Inpatient video-EEG Monitoring Research Articles

Effect evaluation of outpatient long-term video EEGs for people with seizure disorders – study protocol of the ALVEEG project: a randomized controlled trial in Germany

BackgroundEpilepsy and other seizure disorders account for a high disease burden in Germany. As a timely diagnosis and accurate treatment are crucial, improving the management of these disorders is important. Outside of Germany, outpatient long-term video EEGs (ALVEEGs) have demonstrated the potential to support the diagnosis and management of epilepsy and other seizure disorders. This study aims to evaluate the implementation of ALVEEGs as a new diagnostic pathway in eastern parts of Germany to diagnose epilepsy and other seizure disorders and to assess if ALVEEGs are equally effective as the current inpatient-monitoring gold standard, which is currently only available at a limited number of specialized centers in Germany.MethodsALVEEG is a prospective, multicenter, randomized controlled equivalence trial, involving five epilepsy centers in the eastern states of Germany. Patients will be randomized into either intervention (IG) or control group (CG), using a permuted block randomization. The sample size targeted is 688 patients, continuously recruited over the trial. The IG will complete an ALVEEG in a home setting, including getting access to a smartphone app to document seizure activity. The CG will receive care as usual, i.e., inpatient long-term video-EEG monitoring. The primary outcome is the proportion of clinical questions being solved in the IG compared to the CG. Secondary outcomes include hospital stays, time until video EEG, time until diagnosis and result discussion, patients’ health status, quality of life and health competence, and number and form of epilepsy-related events and epileptiform activity. Alongside the trial, a process implementation and health economic evaluation will be conducted.DiscussionThe extensive evaluation of this study, including an implementation and health economic evaluation, will provide valuable information for health policy decision-makers to optimize future delivery of neurological care to patients affected by epilepsy and other seizure disorders and on the uptake of ALVEEG into standard care in Germany.Trial registrationGerman Clinical Trials Register (DRKS00032220), date registered: December 11, 2023.

MRI-Derived Modeling of Disease Progression Patterns in Patients With Temporal Lobe Epilepsy.

Temporal lobe epilepsy (TLE) is assumed to follow a steady course that is similar across patients. To date, phenotypic and temporal diversities of TLE evolution remain unknown. In this study, we aimed at simultaneously characterizing these sources of variability based on cross-sectional data. We studied consecutive patients with TLE referred for evaluation by neurologists to the Montreal Neurological Institute epilepsy clinic, who underwent in-patient video EEG monitoring and multimodal imaging at 3 Tesla, comprising 3D T1 and fluid-attenuated inversion recovery and 2D diffusion-weighted MRI. The cohort included patients with drug-resistant epilepsy and patients with drug-responsive epilepsy. The neuropsychological evaluation included Wechsler Adult Intelligence Scale-III and Leonard tapping task. The control group consisted of participants without TLE recruited through advertisement and who underwent the same MRI acquisition as patients. Based on surface-based analysis of key MRI markers of pathology (gray matter morphology and white matter microstructure), the Subtype and Stage Inference algorithm estimated subtypes and stages of brain pathology to which individual patients were assigned. The number of subtypes was determined by running the algorithm 100 times and estimating mean and SD of disease trajectories and the consistency of patients' assignments based on 1,000 bootstrap samples. Effect of normal aging was subtracted from patients. We examined associations with clinical and cognitive parameters and utility for individualized predictions. We studied 82 patients with TLE (52 female, mean age 35 ± 10 years; 11 drug-responsive) and 41 control participants (23 male, mean age 32 ± 8 years). Among 57 operated, 43/37/20 had Engel-I outcome/hippocampal sclerosis/hippocampal isolated gliosis, respectively. We identified 3 trajectory subtypes: S1 (n = 35), led by ipsilateral hippocampal atrophy and gliosis, followed by white-matter damage; S2 (n = 27), characterized by bilateral neocortical atrophy, followed by ipsilateral hippocampal atrophy and gliosis; and S3 (n = 20), typified by bilateral limbic white-matter damage, followed by bilateral hippocampal gliosis. Patients showed high assignability to their subtypes and stages (>90% bootstrap agreement). S1 had the highest proportions of patients with early disease onset (effect size d = 0.27 vs S2, d = 0.73 vs S3), febrile convulsions (χ2 = 3.70), drug resistance (χ2 = 2.94), a positive MRI (χ2 = 8.42), hippocampal sclerosis (χ2 = 7.57), and Engel-I outcome (χ2 = 1.51), pFDR < 0.05 across all comparisons. S2 and S3 exhibited the intermediate and lowest proportions, respectively. Verbal IQ and digit span were lower in S1 (d = 0.65 and d = 0.50, pFDR < 0.05) and S2 (d = 0.76 and d = 1.09, pFDR < 0.05), compared with S3. We observed progressive decline in sequential motor tapping in S1 and S3 (T = -3.38 and T = -4.94, pFDR = 0.027), compared with S2 (T = 2.14, pFDR = 0.035). S3 showed progressive decline in digit span (T = -5.83, p = 0.021). Supervised classifiers trained on subtype and stage outperformed subtype-only and stage-only models predicting drug response in 73% ± 1.0% (vs 70% ± 1.4% and 63% ± 1.3%) and 76% ± 1.6% for Engel-I outcome (vs 71% ± 0.8% and 72% ± 1.1%), pFDR < 0.05 across all comparisons. Cross-sectional MRI-derived models provide reliable prognostic markers of TLE disease evolution, which follows distinct trajectories, each associated with divergent patterns of hippocampal and whole-brain structural alterations, as well as cognitive and clinical profiles.

