EPILEPSY MONITORING UNIT (EMU)

MATSU REGIONAL MEDICAL CENTER

in Wasilla Alaska

Directory: Jeffrey L. Sponsler, MD

The Epilepsy Monitoring Unit (EMU) at Matsu Regional Medical Center specializes in caring for people who need to be hospitalized during seizure evaluation. The unit is located in the hospital and the staff for the EMU includes the attending neurologist, Dr. Sponsler, professional registered nurses, and 24 hour dedicated monitoring by EEG technologists (trained and supervised by Dr. Sponsler).

Patients are admitted to the unit when their condition requires prolonged electroencephalogram (EEG) monitoring. Such extensive monitoring helps the neurology attending characterize the seizure type, localize the area where the seizure begins and exclude non-epileptic seizures from the diagnosis. The detailed information helps the epilepsy team develop customized treatment plans for each patient.

Seizure monitoring usually requires patients to stop taking some or all of their seizure medications. This can result in frequent, more intense seizures during monitoring. Patients may be asked to remain awake some nights to provoke seizures during monitoring.

Patients in the unit receive continuous EEG and video monitoring. The EEG monitors electrical impulses from the nerve cells in the brain to record the brain's activities. EEG leads with wires are glued to the scalp with special purpose glue. The EEG is recorded continuously in another room in the unit. Patients also are monitored 24 hours a day by video camera. Monitoring typically requires a two- to five-day hospital stay.

Frequently Asked Questions:

What patients are appropriate for the EMU?

Patients that have new onset seizure disorder can be monitored. This allows classification of the seizure type and will guide further therapy and treatments.

Any patient with unexplained loss of awareness can be monitored. This includes seizures, but also, fainting spells (syncope), severe dizziness, events of memory loss (amnesia).

Is this a risky test?

There is some risks involved and a procedure consent form is signed by the patient (or guardian). The risks include all of the usual risks associated with having a seizure or severe fainting spell. The risks include injury to muscle, bones, or nerves, head injury, even death. However, the testing is done in a very controlled environment with continuous monitoring by video and with a nurse very close by. The attending neurologist is on call 24 hours per day for the EMU. The EMU monitoring is considered worth the risks listed above because uncontrolled seizures (outside of the hospital) have the same risks and it is imperative to find out about the seizures so to provide better care for the patient.

I am only having one or two seizures per year. Is this really necessary?

The standard of medical care for an epilepsy patient at this time is "No seizures and no side effects" if possible. Therefore, a few seizures per year is considered uncontrolled and every effort is made to improve this seizure frequency (if possible). The EMU is the "gold standard" for diagnosing seizures and epilepsy.

How many seizures will I have while in the EMU?

The convention is two obtain video and EEG data on five seizures or typical events.

I had an EEG test as an out-patient in the past. Why can't we just use that information?

This is a very good question and the answer is statistical. A 20 to 40 minute EEG is able to capture the abnormal brain waves about half of the time in a seizure patient. The long term monitoring EMU testing has better sensitivity of 95% or higher. That means that if there is an epilepsy disorder the EMU testing will find this out 95% of cases and miss the correct diagnosis only 5% of cases.

Will my anti-antileptic drugs be changed or stopped while in the EMU?

Most of the time, AEDs will be reduced or even stopped. This allows the untreated brain activity to be recorded by the EEG computer. If no seizures (or spells) occur while in the hospital, some data is still found useful but actual seizure events are the key information that is to be collected.

Why is prolonged video/EEG monitoring required?

A traditional EEG lasts about a half hour. It gives us a "snapshot" of the brain's activity during that particular recording period. This may not be sufficient to give us the information we need to treat your seizures adequately. Our recording has two components:

• A camera will record all your physical activity while you are on the EEG. The EEG technologists in the monitoring room will watch you at all times.This way we can detect all seizures that occur during your admission. By videotaping your seizures we can see exactly what happens during one of your seizures. This is usually more accurate than any reports you or a family member can give us about your seizures. All of our technologists and nurses are specially trained in recognizing and responding to seizures, to maximize your safety.
• EEG RECORDING: While in the epilepsy monitoring unit (EMU) you will also have a continuous EEG recording. This way we can detect any seizure activity that occurs, even if you are not aware it is happening. It helps us determine where in your brain your seizures begin so we can decide just what type of seizure you are experiencing. It also gives us information about how your brain functions between seizures. This type of recording allows us to make an accurate count of your seizures and to see if you might have more than one type of seizure.

Why can't I have these tests at my local hospital?

The video/EEG equipment is very specialized and not available at most hospitals. Our staff of EEG technologists and nurses are very experienced in caring for people with seizures. Our doctors have advanced training in EEG interpretation and epilepsy treatment. We also have access to a neuropsychologist and other specialists as needed. We feel our Epilepsy Monitoring Unit offers you the best opportunity for receiving a comprehensive and expert evaluation of your seizure disorder.

