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.

The manuscript is now closed for comments. The revised version of the manuscript is being reviewed by the ILAE and will then be submitted for publication.

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

Comments

30 October 2020

Dear ILAE,

Thank you for working on these guidelines.

My comments:

• Highlight 2: 'Their (not There) existing high-level evidence'
• Indications: also specifically looking at nocturnal seizures/events and nocturnal (increase in) epileptic activity/ESES/CSWS
• Technical standards: 'Interictal EEG abnormalities alone are insufficient to provide a definitive diagnosis' -> how about Rolandic epilepsy?
• Technical standards: if the recommendation to use 25 electrodes, only scalp-based, is solely to augment the basal temporal regions coverage for TLE, I think it could be a good recommendation for adults, but less realistic for children, especially the young or mentally disabled ones
• Safety: the EMU should make sure to record (and store) rescue medication and dose needed for each specific patient. 'When to administer rescue ASM is center-specific and relative to seizure type and duration' -> so also patient-specific e.g. Dravet syndrome
• Safety: for underaged children: presence of a parent during the night? (also for more precise seizure reporting/description - so also keep a standardized observation note) As you mention: 'average response time from caregivers was twice as fast as the response by EMU-based personnel'
• Table 5: review entire video clips -> do you mean looking at the complete video at real-time speed?!  Please specify.

Sincerely
Anouk Van de Vel

30 October 2020

Dear EEG Task Force,

We applaud the Task Force’s effort for developing this thorough guideline which provides much needed recommendations for standardising the practice of long-term video-EEG monitoring (LTVEM) globally.

We represent epileptologists, neurophysiology technicians and scientists from two large Comprehensive Epilepsy Units in Melbourne, Australia. Our units admitted a combined total of 390 patients in 2019 for LTVEM.

Taken together, this is an excellent guideline with clear evidence based position statements. We commend the ILAE and IFCN in developing this international guideline which should provide a clear standard for individual epilepsy units. It has also allowed our units to benchmark our own practice against these consensus practice recommendations.

We agree with the vast majority of the recommendations proposed in this document. However, there are several sections that we feel warrant comment.

Section 3.4 Seizure Characterization for Surgical Management
We believe the ILAE task force should make a ‘Strong’ recommendation for LTVEM for presurgical evaluation in drug-resistant extra-temporal epilepsy.

In order to define a surgical strategy (resection, ablation, iEEG) clinicians must generate one or more hypotheses about the epileptic network and epileptogenic zone. The basis for generating this hypothesis is formulating anatomical electroclinical correlations. Although subjective semiology and outpatient interictal EEG can assist with this correlation, one of the most valuable pieces of non-invasive data is LVTEM seizure analysis.

As the authors state in section 5.4.4 “For surgery, at least 3 seizures are generally representative in uncomplicated cases though higher number of seizures may be required when more than one epileptogenic zone is suspected.”

For extra-temporal lobe epilepsy in particular, a ‘Strong recommendation’ for LTVEM is supported by data showing that:

• Patients’ memory of seizure semiology is almost always fragmentary and complete recall of a seizure is almost never obtained. (Mielke et al. Epilepsia 2020)
• The sequence of seizure semiology, including the delay between EEG onset and clinical onset , can be lateralising and localising. This is particularly important for identifying insular epilepsies, differentiating sublobar types of frontal lobe epilepsy and for considering the extra-temporal seizure onset for types of hyperkinetic epilepsies (Isnard et al. Rev Neurol. 2019; Gibbs et al. Epilepsia. 2018; Bonini et al. Epilepsia. 2014; Fayerstein et al. Epilepsia 2020).
• This guideline has described the importance of EEG ictal patterns. However, the lack of a clear scalp EEG ictal onset can be supportive of an insular or deep mesial onset in the setting of concordant semiology (Theys et al. Epileptic Disorders 2018; Peltola et al. Epilepsy & Behavior 2020)

Alternative non-invasive tools (eg MRI, PET, MEG) should rarely define a surgical plan in isolation (ie without incorporating anatomical electroclinical correlations) as all of these tests can show abnormalities extending beyond or even completely separate to the epileptogenic zone (Rampp et al. Brain 2019; Barba et al. Brain 2016; Aubert et al. Brain 2009; Lagarde et al. Eur J Nucl Med Mol Imaging 2020).