Role of short term Video EEG monitoring and MRI in refractory Epilepsy

Introduction: Inpatient video EEG monitoring is widely used for the diagnosis, seizure classification and pre surgical evaluation of patients with epilepsy. Only few studies have highlighted the role of short term video EEG in the diagnosis of paroxysmal events. The present study was undertaken to identify the role of short term video EEG in refractory epilepsy. Materials &amp; Methods: Forty patients, attending neurology outpatient department in our institution, during the study period, fulfilling the criteria for refractory epilepsy were included. Short term video EEG and MRI Brain were done for all of them. Outcomes measured were 1) Video recording of epileptic seizures with concurrent ictal pattern or psychogenic non epileptic seizure. 2) Identification of new interictal epileptiform discharges, which were not there in the previous routine EEG. 3) Observation of congruency between EEG and MRI Brain. Results: Clinical events were recorded in 12.5% of patients - 7.5% had epileptic seizures and 5% had psychogenic non epileptic seizures recorded. Short term video EEG was abnormal in 70% of the patients, whereas previous routine EEG was abnormal in only 30% and these observations were statistically significant. Short term video EEG was useful in diagnostic classification in 70% of the cases. MRI Brain was abnormal in 35% and among them, 30% had lateralized epiletiform discharges and the congruency between them is not statistically significant. Conclusions: Short term video EEG monitoring could be an initial investigation to sort our more frequent seizure group and proceed to long term VEEG if short term VEEG is inconclusive.

N-of-1 Trial in Epilepsy With Fixation-Off Sensitivity: Swimming in the Bathroom.

To evaluate the use of transparent goggles in the prevention of eye closure and subsequent seizures due to fixation-off sensitivity (FOS). An N-of-1 trial was conducted during which 7 consecutive cycles of showering with and without goggles were evaluated. We found 100% provocation of eyelid myoclonia during each cycle without goggle usage on daily review of smartphone videos with seizure freedom during each cycle with goggles. The semiology on smartphone videos was identical to absences with eyelid myoclonia confirmed by inpatient video-EEG monitoring. At the 6-month follow-up, subjective quality of life improved with no shower-related seizures, greater independence while bathing, and reduction of anticipatory anxiety. Transparent swimming goggles were effective in this N-of-1 trial to render a patient with drug-resistant epilepsy seizure-free and avert ongoing injury due to FOS. Behavioral modification is a critical adjunct to medical therapy in patients with fixation-off sensitivity.

Cyclical underreporting of seizures in patient-based seizure documentation.