What can I expect in the epilepsy monitoring unit?

• While you are in the hospital you will be under the care of and seen daily by one of our physicians who is an epilepsy specialist. In addition, a resident doctor will see you on admission and do a physical examination with added neurological tests. You will be asked questions about your past medical history and your seizures. If you cannot provide this information, please try to bring someone with you, a family member or friend, who can do this. It is especially helpful if the person can provide a description of your typical seizures.
• You will have EEG electrodes applied to your scalp and the technologist will first perform a standard EEG test. Then the electrodes will be connected to a video/EEG monitor. The camera will be turned on and your evaluation will begin. The cable that attached the EEG wires to the monitoring machine is long enough for you to be able to use the bathroom. However, it is very important that you stay on camera at all times.
• At the side of your bed you will find 2 alarm buttons. One is a nurse call button and the other red one is called an event button. If you have any warning about your seizures, please push the event button. If a friend or family member is with you, he or she, can also trigger the alarm if a seizure occurs. We also ask you to keep a diary of any unusual feelings of seizures you can remember. Our EEG technologist will explain these to you when you arrive.
• When you have a seizure an EEG technologist will enter the room to closely observe your event and do some testing. Your nurse will also be alerted. We do everything possible to prevent injury during seizures.
• Special thin wires called sphenoidal electrodes may be inserted. These are placed under the skin just above the jaw with a small needle which is then removed. These electrodes give us more information about seizure activity in the temporal lobes. It is normal for your jaw to feel sore for about a day after they are inserted.
• All patients see our neuropsychologist and have neuropsychological testing during the first few days of monitoring. These written tests give us information about your brain functioning and may show areas that are affected by seizure activity. This testing takes about three to four hours.
• Your antiepileptic medicines may be decreased or stopped while you are in the hospital. We do this to try to bring on seizures. We do not usually reduce medications prior to your admission.
• A capped intravenous line will be placed in one of your veins. This is for your safety. If you have a lot of seizures or a very strong one, we can rapidly give you medicine in the intravenous line to stop the seizures. This intravenous line is checked every shift by your nurse to make sure it is working properly. The site where it is placed will be changed every few days. It will also be changed if it stops working.
• We might sleep deprive you to try to bring on a seizure. This means you would stay up for 24 hours without sleep or naps. When the brain is very tired, it gets irritable and is more likely to have a seizure.
• Every day your doctor will visit and update you on your progress. We will discuss what information we have gathered so far and let you know what to expect next. Please feel free to ask any questions you have at this time. We will also make arrangements to talk with your family during your admission.
• You will have the opportunity to learn more about epilepsy and its treatment. Our nurse clinician will meet with you and your family to discuss any questions you might have. We have videotapes and pamphlets that can provide you with more information about epilepsy.

When will I get the results of my tests?

Your doctor will visit daily to review your progress. We will usually discuss with you a plan of action before you are discharged if the results of all tests are available. If you normally see one of our doctors, you will be given a follow-up appointment at the time of your discharge. At that time we will formally review all your test results with you and your family.

If you were referred to us by another doctor, he or she will receive a written report of all your tests shortly after you have been discharged. Sometimes our doctors also call your doctor to discuss our findings at the time of discharge. Our report will include recommendations for care of your seizure disorder. You will need to discuss these results with your doctor.

Am I a candidate for epilepsy surgery?

The initial evaluation for epilepsy surgery begins with admission to the epilepsy monitoring unit to record seizures. You will be admitted to University Hospital, where your physical movements and brain activity will be monitored around-the-clock by videotape and electroencephalogram. In this way, we are able to locate seizure-triggering areas in the brain. Other testing that is used includes MRI, PET and SPECT scans. We recommend surgery only when we can be certain that the area of seizure activity in your brain can be removed without undue risk to normal brain function. We offer several procedures for surgical treatment of seizures:

• Temporal lobe resection
• Frontal lobe resection
• Corpus callosal section
• Extratemporal resection
• "Lesionectomy"
• Vagal nerve stimulator

Some patients require invasive electrode monitoring (phase II) where small electrodes are inserted into brain tissue, or electrodes are placed directly on the brain surface. These procedures are performed if it is uncertain where seizures arise in the brain or if the seizure-producing brain tissue is close to important functional areas of the brain (such as motor control or speech and language centers). The decision to perform surgery is made only after a thorough discussion of a patient's case at the epilepsy surgery conference.

The results from epilepsy surgery are very favorable, however, each individual's chance of improving with surgery differs and your physician will discuss with you what your particular chance of becoming seizure-free is, and what the potential risks for surgery are in your particular case.

EXAMPLE EEG WAVEFORMS:

EEG WAVEFORMS THAT SHOW A SEIZURE: