Faculty Bibliography

OBJECTIVES/OBJECTIVE:Long-term video-electroencephalographic monitoring (LTVEM) represents the gold-standard method to evaluate whether events represent electrographic seizures, but limited work has evaluated the quality of inpatient event capture. We evaluated the frequency of audiovisual factors impairing the ideal electroclinical correlation of seizure-like episodes during LTVEM. METHODS:We retrospectively reviewed consecutive inpatient LTVEM studies (11/2019-12/2019) from three academic epilepsy centers. We evaluated all pushbutton events for audiovisual characteristics such as whether the event was narrated, whether the patient was blocked on camera, and what diagnostic challenges impaired the electroencephalographer's ability to understand either the reason the event button was pushed or clinical semiology ("electroclinical correlation"). We determined the percent of events and studies with each outcome. RESULTS:There were 154 studies with 520 pushbutton events. The pushbutton was most commonly activated by patients (41%), followed by nurses (31%) or family (17%). Twenty-nine percent of events represented electrographic seizures, and 78% occurred in the Epilepsy Monitoring Unit. The reason for the push was not stated in 45% of events, and inadequate narration impaired electroclinical correlation in 19% of events. At least one relevant part of the patient's body was blocked during 12% of events, but this impaired electroclinical correlation in only 1% of events. There was at least one factor impairing electroclinical correlation in 21% of events, most commonly due to incomplete narration (N = 99), lights off (N = 15), or blankets covering the patient (N = 15). At least one factor impaired electroclinical correlation for any event in 36% of studies. CONCLUSION/CONCLUSIONS:Audiovisual factors impairing the electroencephalographer's ability to render an electroclinical correlation were common, particularly related to inadequate narration from bedside observers to explain the reason for pushing the button or event semiology. Future efforts to develop targeted countermeasures should address narration challenges and improve inpatient seizure monitoring quality metrics.

OBJECTIVE:The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) is a brief neuropsychological battery that has been validated in the assessment of dementia and other clinical populations. The current study examines the utility of the RBANS in patients with epilepsy. METHODS:Ninety-eight patients with epilepsy completed the RBANS as part of a more comprehensive neuropsychological evaluation. Performance on the RBANS was evaluated for patients with a diagnosis of temporal lobe epilepsy (TLE; n = 51) and other epilepsy patients (non-TLE, n = 47) in comparison to published norms. Multivariate analysis of variance compared group performances on RBANS indices. Rates of impairment were also compared across groups using cutoff scores of ≤1.0 and ≤1.5 standard deviations below the normative mean. Exploratory hierarchical regressions were used to examine the relations between epilepsy severity factors (i.e., age of onset, disease duration, and number of antiepileptic drugs [AEDs]) and RBANS performance. RESULTS:TLE and non-TLE patients performed below the normative sample across all RBANS indices. Those with TLE performed worse than non-TLE patients on the Immediate and Delayed Memory indices and exhibited higher rates of general cognitive impairment. Number of AEDs was the only epilepsy severity factor that significantly predicted RBANS total performance, accounting for 14% of the variance. CONCLUSIONS:These findings suggest that the RBANS has utility in evaluating cognition in patients with epilepsy and can differentiate TLE and non-TLE patients. Additionally, number of AEDs appears to be associated with global cognitive performance in adults with epilepsy.

OBJECTIVE:There is evidence for central nervous system complications of coronavirus disease 2019 (COVID-19) infection, including encephalopathy. Encephalopathy caused by or arising from seizures, especially nonconvulsive seizures (NCS), often requires electroencephalography (EEG) monitoring for diagnosis. The prevalence of seizures and other EEG abnormalities among COVID-19-infected patients is unknown. METHODS:Medical records and EEG studies of patients hospitalized with confirmed COVID-19 infections over a 2-month period at a single US academic health system (four hospitals) were reviewed to describe the distribution of EEG findings including epileptiform abnormalities (seizures, periodic discharges, or nonperiodic epileptiform discharges). Factors including demographics, remote and acute brain injury, prior history of epilepsy, preceding seizures, critical illness severity scores, and interleukin 6 (IL-6) levels were compared to EEG findings to identify predictors of epileptiform EEG abnormalities. RESULTS:Of 111 patients monitored, most were male (71%), middle-aged or older (median age 64 years), admitted to an intensive care unit (ICU; 77%), and comatose (70%). Excluding 11 patients monitored after cardiac arrest, the most frequent EEG finding was moderate generalized slowing (57%), but epileptiform findings were observed in 30% and seizures in 7% (4% with NCS). Three patients with EEG seizures did not have epilepsy or evidence of acute or remote brain injury, although all had clinical seizures prior to EEG. Only having epilepsy (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.4-21) or seizure(s) prior to EEG (OR 4.8, 95% CI 1.7-13) was independently associated with epileptiform EEG findings. SIGNIFICANCE/CONCLUSIONS:Our study supports growing evidence that COVID-19 can affect the central nervous system, although seizures are unlikely a common cause of encephalopathy. Seizures and epileptiform activity on EEG occurred infrequently, and having a history of epilepsy or seizure(s) prior to EEG testing was predictive of epileptiform findings. This has important implications for triaging EEG testing in this population.