Circadian and multidien cycles of seizure occurrence are increasingly discussed as to their biological underpinnings and in the context of seizure forecasting. This study analyzes if patient reported seizures provide valid data on such cyclical occurrence. We retrospectively studied if circadian cycles derived from patient-based reporting reflect the objective seizure documentation in 2003 patients undergoing in-patient video-EEG monitoring. Only 24.1% of more than 29000 seizures documented were accompanied by patient notifications. There was cyclical underreporting of seizures with a maximum during nighttime, leading to significant deviations in the circadian distribution of seizures. Significant cyclical deviations were found for focal epilepsies originating from both, frontal and temporal lobes, and for different seizure types (in particular, focal unaware and focal to bilateral tonic-clonic seizures). Patient seizure diaries may reflect a cyclical reporting bias rather than the true circadian seizure distributions. Cyclical underreporting of seizures derived from patient-based reports alone may lead to suboptimal treatment schemes, to an underestimation of seizure-associated risks, and may pose problems for valid seizure forecasting. This finding strongly supports the use of objective measures to monitor cyclical distributions of seizures and for studies and treatment decisions based thereon.

Sleep and respiratory abnormalities in adults with developmental and epileptic encephalopathies using polysomnography and video-EEG monitoring.

This study evaluated sleep and respiratory abnormalities, and their relationship with seizures, in adults with developmental and epileptic encephalopathies (DEEs). We studied consecutive adults with DEEs undergoing inpatient video-EEG monitoring and concurrent polysomnography between December 2011 and July 2022. Thirteen patients with DEEs were included (median age: 31 years, range: 20-50; 69.2% female): Lennox-Gastaut syndrome (n = 6), Lennox-Gastaut syndrome-like phenotype (n = 2), Landau-Kleffner syndrome (n = 1), epilepsy with myoclonic-atonic seizures (n = 1), and unclassified DEEs (n = 3). Sleep architecture was often fragmented by epileptiform discharges and seizures resulting in arousals (median arousal index: 29.0 per h, range: 5.1-65.3). Moderate-to-severe obstructive sleep apnea (OSA) was observed in seven patients (53.8%). Three patients (23.1%) had tonic seizures that frequently occurred with central apnea; one met criteria for mild central sleep apnea. Of the patients with tonic seizures, two had other identifiable seizure manifestations, but in one patient, central apnea was commonly the only discernable seizure manifestation. Polysomnography during video-EEG is an effective diagnostic tool in detecting sleep and seizure-related respiratory abnormalities. Clinically significant OSA may increase the risk of comorbid cardiovascular disease and premature mortality. Treatment of epilepsy may improve sleep quality, and conversely, improved sleep, may decrease seizure burden.

Minimum Technical Requirements for Performing Ambulatory EEG

Ambulatory EEG (AEEG) devices offer portable, multichannel, digital EEG recording with or without video in the patient's natural environment. The technology applied for AEEG recording is like the technology for routine EEG and inpatient long-term video-EEG monitoring but designed to be compact and wearable. Computer-based AEEG technology is well-suited to digital recording, signal processing, and visual display. However, acquiring interpretable EEG outside of the hospital setting presents its own technical challenges. Published guidelines have established technical standards for performing routine EEG and inpatient video-EEG monitoring, but technical standards for AEEG are lacking. Therefore, this guideline provides minimal technical standards for the performance of AEEG which are essential to ensure the quality of studies for clinical and research practice. We expect these minimum standards to evolve over time with improved performance and advances in the technology.

P 91 Characterization of amygdala enlargement in patients with mesial temporal lobe epilepsy by MRI volumetry

Question: Amygdala enlargement (AE) can be a cause of mesial temporal lobe epilepsy (mTLE). Clinical characteristics of AE and pathophysiological relationship between AE and mTLE are not fully understood. In this study, patients with AE and mTLE were examined clinically and by magnetic resonance imaging (MRI) to describe this form of epilepsy in more detail. Methods: We retrospectively included patients examined in inpatient video-EEG monitoring with AE confirmed by neuroradiologists based on MRI. We determined amygdala size by autoamated volumetry of 3D T1-weighted images in the software freesurfer (v7.1.1) using amygdala size as a surrogate parameter for amygdala pathology. We compared the results of normalized volumetry of subcortical structures with those of a healthy control group, and correlated the volumes with various clinical parameters. Results: Of 52 patients (50% female, age 15-66 years), 38 (73.1%) showed a seizure onset zone concordant to the side of the AE. The most common seizure patterns were dialeptic (90.4%) and automotor (88.5%) seizures. Auras occurred in 65.4%, mainly psychic (30.8%), epigastric (23.1%), and gustatory auras (11.5%). A total of 88.5% of patients were drug refractory; of these, 13 underwent epilepsy surgery and 7 (53.8%) achieved complete seizure freedom (Engel 1A). On histology, the cause of AE was found to be tumor in 3 patients, focal cortical dysplasia (FCD) in 5 patients, and gliosis in 2. An autoimmune inflammatory pathology could be reliably determined in only 3 patients (5.8%). In 30 of 52 patients, automatic volumetry showed a significant enlargement of an amygdala (Z-score >1.96) compared to the normal cohort (N=175). Volumetrically determined AE was concordant to the radiologically diagnosed side in 80%. This group showed a mean amygdala volume of 2151mm 3 on the left side (range 1799-2515mm 3 ) and 2293mm 3 on the right side (range 2000-2560mm 3 ) compared to the normal cohort (mean 1773mm 3 left and 1909mm 3 right side, respectively). There was no significant correlation of amygdala size with epilepsy duration (p=0.4) and no significant clinical differences between purely radiologically and additionally volumetrically detected AE. Conclusions: Temporal lobe epilepsies due to AE have predominantly similar clinical characteristics despite heterogeneous etiopathogenesis. Automatic volumetry of AE does not detect all visually abnormal findings.

Intracranial EEG and laser interstitial thermal therapy in MRI-negative insular and/or cingulate epilepsy: case series.

The goal of this study was to assess the success rate and complications of stereo-electroencephalogra-phy (sEEG) and laser interstitial thermal therapy (LITT) in the treatment of nonlesional refractory epilepsy in cingulate and insular cortex. The authors retrospectively analyzed the treatment response in 9 successive patients who underwent insular or cingulate LITT for nonlesional refractory epilepsy at their center between 2011 and 2019. Localization of seizures was based on inpatient video-EEG monitoring, neuropsychological testing, 3-T MRI, PET scan, magnetoencephalography scan, and/or ictal SPECT scan. Eight patients underwent sEEG, and 1 patient had implantation of both sEEG electrodes and subdural grids for localization of epileptogenic zones. LITT was performed in 5 insular cases (4 left and 1 right) and 3 cingulate cases (all left-sided). One patient also underwent both insular and cingulate LITT on the left side. All of the patients who underwent insular LITT as well as 2 of the 3 who underwent cingulate LITT were right-hand dominant. The patient who underwent insular plus cingulate LITT was also right-hand dominant. Following LITT, 67% of the patients were seizure free (Engel class I) at follow-up (mean 1.35 years, range 0.6-2.8 years). All patients responded favorably to treatment (Engel class I-III). Two patients developed small intracranial hemorrhages during the sEEG implantation that did not require surgical management. One patient developed a large intracranial hemorrhage during an insular LITT procedure that did require surgical management. That patient experienced aphasia, incoordination, and hemiparesis, which resolved with inpatient rehabilitation. No permanent neurological deficits were noted in any of the patients at last follow-up. Neuropsychological status was stable in this cohort before and after LITT. sEEG can be safely used to localize seizures originating from insular and cingulate cortex. LITT can successfully treat seizures arising from these deep-seated structures. The insula and cingulum should be evaluated more frequently for seizure onset zones.

The rate of psychiatric disorders in veterans undergoing intensive EEG monitoring is associated with symptom and performance invalidity

Objective: To determine if the number of participants with psychiatric disorders increased in association with failures on symptom validity tests (SVTs) and a performance validity test (PVT) in Veterans admitted for evaluation of possible seizures. Method: The 254 participants were Veterans undergoing inpatient video-EEG monitoring for the diagnosis of possible seizures. DSM-IV psychiatric disorders were diagnosed with the SCID IV. Symptom exaggeration was assessed with the MMPI-2-RF and performance validity with the TOMM. Results: On the MMPI-2-RF, 27.6%–32.7% showed symptom exaggeration. Participants who exaggerated on the MMPI-2-RF were more often diagnosed with psychiatric disorders. The TOMM was failed by 15.4% of the sample. Participants who failed the TOMM were more often diagnosed with an Axis I disorder but not with a personality disorder. The MMPI-2-RF was invalid in more cases than the TOMM, but 7.9% of the sample generated a valid MMPI-2-RF and an invalid TOMM. Conclusions: The correlational design does not allow conclusions about cause and effect. The invalid groups may have had a higher rate of psychopathology. The number of participants with psychiatric disorders increased in association with symptom exaggeration and performance invalidity. Symptom exaggeration was more frequent than performance invalidity, but the TOMM made a unique contribution to identification of invalidity. The routine clinical use of SVTs and PVTs is supported. The results also suggest the need for caution in diagnosing psychiatric disorders when there is symptom exaggeration or performance invalidity, because diagnostic validity is dependent on the accuracy of symptom reporting.

