11y, seizures

The following pages are different montages of the same epochs, and the patient is awake and playing on the cell phone.

The waveform is coincident with the ECG, but the distribution of the waveform is not typical of ECG. The discharge is seen at T3-T5, but also at FP1 on the bipolar montage. The field of the discharge therefore indicates that it is generated in the cortex. There is an electrode artifact at F7, but this does not explain the discharge, unlike the way that appears at the end of the page. The wave has a biphasic morphology, with the second phase appearing almost artefactually "vertical". This is typical of a small sharp spike, which is also termed benign epileptiform transient of sleep (BETS) or benign small sharp spikes of sleep (BSSS). This requires confirmation on other montages

On the referential montage the very large field becomes apparent, even allowing for the problems of reference contamination with discharges that have a large field (this is the most important disadvantage of the referential montage using the common average). This very large field is characteristic of small sharp spikes, but why the occurrence in wakefulness? It is recognised in some, but not all texts that these may occur in people who are awake. This under-appreciation of phenomenon is problematic because, having no other explanation, readers may inadvertently default to calling these spikes. If you read the following text, you probably would not know that the discharge shown here is benign.

EEG Benign Variants - StatPearls - NCBI Bookshelf

The following 3 pages from the same epoch in sleep. Notice that the distribution and morphology is nearly identical to the discharge that occurred during wakefulness. This is typical of small sharp spikes. 

 Notice the subtle after coming slow wave in channels 10, 14 and 16 below in the coronal montage, but the slow wave also has a large field. Such small sharp spikes sometimes have a "pseudo-" slow-wave.

 The following is the common average montage; compare this to the discharge during wakefulness. The similarity of the field is apparent. Because of the occurrence of the discharge in wakefulness, you might have thought that someone would have come up with an even better term than the above three, namely "Benign Small Sharp Spikes of Wakefulness and Sleep" (BSSSWS; apologies, this is not existing terminology)

 Bottom line?
While the majority of "benign small sharp spikes of sleep" may occur in sleep, some undoubtedly occur during wakefulness. Be on the lookout and, if nothing else, avoid calling low amplitude spike -like waves "spikes" because you may condemn someone who does not have epilepsy to years and even decades of antiseizure medication.