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Electroneurodiagnostics
Electro - Neuro -Diagnostics ( END )

The purpose of this site is to provide a collaboration of information, opinions and experiences in the field of Electroneurodiagnostics.

What is Electroneurodiagnostics?
Electroneurodiagnostic [END] technology is the allied health care profession that analyzes and monitors nervous system function to promote the effective treatment of neuropathological conditions. Technologists record electrical activity arising from the brain, spinal cord, peripheral nerves, somatosensory or motor nerve systems using a variety of techniques and instruments.





Guidelines for Epilepsy Centers



Essential services, personnel, and facilities in specialized epilepsy centers—Revised 2010 guidelines
*David M. Labiner, yAnto I. Bagic, zSusan T. Herman, xNathan B. Fountain, {Thaddeus S. Walczak, and {#Robert J. Gumnit for the National Association of Epilepsy Centers1
*Department of Neurology, University of Arizona, Tuscon, Arizona, U.S.A.; yDepartment of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A.; zDepartment of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.; xDepartment of Neurology, University of Virginia, Charlottesville, Virginia, U.S.A.; and Departments of {Neurology and #Experimental/Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota, U.S.A.
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SUMMARY
This document was developed by the members of the Committee to Revise the Guidelines for Services, Person- nel, and Facilities at Specialized Epilepsy Centers. After discussions with the general membership they were
This is the third iteration of guidelines adopted by the National Association of Epilepsy Centers (NAEC). The ini- tial document, published in 1990, established guidelines for services, personnel, and facilities that characterized special- ized epilepsy centers (NAEC, 1990). The revised guidelines published in 2001 (Walczak, 2001) were a further step in the maturation of epilepsy centers.
The goal of epilepsy care since the initial guidelines were released has not fundamentally changed. The goal of treat- ment—no seizures and no side effects (CDCP, 1997—is increasingly achievable and expected. At the same time, purchasers of health care services expect this goal to be achieved more efficiently and at lower costs. Both consum- ers and purchasers of health care services have increasingly demanded that these treatments clearly and directly improve quality of life. The convergence of these forces continues to motivate NAEC to provide specialized epilepsy centers with
Accepted April 25, 2010; Early View publication June 18, 2010.
Address correspondence to Robert J. Gumnit, MD, National Association of Epilepsy Centers, 5775 Wayzata Boulevard, Minneapolis, MN 55416, U.S.A. E-mail: rjgumnit@naec-epilepsy.org; www.naec-epilepsy.org 1Officers and Board Members—2010
Robert J. Gumnit, M.D., President, Minneapolis, MN Gregory L. Barkley, M.D., Vice President, Detroit, MI David M. Labiner, M.D., Secretary/Treasurer, Tucson, AZ Nathan B. Fountain, M.D., Charlottesville, VA Christianne Heck, M.D., MMM, Los Angeles, CA
Susan T. Herman, M.D., Boston, MA Paul C. VanNess, M.D., Dallas, TX.
Wiley Periodicals, Inc. a 2010 International League Against Epilepsy
adopted by the Board of the National Association of Epi- lepsy Centers. The Guidelines will be reviewed and updated when considered necessary by the Board.
KEY WORDS: Guidelines, Epilepsy center, Epilepsy spe- cialty care.
a framework for a systematic, well-organized approach to subspecialty epilepsy care.
We define a specialized epilepsy center to be a program that not only provides routine care to individuals with seizures or epilepsy, but also specializes in providing com- prehensive diagnostic and treatment services to individuals with uncontrolled seizures, (i.e., intractable or refractory epilepsy). Of the 2.7 million Americans estimated to have some form of epilepsy, approximately 25–30% of these individuals do not attain adequate seizure control and have intractable epilepsy (Kobau et al., 2008).
These guidelines summarize the essential services, personnel, and facilities that level 3 and 4 epilepsy centers should provide (Appendix). The previous guidelines defined medical and surgical centers as separate entities. This committee has concluded that the evolution of epilepsy centers has progressed to a point where these distinctions are blurred, and these guidelines remove this differentiator.
These guidelines are structured differently than those of previous versions. We present an overview of the essential elements of level 3 and 4 specialized epilepsy centers in the text, and lay out specific recommended resource require- ments and center capabilities in the appendices.
The Spectrum of Epilepsy Care and Referral Guidelines
Typically, epilepsy care starts with an evaluation in an emergency room or a primary care physician’s office. This
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is considered the first level of epilepsy care. It then most often proceeds to the second level of epilepsy care, which is a consultation with a general neurologist or possibly a specialized epilepsy center if considered necessary and is locally available. Many, and perhaps most, patients with seizures can be initially evaluated and managed at the first or second level of epilepsy care by a primary care physician or a general neurologist in their local community. If seizure control is obtained, no further specialized epilepsy evalua- tion may be warranted. If seizures persist and cannot be brought under control by the primary care provider within 3 months, further neurologic intervention is appropriate; the neurologist should assume full management of the patient’s seizures at this point (Scheuer & Pedley, 1990). Recent evi- dence suggests that up to 70% of patients have seizures fully controlled with medication (Velis et al., 2007). Once sei- zures are under control, care can be transferred back to the primary care provider.
