Chapter 5: Establishing a Video-EEG Monitoring Unit

Introduction

The Video-EEG Monitoring Unit (v-EMU) has evolved over recent decades to aid the practitioner in the evaluation of people with recurrent transient neurologic events and the pre-surgical work-up of epilepsy patients. In this chapter, we discuss the various approaches to starting and operating a v-EMU at the various service levels recognized by professional organizations. Procedure and safety in the v-EMU is also reviewed.

Background

Video-electroencephalography monitoring (VEM) units have been evolving for more than 40 years, with monumental progress since the early years of units, which relied on machines that used vacuum tube amplifier technology and recording on paper.¹ Many individuals and organizations contributed to this development. Albert and Ellen Grass and the Grass Instrument Company were pivotal in early technological progress, starting in the 1930s. This was complemented by Frederic and Erna Gibbs, who correlated specific electroencephalogram (EEG) patterns to seizures in limbic epilepsy in the 1940s.² The foundation for modern VEM units was laid at the Brain Research Institute of the University of California at Los Angeles through advances in epilepsy surgery in the 1960s and translational research conducted in the 1970s and 1980s.^3,4 This progress was partly supported by the U.S. National Aeronautics and Space Administration (NASA), which pioneered remote EEG monitoring during early missions in preparation for manned space flight.⁵ Multiple clinicians, researchers, institutions, and equipment manufacturers around the world continue to refine the process toward improved clinical evaluation.

VEM units have been shown to provide a definitive diagnosis in 88% of admissions, and the information obtained has been shown to influence the treatment plan in 80% of these cases.^6,7 Recent reports have highlighted the increasing numbers of admissions to hospital for seizures,⁸ which is likely to indicate increased numbers of patients undergoing VEM and related specialized clinical neurophysiology services.

Credentialing and Certifications

The VEM unit has multiple functions, including classifying and characterizing changes in behavior and EEG that may represent epileptic seizures, with a primary role in the localization of seizures as a component of an epilepsy surgery evaluation.^9–15 Advancements in the technology used in VEM units have spawned an expansion in the use of monitoring services outside VEM units.¹⁶ Long-term quantitative EEG trending in the intensive care unit is one such adaptation of VEM technology. As a diagnostic resource for epilepsy, VEM units may be accredited by the National Association of Epilepsy Centers (NAEC). The NAEC has established guidelines for defining four levels of epilepsy care of progressively greater expertise and resources.¹⁷

• Level 1: Care is provided by a primary care physician.

• Level 2: Care is provided by a neurologist.

• Level 3: Care includes basic services for patients with medication refractory seizures. This includes a range of medical, neurodiagnostics, neuropsychological, and psychosocial services, which may include implantation of ...