Valproate but not levetiracetam slows the EEG alpha peak frequency – A pharmaco-EEG study

ObjectiveStudies of the effect of valproate (VPA) on the background EEG have shown varying results. Therefore, we compared the effect of VPA and levetiracetam (LEV) on the EEG alpha peak frequency (APF). MethodsWe retrospectively examined the APF in resting-state EEG of patients undergoing inpatient video-EEG monitoring (VEM) during withdrawal of VPA or LEV. We assessed APF trends by computing linear fits across individual patients’ APF as a function of consecutive days, and correlated the APF and daily antiseizure medication (ASM) doses on a single-patient and group level. ResultsThe APF in the VPA-group significantly increased over days with falling VPA doses (p = 0.005, n = 13), but did not change significantly in the LEV-group (p = 0.47, n = 18). APF correlated negatively with daily ASM doses in the VPA-group (average of r = −0.74 ± 0.12 across patients, p = 0.0039), but not in the LEV-group (average of r = −0.17 ± 0.18 across patients, p = 0.4072). ConclusionsOur results suggest that VPA treatment slows the APF. This APF reduction correlates with the daily dose of VPA and is not present in LEV treatment. SignificanceOur study identifies a VPA-related slowing of the APF even in patients without electroencephalographic or overt clinical signs of encephalopathy.

Psychiatric symptoms are the strongest predictors of quality of life in patients with drug-resistant epilepsy or psychogenic nonepileptic seizures

ObjectiveThis cross-sectional study aimed to determine the effect of psychiatric comorbidity and neurocognitive deficits on the quality of life in a cohort of patients admitted for Video-EEG Monitoring (VEM) for investigation into a presumed seizure disorder. MethodsPatients were recruited from an inpatient VEM unit between January 2009 and December 2016. All patients had formal neuropsychiatric assessment. All patients completed questionnaires assessing psychiatric symptomatology (SCL-90-R), Anxiety and Depression (HADS), quality of life (QOLIE-89), and cognition (NUCOG). ResultsA total of 451 patients were enrolled. Upon discharge, 204 patients were diagnosed to have epilepsy, 118 psychogenic nonepileptic seizures (PNES), and 29 both epilepsy and PNES, while the diagnosis was uncertain diagnosis in 100. Diagnosis (p = .002), HADS Depression score (p < .001), SCL-90-R positive symptoms total (p < .001), and NUCOG total score (p < .001) were found to be significant predictors of QOLIE-89 total scores, together explaining 65.4% of variance in quality of life. Seizure frequency was not a significant predictor of quality of life (p = .082). Patients with PNES had significantly worse quality of life, and scored higher on measures of psychiatricsymptomatology, compared to patients with epilepsy alone. The prevalence of psychiatric comorbidity was significantly higher in patients with PNES (70.3%) or both PNES and epilepsy (62.1%) compared to patients with epilepsy alone (41.2%) (p < .001). SignificancePsychiatric symptomatology, depression, and cognition were stronger determinants of quality of life than seizure frequency in this study population of patients with drug-resistant epilepsy and PNES. Patients with PNES with or without comorbid epilepsy had similar neuropsychiatric profiles.

Ambulatory EEG: Crossing the divide during a pandemic.

The COVID-19 pandemic forced temporary closure of epilepsy monitoring units across the globe due to potential hospital-based contagion. As COVID-19 exposures and deaths continues to surge in the United States and around the world, other types of long-term EEG monitoring have risen to fill the gap and minimize hospital exposure. AEEG has high yield compared to standard EEG. Prolonged audio-visual video-EEG capability can record events and epileptiform activity with quality like inpatient video-EEG monitoring. Technological advances in AEEG using miniaturized hardware and wireless secure transmission have evolved to small portable devices that are perfect for people forced to stay at home during the pandemic. Application of seizure detection algorithms and Cloud-based storage with real-time access provides connectivity to AEEG interpreters during prolonged "shut-down". In this article we highlight the benefits of AEEG as an alternative to diagnostic inpatient VEM during the paradigm shift to mobile heath forced by the Coronavirus.