Somewhat more difficult to define is the appropriate time for a general neurologist to refer a patient to a level 3 or 4 specialized epilepsy center. Studies by Kwan and Brodie (2000) have shown that only a small percentage of patients in whom the first antiepileptic drug was ineffective would ever become seizure free with additional anticonvulsant drug treatment alone. The authors concluded that patients with inadequate response to initial medical therapy likely had refractory epilepsy that would persist even when newer medications were tried (Kwan & Brodie, 2000). At the same time with the availability of multiple new medications, some have argued that adequate medication trials may now take longer to achieve. In addition, the Agency for Health- care Research and Quality (AHRQ) has published an evi- dence-based report that shows that nonpharmacologic treatments (read surgery) are desired strategies for epilepsy after initial medication treatment failure (AHRQ, 2003). This being the case, patents would benefit from the compre- hensive evaluation, in some cases a surgical workup in a level 3 or 4 center. For these reasons, NAEC recommends that referral to a level 3 or 4 specialized epilepsy center should occur when a patient’s seizures are not fully con- trolled with the resources available to the general neurolo- gist after 1 year. This recommendation was included in a technical assistance document supported by a grant from the Centers for Disease Control and Prevention (CDC) for state Medicaid programs in contracting with managed care plans for epilepsy services (CHSRP, 2002).
If the diagnosis of epilepsy is in question or if psycho- genic nonepileptic events are suspected, a referral to an epi- lepsy center is appropriate early in the evaluation process for diagnostic purposes. Accurate diagnosis of the epilepsy syndrome and rapid treatment with the best possible medi- cation may minimize the number of seizures and anticon- vulsant trials and minimize impact of the seizures on quality of life. Early diagnosis of nonepileptic events is associated with improved outcome (Walczak et al., 1995).
Guidelines for Specialized Epilepsy Centers
Referrals to specialized epilepsy centers for acutely ill patients with uncontrolled seizures, status epilepticus, or patients with epileptic foci adjoining eloquent cortex should occur as early as possible. These patients are in need of an immediate thorough evaluation and aggressive treatment. As with all patient care, referrals for epilepsy patients should focus on what is in the best interest of the patient and emphasize treatment that is likely to improve the patient’s health, safety, and quality of life.
The NAEC believes very strongly that the needs of the patients with seizures can best be met through well-devel- oped cooperative relationships between primary care physi- cians, general neurologists, and specialized epilepsy centers. It is the responsibility of the epilepsy center to develop a clear specific treatment plan that the center and primary care physician or general neurologist can together carry out. The flow diagram below suggests a strategy for having an adult patient with seizures or epilepsy appropriately evaluated for proper diagnosis and treatment and ultimate referral to a spe- cialized epilepsy center when appropriate (Walczak, 2001). International League Against Epilepsy (ILAE) recommen- dations exist for children that are similar to this paradigm for adults (Cross et al., 2006). Specifically, they suggest a child be evaluated by a pediatric epilepsy center when they have uncontrolled seizures (defined as failure of two or three appropriate medications), they are disabled by the seizures or medication side effects, or they are a possible candidate for surgical intervention. In addition, the recommendations suggest that if childhood epilepsy requires syndromic classi- fication then specialty evaluation is appropriate.
Essential Elements of Care Provided by Specialized Epilepsy Centers
As stated previously most patients with epilepsy can be effectively treated by a primary care physician or general neurologist, which is considered the first and second levels of epilepsy care (Fig. 1). However, as the now widely dis- seminated work of Kwan and Brodie (2000) has suggested, it may be possible to identify patients who are not respond- ing to standard medical therapy much earlier in their treat- ment paradigm. These patients who have either persistent seizures or side effects should be considered to have failed standard treatment and should be referred to a third- or fourth-level specialty epilepsy center. Level 3 and 4 epi- lepsy centers provide an interdisciplinary and comprehen- sive approach to the diagnosis and treatment of patients with epilepsy. The primary goal of the team is to achieve complete control or at least a reduction in the frequency of seizures and/or medical side effects in patients with intracta- ble epilepsy. A discussion of the common elements of all level 3 and 4 epilepsy centers follows. These are:
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1. Interdisciplinary Care Team Approach 2. ElectrodiagnosticFacilities 3. SafetyProtocolsandQualityMeasures 4. PatientEducation
Interdisciplinary care team approach
The care of the epilepsy patient at specialized epilepsy centers is provided by a collaborative interdisciplinary team that is directed by a neurologist or neurosurgeon with special expertise in epilepsy. The team typically includes neurologists and neurosurgeons, neuropsychologists, nurse specialists, electroencephalography (EEG) technologists, and other personnel with special training and experience in the treatment of epilepsy. Although every facility will have different personnel, the interdisciplinary team may include staff with special expertise in the areas below or have identi- fied other centers for patient referrals (Table 1).
The primary task of the team is to accurately diagnose the patient’s epilepsy and develop a treatment plan with the goal of controlling seizures with no side effects. This is accomplished through a comprehensive epilepsy evalua- tion, which provides epilepsy specialists with the necessary information to formulate a treatment plan, whether medical, surgical, or using an implanted stimulator. Video-EEG monitoring is the essential diagnostic tool used in level 3 and 4 epilepsy centers. An even more intensive evaluation is a necessary prelude to selecting the 10% of intractable patients who would benefit from resective brain surgery or implanted brain stimulators.
A comprehensive epilepsy evaluation can include video- EEG monitoring, cognitive testing, and other specialized brain imaging and procedures to determine the diagnosis and to prepare the most effective medical or surgical treatment plan. During hospitalization, anticonvulsant medication withdrawal is often necessary in order for the patient to experience seizures. In some cases, this may precipitate overt seizures (balancing the need to provoke seizures but not induce status epilepticus requires expertise and intensive care). Seizures are recorded with video and EEG and analyzed by an epileptologist. Large amounts of data are collected and evaluated by the members of the center team who collectively determine the patient’s course of treatment.
