A high-density 256-channel cap for dry electroencephalography

Effects of Tai Chi on anxiety and theta oscillation power in college students during the COVID-19 pandemic: A randomized controlled trial

BACKGROUND

College students, especially during the COVID-19 pandemic, face substantial psychological stress. This study investigates the impact of Tai Chi (TC) practice on anxiety levels and theta oscillatory power activation characteristics among college students, aiming to provide empirical evidence for their psychological well-being.

METHODS

In this randomized controlled trial with 45 healthy college students, brainwave activity and changes in anxiety levels were measured. A 2 (TC group vs control group)×2 (pre-test vs post-test) factorial design was analyzed to explore TC's regulatory effects on brainwave activity and anxiety.

RESULTS

Following 12 weeks of TC practice, the TC group exhibited a significant decrease in state-trait anxiety differences (-6.14±14.33), state anxiety differences (-3.45±7.57), and trait anxiety differences (-2.68±7.43), contrasting with an increase in the control group. Moreover, contrasting with a decrease in the control group, TC group demonstrated significance increased theta oscillatory power in C3, C4, F4, P3, T7, and T8, and a significant negative correlations were observed between state anxiety and F4-θ (r = -0.31, p = 0.04), T7-θ (r = -0.43, p = 0.01), and T8-θ (r = -0.30, p = 0.05).

CONCLUSION

The positive influence of TC on college students' psychological well-being and brain function is evident, leading to reduced anxiety levels and increased theta oscillatory activity. While encouraging further research to delve into the mechanisms of TC on anxiety and theta brainwave characteristics, the study recommends actively promoting TC practice among college students to enhance mental health and address post-pandemic psychological challenges.

HYBRIDMINDS-summary and outlook of the 2023 international conference on the ethics and regulation of intelligent neuroprostheses

Neurotechnology and Artificial Intelligence (AI) have developed rapidly in recent years with an increasing number of applications and AI-enabled devices that are about to enter the market. While promising to substantially improve quality of life across various severe medical conditions, there are also concerns that the convergence of these technologies, e.g., in the form of intelligent neuroprostheses, may have undesirable consequences and compromise cognitive liberty, mental integrity, or mental privacy. Therefore, various international organizations, such as the Organization for Economic Cooperation and Development (OECD) or United Nations Educational, Scientific and Cultural Organization (UNESCO), have formed initiatives to tackle such questions and develop recommendations that mitigate risks while fostering innovation. In this context, a first international conference on the ethics and regulation of intelligent neuroprostheses was held in Berlin, Germany, in autumn 2023. The conference gathered leading experts in neuroscience, engineering, ethics, law, philosophy as well as representatives of industry, policy making and the media. Here, we summarize the highlights of the conference, underline the areas in which a broad consensus was found among participants, and provide an outlook on future challenges in development, deployment, and regulation of intelligent neuroprostheses.

Electromagnetic Source Imaging in Presurgical Evaluation of Children with Drug-Resistant Epilepsy

For children with drug-resistant epilepsy (DRE), seizure freedom relies on the delineation and resection (or ablation/disconnection) of the epileptogenic zone (EZ) while preserving the eloquent brain areas. The development of a reliable and noninvasive localization method that provides clinically useful information for the localization of the EZ is, therefore, crucial to achieving successful surgical outcomes. Electric and magnetic source imaging (ESI and MSI) have been increasingly utilized in the presurgical evaluation of these patients showing promising findings in the delineation of epileptogenic as well as eloquent brain areas. Moreover, the combination of ESI and MSI into a single solution, namely electromagnetic source imaging (EMSI), performed on simultaneous high-density electroencephalography (HD-EEG) and magnetoencephalography (MEG) recordings has shown higher source localization accuracy than either modality alone. Despite these encouraging findings, such techniques are performed in only a few tertiary epilepsy centers, are rarely recorded simultaneously, and are underutilized in pediatric cohorts. This study illustrates the experimental setup for recording simultaneous MEG and HD-EEG data as well as the methodological framework for analyzing these data aiming to localize the irritative zone, the seizure onset zone, and eloquent brain areas in children with DRE. More specifically, the experimental setups are presented for (i) recording and localizing interictal and ictal epileptiform activity during sleep and (ii) recording visual-, motor-, auditory-, and somatosensory-evoked responses and mapping relevant eloquent brain areas (i.e., visual, motor, auditory, and somatosensory) during visuomotor task, as well as auditory and somatosensory stimulations. Detailed steps of the data analysis pipeline are further presented for performing EMSI as well as individual ESI and MSI using equivalent current dipole (ECD) and dynamic statistical parametric mapping (dSPM).

