an absence seizure is something that we typically see in children, and as they grow up, for the most part, they either grow out of it or it changes flavors into a different type of epilepsy syndrome. But that typically is one of those patterns I was telling you about, where somebody might have a developmental predisposition towards having seizures, and they have these electrical short circuiting patterns happening pretty frequently. And if it goes on for long enough, like, if we see those patterns for about 10 seconds or so, that's when, the person themselves, they tend to have a small pause. So if somebody was reading a book, for instance, reading that aloud, you might find a. That they pause for a second or so, and then they keep going. They don't realize that there was that pause. So in the.
>> Debra Schindler:It's a blackout, except they don't really go unconscious?
>> Dr. Syed Shabbir:Correct. They don't lose consciousness, but they have an impaired awareness of what's happening. So as far as they're concerned, they realize that they're losing, spots of time when other people interacting with them. What they notice is they become unresponsive for short periods of time.
>> Debra Schindler:So that patient, that child would be brought in for an EEG, and then you would diagnose them with epilepsy.
>> Dr. Syed Shabbir:Correct. So that would depend on what the context is. I mean, is the child daydreaming? Is the child suffering from, attention deficit disorder, or is it something like absence seizures? That's very much a very real possibility. And this is the sort of thing either the parent brings up or the school teachers bring up is the student seems to be kind of, dozing off every few seconds, not paying attention in class, that kind of stuff. And we see very typical patterns, on EEG. And that's when we would diagnose them with, absence epilepsy. Potentially we might treat them. Now, I'm not a pediatric neurologist, but I do read pediatric eegs. And so we see, kids, we see infants, we see young adults, and we see older individuals as well. what we generally find, or at least what I generally find, is there's a little bit of, this prevalence when we're younger and when we're older. And the causes of it is different, though, as we get older, there's increased risk of having strokes or bleeds or some kind of damage to the brain or dementia or Alzheimer's. That predisposes you to have developing epilepsy. So I see that later in life that a lot of people can develop seizures as well.
>> Debra Schindler:Now, you mentioned that there's 26 points, is that right? 20 points.
>> Dr. Syed Shabbir:So, typically, for a routine eeg, we actually use 21 electrodes all over the brain. There is a version of eegs where we have a lot more of those electrodes. That's when we're trying to be a little bit more detail oriented, and that's something we might do in the context of, epilepsy surgeries. epilepsy surgeries used to be removing a part of the brain called the temporal lobe. That's the part of the brain where there's, Traditionally, it's very epileptogenic. There's a lot of seizures that emanate from that part of the brain. And historically, people didn't treat their seizures as aggressively. I feel maybe it was a taboo topic. And so people would go on years without treating their seizures, and it would ended up, That part of the brain ended up getting scarred over, and we would call it mesial temporal sclerosis. So when we saw that removing that part of the brain had really good outcomes, people had a chance of becoming seizure free up to 50% of the time, meaning they might not have seizures ever again. So they were very successful. This day and age, we're finding less and less of those cases because healthcare, is more widely available. People, are being treated more aggressively and quickly, so we generally don't find that to be the case.
>> Debra Schindler:And those surgeries are available at MedStar Georgetown University Hospital, all of them.
>> Dr. Syed Shabbir:And definitely here at Franklin square, we do vns the VNS refers to the vagal nerve stimulator. So what's happening is they implant a small device, which is the size of a round usb, and they implant it, in the chest with electrodes going through the vagal nerve. Now, that's one of the nerves that is closer to the chest, but it goes all the way up to the brain. And what the data shows is that over long term use, it's able to reduce the number and the frequency of seizures by about 50%. And this is an option that is relatively safe, relatively non invasive, because there's nobody going inside the brain and doing anything there. It's definitely reversible because you can always remove the leads and it's a non medication option, so you're not having to deal with the side effects of being on a medicine constantly. So that's a very reasonable option. Again, in the right cases where medicines have not been effective.
>> Debra Schindler:What is an event related potential?
>> Dr. Syed Shabbir:it's a broader term, but in the medical, kind of, practice, we call it evoked potentials. And what that refers to is the echo in the brain as a result of some kind of stimulus. Now, it could be a visual stimulus and we call it visual evoked potentials. It could be an auditory, it could be, we would call it an auditory evoke potential. It could be somatosensory, where we either touch one side of the body or if we send an electrical signal, and what we're looking for is the echo. So if you clapped, your hands and the sound waves would bounce back from a wall and come back, that's that echo. It's the same idea with this, where we send an electrical signal, we do a stimulus in one nerve or another, in the arm or the leg, and then we wait to see if there's that echo as that electrical signal is making its way up the wires up to the brain. So we see that signal as it touches the spinal cord, we see that signal as it goes to the brainstem. Now, over the years, we have seen its use kind of be redefined and changed a little bit. So back in the day, visual evoke potentials would be used to diagnose problems with the eye. So somebody, maybe with multiple sclerosis, could have been part of the testing for them. the auditory evoke potentials that is potentially used to detect hearing loss. when kids are born, that is something that can be used without having, because kids are not able to tell you if they can hear something or not. That's how we know, we send an electrical signal, in the air, and we try to see if, on the exact same moment, are they having that echo in the brain, or is that part of the brain lighting up that tells us that pathway is working, all.
>> Debra Schindler:Determined by an EEG?
>> Dr. Syed Shabbir:Correct. So there's an electrical signal, and these are the same kind of, electrical metal leads that are placed on the head that are looking for those electrical signals. The way we use it at Franklin Square is primarily in the neuro ICus, and the ICus for neuroprognostication. So these are people who have had devastating, injuries to the brain, potentially as a result of some kind of a cardiac arrest. And you can imagine they're very sick. And questions that the providers are trying to answer and the family members want to know is, what are the chances that the loved one is going to recover? And it can be, again, very challenging. So one of the great modalities that we have is what we call sseps, or somatosensory evoked potentials, which is exactly that. We do these evoke potentials by giving an electrical signal in one of the arm or the legs. and then we're looking for that signal. What the studies tell us, if somebody's had this kind of devastating brain injury and we don't see that signal on both sides of the brain, and there's a pretty high 95% chance of not having a very good outcome. And that can help, the critical care doctors can help, the patient's loved ones kind of make some difficult but important decisions as to what they want to do. So it is a very useful test because of this great sensitivity. It has to pick up something.
>> Debra Schindler:I read something very interesting, Doctor Shabbir that said that most of what we have learned about the brain has been derived in the past 20 years, and that we are actually living in a golden age of neuroscience. Do you agree with that?
>> Dr. Syed Shabbir:I would say yes or no. In general, all the fields, they're kind of progressing exponentially when it comes to, the brain. We're still. I feel it's still the wild, wild west. We're still the frontier. and that may be why that's the next step. That's the golden age, I suppose, for us to learn more about the brain, and we certainly are. There's so much that we don't quite understand. And, sometimes I kind of feel that when it comes to the brain, we're still in this, in the Stone Age. So I do feel that there's a lot for us to learn, but for sure, the advancements that at least I've seen a lot of new medicines that have helped people with epilepsy, with multiple sclerosis, with migraines. It's been. It's been incredible.
>> Debra Schindler:Well, thank you for what you do.
>> Dr. Syed Shabbir:My pleasure. Thank you for having me.
>> Debra Schindler:We've been talking with MedStar health neurologist doctor Syed Shabbir Thank you for sharing your expertise with us here on Doctor. To schedule an appointment with Dr. Shabbir or another member of the MedStar Franklin Square neurology team, call 4437-7320.
