Proposed guideline: Minimum Standards for Long-term Video-EEG Monitoring

A joint EEG Task Force from the ILAE and the International Federation of Clinical Neurophysiology (IFCN) has developed a proposed clinical practice guideline for minimum standards for long-term video-EEG monitoring. The ILAE guideline process requires obtaining feedback and comments from its members on the proposed guideline. These comments from our international community will be reviewed by the working group before finalizing the guideline.

Please see the draft guideline: Minimum Standards for Long-term Video-EEG Monitoring, and submit your comments via email to Deb Flower.

Deadline for comments: October 31, 2020

Thank you for your help in this important effort of the ILAE and IFCN.


Comments

22 October 2020

Dear authors,

Thank you very much for this very helpful guideline for the standards of video-eeg monitoring. To my view in the indications section one aspect is missing. In all centres several patients are known with unrecognized seizures especially absences, focal unaware seizures without aura or seizures during the night and the treatment decision are still based on weak informations. Since we do not have an efficient seizure detection device in hand for such seizures it is sometimes helpful to clarify during a video-eeg monitoring if unrecognized seizures are present. It would be helpful to have this indication also mentioned.

Regards,
Yvonne Weber


20 October 2020

Good effort and good consensus. But ...

On 5 Technical Standards; 5.1. Electrode Array and EEG Recording - No recommendation why? Why not " In Scalp EEG for LTVEM use of 25 electrodes + localized addressed dense arrays in case of focal epilepsies”.

A limitation on recommendations: the 256 samples/second rate could be insufficient if some calculation on signal is necessary. Please stress that this value is the minimum.

António Martins-da-Silva


13 October 2020

Thank you for providing an opportunity for ASET members and leadership to review the ILAE Proposed Guideline for Minimum Standards for Long-term Video-EEG Monitoring. While this guideline is open for public comment, our Board of Trustees respectfully requests that the ASET Position Statement below be added to the final document. View the ASET Position Statement as a pdf

ASET Position Statement on the Definition of a Qualified Neurodiagnostic Technologists

Qualified Neurodiagnostic Technologists:

  • Are credentialed
  • Have met a minimum education and related educational and performance standards
  • Meet continuing education requirements
  • Perform within a code of ethics and defined scope of practice
  • Perform under the direction of clinical leadership or a physician
  • Are recognized by physicians, employers, the public, governmental agencies, payers and other health care professionals
  • Form a national society whose activities include advocating for the profession, and
  • Contribute to the advancement of knowledge in neuroscience.

-- Approved by the ASET Board of Trustees May 27, 2020

This Position Statement appropriately defines the attributes of a qualified Neurodiagnostic/EEG technologists as it relates to the ILAE draft in paragraph three of section 5.4.3 Staffing. In addition, ASET respectfully requests that “monitoring technicians” be replaced with "Neurodiagnostic monitoring technologists" in the same section.

Qualified EEG technologists and monitoring technicians are key members of the team during LTVEM to recognize events and interact with nursing staff and provide feedback during seizure monitoring.

ASET Position Statement:
Minimum Education and Credentialing Recommendations for Performing Neurodiagnostic Procedures

Competent technical recording of Neurodiagnostic procedures requires the technologist to exercise a significant degree of independent judgment. Neurodiagnostic procedures, including patient interaction, safety, and appropriate system settings, are tailored to the individual patient’s needs, the reason for the referral, and medical history. Both Neurodiagnostic Technology education and clinical experience are necessary in order to attain an adequate knowledge base. ASET strongly recommends that individuals performing Neurodiagnostic procedures possess the following:

  • Neurodiagnostic Technology education from a program reviewed by the Committee on Accreditation for Education in Neurodiagnostic Technology (CoA-NDT) accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP).

OR

  • An Associate’s Degree or higher from an accredited college or university.

AND

  • Credential in an area of Neurodiagnostic specialty from the appropriate credentialing board. If the individual is not credentialed at the time of hire, a deadline for obtaining the credential established by the employer is recommended.

This position statement reflects best practices for the profession, and supports the credentialing eligibility requirements established by ABRET Neurodiagnostic Credentialing and Accreditation, as well as the American Board of Electrodiagnostic Medicine (ABEM), the American Association of Electrodiagnostic Technologists (AAET), and the Board of Registered Polysomnographic Technologists (BRPT). ASET encourages and promotes adoption of these within hospital laboratories.