In addition to video-EEG monitoring, cognitive testing, and other specialized imaging the following additional components are assessed by the interdisciplinary team and used to develop a treatment plan:
1. Patientandfamilyeducationneeds 2. Injuryandsafetyassessment 3. Medicalcomorbidities 4. Psychiatriccomorbidities
5. Reproductiveissues 6. Cognitivedysfunction 7. Socialdysfunction 8. Occupationaldysfunction 9. Educationaldysfunction
10. Rehabilitationneeds
The treatment plan is then developed in collaboration with the interdisciplinary team. Although it is not this guide- lines’ purpose to prescribe specific practice parameters to each institution, publications exist that outline minimal standards for treatment of epilepsy that should form the foundation from which specialized centers develop their own protocols (National Institute for Clinical Excellence, 2004; Caplin et al., 2006). A treatment plan is individual- ized to each patient, reflecting the patient’s unique condi- tion, identified clinical needs, and expectations and desires regarding treatment.
The comprehensive evaluation provided to candidates for epilepsy surgery requires formal interdisciplinary collabora- tion. This is usually accomplished in a weekly or bimonthly case management conference attended by the entire inter- disciplinary team, where all relevant data about the patient’s evaluation is reviewed before the treatment plan is deter- mined. Documentation of the interdisciplinary team meet- ings and care plan should be included in the patient’s medical record.
Electrodiagnostic facilities
Inpatient and outpatient units evaluating and treating patients with epilepsy require features beyond those needed for routine patient care. Unit layout, unit furnishings, and personnel needs must be considered as well as the availabil- ity of emergency and intensive care services. The essential components of level 3 and 4 epilepsy center facilities


including prepregnancy counseling
Neurophysiology Management of nonepileptic psychogenic events Management of status epilepticus and seizures in hospitalized patients Management of epilepsy in special populations (i.e., women, elderly,
children, developmentally disabled, and individuals with multiple
medical problems) Brain imaging Cognitive comorbidities Alternative or complementary medicine
Table 1. Areas of staff expertise at specialized epilepsy centers
Epilepsy surgery Vagus nerve stimulator or other neuromodulatory devices Antiepileptic drugs Investigational drug and/or device trials Ketogenic diet Genetics Psychiatric comorbidities Management of women with epilepsy during pregnancy
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are fully described in the Appendix. Although requirements for epilepsy monitoring units vary according to the level of the epilepsy center, all electrodiagnostic facilities should have certain common features, including the presence and availability of qualified EEG technologists and medical staff at all times. Spike and seizure detection software can supplement but cannot replace the need for highly trained personnel. When the patient has intracranial electrodes in place, the continuous presence of well-trained nurses responsible for patient safety is mandatory; these nurses work in conjunction with monitoring technologists who are responsible for the integrity of the recording. The facility should be designed, whether in-patient or out-patient, so that the staff has easy access to patients to facilitate examination and provision of first aid and medical care. Furthermore, the layout must minimize the risk of injury due to falls.
Protocols for situations frequently encountered in the care of epilepsy patients are advisable. These could include, but are not limited to protocols for:
  1. Medication reduction to increase seizure yield (not recommended in the outpatient setting);
  2. Patientexaminationduringseizures;
  3. The number or duration of seizures over a given period
    that requires physician notification;
  4. Designated provider of emergency services in the event
    of emergencies (if an outpatient facility);
  5. Measures to be taken if number, duration, or severity of
    seizures observed is excessive;
  6. Care of head-dressings in patients studied with intracra-
    nial electrodes; and
  7. Measures to prevent postoperative infections or other
    complications in patients studied with intracranial electrodes.
Safety protocols and quality measures
Seizures are potentially dangerous events that can lead to serious injury or death. It is often necessary to reduce a patient’s medications or do other procedures to provoke sei- zures in an epilepsy monitoring unit. It is, therefore, abso- lutely incumbent on an epilepsy center to have safety protocols in place. This has been recommended by the ILAE (Velis et al., 2007) and at a recent American Epilepsy Soci- ety Symposium (AES, 2008).
Although there is potentially no limit to protocols that can be put in place to manage patients treated in specialized epilepsy centers, nursing protocols regarding patient safety are a must. These should include, but are not limited to, guidelines for patients while in and out of bed in the event of a seizure. Because of the need for increased nursing care, inpatient epilepsy monitoring units often require a higher nurse-to-patient ratio than is standard for the institution. It is important that in addition to adequate levels of nursing to provide quality care, there should be a formal
Guidelines for Specialized Epilepsy Centers
educational program at centers to assure nursing compe- tency with regard to patient safety. This should include epi- lepsy-specific training for nursing staff that will be responsible for the patients undergoing video-EEG monitor- ing and other diagnostic testing.
The management of seizure emergencies is an issue of fundamental importance. A protocol similar to cardiac arrest should be in place. Although emergency resuscitative equipment is required in all medical facilities, access to additional care may be required. This may include arrange- ments with nearby hospitals to provide emergency services when needed, if an outpatient facility. For inpatient facili- ties, ready access to an intensive care unit and anesthesia services is necessary in the event of status epilepticus.
Quality of care
Diagnosing and treating epilepsy is a multistep process that can involve complex testing and can be undertaken by different specialties. Medical professionals caring for epi- lepsy patients vary in their skill and approach to diagnosing epilepsy, determining seizure type, identifying causation, and administering appropriate therapy. For these reasons, the development of quality performance measures has been an important step in improving patient outcomes and quality of life.