Seizure symptoms and ambulatory EEG findings: incidence of epileptiform discharges.

Ambulatory video-EEG monitoring has been utilized as a cost-effective alternative to inpatient video-EEG monitoring for non-surgical diagnostic evaluation of symptoms suggestive of epileptic seizures. We aimed to assess incidence of epileptiform discharges in ambulatory video-EEG recordings according to seizure symptom history obtained during clinical evaluation. This was a retrospective cohort study. We queried seizure symptoms from 9,221 consecutive ambulatory video-EEG studies in 35 states over one calendar year. We assessed incidence of epileptiform discharges for each symptom, including symptoms that conformed to a category heading, even if not included in the ILAE 2017 symptom list. We report incidences, odds ratios, and corresponding p values using Fisher's exact test and univariate logistic regression. We applied multivariable logistic regression to generate odds ratios for the six symptom categories that are controlled for the presence of other symptoms. History that included motor symptoms (OR=1.53) or automatisms (OR=1.42) was associated with increased occurrence of epileptiform discharges, whereas history of sensory symptoms (OR=0.76) predicted lack of epileptiform discharges. Patient-reported symptoms that were associated with increased occurrence of epileptiform discharges included lip-smacking, moaning, verbal automatism, aggression, eye-blinking, déjà vu, muscle pain, urinary incontinence, choking and jerking. On the other hand, auditory hallucination memory deficits, lightheadedness, syncope, giddiness, fibromyalgia and chronic pain predicted absence of epileptiform discharges. The majority of epileptiform discharges consisted only of interictal sharp waves or spikes. Our study shows that the use of ILAE 2017 symptom categories may help guide ambulatory video-EEG studies.

Video Ambulatory EEG in Children: A Quality Improvement Study.

We implemented a video ambulatory EEG (VA-EEG) Program as an alternative to inpatient video EEG monitoring for some patients given potential benefits related to quicker access, greater convenience, and lower cost. To evaluate the newly initiated program, we performed a quality improvement study to assess whether VA-EEG yielded studies with interpretable EEG and video quality that generated clinically beneficial data. This was a single-center prospective quality improvement study. We surveyed ordering clinicians, electroencephalographers, and caregivers regarding consecutive children who underwent clinically indicated VA-EEG. The primary outcome was the percentage of VA-EEG studies in which the ordering clinician reported that the study had answered the question of interest. We evaluated 74 consecutive children selected to undergo clinically indicated VA-EEG by their clinicians and caregivers. Ordering clinicians reported that 77% of studies answered the question of interest. Electroencephalographers reported that the quality of the EEG and video was excellent or adequate in 100% and 92% of patients, respectively. Additionally, 84% of caregivers reported preferring VA-EEG if EEG data were needed in the future. Video ambulatory EEG may be an effective diagnostic modality among children selected by clinicians and caregivers to undergo long-term EEG monitoring. Given it is effective as well as convenient, accessible, and lower cost than inpatient EEG monitoring, all of which align with our institution's quality goals, we intend to expand our VA-EEG Program.

Long-term Home Video EEG for Recording Clinical Events.

Around 50 years after the first EEG acquisition by Hans Berger, its use in ambulatory setting was demonstrated. Ever since, ambulatory EEG has been widely available and routinely used in the United States (and to a lesser extent in Europe) for diagnosis and management of patients with epilepsy. This technology alone cannot help with semiological characterization, and absence of video is one of its main drawbacks. Addition of video to ambulatory EEG potentially improves diagnostic yield and opens new aspects of utility for better characterization of patient's events, including differential diagnosis, classification, and quantification of seizure burden. Studies evaluating quality of ambulatory video EEG (aVEEG) suggest good quality recordings are feasible. In the utilization of aVEEG, to maximize yield, it is important to consider pretest probability. Having clear pretest questions and a strong index of suspicion for focal, generalized convulsive or non-epileptic seizures further increases the usefulness of aVEEG. In this article, which is part of the topical issue "Ambulatory EEG," the authors compare long-term home aVEEG to inpatient video EEG monitoring, discuss aVEEG's use in diagnosis and follow-up of patients, and present the authors' own experience of the utility of aVEEG in a teaching hospital setting.

