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 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.