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Electroencephalography in the Differential Diagnosis of Dementia

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Electroencephalography in the Differential Diagnosis of Dementia Electroencephalography in the Differential Diagnosis of Dementia Alida A. Gouw1,2 and Cornelis J. Stam1 1 Department of Clinical Neurophysiology and Magnetoencephalograpy Center, VU University Medical Center, Amsterdam, The Netherlands 2 Alzheimer Center and Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands Summary Der Stellenwert der Elektroenzephalographie in der Differenzialdiagnose demenzieller Erkran- In this short clinically oriented review, the value of kungen electroencephalography (EEG) in the diagnostic evalu- ation of cognitive decline is discussed, based on the Basierend auf den Empfehlungen der Europäischen recommendations of the European and Dutch guide- und Niederländischen Guidelines gibt dieser kurze, lines. In general, an EEG with diffuse slowing with or klinisch orientierte Review einen Überblick über den without focal abnormalities argues for the presence of diagnostischen Stellenwert der Elektroenzephalogra- an underlying neurodegenerative illness and against phie (EEG) in der Untersuchung demenzieller Erkran- subjective memory complaints or a psychiatric illness kungen bzw. kognitiven Abbaus. Grundsätzlich spricht such as a depression. The value of an EEG in the differ- eine diffuse Verlangsamung im EEG, mit oder ohne ential diagnosis between the most common causes of fokale Auffälligkeiten, eher für eine zugrundeliegende dementia is dependent on the specific clinical problem. neurodegenerative Erkrankung als für subjektive Ge- One of the clinical problems in which EEG has the high- dächtnisstörungen oder Psychiatrische Erkrankungen est yield is the distinction between the two most com- wie Depression. Die Aussagekraft des EEGs in der Un- mon dementia types, i.e. Lewy Body Dementia (DLB) terscheidung häufiger Demenzen ist abhängig von der and Alzheimer’s Disease (AD): severe slowing of the jeweiligen klinischen Fragestellung. Eine hohe Treffsi- background rhythm with a peak frequency in the theta cherheit hat das EEG in der Differenzialdiagnose einer frequency band (4 - 8 Hz) accompanied by frontal in- Lewy-Body-Demenz (DLB) gegenüber einer Alzheimer termittent rhythmic delta activity (FIRDA) gives strong Demenz (AD), zwei der häufigsten vorkommenden De- EEG support for DLB, whereas a diagnosis of AD is more menztypen: eine schwere Verlangsamung der Grund- likely when the EEG is normal or when only mild diffuse aktivität mit einem maximalen Frequenzspektrum im slowing is found. Furthermore, a normal EEG in an early Theta-Band (4 - 8 Hz), begleitet von frontalen inter- onset dementia gives support for the diagnosis fronto- mittierenden rhythmischen Delta-Wellen (FIRDA) ist temporal lobar degeneration. In addition, EEG is very ein direkter Hinweis auf das Vorliegen einer DLB, wo- useful when a metabolic, toxic or infectious encepha- hingegen bei einer AD ein Normalbefund im EEG bzw. lopathy is suspected. An EEG should be performed in nur eine leichte, eher diffus verteilte Verlangsamung subacute disease courses, with auto-immune encepha- der Grundaktivität zu erwarten ist. Ebenso findet sich litis or Creutzfeldt-Jakob disease as possible causes, or im Frühstadium einer frontotemporalen Lobärdegene- when (temporal lobe) epilepsy is suspected. In conclu- ration häufig ein normales EEG. Des Weiteren bringt sion, EEG is most valuable in a specific differential di- das EEG nützliche Zusatzinformation in vermuteten agnosis together with the clinical context and other metabolischen, toxischen oder infektiösen Enzephalo- diagnostic tests. Distinct EEG patterns can then help to pathien. Die Durchführung eines EEGs ist auch hilfreich make one of the diagnoses a more or less likely cause of bei subakuten Krankheitsverläufen, zum Beispiel bei the patient’s symptoms. einer möglichen Autoimmun-Enzephalitis oder Creutz- feldt-Jakob-Erkrankung, aber auch bei Verdacht auf Epileptologie 2016; 33: 173 – 182 Temporallappen-Epilepsie. Zusammenfassend, bringt Key words: Electroencephalography, dementia, memo- ry clinic, diagnostic tool This text is based upon a workshop during the 2016 annual meeting of the Dutch Clinical Neurophysiology Society. Electroencephalography in the Differential Diagnosis of Dementia | A. A. Gouw, C. J. Stam Epileptologie 2016; 33 173 das EEG gemeinsam mit den klinischen und diagnos- of a one-day screening. The diagnostic decision making tischen Befunden wertvolle Zusatzinformationen zur takes place at two different levels: the establishment of Unterscheidung demenzieller Entitäten. Charakteristi- the presence or absence of the syndrome diagnosis “de- sche EEG-Befunde können die Diagnosefindung erheb- mentia” [1]; and the diagnosis of the underlying cause lich erleichtern. of