OBJECTIVE: The Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) is a self-report instrument, previously shown to differentiate patients with epileptic seizures (ES) and psychogenic non-epileptic seizures (PNES). At present, the odds of MMPI-2-RF scale elevations in PNES patients, as well as the diagnostic predictive value of such scale elevations, remain largely unexplored. This can be of clinical utility, particularly when a diagnosis is uncertain. METHOD: After looking at mean group differences, we applied contingency table derived odds ratios to a sample of ES (n=92) and PNES (n=77) patients from a video EEG (vEEG) monitoring unit. We also looked at the positive and negative predictive values (PPV, NPV), as well as the false discovery rate (FDR) and false omission rate (FOR) for scales found to have increased odds of elevation in PNES patients. This was completed for the overall sample, as well as the sample stratified by sex. RESULTS: The odds of elevations related to somatic concerns, negative mood, and suicidal ideation in the PNES sample ranged from 2 to 5 times more likely. Female PNES patients had 3-6 times greater odds of such scale elevations, while male PNES patients had odds of 5-15 times more likely. PPV rates ranged from 53.66% to 84.62%, while NPV rates ranged from 47.52% to 90.91%. FDR across scales ranged from 15.38% to 50%, while the FOR ranged from 9.09% to 52.47%. CONCLUSIONS: Consistent with prior research, PNES patients have greater odds of MMPI-2-RF scale elevations, particularly related to somatic concerns and mood disturbance. Female PNES patients endorsed greater emotional distress, including endorsement of suicide related items. Elevations of these scales could aid in differentiating PNES from ES patients, although caution is warranted due to the possibility of both false positives and the incorrect omissions of PNES cases.

With an increasing focus on quality metrics, hospital length of stay (LOS) in the U.S. has garnered significant scrutiny. To help establish evidence-based benchmarks for epilepsy monitoring unit (EMU) metrics, we evaluated the impact of multiple variables on LOS through a retrospective analysis of 905 consecutive inpatient adult EMU admissions. The most common reasons for admission were event characterization (n=494), medication adjustment (n=189), and presurgical evaluation (n=96). Presurgical evaluations experienced a longer average LOS (aLOS) of 7.1days versus patients admitted for other indications (p<0.001). Patients with symptomatic generalized epilepsy (n=22) had a longer aLOS (6.9days) than patients with other types of epilepsy/events (p<0.001). Patients admitted on two or fewer antiepileptic drugs (AEDs) had a shorter aLOS than patients admitted on three or more AEDs (4.3days vs 6.3days, respectively; p<0.001). A history of previous invasive epilepsy management was associated with a longer aLOS than those without (6.2days vs 4.7days, respectively; p<0.0001). Epilepsy monitoring unit aLOS is influenced by admission indication, epilepsy classification, medication burden, and having had prior invasive management. Multiple variables should be considered when analyzing LOS EMU metrics, arguing against a "one size fits all" approach.

Rationale: Reducing hospital admission length of stay (LOS) has been identified as one way to improve quality and reduce healthcare costs. The epilepsy monitoring unit (EMU) poses unique challenges to reductions in LOS, given the elective nature of the admissions and the need to safely provoke seizures. Data delineating the factors that impact EMU LOS are currently very limited. In an attempt to establish benchmarks for care, we evaluated the time to first, second, and third target events (TE) in patients admitted to the EMU at a large tertiary care epilepsy center. Methods: We reviewed the medical records of 905 consecutive patients who were admitted for diagnostic scalp video-EEG monitoring at NYU's Comprehensive Epilepsy Center from January 1, 2011 to December 31, 2011. Admission reason and time to TE were assessed. Results: 40.4% of patients (366/905) experienced a first TE; mean time to first TE for pre-surgical patients was 3.4 days (D) vs. 2.5D for non-surgical patients. 31.7% (287/905) experienced a second TE; the mean time to second TE was 4.4D for pre-surgical patients vs. 2.7D for non-surgical patients. 24.7% (224/905) experienced three or more TEs; the mean time to third TE for pre-surgical patients was 4.9D vs. 2.9D for non-surgical patients. Of the patients who experienced TEs during admission, 21.5% (79/366) had only one TE during admission; of these patients, mean LOS was 7.2D for pre-surgical patients (12/79) vs. 5.1D for non-surgical patients. 17.2% (63/366) experienced only two TEs during admission; mean LOS was 8D for pre-surgical patients (14/63) vs. 5.3D for non-surgical patients. 61.2% (224/366) experienced three or more TEs during admission; mean LOS was 6.7D for pre-surgical patients (54/224) vs. 6.3D for non-surgical patients. Conclusions: Time to first TE is longer in patients admitted to the EMU for pre-surgical evaluation vs. non-surgical patients. The latter group includes patients with psychogenic non-epileptic seizures; such patients produce events more quickly i!

Rationale: Increasingly, hospitals are striving to shorten length of stay (LOS) in an effort to improve care. Beyond the impact on expense, longer stays in the hospital increase the risk of iatrogenic or other complications. The epilepsy monitoring unit (EMU) is a unique hospital setting where the admission goal focuses on capturing one or more events/seizures. Seizure provocation is performed in a controlled manner to minimize the risk of secondarily generalized convulsions and status epilepticus, and to maintain patient safety. To better establish benchmarks for care, we evaluated both the impact of admission objectives and select patient characteristics on EMU LOS. Methods: We reviewed the medical records of 905 consecutive patients who were admitted for diagnostic scalp video-EEG monitoring at NYU's Comprehensive Epilepsy Center from January 1, 2011 to December 31, 2011. Reasons for admission, number of anti-epileptic drugs on admission, and time to target events were documented. Results: Of the 905 patients included, the mean length of stay was 4.8+3.2 days. The median length of stay was 4 days. 95 subjects were admitted for pre-surgical evaluation with a mean LOS of 7.2 days, vs. 4.5 days (p<0.001) for those admitted for diagnostic evaluations. 12.8% (116/905) of patients admitted to the EMU had a previous history of epilepsy surgery and the majority of these patients were admitted for medication adjustment; patients who had undergone prior epilepsy surgery experienced longer length of stays (5.9 days) compared to those without a prior epilepsy surgical history (4.7 days) (p<0.0002). Patients admitted on three or more antiepileptic drugs (AEDs) on admission experienced longer lengths of stay (6.3 days) vs. patients on less than three concomitant AEDs (4.3 days). Patients were further stratified by reason for admission. 494/905 patients were primarily admitted for seizure characterization and these patients experienced a mean LOS of 3.9 days whereas patients who were admitted for medicatio!

Purpose of Review: Selection of the ideal antiepileptic drug (AED) for an individual patient can be a daunting process. Choice of treatment should be based on several factors, including but not limited to epilepsy classification, AED mechanism of action, AED side-effect profile, and drug interactions. Special consideration must be given to populations such as women, older adults, patients with other medical comorbidities, and patients who are newly diagnosed.Recent Findings: Head-to-head trials between AEDs in newly diagnosed patients rarely demonstrate that one AED is more or less effective. The second-generation drugs, lamotrigine, topiramate, oxcarbazepine, zonisamide, and levetiracetam, have undergone head-to-head trials confirming similar efficacy and equal or better tolerability than standard drugs in focal epilepsy.Summary: A thoughtful approach to the AED selection process must factor in data from clinical AED trials as well as a variety of patient characteristics and confounding factors. When neurologists apply an individualized approach to AED drug selection for their patients, they can find an effective and well-tolerated drug for most patients.