Optimization of Epilepsy Program Procedures With Linear Programming

The goal of comprehensive epilepsy centers (CECs) is to diagnose and treat individuals with epilepsy and other episodic disorders. To do this, epilepsy specialists rely upon electroencephalographic (EEG) techniques. EEG is a central component of CECs, providing critical information for the diagnosis and management of patients with seizure disorders. Additionally, EEG is a critical revenue generator for epilepsy programs, allowing for sustained growth and expansion programs in most institutions. This study uses a linear programming model to determine optimal allocation of EEG resources within a CEC, specifically considering volumes of inpatient routine EEG, outpatient EEG, and inpatient Video-EEG monitoring. The study demonstrates that the most significant contributor to overall revenue to the program was available EEG technologist hours. This finding suggests that CECs should prioritize programs related to increased EEG technologist training, recruitment, and retention to maintain and expand revenue and procedure volume.

Antiepileptic drugs are not independently associated with cognitive dysfunction.

To test the hypothesis that individual antiepileptic drugs (AEDs) are not associated with cognitive impairment beyond other clinically relevant factors, we performed a cross-sectional study of patients admitted to an inpatient video-EEG monitoring unit. We prospectively enrolled patients admitted to an inpatient specialist epilepsy program between 2009 and 2016. Assessments included objective cognitive function, quality of life subscales for subjective cognitive function, and questionnaires for anxiety and depressive symptoms. Bayesian model averaging identified predictors of cognitive function. Bayesian model selection approach investigated effect of individual AEDs on cognition. Conventional frequentist analyses were also performed. A total of 331 patients met inclusion criteria. Mean age was 39.3 years and 61.9% of patients were women. A total of 45.0% of patients were prescribed AED polypharmacy, 25.1% AED monotherapy, and 29.9% no AED. Age, seizure frequency, and a diagnosis of concomitant epilepsy and psychogenic nonepileptic seizure were predictors of objective cognitive function. Depression, anxiety, and seizure frequency were predictors of subjective cognitive function. Individual AEDs were not independently associated with impaired cognitive function beyond other clinically relevant variables. This study found that no AED was independently associated with cognitive dysfunction. Significant determinants of objective and subjective cognitive dysfunction included seizure frequency and depression, respectively. These findings suggest that optimizing therapy to prevent seizures is not likely to occur at the expense of cognitive function.

Seizures and Epilepsy in the Elderly: Diagnostic and Treatment Considerations

The purpose of this review is to highlight important clinical aspects in diagnosis and management of epilepsy in the elderly and to highlight recent literature and its relevance to current practice. Recent studies have shown that elderly patients are under referred for evaluation to epilepsy monitoring units and for epilepsy surgery, which has been demonstrated to be safe and effective in this population. The elderly are at increased risk for acute symptomatic seizures and epilepsy. Accurate diagnosis can be challenging in older patients due to limitations in history, atypical symptoms, and medical comorbidities. Inpatient video-EEG monitoring is a valuable tool for the clinician when diagnosis is unclear or patients are unresponsive to medication. Drug resistance rates in the elderly are similar to younger adults with epilepsy, but elderly patients are less likely to be referred for epilepsy monitoring unit admissions and epilepsy surgery, despite evidence of safety and effectiveness.

Ambulatory EEG to Classify the Epilepsy Syndrome.

Recording of interictal epileptiform discharges to classify the epilepsy syndrome is one of the most common indications for ambulatory EEG. Ambulatory EEG has superior sampling compared with standard EEG recordings and advantages in terms of cost-effectiveness and convenience compared with a prolonged inpatient EEG study. Ambulatory EEG allows for EEG recording in all sleep stages and transitional states, which can be very helpful in capturing interictal epileptiform discharges. In the absence of interictal epileptiform discharges or in patients with atypical events, the characterization of an epilepsy syndrome may require recording of the habitual events. Diagnostic ambulatory EEG can be a useful alternative to inpatient video-EEG monitoring in a selected number of patients with frequent events who do not require medication taper or seizure testing for surgical localization.