5.1 Electrode array and EEG recording

Table 3 refers to the technical capabilities of a VEM unit. We suggest clearly outlining in the table title or legend that these are not minimum mandatory standards but technical features that should be available in a VEM unit and can therefore be tailored to an individual patient.

We believe that having the technical capability to perform intracranial EEG (iEEG) should not be a prerequisite for a VEM unit (as per table 3) as many centres may never undertake iEEG.

5.4.1 Seizure Monitoring

We agree that a written, standardised protocol can be used in each LTVEM for managing and testing patients during seizures (conditional recommendation).

In addition, epilepsy teams should be encouraged to modify their standard testing protocol for specific patients depending upon the indication for LTVEM. An individualised protocol should take into account seizure types, epileptogenic zone hypothesis and possible relationship with eloquent cortex. For example examining for a Todd’s paresis in a patient with focal aware motor seizures, may be a higher priority than post-ictal visual naming.

5.4.3 Staffing

The rationale of having 2 technologists per patient (see table 5) is not explained in the document. Also the role of nursing staff, "EEG technologists", and "monitoring technologists" is not clearly defined. Different countries may use different titles for these positions, or have dual trained nurses and technologists/neurophysiology scientists. One suggestion would be to more clearly define the role of each staff member involved in LTVEM in this guideline.

We support a 1:4 ratio of technologists to patients in addition to a 1:4 ratio of nurses to patients. However, we acknowledge that the ratio of technologists to patients may be influenced by local resources and patient complexity (eg intracranial EEG vs patient for ictal SPECT vs psychogenic non-epileptic attacks).

5.4.5 Activation

In the literature review provided by the authors, we believe there is sufficient evidence to recommend (at least weakly) hyperventilation and sleep deprivation to provoke seizures in patients with focal epilepsy undergoing LTVEM.

Ictal SPECT

We note that the Task Force has not mentioned ictal SPECT in this guideline. We acknowledge that this is an advanced non-invasive tool and not a minimum standard in LTVEM. However this guideline does describe other advanced investigations in table 3 such as 10-10 system, intracranial monitoring and source localisation.

The Task Force could consider referencing ictal SPECT in section 3.4 as a LTVEM investigation that can be strongly considered for pre-surgical evaluations in comprehensive epilepsy units. For patients with nocturnal seizures, sleep reversal can be utilised to increase the likelihood of habitual seizures occurring during daytime hours, when radiotracer is available.

Thank you again for developing this important guideline.

Dr Andrew Neal, on behalf of the Alfred Hospital and Royal Melbourne Hospital Comprehensive Epilepsy Units

29 October 2020

Dear ILAE-IFCN EEG Task Force,

I congratulate you on your considerable efforts in developing the proposed clinical practice guidelines. The recommendations put forward are justified and appropriately measured given the evidence available and considerable significance of long-term video-EEG monitoring in clinical practice.

Ambulatory monitoring has become common clinical practice in many countries including the United Kingdom, Australia, and the United States of America (Brunnhuber et al., Epilepsia 2020). I note however that there is no mention of the body of work validating at-home long-term video-EEG in the draft guideline, despite several studies cited in the study being focused on ambulatory recordings (references 83, 118, 168). I also note that (Syed et al., Seizure 2019) is not referenced, despite it demonstrating that ambulatory video-EEG has acceptable event capture rates compared to in-patient monitoring with a large cohort, and hence the capability of informing changes to patient management.

As well there are some important differences in ambulatory monitoring compared to inpatient monitoring; sleep deprivation is usually not employed, and medications are rarely altered. This may be important in determining the optimal recording duration in this situation, which may be longer than required for inpatient monitoring. This has important implications for scheduling the duration of recordings, and consequently strategies around reimbursement.