For detailed information, please refer to the ASET Handbook of Neurodiagnostic Job Descriptions and Competencies.
-- Approved by the ASET Board of Trustees July 29, 2013

ASET’s position on the definition of Qualified Neurodiagnostic Technologists is intended to promote patient safety through a demonstration of professional competence. The measure of professional competence, as is practiced by most other allied health professions, requires successful completion of board examinations resulting in nationally recognized professional credentials (e.g. credentials recognized in the United States the R. EEG T. and CLTM, and in Canada, the R.E.T.).

Knowing that the ILAE shares our concerns about the risks associated with Neurodiagnostic testing and the concern for patient safety in the long-term monitoring environment, we respectfully request the Position Statement be added to the ILAE document.

The ASET Board of Trustees appreciates your consideration in support of this important matter.

Kevin Helm, ASET


8 October 2020

I had two minor editing suggestions in the introduction that I have noted here in bold italic.

1. Introduction With more than 70 million cases of epilepsy are reported world-wide, objective measures are needed to evaluate people for seizures. 1-4 Seizures impart safety risk, 5 affect people of all ages, gender, ethnic background, and cultures, 2, 4 with one-third of people with epilepsy who are uncontrolled by antiseizure medication (ASM). 6, 7 Practice guidelines and quality measures are available providing national and international standards for diagnosis and treatment of patients. 8-10 Because the manifestations of epilepsy are intermittent, a standard EEG often fails to reveal the epileptiform activity necessary to support the diagnosis of epilepsy. Long-term video-EEG monitoring (LTVEM) is therefore the most robust reference standard for recording epileptiform activity and seizures.11 In this clinical practice guideline, LTVEM refers to scalp EEG monitoring using the 10-20 system of electrode placement and a single channel of electrocardiogram (ECG) along with continuous video monitoring. Video-EEG remains the best technique to evaluate people with recurrent paroxysmal events with and without impaired consciousness when routine evaluation is unrevealing5, 12-20 Position papers and standards16 , services21 and guidelines11, 14, 22-25 exist for specific indications and certain aspects of LTVEM, though an international guideline to identify minimum performance standards is needed. The International League Against Epilepsy (ILAE) and the International Federation of Clinical Neurophysiology (IFCN) are developing clinical practice guidelines for application of neurophysiological methods in people with epilepsy. The target audience for this clinical practice guideline are clinicians and allied healthcare personnel. The objective of this guideline is to provide recommendations on standards performance of LTVEM  

Krista Doyle


7 October 2020

Dear Colleagues,

It is a big task to put together some International Guidelines and I am pleased that this is progressing. My experience as an occupational therapist provides a different perspective for the multidisciplinary team and have read the guidelines and listed my thoughts for consideration.

1) Differential Diagnosis
LTVEM monitoring should be used to differentiate between epileptic and non-epileptic events, in patients where the diagnosis is in question (strong recommendation).

Agree:
It is unclear how many studies are from different countries – Poland was the only country mentioned.
It is unclear how many of the articles are about adults versus children. The one study mentioned 323 children in which 53% needed to be re-classified because of LTVEM. That is strong proportion.

2) Classification
LTVEM may help classify patients with epilepsy in whom the seizure type or epilepsy syndrome is undetermined (weak recommendation)
My concerns are for those children and families and those episodes that occur in sleep. The recommendation needs to support for this group as part of a multidisciplinary team as MORE research is needed for this group.

3) Quantification
The usefulness of LTVEM to quantify seizures in patients with epilepsy is weak.
Unsure of the articles that differentiated between adults or children. I would suggest that the group considers writing that expert opinion for quantification is needed. This would mean that those would need appropriate training and competency to help in the objective management and as part of the medical team.

4) Surgery
LTVEM must be used in the presurgical evaluation in drug resistant TLE patients (strong recommendation). There is neither evidence for nor against LTVEM to characterize patients with drug-resistant extra temporal epilepsy in the presurgical evaluation (weak recommendation).

AGREE that LTVEM must be used for presurgical evaluation. Within the articles how many of the 10 million surgical candidates were adults versus children? For International Guidelines I would recommend that in the first instance surgery for children needs to follow the consensus guidelines (UK) to begin guiding each country in a set standard access to the appropriately skilled and trained individuals, hospital, and multidisciplinary teams.