Recommendations for performance or quality measures and practice guidelines exist from both national and interna- tional sources. These include: Scottish Intercollegiate Guide- line Network (2003), National Institute for Health and ClinicalExcellence(Stokeset al.,2004),SingaporeMinistry of Health (2007), and American Academy of Neurology (AAN). The AAN, in collaboration with the NAEC and the American Epilepsy Society, is developing physician perfor- mance measures using the American Medical Association’s Physician Consortium for Performance Improvement model. These measures are evidence-based and encompass multiple facets of epilepsy diagnosis and treatment including the use of diagnostic tests, documentation of etiology of seizure type and seizure frequency, and counseling about drug side effects and safety issues. Furthermore, they should be rela- tively easily monitored in an epilepsy center.
Patient and provider education
A cornerstone of the comprehensive epilepsy center is education, directed to the patient, family, and caretakers. Patient direct involvement and self-management of the epilepsy treatment plan is critical to good health and qual- ity of life. Patient education methods can include formal courses; informational brochures; consultations with epi- lepsy nurse specialists, social workers, and other educators; and referrals to the local affiliate of the Epilepsy Founda- tion. Comprehensive epilepsy center personnel also participate in education of the larger health care community. Within the epilepsy center, continuing educa- tion can take the form of journal clubs, case management
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conferences, didactic lectures, development of care plans or clinical pathways, and quality assessment and improve- ment activities.
Guidelines for Level 3 and Level 4 Epilepsy Centers
Third-level epilepsy center
A third-level epilepsy center should provide the basic range of medical, neuropsychological, and psychosocial diagnostic and treatment services needed to treat patients with refractory epilepsy. In addition, many level 3 centers offer noninvasive evaluation for epilepsy surgery, straight- forward resective epilepsy surgery, and implantation of devices, such as the vagus nerve stimulator (VNS). Knowledge and experience with epilepsy surgery have become sufficiently widespread that lesionectomy and ante- rior temporal lobectomy in the presence of clear-cut mesio- temporal sclerosis can be performed at level 3 epilepsy centers.
However, third-level centers that offer such surgery should meet additional requirements, especially for an expe- rienced neurosurgeon and neuropsychometric and neurora- diologic expertise. The physicians making health care decisions at such centers must be fully knowledgeable regarding all surgical options available and establish appro- priate referral arrangements for more complex surgeries with fourth-level centers (see Appendix I.A.2.g.). If such surgery is to be considered, the best surgical procedure for the particular situation must be recommended and this may not necessarily be the procedure that can be provided by the level 3 center.
Cooperating third- and fourth-level centers should attempt to standardize data collection and make data exchange portable so that diagnostic studies do not have to
be repeated for referred patients. This might include uniform imaging protocols, uniform video-EEG monitoring proto- cols, easy access to referring physicians, and agreements to send all appropriate information with the patients.
Epilepsy surgery at level 3 centers
Knowledge and experience with resective epilepsy sur- gery have disseminated widely since the 1990 guidelines were published [NAEC (National Association of Epilepsy Centers), 1990; NIH Consensus Conference, 1990]. We define resective epilepsy surgery as resection of cerebral cortex with the primary aim of treating epilepsy. Epilepsy training programs have increased the number of individuals capable of performing epilepsy surgery. Table 2 summa- rizes the services and personnel typically needed at a level 3 center. With this capacity it is reasonable to perform straightforward lesionectomy and straightforward anterior temporal lobectomy at the third level of epilepsy care (Table 2).
We define lesionectomy as resection of a structural epileptogenic lesion and surrounding tissue that is per- formed primarily to treat epileptic seizures. In excellent candidates for lesionectomy, a single epileptogenic lesion is present, the lesion is an appropriate distance from cerebral regions necessary for normal function, and noninvasive electrophysiologic evaluation indicates that the lesion and surrounding area are responsible for the patient’s seizures. Straightforward lesionectomy, defined in this manner, can be performed at a third-level center. If these criteria are not met, the situation is usually not straightforward and intracra- nial evaluation will probably be necessary. Such patients should generally be referred to a fourth-level epilepsy center.
We define anterior temporal lobectomy as the removal of a small amount of lateral temporal cortex followed by


Epilepsy surgery including VNS (routine lesional surgeries and those not requiring invasive monitoring)
Neuroimaging Neuropsychological and psychological services
Pharmacologic expertise Nursing support (specific to epilepsy) Rehabilitation (in patient and outpatient) including physical,
occupational, and speech therapy Consultative expertise in multiple fields: neurosurgery, psychiatry,
internal medicine, pediatrics, general surgery, and obstetrics/gynecology Other
Neurologists (adult and/or pediatric) with special expertise in epilepsy
EEG technologists and related personnel Neurosurgeon(s) with special expertise in epilepsy
Neuroradiologist Neuropsychologist/neuropsychometrist Psychosocial personnel including clinical psychologist,
social worker, school services for children Access to consultation with clinical pharmacist Nurse specialist Rehabilitation service personnel
Interdisciplinary clinical services available Biomedical engineer and IT support

Table 2. Third level epilepsy centers
Services provided Personnel
Electrodiagnostic EEG services including long term monitoring
Adapted from Epilepsia, 42(6):804–814, 2001. IT, information technology; VNS, vagus nerve stimulation.
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Evoked potential recording capable of being used safely with intracranial electrodes.
Electrocorticography. Placement of intracranial electrodes. Resection of epileptogenic tissue in the absence of structural lesions. Adequate clinical experience by both the neurosurgeon and
neurologist/epileptologist. Specialized neuroimaging either on site or by established arrangement
including interictal positron emission tomography (PET) and/or ictal single photon emission computed tomography (SPECT)
Table 3. Features distinguishing level 4 centers
Functional cortical mapping by stimulation of subdural electrodes either extraoperatively or intraoperatively.