Accuracy of dipole source reconstruction in the 3-layer BEM model against the 5-layer BEM-FMM model

Objective

To compare cortical dipole fitting spatial accuracy between the widely used yet highly simplified 3-layer and modern more realistic 5-layer BEM-FMM models with and without adaptive mesh refinement (AMR) methods.

Methods

We generate simulated noiseless 256-channel EEG data from 5-layer (7-compartment) meshes of 15 subjects from the Connectome Young Adult dataset. For each subject, we test four dipole positions, three sets of conductivity values, and two types of head segmentation. We use the boundary element method (BEM) with fast multipole method (FMM) acceleration, with or without (AMR), for forward modeling. Dipole fitting is carried out with the FieldTrip MATLAB toolbox.

Results

The average position error (across all tested dipoles, subjects, and models) is ~4 mm, with a standard deviation of ~2 mm. The orientation error is ~20° on average, with a standard deviation of ~15°. Without AMR, the numerical inaccuracies produce a larger disagreement between the 3- and 5-layer models, with an average position error of ~8 mm (6 mm standard deviation), and an orientation error of 28° (28° standard deviation).

Conclusions

The low-resolution 3-layer models provide excellent accuracy in dipole localization. On the other hand, dipole orientation is retrieved less accurately. Therefore, certain applications may require more realistic models for practical source reconstruction. AMR is a critical component for improving the accuracy of forward EEG computations using a high-resolution 5-layer volume conduction model.

Significance

Improving EEG source reconstruction accuracy is important for several clinical applications, including epilepsy and other seizure-inducing conditions.

Effective relax acquisition: a novel approach to classify relaxed state in alpha band EEG-based transformation

A relaxed state is essential for effective hypnotherapy, a crucial component of mental health treatments. During hypnotherapy sessions, neurologists rely on the patient's relaxed state to introduce positive suggestions. While EEG is a widely recognized method for detecting human emotions, analyzing EEG data presents challenges due to its multi-channel, multi-band nature, leading to high-dimensional data. Furthermore, determining the onset of relaxation remains challenging for neurologists. This paper presents the Effective Relax Acquisition (ERA) method designed to identify the beginning of a relaxed state. ERA employs sub-band sampling within the Alpha band for the frequency domain and segments the data into four-period groups for the time domain analysis. Data enhancement strategies include using Window Length (WL) and Overlapping Shifting Windows (OSW) scenarios. Dimensionality reduction is achieved through Principal Component Analysis (PCA) by prioritizing the most significant eigenvector values. Our experimental results indicate that the relaxed state is predominantly observable in the high Alpha sub-band, particularly within the fourth period group. The ERA demonstrates high accuracy with a WL of 3 s and OSW of 0.25 s using the KNN classifier (90.63%). These findings validate the effectiveness of ERA in accurately identifying relaxed states while managing the complexity of EEG data.

Simultaneous Dry and Gel-Based High-Density Electroencephalography Recordings

Evaluations of new dry, high-density EEG caps have only been performed so far with serial measurements and not with simultaneous (parallel) measurements. For a first comparison of gel-based and dry electrode performance in simultaneous high-density EEG measurements, we developed a new EEG cap comprising 64 gel-based and 64 dry electrodes and performed simultaneous measurements on ten volunteers. We analyzed electrode-skin impedances, resting state EEG, triggered eye blinks, and visual evoked potentials (VEPs). To overcome the issue of different electrode positions in the comparison of simultaneous measurements, we performed spatial frequency analysis of the simultaneously measured EEGs using spatial harmonic analysis (SPHARA). The impedances were 516 ± 429 kOhm (mean ± std) for the dry electrodes and 14 ± 8 kOhm for the gel-based electrodes. For the dry EEG electrodes, we obtained a channel reliability of 77%. We observed no differences between dry and gel-based recordings for the alpha peak frequency and the alpha power amplitude, as well as for the VEP peak amplitudes and latencies. For the VEP, the RMSD and the correlation coefficient between the gel-based and dry recordings were 1.7 ± 0.7 μV and 0.97 ± 0.03, respectively. We observed no differences in the cumulative power distributions of the spatial frequency components for the N75 and P100 VEP peaks. The differences for the N145 VEP peak were attributed to the different noise characteristics of gel-based and dry recordings. In conclusion, we provide evidence for the equivalence of simultaneous dry and gel-based high-density EEG measurements.