5) Technical Standards
Electrodes ; unsure of the exact international recommendation
Video should be combined with EEG during the use of LTVEM (strong recommendation)

AGREE

6) Safety
The safe, maximal patient to nurse ration may be 1:4 (weak recommendation)

AGREE As in most countries and local areas they would need to following World Health Organization advice and complete risk assessments, see US (OSHA) and UK (HSE)

Table 4 is a beginning starting point for any centre

7) Practice and Personnel
So, the recommendation is that VEM needs to be included with further research into the quantity and type of device.

Seizure Monitoring
A written, standardized protocol may be used in each LTVEM unit for managing and testing patients during seizures (conditional recommendation).

In my opinion, as this was a survey across the European centres, this needs to continue to be researched to be able to make this an International Guideline recommendation. For International Guidelines I would recommend that in the first instance VEM for children needs to follow the European recommendations and follow evidence-based LTVEM practices. This will begin guiding each country in a set a standard across the appropriately countries, hospitals, communities, and caregivers.

Staffing

Table 5 is a clear chart for a standard
Activation
Patients with GGE should undergo hyperventilation in conjunction with ADM withdrawal as an effective activating procedure (strong recommendation) AGREE

Drug reduction
In patients without a history of status epilepticus or frequent daily seizures a taper of 30-50% daily should be considered (strong recommendation) AGREE

Automated Analyses
Automated algorithms for spike and seizure detection may provide complementary aid to expert assessment (weak recommendation)
From articles the research is limited to be confident in making a stronger recommendation, however, from case reports and some of the studies, the analyses is useful but also needs to have the overview of the clinician to further detect patterns that may occur. I suggest that further research is needed.

Deanna Middleton


6 October 2020

Dear colleague:

Thank you for your interesting work with Long-term monitoring EEG protocol for ILAE. One question: have you considered to include some comments about cEEG in neonates? There are some interesting papers about that, and for me, as a Pediatric Neurologist, is an essential tool in my daily work.

These are some articles:
-Shellhaas RA, Chang T, Tsuchida T, et al. The American Clinical Neurophysiology Society’s guideline on continuous electroencephalography monitoring in neonates. J Clin Neurophysiol 2011;28(06):611–617
- Shellhaas RA. Continuous long-termelectroencephalography: the gold standard for neonatal seizure diagnosis. Semin Fetal Neonatal Med 2015;20(03):149–153.

Thank you again for your work!!!

Salvador Ibanez-Mico


6 October 2020

Hello.

This is a nice guideline for minimum standards in LTVEEG. There are two minor concerns.

1) In section 3.5, the authors did not include our study of 118 TLE patients from NIH for surgical outcome based on video EEG.
Preoperative prediction of temporal lobe epilepsy surgery outcome.
Goldenholz DM, Jow A, Khan OI, Bagić A, Sato S, Auh S, Kufta C, Inati S, Theodore WH. Epilepsy Res. 2016 Nov;127:331-338. doi: 10.1016/j.eplepsyres.2016.09.015. Epub 2016 Sep 22. PMID: 27701046 Free PMC article.

2) In section 5.4.5, the authors discuss the concept of sleep deprivation. We recently published a systemic review of this topic, finding that there is no clear evidence for or against the idea of using sleep deprivation to modify seizure risk.

Insufficient Sleep, Electroencephalogram Activation, and Seizure Risk: Re-Evaluating the Evidence.
Rossi KC, Joe J, Makhija M, Goldenholz DM. Ann Neurol. 2020 Jun;87(6):798-806. doi: 10.1002/ana.25710. Epub 2020 Mar 23. PMID: 32118310

Moreover, in that paper, we mention the only RCT that actually tested the concept of sleep deprivation in the EMU, and that study, despite some flaws, found NO EFFECT of sleep deprivation. Given that this was the only study that ALMOST addressed the question directly, I think this study (as well as our meta analysis) should be included in your guideline report.

Malow BA, Passaro E, Milling C, Minecan DN, Levy K. Sleep deprivation does not affect seizure frequency during inpatient video-EEG monitoring. Neurology. 2002 Nov 12;59(9):1371-4. doi: 10.1212/01.wnl.0000031810.15811.9e. PMID: 12427886.

Daniel Goldenholz