Figure 1.
Suggestions for appropriate level of care according to degree of seizure control. Flow chart indicates points at which referral to a specialized epilepsy center should be considered. PCP, pri- mary care physician.
Epilepsia ILAE
aggressive amygdalar, parahippocampal, and hippocampal resection. In excellent candidates for anterior temporal lobectomy, magnetic resonance imaging detects unilateral mesial temporal sclerosis, noninvasive electrophysiologic evaluation indicates that the same temporal lobe is responsi- ble for the patient’s seizures, and neuropsychometric evalu- ation including intracarotid amobarbital testing indicates that temporal lobectomy can be safely performed. Straight- forward anterior temporal lobectomy, defined in this man- ner, can be performed at a third-level center. If these criteria are not met, the situation is usually not straightforward. Further evaluation is necessary, often including intracranial recording. Such patients should generally be referred to a fourth-level epilepsy center.
Current experience indicates that the VNS rarely cures epilepsy. In contrast, straightforward lesionectomy and straightforward anterior temporal lobectomy as defined pre- viously cure epilepsy in the large majority of cases. Patients with refractory epilepsy should, therefore, be evaluated for resective epilepsy surgery before VNS is considered.
There is no absolute number of surgeries that are required for designation as a third-level center (see Appendix I.A. 2.e.). Rather, experienced medical personnel (epileptologist and epilepsy surgeon with at least 2 years of experience each) and adequate volume of video-monitoring of patients annually (defined as at least 50 cases) should be the determi- nants.
Fourth-level epilepsy centers
Fourth-level epilepsy centers serve as regional or national referral facilities for intractable epilepsy patients. These centers should provide the more complex forms of intensive neurodiagnostic monitoring, as well as more extensive med- ical, neuropsychological, and psychosocial treatment. Fourth-level centers also offer a complete evaluation for epilepsy surgery, including intracranial electrodes, and pro- vide a broad range of surgical procedures for epilepsy. Many level 4 centers are actively involved in clinical trials and are well aware of trials conducted in other level 4 cen- ters to make patient referrals.
Guidelines for Specialized Epilepsy Centers
The major distinction between level 3 and 4 centers is the comprehensive nature of the services provided. Table 3 lists some of the additional capabilities that a level 4 center must have to distinguish itself from the level 3 centers.
Epilepsy surgery at level 4 centers
Sectioning of the corpus callosum is being performed less frequently. Hemispherectomy is indicated infre- quently in adults but still has a role in pediatric epilepsy surgery for specific clinical situations. Consequently, we do not recommend that fourth-level centers must be able to perform corpus callosum section or hemispherectomy. However, physicians making health care decisions at these centers should be aware of the indications for these procedures. They should establish referral arrangements with other fourth-level centers that perform these proce- dures and refer patients requiring these procedures when necessary.
There is no absolute number of surgeries that are required for a level 4 center (see Appendix II.A.2.h.). Rather,
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experienced medical personnel (epileptologist and epilepsy surgeon with at least 5 years experience each) AND ade- quate volume of video-monitoring patients annually, partic- ularly surgical evaluations (defined as at least 100 cases), should be the determinants.
Disclosures
We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. None of the authors has any conflict of interest to disclose.
References
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AHRQ (Agency for Healthcare Research and Quality). (2003) Management of treatment-resistant epilepsy. Evidence Report/Technology Assess- ment, Number 77. AHRQ Publication number 03-E027, Agency for Healthcare Research and Quality, Rockville, MD. Available at : http:// www.ahrq.gov/clinic/epcsums/epilsum.htm.
Am EEG Society. (1994) American electroencephalographic society guide- lines for long term diagnostic monitoring in epilepsy. J Clin Neurophys- iol 11:88–110.
Caplin DA, Rao JK, Filloux F, Bale JF, Orman CV. (2006) Development of performance indicators for the primary management of pediatric epi- lepsy: expert consensus recommendations based on the available evi- dence. Epilepsia 47:2011–2019.
CDCP (Centers for Disease Control and Prevention). (1997) Living well with epilepsy. Report of the 1997 National Conference on Public Health and Epilepsy. National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, pp. 1–22.
CHSRP (Center for Health Services Research Policy). (2002) Optional purchasing specifications for services related to epilepsy: a technical assistance document. GWUMC School of Public Health and Health Services, Washington, DC.
Cross JH, Jayakar P, Nordli D, Delalande O, Duchowny M, Wieser HG, Guerrini R, Mathern GW. (2006) Proposed criteria for referral and eval- uation of children for epilepsy surgery: recommendations of the sub- commission for pediatric epilepsy surgery. Epilepsia 47:952–959.
Kobau R, Zahran H, Thurman DJ, Zack MM, Henry TR, Schachter SC, Price PH. (2008) Epilepsy surveillance among adults – 19 states, behav- ioral risk factor surveillance system, 2005. MMWR 57(No.SS-6):1-20 [errata 2008 57:876.]
Kwan P, Brodie MJ. (2000) Early identification of refractory epilepsy. N Engl J Med 342:314–319.
NAEC (National Association of Epilepsy Centers). (1990) Recommended guidelines for diagnosis and treatment in specialized epilepsy centers. Epilepsia 31:S1–S12.
National Institute for Clinical Excellence. (2004) The diagnosis and care of children and adults with epilepsy. Available at: http://www.nice.org.uk/ nicemedia/pdf/CG020publicinfoenglish.pdf.