the dementia, the “nosologic diagnosis”. The Dutch guideline “diagnosis and treatment of dementia” ad- Schlüsselwörter: Elektroenzephalographie, Demenz, vises to perform additional assessments in the case of Memory-Klinik, diagnostische Massnahmen an established diagnosis of dementia, but with an un- certain nosologic diagnosis [2]. These may include MRI (or CT) imaging, but also electroencephalography (EEG), L’électroencéphalographie dans le diagnostic dif- a lumbar puncture or positron emission tomography férentiel des démences (PET)/single-photon emission computed tomography (SPECT) scanning. Dans cette revue, nous discutons du rôle de l’élec- Several memory clinics offer EEG as an additional troencéphalographie (EEG) dans le diagnostic et l’éva- investigation, both as a standard examination during a luation clinique du déclin cognitif, en nous référant day screening or as an additional test after the first as- aux recommandations néerlandaises et européennes. sessment of the medical specialist [3]. The latest Dutch D’une manière générale, un ralentissement diffus à guideline on dementia which was published in 2014 l’EEG, avec ou sans anomalie locale, suggère la pré- gives recommendations when to perform an EEG dur- sence d’une maladie neurodégénérative sous-jacente, ing the diagnostic evaluation of cognitive complaints et parle contre un trouble subjectif de la mémoire, ou (Table 1). Important to note is that these recommen- une maladie psychiatrique telle qu’une dépression. Le dations are in line with the European guidelines on rôle de l’EEG dans le diagnostic différentiel des causes dementia and Alzheimer’s disease [4, 5]. Furthermore, les plus courantes de démence dépend du contexte it needs to be emphasized that these guidelines are clinique. L’un des problèmes dans lesquels l’EEG est le aimed to give guidance to a broad range of profession- plus à même de se révéler utile est la distinction parmi als in dementia care, including primary care providers deux des causes les plus fréquentes de démence, c’est- (e.g. general practitioner, specialized nurses), medical à-dire la démence à corps de Lewy (DCL) et la maladie specialists (e.g. neurologists, nursing home physician d’Alzheimer (MA): un ralentissement diffus marqué specialists, geriatricians) and academic expertise cent- avec pic de fréquence dans la bande thêta (4 - 8 Hz), ac- ers. The first recommendation of the guideline, stat- compagné d’une activité delta rythmique intermittente ing “not to perform an EEG on a routine basis during au niveau frontal (FIRDA) suggère fortement une DCL, dementia diagnostic screening”, therefore needs to be tandis que la présence d’une MA est plus probable en interpreted in this context. A large proportion of the pa- présence d’un EEG normal ou avec ralentissement dif- tients with dementia are elderly subjects with memory fus modéré. Par ailleurs, un EEG normal au cours d’une complaints, and there will be little doubt on the under- démence d’apparition précoce suggère une dégénéres- lying disease, i.e. Alzheimer’s disease. This large patient cence lobaire fronto-temporale. L’EEG est également group will be diagnosed and treated by the primary très utile si une encéphalopathie métabolique, toxique care physicians. The patient group that is referred to a ou infectieuse est suspectée. Un EEG est recommandé memory clinic will therefore be a selected group, usu- en cas de progression lente si une encéphalite auto- ally young, with more patients presenting with a diag- immune, une maladie de Creutzfeldt-Jakob ou une épi- nostic dilemma. In these patients, the second and third lepsie (du lobe temporal) sont une cause possible. En recommendation of the guidelines will more often be résumé, l’EEG peut s’avérer très utile dans certains dia- applicable. These recommendations state to perform gnostics différentiels, en fonction du contexte clinique an EEG when there is a suspicion for Creutzfeldt-Jakob et en relation avec d’autres tests. Certains tracés EEG disease or temporal epilepsy. It can also be considered peuvent appuyer, ou contredire certains diagnostics when in doubt of Lewy Body Dementia and when the suspectés. differential diagnosis includes a metabolic, toxic or in- fectious encephalopathy. In addition, an EEG can pro- Mots clés : Electroencéphalographie, démence, clinique vide support for or against a diagnosis when there is de la mémoire, outils diagnostiques doubt on the existence of the underlying cause of de- mentia, depending on the differential diagnostic con- siderations. However, to be able to assess in which dif- Background ferential diagnostic considerations an EEG may be use- ful and to be able to actually differentiate between two The diagnostic evaluation of patients with cognitive diagnoses, knowledge on the different EEG patterns in complaints, both in the Netherlands and in other
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