Therefore, we suggest augmenting the recommendation in Section 4 to also include the use of ambulatory monitoring to result in change of management in some patients, most particularly to indicate recommended duration of recordings, the optimal number of events that should be captured, and that both these may vary according to the intent of the recording (characterisation of known events vs. initial diagnostic vs. identification of unrecognised events etc).

There is still considerable work to be done to validate the safety, clinical validity and clinical utility of at-home video-EEG, however we believe that it continues to be of substantial importance in the diagnosis and management of seizure disorders.

Best Regards,
Mark Cook

29 October 2020

Thank you for drafting these guidelines ..they are much needed. I have 2 comments to make.

Firstly in the Introduction you refer to LTVEM being used to record epileptiform activity and seizures. Not sure if this meant 'with seizures' which is fine or if you meant LTVEM is used to record interictal EEG activity (not so fine). You don't mention interictal recording as an Indication in section 3 so assuming you are not advocating its use as an interictal investigation. Please could you make this clearer.

Secondly you mention in section 5.3.1 the evidence from our UK national study of safety in VT units. As you say we didn't get strong evidence for the best nurse to patient ratio but we did show fairly conclusively that nurses dedicated to the VT unit resulted in better safety. This might not be an issue in some parts of the world but certainly in the UK there are still units where nurses look after the VT beds as well as other patients on the ward. I feel it would be worth including this in your recommendations for those centres who are still struggling to get nurses dedicated to their VT units.

Thank you for considering these points and thank you again for the immense amount of work in producing these evidence based guidelines.

Rosalind Kandler

26 October 2020

Thank you for developing a draft of guidelines for Long Term Video EEG Monitoring. I would like to briefly comment on the Technical, Educational and Staffing Requirements for Long Term Video EEG Monitoring. Personally, I believe the requirements drafted are very reasonable for Epilepsy Programs in developed countries, however many of the requirements or recommendations are not inclusive or attainable for most undeveloped countries. Many of these countries are attempting to provide long term video monitoring as they grow their neurology departments. I want ILAE to recognize it may alienate undeveloped countries who lack resources to actually meet these recommended guidelines.

Would ILAE consider creating a task force or separate requirements for countries who do not have the infrastructure for the drafted Long Term Video EEG Monitoring guidelines? From my involvement in Global Health and EEG many neurologists and EEG Technicians want to improve access and eventually provide some type of Long Term Video EEG Monitoring. In countries that are developing these Epilepsy and Long Term Video EEG Monitoring programs I believe a more basic or hybrid guidelines would be more inclusive or attainable.

Thanks for hearing my feedback and would be happy to get involved if needed, I wish ILAE the best on this topic.

Keith Morgan

26 October 2020

Thank you so much for your recommendation.In egypt we usually use 24 hours or less.

Esraa Kamal Elbaz

25 October 2020

First, I would like to thank everyone that has worked in or has been involved in the process of generating this proposal. At the same time, reading all the interesting, diverse comments from our colleagues has been an enjoyable learning experience, as well as a motivation for thinking about our own perspective. 

There is a great amount of workload behind this document, and a comprehensive review of published evidence was made. Therefore, the following comments are just an opinion regarding some issues that could emerge when these recommendations get to be implemented in clinical practice... Read complete comment here

Thank you,
Juan Moya Vilches

25 October 2020

The term "Long-term Video-EEG Monitoring" is ASSUMED to refer to INPATIENT monitoring. This assumption was valid 20 years ago, but no longer is. With current technology, "long-term video-EEG monitoring" can be performed in the home or ambulatory setting. This should be at least mentioned, and specifically the pros and cons of each should be discussed. See for example Benbadis et al, Epileptic Disord 2020; 22(2):143-55, and Expert Rev. Neurother 2015;1–4.

Guidelines should adjust to changes and progress. Another old assumption was the "ambulatory EEG" did not include video, but nowadays it does. There are several studies on the yield of ambulatory EEG-video.

Selim Benbadis

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