NIH Consensus Conference. (1990) Surgery for Epilepsy. NIH Consensus Development Conference Statement 8:1–20.
Scheuer ML, Pedley TA. (1990) The evaluation and treatment of seizures. N Engl J Med 22:1468–1474.
Scottish Intercollegiate Network. (2003) Diagnosis and management of epi- lepsy in adults: a national clinical guideline. Available at: http:// www.sign.ac.uk/pdf/sign70.pdf.
Singapore Ministry of Health (2007) MOH Clinical Practice Guidelines 1/2007: Epilepsy in Adults. Available at: http://www.moh.gov.sg/ mohcorp/uploadedFiles/Publications/Guidelines/Clinical_Practice_Guide lines/Diagnosis%20and%20Management%20of%20epilepsy%20in%20 adults.pdf.
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Appendix
I. Third Level Epilepsy Center
A. Services provided
1. Electrodiagnostic a. Twenty-four hour video-EEG with surface electrodes
supplemented with sphenoidal or appropriate additional electrodes. Continuous supervision by EEG technologist or epilepsy staff nurse, supported when appropriate by monitoring technician or automated seizure and interictal activity detection program.
b. Intracarotidamobarbital(Wada)testingormechanismto obtain one
c. Intraoperative Electrocorticography d. Adequate volume of video-EEG monitoring for seizure
classification or localization annually (at least 50 cases)
2. Epilepsysurgery a. Emergency or elective neurosurgery, including biopsy
and removal of incidental lesions and treatment of
cerebral complications of epileptic seizures. b. Management of surgical complications. c. Surgical resection of epileptogenic structural lesions
with the goal of treating seizures (‘‘straightforward
lesionectomy’’). Standard anterior temporal lobectomy in the presence of mesial temporal sclerosis. d. Experience in resective epilepsy surgery e. Implantation and management of vagus nerve stimula-
tors or other neuromodulatory devices. f. If the third level center does not actually perform surgery,
it must have established referral procedures with one or more level 4 surgical centers.
3. Imaging a. Magnetic resonance imaging (in 2009, defined as a
minimum of 1.5T) with appropriate magnet strength and sequences for the sensitive detection of mesial temporal sclerosis and common epileptogenic lesions.
b. Computerizedaxialtomography c. Cerebralangiography
4. Pharmacologicalexpertise a. Quality-assured anticonvulsant serum drug levels. Lev-
els of newer anticonvulsant drugs and free drug levels should be readily available.
b. c.
5. a. b.
c. d. e. f.
g.
6. a.
b.
7. a.
b. c. d. e. f. g.
Twenty-fourhourantiepilepticdruglevelservice Pharmacokinetic expertise by at least one member of the team.
Neuropsychological/psychosocialservices Comprehensiveneuropsychologicaltestbatteriesfor evaluation of cerebral dysfunction for vocational and rehabilitative purposes; localization of cerebral dysfunction in evaluation for epilepsy surgery basic assessment of characterological and psychopatho- logical issues. An established referral arrangement for comprehensive management of psychogenic nonepileptic events.
Clinical psychological services for assessment and basic treatment of emotional disorders associated with chronic epilepsy.
Basic assessment of social and vocational needs.
Rehabilitation(inpatientandoutpatient) Physical, occupational, and speech therapy for basic evaluation and treatment of multiply handicapped individuals. Sufficientphysical,occupational,andspeechtherapyfor managing complications of surgeries performed at the center.
Consultative expertise Psychiatrist, board-certified (ABPN), with special inter- est in treatment of people with epilepsy and psychiatric disorders Internal medicine Pediatrics Generalsurgery Obstetrics/gynecology
Neuropathology Neuroradiology
Guidelines for Specialized Epilepsy Centers
ology certification. At least one of these individuals should have experience in the selection of patients for and the adjustment of the vagus nerve stimulator.
c. At least one board certified neurosurgeon with special interest in epilepsy, experience in resective epilepsy sur- gery, and in the implantation of the vagus nerve stimula- tor.
d. Experienced epileptologist and epilepsy surgeon are defined as having at least 2 years experience each post fellowship and an adequate volume of video EEG moni- toring annually (at least 50 cases).
2. Neuropsychologist/neuropsychometrist a. Neuropsychologist – Ph.D. in clinical psychology with
specialization in clinical neuropsychology as evidenced by pre- or postdoctoral training and/or work experi- ence; or, a Ph.D. in psychology with postdoctoral train- ing from an APA-approved clinical neuropsychology program. The neuropsychologist would supervise neu- ropsychological evaluations and assessments and may also supervise interventional psychologists. This indi- vidual should have specific experience in use of neuro- psychometric tests in evaluation for epilepsy surgery; and interpreting results of intracarotid amobarbital tests.
b. Psychometrist – A bachelor’s degree in a behavioral sci- ence plus supervised experience in neuropsychometric instrument administration and scoring under the direc- tion of a qualified neuropsychologist. This individual would administer and score the neuropsychological tests.