An ecological study protocol for the multimodal investigation of the neurophysiological underpinnings of dyadic joint action

A novel multimodal experimental setup and dyadic study protocol were designed to investigate the neurophysiological underpinnings of joint action through the synchronous acquisition of EEG, ECG, EMG, respiration and kinematic data from two individuals engaged in ecologic and naturalistic cooperative and competitive joint actions involving face-to-face real-time and real-space coordinated full body movements. Such studies are still missing because of difficulties encountered in recording reliable neurophysiological signals during gross body movements, in synchronizing multiple devices, and in defining suitable study protocols. The multimodal experimental setup includes the synchronous recording of EEG, ECG, EMG, respiration and kinematic signals of both individuals via two EEG amplifiers and a motion capture system that are synchronized via a single-board microcomputer and custom Python scripts. EEG is recorded using new dry sports electrode caps. The novel study protocol is designed to best exploit the multimodal data acquisitions. Table tennis is the dyadic motor task: it allows naturalistic and face-to-face interpersonal interactions, free in-time and in-space full body movement coordination, cooperative and competitive joint actions, and two task difficulty levels to mimic changing external conditions. Recording conditions-including minimum table tennis rally duration, sampling rate of kinematic data, total duration of neurophysiological recordings-were defined according to the requirements of a multilevel analytical approach including a neural level (hyperbrain functional connectivity, Graph Theoretical measures and Microstate analysis), a cognitive-behavioral level (integrated analysis of neural and kinematic data), and a social level (extending Network Physiology to neurophysiological data recorded from two interacting individuals). Four practical tests for table tennis skills were defined to select the study population, permitting to skill-match the dyad members and to form two groups of higher and lower skilled dyads to explore the influence of skill level on joint action performance. Psychometric instruments are included to assess personality traits and support interpretation of results. Studying joint action with our proposed protocol can advance the understanding of the neurophysiological mechanisms sustaining daily life joint actions and could help defining systems to predict cooperative or competitive behaviors before being overtly expressed, particularly useful in real-life contexts where social behavior is a main feature.

Design and verification of a wearable wireless 64-channel high-resolution EEG acquisition system with wi-fi transmission

Brain-computer interfaces (BCIs) allow communication between the brain and the external world. This type of technology has been extensively studied. However, BCI instruments with high signal quality are typically heavy and large. Thus, recording electroencephalography (EEG) signals is an inconvenient task. In recent years, system-on-chip (SoC) approaches have been integrated into BCI research, and sensors for wireless portable devices have been developed; however, there is still considerable work to be done. As neuroscience research has advanced, EEG signal analyses have come to require more accurate data. Due to the limited bandwidth of Bluetooth wireless transmission technology, EEG measurement systems with more than 16 channels must be used to reduce the sampling rate and prevent data loss. Therefore, the goal of this study was to develop a multichannel, high-resolution (24-bit), high-sampling-rate EEG BCI device that transmits signals via Wi-Fi. We believe that this system can be used in neuroscience research. The EEG acquisition system proposed in this work is based on a Cortex-M4 microcontroller with a Wi-Fi subsystem, providing a multichannel design and improved signal quality. This system is compatible with wet sensors, Ag/AgCl electrodes, and dry sensors. A LabVIEW-based user interface receives EEG data via Wi-Fi transmission and saves the raw data for offline analysis. In previous cognitive experiments, event tags have been communicated using Recommended Standard 232 (RS-232). The developed system was validated through event-related potential (ERP) and steady-state visually evoked potential (SSVEP) experiments. Our experimental results demonstrate that this system is suitable for recording EEG measurements and has potential in practical applications. The advantages of the developed system include its high sampling rate and high amplification. Additionally, in the future, Internet of Things (IoT) technology can be integrated into the system for remote real-time analysis or edge computing.

