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1.  EEG Interpretation Reliability and Interpreter Confidence: A Large Single Center Study 
Epilepsy & behavior : E&B  2014;32:102-107.
The intrarater and interrater reliability (I&IR) of EEG interpretation has significant implications for the value of EEG as a diagnostic tool. We measured both I&IR of EEG interpretation based on interpretation of complete EEGs into standard diagnostic categories and rater confidence in their interpretations, and investigated sources of variance in EEG interpretations. During two distinct time intervals six board-certified clinical neurophysiologists classified 300 EEGs into one or more of seven diagnostic categories, and assigned a subjective confidence to their interpretations. Each EEG was read by three readers. Each reader interpreted 150 unique studies, and 50 studies twice to generate intrarater data. A generalizability study assessed the contribution of subjects, readers, and the interaction between subjects and readers to interpretation variance. Five of the six readers had a median confidence of ≥ 99%, and the upper quartile of confidence values was 100% for all six readers. Intrarater Cohen’s kappa (κc) ranged from 0.33 to 0.73 with an aggregated value of 0.59. κc ranged from 0.29 to 0.62 for the 15 reader pairs, with an aggregated Fleiss kappa of 0.44 for interrater agreement. The κc were not significantly different across rater pairs (Chi-Square = 17.3, df=14, p = 0.24). Variance due to subjects (i.e. EEGs) was 65.3%, to readers was 3.9%, and to the interaction between readers and subjects was 30.8%. Experienced epileptologists have very high confidence in their EEG interpretations and low to moderate I&IR, a common paradox in clinical medicine. A necessary but insufficient condition to improve EEG interpretation accuracy is to increase intrarater and interrater reliability. This goal could be accomplished, for instance, with an automated on-line application integrated into a continuing medical education module that measures and reports EEG I&IR to individual users.
PMCID: PMC3965251  PMID: 24531133
interrater reliability; intrarater reliability; confidence; EEG
2.  Mapping and mining interictal pathological gamma (30–100 Hz) oscillations with clinical intracranial EEG in patients with epilepsy 
Expert systems with applications  2012;39(8):7355-7370.
Localizing an epileptic network is essential for guiding neurosurgery and antiepileptic medical devices as well as elucidating mechanisms that may explain seizure-generation and epilepsy. There is increasing evidence that pathological oscillations may be specific to diseased networks in patients with epilepsy and that these oscillations may be a key biomarker for generating and indentifying epileptic networks. We present a semi-automated method that detects, maps, and mines pathological gamma (30–100 Hz) oscillations (PGOs) in human epileptic brain to possibly localize epileptic networks. We apply the method to standard clinical iEEG (<100 Hz) with interictal PGOs and seizures from six patients with medically refractory epilepsy. We demonstrate that electrodes with consistent PGO discharges do not always coincide with clinically determined seizure onset zone (SOZ) electrodes but at times PGO-dense electrodes include secondary seizure-areas (SS) or even areas without seizures (NS). In 4/5 patients with epilepsy surgery, we observe poor (Engel Class 4) post-surgical outcomes and identify more PGO-activity in SS or NS than in SOZ. Additional studies are needed to further clarify the role of PGOs in epileptic brain.
PMCID: PMC3480232  PMID: 23105174
Epileptic network; Interictal epileptic discharge; Pathological gamma oscillation; Detection; Mapping; Data-mining
3.  Acute postictal confusion and violence: Two cases with unfortunate outcomes☆ 
Patients with temporal lobe epilepsy (TLE) often have a brief postictal state characterized by confusion and disorientation. Less common postictal behaviors include wandering and violence — both reactive and spontaneous. We describe two male patients with left TLE and unusual postictal states that led to unfortunate outcomes. The first patient's postictal state included an intense urge to peregrinate, as well as reactive violence. When a frightened houseguest prevented the patient from exiting his bedroom during a postictal state, the patient climbed out the window and fell to his death. The second patient's postictal state included menacing posturing, loud exclamation of guttural sounds or profanities, clapping or smacking his hands together, and punching nearby objects. During a postictal state at home, he grabbed a bat and destroyed furnishings. After he had two seizures at work followed by his typical postictal state, he was dismissed because of his perceived threat to coworkers.
PMCID: PMC4150615  PMID: 25667832
Postictal violence; Postictal state; Temporal lobe epilepsy; Seizure
4.  Data mining neocortical high-frequency oscillations in epilepsy and controls 
Brain  2011;134(10):2948-2959.
Transient high-frequency (100–500 Hz) oscillations of the local field potential have been studied extensively in human mesial temporal lobe. Previous studies report that both ripple (100–250 Hz) and fast ripple (250–500 Hz) oscillations are increased in the seizure-onset zone of patients with mesial temporal lobe epilepsy. Comparatively little is known, however, about their spatial distribution with respect to seizure-onset zone in neocortical epilepsy, or their prevalence in normal brain. We present a quantitative analysis of high-frequency oscillations and their rates of occurrence in a group of nine patients with neocortical epilepsy and two control patients with no history of seizures. Oscillations were automatically detected and classified using an unsupervised approach in a data set of unprecedented volume in epilepsy research, over 12 terabytes of continuous long-term micro- and macro-electrode intracranial recordings, without human preprocessing, enabling selection-bias-free estimates of oscillation rates. There are three main results: (i) a cluster of ripple frequency oscillations with median spectral centroid = 137 Hz is increased in the seizure-onset zone more frequently than a cluster of fast ripple frequency oscillations (median spectral centroid = 305 Hz); (ii) we found no difference in the rates of high frequency oscillations in control neocortex and the non-seizure-onset zone neocortex of patients with epilepsy, despite the possibility of different underlying mechanisms of generation; and (iii) while previous studies have demonstrated that oscillations recorded by parenchyma-penetrating micro-electrodes have higher peak 100–500 Hz frequencies than penetrating macro-electrodes, this was not found for the epipial electrodes used here to record from the neocortical surface. We conclude that the relative rate of ripple frequency oscillations is a potential biomarker for epileptic neocortex, but that larger prospective studies correlating high-frequency oscillations rates with seizure-onset zone, resected tissue and surgical outcome are required to determine the true predictive value.
PMCID: PMC3187540  PMID: 21903727
high-frequency oscillations; epilepsy; intracranial EEG

Results 1-4 (4)