3. Psychosocial a. Clinical psychologist/counseling psychologist – Ph.D.
from an APA-approved clinical or counseling psychol-
ogy program and a special interest in epilepsy. b. Social worker – ACSW preferred with experience coor- dinating case services for epilepsy patients in an outpa-
tient setting
4. Nursing a. Clinical nurse specialist/nurse clinician – qualifications
include nursing degree with experience in epilepsy. Res- ponsibilities include providing patient and family educa- tion and coordinate nursing services for epilepsy center
b. Head nurse/staff nurse – Qualifications include R.N. with experience in epilepsy. Responsibilities include coordinate nursing functions for inpatient service
5. EEG Technologists and personnel a. When intensive neurodiagnostic monitoring of patients
is performed, an EEG technologist, monitoring techni- cian, or epilepsy staff nurse must observe the patient and maintain recording integrity. An EEG technologist attaches electrodes, maintains integrity of the recording, is capable of observing for seizures and examining
Epilepsia, 51(11):2322–2333, 2010 doi: 10.1111/j.1528-1167.2010.02648.x
B. Personnel
1. Physicians a. A neurologist or neurosurgeon with special expertise in
epilepsy should serve as program director. b. At least two board certified neurologists with expertise in epilepsy, clinical neurophysiology, video-EEG moni- toring, selection of patients for epilepsy surgery, and the pharmacology of anticonvulsant drugs except for centers in isolated geographic areas where one board certified neurologist is sufficient in meeting this guideline (all other standards for level 3 centers must be met). Gener- ally neurologists would have undergone fellowship train- ing in these topics. At least one of these individuals should be board certified in clinical neurophysiology by either the American Board of Clinical Neurophysiology or the American Board of Psychiatry and Neurology with added qualifications in clinical neurophysiology. Appro- priate experience may substitute for clinical neurophysi-
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D. M. Labiner et al.
patients during seizures, and operates recording equip- ment. A monitoring technician is defined as an individual trained in seizure observation and capable of maintaining recording integrity in the temporary absence of an EEG technologist.
  • All technologists and technicians should be certified in basic life support. All technologists preferably would be board-eligible or certified by the American Board of Registration for EEG Technology (ABRET). All technologists should meet American EEG Society long-term monitoring qualifications (Am EEG Society, 1994). The chief technologist should be ABRET-regis- tered and have additional training in long-term moni- toring.
  • At least one technologist should have experience with the technical and safety issues encountered during elec- trocorticographic recordings in the operating room.
6. Rehabilitationservices
  • Registeredoccupationaltherapist
  • Physicaltherapistsupervisedbyphysician
  • Physiatrist with special interest in neurological dysfunc-
    tion
  • Speechtherapistandvocationalcounselorpreferred
7. Supportservices a. Biomedicalengineerand/orITspecialist.
C. Outpatient video-EEG monitoring units
1. Layoutandfurnishingsshould
  • Allow nursing or monitoring staff easy access to patients
    to facilitate examination and first aid
  • Minimizeriskofinjuryduetofalls.
2. Personnel a. Continuous observation by qualified providers such as
EEG technologists is mandatory. Additionally, physician or staff epilepsy nurse should be readily available.
3. Useful Protocols (modified as necessary to account for individual situations)
  • Examinationduringseizures
  • Numberordurationofseizuresovergivenperiodrequir-
    ing physician notification
  • Transportation and designated provider of emergency
    services in the event of emergencies.
  • Medication reduction to increase seizure yield is not rec-
    ommended in the outpatient setting. It should not be done without physician or extensively trained nurse clinician on premises.
4. Access to additional care.
  • Ready access to emergency resuscitative equipment in
    the monitoring unit
  • Arrangement with nearby hospital to provide emergency
    services when needed.
Epilepsia, 51(11):2322–2333, 2010 doi: 10.1111/j.1528-1167.2010.02648.x
D. Inpatient units at third level epilepsy centers
1. Layoutandfurnishingsshould a. Minimize risk due to injury and falls. Measures taken
should be more thorough than in the outpatient setting because likelihood of seizures occurring is greater with medication reduction.
b. Decrease risks for leaving unit or confused wandering in the postictal state.
c. Allow continuous observation of patients for the pur- poses of safety and examination during video-EEG mon- itoring. Observation should be possible during wakefulness and sleep. Arrangements should assure pri- vacy when appropriate, e.g. when patients use the bath- room but rapid access must be available at all times.
2. Personnel a. Continuous observation by EEG technologists or epi-
lepsy staff nurses is highly recommended, supplemented as appropriate by frequently reviewed spike and seizure detection. Reliable and appropriately trained family members or nursing assistants may assist in some situa- tions. A higher nurse to patient ratio than in standard care is necessary.
b. Epilepsy staff nurses must be continuously present on site. EEG technologists must be continuously available.
c. Twenty-four hour physician on site. Twenty-four hour availability of epileptologist.
3. MandatoryProtocols(modifiedasnecessarytoaccount for individual situations)
a. Examination of speech, memory, level of con- sciousness and motor function during and following a seizure.
b. Number or duration of seizures over given period requir- ing physician notification.
c. Measures to be taken if number, duration, or severity of seizures observed is excessive.
4. Accesstoadditionalcare a. Ready access to intensive care unit and anesthesia ser-
vices in the event of status epilepticus.
II. Fourth Level Epilepsy Center
A. Services provided
1. Electrodiagnostic a. Twenty-four hour video-EEG with surface electrodes
supplemented with sphenoidal or appropriate additional electrodes. Continuous supervision by EEG technologist or epilepsy staff nurse, supported when appropriate by monitoring technician or automated seizure and interictal activity detection program
b. Twenty-four hour video-EEG recording with intracranial electrodes (subdural, epidural or depth electrodes) under continuous supervision and observation as above. Level
3. a.
b. c. d.