Flexible Electrodes for Brain-Computer Interface System

Brain-computer interface (BCI) has been the subject of extensive research recently. Governments and companies have substantially invested in relevant research and applications. The restoration of communication and motor function, the treatment of psychological disorders, gaming, and other daily and therapeutic applications all benefit from BCI. The electrodes hold the key to the essential, fundamental BCI precondition of electrical brain activity detection and delivery. However, the traditional rigid electrodes are limited due to their mismatch in Young's modulus, potential damages to the human body, and a decline in signal quality with time. These factors make the development of flexible electrodes vital and urgent. Flexible electrodes made of soft materials have grown in popularity in recent years as an alternative to conventional rigid electrodes because they offer greater conformance, the potential for higher signal-to-noise ratio (SNR) signals, and a wider range of applications. Therefore, the latest classifications and future developmental directions of fabricating these flexible electrodes are explored in this paper to further encourage the speedy advent of flexible electrodes for BCI. In summary, the perspectives and future outlook for this developing discipline are provided.

Flower electrodes for comfortable dry electroencephalography

Dry electroencephalography (EEG) electrodes provide rapid, gel-free, and easy EEG preparation, but with limited wearing comfort. We propose a novel dry electrode comprising multiple tilted pins in a flower-like arrangement. The novel Flower electrode increases wearing comfort and contact area while maintaining ease of use. In a study with 20 volunteers, we compare the performance of a novel 64-channel dry Flower electrode cap to a commercial dry Multipin electrode cap in sitting and supine positions. The wearing comfort of the Flower cap was rated as significantly improved both in sitting and supine positions. The channel reliability and average impedances of both electrode systems were comparable. Averaged VEP components showed no considerable differences in global field power amplitude and latency, as well as in signal-to-noise ratio and topography. No considerable differences were found in the power spectral density of the resting state EEGs between 1 and 40 Hz. Overall, our findings provide evidence for equivalent channel reliability and signal characteristics of the compared cap systems in the sitting and supine positions. The reliability, signal quality, and significantly improved wearing comfort of the Flower electrode allow new fields of applications for dry EEG in long-term monitoring, sensitive populations, and recording in supine position.

Spatiotemporal phase slip patterns for visual evoked potentials, covert object naming tasks, and insight moments extracted from 256 channel EEG recordings

Phase slips arise from state transitions of the coordinated activity of cortical neurons which can be extracted from the EEG data. The phase slip rates (PSRs) were studied from the high-density (256 channel) EEG data, sampled at 16.384 kHz, of five adult subjects during covert visual object naming tasks. Artifact-free data from 29 trials were averaged for each subject. The analysis was performed to look for phase slips in the theta (4-7 Hz), alpha (7-12 Hz), beta (12-30 Hz), and low gamma (30-49 Hz) bands. The phase was calculated with the Hilbert transform, then unwrapped and detrended to look for phase slip rates in a 1.0 ms wide stepping window with a step size of 0.06 ms. The spatiotemporal plots of the PSRs were made by using a montage layout of 256 equidistant electrode positions. The spatiotemporal profiles of EEG and PSRs during the stimulus and the first second of the post-stimulus period were examined in detail to study the visual evoked potentials and different stages of visual object recognition in the visual, language, and memory areas. It was found that the activity areas of PSRs were different as compared with EEG activity areas during the stimulus and post-stimulus periods. Different stages of the insight moments during the covert object naming tasks were examined from PSRs and it was found to be about 512 ± 21 ms for the 'Eureka' moment. Overall, these results indicate that information about the cortical phase transitions can be derived from the measured EEG data and can be used in a complementary fashion to study the cognitive behavior of the brain.

High performance clean versus artifact dry electrode EEG data classification using Convolutional Neural Network transfer learning

Objective

Convolutional Neural Networks (CNNs) are promising for artifact detection in electroencephalography (EEG) data, but require large amounts of data. Despite increasing use of dry electrodes for EEG data acquisition, dry electrode EEG datasets are sparse. We aim to develop an algorithm for clean versus artifact dry electrode EEG data classification using transfer learning.

Methods

Dry electrode EEG data were acquired in 13 subjects while physiological and technical artifacts were induced. Data were per 2-second segment labeled as clean or artifact and split in an 80% train and 20% test set. With the train set, we fine-tuned a pre-trained CNN for clean versus artifact wet electrode EEG data classification using 3-fold cross validation. The three fine-tuned CNNs were combined in one final clean versus artifact classification algorithm, in which the majority vote was used for classification. We calculated accuracy, F1-score, precision, and recall of the pre-trained CNN and fine-tuned algorithm when applied to unseen test data.

