The sleep-deprived electroencephalogram: evidence and practice.

BACKGROUND: Sleep deprivation for the initial electroencephalogram for suspected seizures is a widespread but inconsistent practice not informed by balanced evidence. Daily practice suggests that nonneurologists are confused by the meaning and value of, and indications for, "sleep" (tracing) vs "sleep deprivation" (and other alternatives). They need specific, informed guidance from general neurologists on best practices.

OBJECTIVES: To document illustratively the variability of neurologists' practices, the level of relevant information among nonneurologists, and the current state of published evidence; and to stimulate formulation of consensus advisories.

DESIGN AND SETTING: I surveyed knowledge and practices of (1) nonneurologists in a community teaching hospital; (2) local and national neurologists and epileptologists; (3) electroencephalogram laboratory protocols; and (4) textbook accounts and recommendations and the relevant journal literature. National professional organizations were contacted for advisories or guidelines.

RESULTS: Most nonneurologists surveyed misunderstood "sleep" vs "sleep-deprived" electroencephalograms and their actual protocols. They are unaware of evidence on benefits vs burdens. Neurologists' practices are inconsistent. Experts generally agree that sleep deprivation produces substantial activation of interictal epileptiform discharges beyond the activation of sleep per se. However, most published recommendations and interviewed epileptologists do not suggest sleep deprivation for the initial electroencephalogram because of "inconvenience" (burdens) for the patient. Evidence-based or reasoned guidance is minimal, and professional societies have not issued advisories.

CONCLUSION: Confusion over sleep deprivation, disparities between evidence and recommendations, and inconsistent practices create a need for expert consensus for guidance, as well as comparative research on alternative methods of increasing diagnostic yield.