Chapter 6: Neurologic Practice in a Video-EEG Monitoring Unit

Introduction

Neurologists working on a video-electroencephalography monitoring (VEM) unit are part of a large team comprising ward nurses and an epilepsy advanced practice nurse (APN), EEG technologists with special expertise in VEM, and usually personnel who monitor the video-EEG continuously, as well as a biomedical engineer and ancillary health care personnel. The neurologists, APN, and chief technologist take responsibility for establishing protocols and overseeing quality control. This chapter will deal specifically with the role of neurologists on VEM units. Nursing and technical issues are covered in other chapters.

Guidelines for Specialized Epilepsy Centers

The National Association of Epilepsy Centers (NAEC) has established guidelines for four levels of epilepsy care, as outlined in Chapter 5.¹ Third-level centers can be medical, which do not perform surgical treatment for epilepsy, or medical-surgical, which are able to perform surgical resections of structural lesions and standard anterior temporal resections. Fourth-level centers also perform more complicated diagnostic surgical procedures, including placement of depth, subdural grid, and strip electrodes. Not all fourth-level centers offer corpuscallosotomy, hemispherectomy, and other specialized therapeutic surgical procedures; however, they are expected to have referral arrangements with fourth-level centers offering these services. These guidelines stipulate that a third-level medical center for epilepsy provide minimum 8-hour VEM with surface electrodes and supervision by an EEG technologist, with assistance by an epilepsy staff nurse or monitoring technician when necessary. Third-level medical-surgical centers provide 24-hour (continuous) VEM with surface electrodes, including sphenoidal or other appropriate additional electrodes, and continuous supervision by EEG technologists or epilepsy staff nurses, supported by monitoring technicians, or automated seizure detection programs when appropriate. Fourth-level centers additionally provide 24-hour video-EEG recording with intracranial electrodes under continuous supervision and observation, as well as functional cortical mapping and evoked potential recording, using intracranial electrodes, which may be performed extraoperatively on the VEM unit. Additional details regarding NAEC guidelines and certification may be found in Chapter 5.

The International League Against Epilepsy (ILAE) has also published recommended standards for epilepsy surgery centers, but guidelines for VEM are not detailed.² Finally, the American Clinical Neurophysiology Society (ACNS) and the International Federation of Clinical Neurophysiology Societies (IFCNS) have issued a series of guidelines for long-term monitoring for epilepsy (LTME), the most recent published in 2008.³ These include indications for long-term monitoring, qualifications and responsibilities for long-term monitoring personnel, long-term monitoring equipment and procedures, equipment and procedures for long-term monitoring of behavior and correlation with EEG, technical and methodological considerations, recommended uses of specific long-term monitoring systems, and guidelines for writing reports. This chapter covers neurologic practice on a VEM unit for a fourth-level epilepsy center, which is most comprehensive, but information should also apply for third-level centers. The chief neurologist of the monitoring unit should be familiar with all of these guidelines.

Personnel

The most recent ACNS guidelines state that the chief or medical supervisor ...