Results

The algorithm was trained on 0.40 million and tested on 0.17 million overlapping EEG segments. The pre-trained CNN had a test accuracy of 65.6%. The fine-tuned clean versus artifact classification algorithm had an improved test accuracy of 90.7%, F1-score of 90.2%, precision of 89.1% and recall of 91.2%.

Conclusions

Despite a relatively small dry electrode EEG dataset, transfer learning enabled development of a high performing CNN-based algorithm for clean versus artifact classification.

Significance

Development of CNNs for classification of dry electrode EEG data is challenging as dry electrode EEG datasets are sparse. Here, we show that transfer learning can be used to overcome this problem.

Polyvinyl alcohol/polyacrylamide double-network hydrogel-based semi-dry electrodes for robust electroencephalography recording at hairy scalp for noninvasive brain-computer interfaces

Objective.Reliable and user-friendly electrodes can continuously and real-time capture the electroencephalography (EEG) signals, which is essential for real-life brain-computer interfaces (BCIs). This study develops a flexible, durable, and low-contact-impedance polyvinyl alcohol/polyacrylamide double-network hydrogel (PVA/PAM DNH)-based semi-dry electrode for robust EEG recording at hairy scalp.Approach.The PVA/PAM DNHs are developed using a cyclic freeze-thaw strategy and used as a saline reservoir for semi-dry electrodes. The PVA/PAM DNHs steadily deliver trace amounts of saline onto the scalp, enabling low and stable electrode-scalp impedance. The hydrogel also conforms well to the wet scalp, stabilizing the electrode-scalp interface. The feasibility of the real-life BCIs is validated by conducting four classic BCI paradigms on 16 participants.Main results.The results show that the PVA/PAM DNHs with 7.5 wt% PVA achieve a satisfactory trade-off between the saline load-unloading capacity and the compressive strength. The proposed semi-dry electrode exhibits a low contact impedance (18 ± 8.9 kΩ at 10 Hz), a small offset potential (0.46 mV), and negligible potential drift (1.5 ± 0.4μV min^-1). The temporal cross-correlation between the semi-dry and wet electrodes is 0.91, and the spectral coherence is higher than 0.90 at frequencies below 45 Hz. Furthermore, no significant differences are present in BCI classification accuracy between these two typical electrodes.Significance.Based on the durability, rapid setup, wear-comfort, and robust signals of the developed hydrogel, PVA/PAM DNH-based semi-dry electrodes are a promising alternative to wet electrodes in real-life BCIs.

EEG-Based BCIs on Motor Imagery Paradigm Using Wearable Technologies: A Systematic Review

In recent decades, the automatic recognition and interpretation of brain waves acquired by electroencephalographic (EEG) technologies have undergone remarkable growth, leading to a consequent rapid development of brain-computer interfaces (BCIs). EEG-based BCIs are non-invasive systems that allow communication between a human being and an external device interpreting brain activity directly. Thanks to the advances in neurotechnologies, and especially in the field of wearable devices, BCIs are now also employed outside medical and clinical applications. Within this context, this paper proposes a systematic review of EEG-based BCIs, focusing on one of the most promising paradigms based on motor imagery (MI) and limiting the analysis to applications that adopt wearable devices. This review aims to evaluate the maturity levels of these systems, both from the technological and computational points of view. The selection of papers has been performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), leading to 84 publications considered in the last ten years (from 2012 to 2022). Besides technological and computational aspects, this review also aims to systematically list experimental paradigms and available datasets in order to identify benchmarks and guidelines for the development of new applications and computational models.

Noise characteristics in spaceflight multichannel EEG

The cognitive performance of the crew has a major impact on mission safety and success in space flight. Monitoring of cognitive performance during long-duration space flight therefore is of paramount importance and can be performed using compact state-of-the-art mobile EEG. However, signal quality of EEG may be compromised due to the vicinity to various electronic devices and constant movements. We compare noise characteristics between in-flight extraterrestrial microgravity and ground-level terrestrial electroencephalography (EEG) recordings. EEG data recordings from either aboard International Space Station (ISS) or on earth's surface, utilizing three EEG amplifiers and two electrode types, were compared. In-flight recordings showed noise level of an order of magnitude lower when compared to pre- and post-flight ground-level recordings with the same EEG system. Noise levels between ground-level recordings with actively shielded cables, and in-flight recordings without shielded cables, were similar. Furthermore, noise level characteristics of shielded ground-level EEG recordings, using wet and dry electrodes, and in-flight EEG recordings were similar. Actively shielded mobile dry EEG systems will support neuroscientific research and neurocognitive monitoring during spaceflight, especially during long-duration space missions.

