Seizure Monitoring (Phase I)
Seizure monitoring is a crucial investigation for certain patients with epilepsy or suspected epilepsy. In essence, seizure monitoring is the direct observation of the patient’s symptoms by the treating team – observation by video and EEG. Data gathered from EMU testing informs the team – the epileptologist (attending/ faculty neurologist who specializes in epilepsy), the nurse practitioner, rotating neurology residents and fellows, nurse coordinators, and EEG technologists – about the type of spell the patient is experiencing. The patient’s symptoms are thoroughly understood first-hand in this manner, and appropriate management plans are made. Patients generally stay for 3-5 days, and anti-seizure medication are usually weaned and/or discontinued to provoke the occurrence of spells.
For patients with medication resistant epilepsy who may be candidates for epilepsy surgery, EMU evaluation is a mandatory procedure – often called ‘Phase I’ evaluation – that informs the treating team about the brain area that is producing seizures and how those seizures spread. Pre-surgical patients also undergo neuropsychological testing while they are admitted to the EMU; sometimes neuropsychological testing is performed after discharge as an outpatient. Together with the results of other tests (MRI, PET etc.) the treating team is able to identify whether the patient will benefit or from surgery, and whether still further tests are required to make that determination. These decisions are made at the conclusion of the patient EMU stay and occur at our weekly multi-disciplinary epilepsy patient management conference.
The Epilepsy Management Conference (EMC)
The EMC is a multidisciplinary weekly meeting when the entire epilepsy team – physicians, surgeons, advanced practice nurses, administrators and coordinators, neuropsychologists and neuroradiologists gather to discuss and synthesize the data gathered for particular patients who have undergone Phase I monitoring. All the relevant data is presented formally and discussed among the whole team. The discussion concludes with a formulation of a consensus management plan for the patient. Often, this is a consideration of whether the patient would benefit from epilepsy surgery. If so, further tests (below) are usually necessary to confirm surgical candidacy, and on the completion of those ancillary tests, the data are re-discussed. In this iterative fashion a final management plan is made which is then communicated to the patient by the team. Some of the ancillary tests we use include:
Positron Emission Tomography (PET) Scan – A PET scan used a radionuclide (18fluoro-deoxy-glucose; FDG) to investigate the metabolic profile of the whole brain; areas of focal epilepsy exhibit reduced metabolism that can be visually identified.
Functional Magnetic Resonance Imaging (fMRI) – fMRI is used to identify ‘eloquent’ cortex in patients in whom there is concern that the seizure focus may be physically close to important brain areas for sensation, motor function or language. Our neuroradiology team employs a full suite of fMRI procedures involving finger tapping, skin sensation, visual function, interpreting speech, reading, etc. to identify these eloquent areas. Results from fMRI are then visualized together with the rest of the patient data to provide the team with a ‘map’ of how important brain areas relate to the seizure focus.
Neuropsychological Testing – Neuropsychology is key to interrogating the cognitive dysfunction that often accompanies long standing focal epilepsy, and tests attention, problem solving, memory, language, I.Q., visual-spatial skills, academic skills, and social-emotional functioning. Results from neuropsychology inform the team whether the patient might tolerate a surgical procedure on their brain with no or minimal alteration in their cognitive function, or whether a proposed procedure would carry a high risk of imposing a significant deficit. In the latter case, epilepsy surgery can be impractical, and the patient may be advised of alternative, non-surgical therapies.
Magnetoencephalography (MEG) Scan – MEG measures the magnetic signals from the brain and localizes significant features of the signal on the 3-D brain volume. We aim to have MEG available at UF in the near future, but for now patients requiring MEG are referred to an external facility for the test, and the results reviewed back with the rest of the ancillary investigations.
Wada Angiogram – The left and right hemispheres of the brain are broadly responsible for different functions, and a Wada test is performed to map out memory and language function in the individual hemispheres. In a sense, Wada is an extension of the neuropsychological evaluation, and aims to determine whether the proposed surgery on the patient would result in significant memory deficits; also in which hemisphere fundamentally is language function represented. Wada is invasive: each hemisphere is anesthetized in sequence using a short acting barbiturate through a catheter inserted in the femoral artery in the groin, and the ‘awake half’ of the brain is tested for language, memory, and learning function. With the advance of technology and availability of newer noninvasive methods, our use of Wada has decreased over the years.
Information for Patients
Welcome to our Epilepsy Monitoring Unit (EMU) that is located on the 5th floor (UB57) of our new Neuromedicine Hospital. Your doctor has determined that a multi-day stay in our EMU is the best way of understanding your seizure disorder, so that the best plans for your long-term treatment can be made. On the day of your arrival, you will report to the admissions area in the main foyer of the NeuroMedicine Hospital, and someone will check your medical record, verify your identity and help you find your way to the EMU.
Each monitoring room has special seizure-monitoring equipment and ceiling-mounted cameras. All monitoring rooms are private rooms. This is a 3-5 day admission. There are times your admission may be a little longer depending on how long it takes to record seizures. The nursing staff will orient you to your room and will explain the use of the nurse-call system, seizure monitoring equipment and information about the hospital routine. A detailed history of your seizures will be obtained by the doctors, nurses, nurse practitioners and/or EEG technicians. The epilepsy team will make rounds daily, when you will have the opportunity to ask the team about the information gathered in the prior 24 hours. You may have lab work at the time of admission, and further lab tests as necessary during your stay. During your stay the team may also request a neuropsychological evaluation to better understand your brain function and its relation to your symptoms. This is a paper and pencil test that evaluates language, memory and other mental functions. We try to create the best environment to record seizures to include slowly tapering seizure medications. During your stay, you may be sleep deprived. This is another way to provoke seizures. Please be assured that you will have IV placed should we need to give fast-acting medications to control seizures; side rails of your hospital bed will be padded to prevent possible injury during a seizure.
We recommend having a companion stay with you during your hospitalization, however, if you do not have someone to stay with you, a bed alarm will be used for your safety. You will need to call your nurse for assistance using the bathroom. Please do not get out of bed alone. Showers are not permitted though you may take a sponge bath. EEG leads and amplifiers must remain dry at all times. Please do not smoke or chew gum or consume hard candy. If you need a nicotine patch, please ask and you will be provided one. For your safety, we provide non-skid grip socks.
Prior to discharge, and depending on the results obtained, you may have more tests organized as an outpatient (e.g. PET, fMRI, MEG, Wada). Some of these are detailed above.You would normally follow up in the outpatient clinic with the doctor who requested the EMU testing. This will be a further opportunity for you to discuss the results obtained, and what those mean for the treatment of your condition.
Again, we welcome to the EMU at UFHealth. We understand that staying in a hospital bed waiting for seizures to occur can seem like a long and stressful experience. Our care team will do their best to make your stay as comfortable as possible.