Multi-Center Evaluation of Gel-Based and Dry Multipin EEG Caps

Dry electrodes for electroencephalography (EEG) allow new fields of application, including telemedicine, mobile EEG, emergency EEG, and long-term repetitive measurements for research, neurofeedback, or brain-computer interfaces. Different dry electrode technologies have been proposed and validated in comparison to conventional gel-based electrodes. Most previous studies have been performed at a single center and by single operators. We conducted a multi-center and multi-operator study validating multipin dry electrodes to study the reproducibility and generalizability of their performance in different environments and for different operators. Moreover, we aimed to study the interrelation of operator experience, preparation time, and wearing comfort on the EEG signal quality. EEG acquisitions using dry and gel-based EEG caps were carried out in 6 different countries with 115 volunteers, recording electrode-skin impedances, resting state EEG and evoked activity. The dry cap showed average channel reliability of 81% but higher average impedances than the gel-based cap. However, the dry EEG caps required 62% less preparation time. No statistical differences were observed between the gel-based and dry EEG signal characteristics in all signal metrics. We conclude that the performance of the dry multipin electrodes is highly reproducible, whereas the primary influences on channel reliability and signal quality are operator skill and experience.

Neurological Outpatients Prefer EEG Home-Monitoring over Inpatient Monitoring-An Analysis Based on the UTAUT Model

Home monitoring examinations offer diagnostic and economic advantages compared to inpatient monitoring. In addition, these technical solutions support the preservation of health care in rural areas in the absence of local care providers. The acceptance of patients is crucial for the implementation of home monitoring concepts. The present research assesses the preference for a health service that is to be introduced, namely an EEG home-monitoring of neurological outpatients-using a mobile, dry-electrode EEG (electroencephalography) system-in comparison to the traditional long-time EEG examination in a hospital. Results of a representative study for Germany (n = 421) reveal a preference for home monitoring. Importantly, this preference is partially driven by a video explaining the home monitoring system. We subsequently analyzed factors that influence the behavioral intention (BI) to use the new EEG system, drawing on an extended Unified Theory of Acceptance and Use of Technology (UTAUT) model. The strongest positive predictor of BI is the belief that EEG home-monitoring will improve health quality, while computer anxiety and effort expectancy represent the strongest barriers. Furthermore, we find the UTAUT model's behavioral intention construct to predict the patients' decision for or against home monitoring more strongly than any other patient's characteristic such as gender, health condition, or age, underlying the model's usefulness.

Design of hydrogel-based wearable EEG electrodes for medical applications

The electroencephalogram (EEG) is considered to be a promising method for studying brain disorders. Because of its non-invasive nature, subjects take a lower risk compared to some other invasive methods, while the systems record the brain signal. With the technological advancement of neural and material engineering, we are in the process of achieving continuous monitoring of neural activity through wearable EEG. In this article, we first give a brief introduction to EEG bands, circuits, wired/wireless EEG systems, and analysis algorithms. Then, we review the most recent advances in the interfaces used for EEG recordings, focusing on hydrogel-based EEG electrodes. Specifically, the advances for important figures of merit for EEG electrodes are reviewed. Finally, we summarize the potential medical application of wearable EEG systems.

The Past, Present, and Future of Tele-EEG

Tele-electroencephalogram (EEG) has become more pervasive over the last 20 years due to advances in technology, both independent of and driven by personnel shortages. The professionalization of EEG services has both limited growth and controlled the quality of tele-EEG. Growing data on the conditions that benefit from brain monitoring have informed increased critical care EEG and ambulatory EEG utilization. Guidelines that marshal responsible use of still-limited resources and changes in broadband and billing practices have also shaped the tele-EEG landscape. It is helpful to characterize the drivers of tele-EEG to navigate barriers to sustainable growth and to build dynamic systems that anticipate challenges in any of the domains that expand access and enhance quality of these diagnostic services. We explore the historical factors and current trends in tele-EEG in the United States in this review.