Imaging Magnetic resonance imaging (in 2009, defined as 1.5T) with appropriate magnet strength and sequences for the sensitive detection of mesial temporal sclerosis and com- mon epileptogenic lesions. Computerizedaxialtomography Cerebralangiography. Access to one or more of the following either on site or by established arrangement: interictalpositronemissiontomography
spherectomy, it should establish referral procedures with fourth level centers offering these services.
e. f. ictalsinglephotonemissioncomputedtomography
  • functionalmagneticresonanceimaging(fMRI)
  • MEG
4. Pharmacologicalexpertise
  • Quality-assured anticonvulsant serum drug levels. Lev-
    els of newer anticonvulsant drugs and free drug levels
    should be readily available.
  • Twenty-fourhourantiepilepticdruglevelservice
  • Pharmacokinetic expertise by at least one member of the
    team.
5. Neuropsychological/psychosocialservices a. Comprehensiveneuropsychologicaltestbatteriesfor:
2331
4 centers should have an average of at least 6 cases with indwelling or intraoperative electrodes annually aver- aged over 4 years.
c. Intracarotid amobarbital (Wada) testing
  • Functional cortical mapping by stimulation of subdural
    electrodes either extraoperatively or intraoperatively.
  • Evoked potential recording capable of being used safely
    with intracranial electrodes.
f. Electrocorticography. g. Adequate volume of video-EEG monitoring for seizure
classification or localization annually (at least 100 cases).
2. Epilepsysurgery
  • Emergency or elective neurosurgery, including biopsy
    and removal of incidental lesions and treatment of cere-
    bral complications of epileptic seizures.
  • Management of surgical complications.
  • Open and stereotactic biopsy
  • Surgical resection of epileptogenic structural lesions
    with the goal of treating seizures (‘‘lesionectomy’’).
  • Anterior temporal lobectomy with or without mesial
    temporal sclerosis.
f. Placementofintracranialelectrodes. g. Resection of epileptogenic tissue in the absence of struc-
tural lesions. h. Implantation and management of the vagus nerve stimu-
lator or other neuromodulatory devices. i. If the center does not offer corpus callosotomy and hemi-
Guidelines for Specialized Epilepsy Centers
b. evaluation of cerebral dysfunction for vocational and rehabilitative purposes
c. localization of cerebral dysfunction for evaluation for epilepsy surgery
d. complete assessment of characterological and psycho- pathological issues.
e. Inpatient and outpatient psychological services for assessment and treatment of emotional disorders associ- ated with chronic epilepsy.
f. Assessment of social and vocational needs. Interventive social services.
g. Comprehensive management of psychogenic nonepilep- tic events.
6. Rehabilitation (inpatient and outpatient) a. Physical, occupational, and speech therapy for evalua-
tion and treatment of multiply handicapped individuals. b. Sufficient physical, occupational, and speech therapy for managing complications of surgeries performed at the
center.
7. Consultativeexpertise a. Psychiatrist, board-certified (ABPN), with special inter-
est in treatment of epileptic patients with psychiatric dis-
orders b. Internalmedicine c. Pediatrics d. Generalsurgery e. Obstetrics/gynecology f. Neuropathology g. Neuroradiology
B. Personnel
1. Physicians
  • A neurologist or neurosurgeon with special expertise in
    epilepsy should serve as program director.
  • Atleasttwoboardcertifiedneurologistswithexpertisein epilepsy, clinical neurophysiology, video-EEG monitor- ing, selection of patients for epilepsy surgery, and the pharmacology of anticonvulsant drugs. Generally neurol- ogists would have undergone fellowship training in these areas. At least one of these individuals should be board certified in clinical neurophysiology by either the Ameri- can Board of Clinical Neurophysiology or the American Board of Psychiatry and Neurology additional qualifica- tions in clinical neurophysiology. Appropriate experience may substitute for clinical neurophysiology certification. At least one of these individuals should have experience in the interpretation of intracranial EEG recordings and cortical stimulation studies. At least one of these individu- als should have experience in the indications for and the
    adjustment of the vagus nerve stimulator.
  • At least one board certified fellowship-trained neuro-
    surgeon with special interest in epilepsy, experience in
    Epilepsia, 51(11):2322–2333, 2010 doi: 10.1111/j.1528-1167.2010.02648.x
2332
D. M. Labiner et al.
resective epilepsy surgery, placement of intracranial electrodes and insertion of the vagus nerve stimulator. Generally neurosurgeons would have undergone fellow- ship training or additional training beyond residency in these topics.
d. Experienced epileptologist and epilepsy surgeon are defined as having at least 2 years experience each post fellowship and an adequate volume of video EEG moni- toring annually (at least 100 cases).
2. PharmacologistorPharm.D. a. Withspecialinterestandtraininginepilepsy
3. Neuropsychologist/neuropsychometrist
  • Neuropsychologist – Ph.D. in clinical psychology with
    specialization in clinical neuropsychology as evidenced by pre- or postdoctoral training and/or work experience; or, a Ph.D. in psychology with postdoctoral training from an APA-approved clinical neuropsychology program. The neuropsychologist would supervise neuropsycho- logical evaluations and assessments and may also super- vise interventional psychologists. This individual should have specific experience in use of neuropsychometric tests in evaluation for epilepsy surgery; and interpreting results of intracarotid amobarbital tests.
  • Psychometrist – A bachelor’s degree in a behavioral sci- ence plus supervised experience in neuropsychometric instrument administration and scoring under the direc- tion of a qualified neuropsychologist. This individual would administer and score the neuropsychological tests.
4. Psychosocial
  • Clinical psychologist/counseling psychologist – Ph.D.
    from an APA-approved clinical or counseling psychol-
    ogy program and a special interest in epilepsy
  • Social worker – ACSW preferred with experience coor- dinating case services for epilepsy patients in an outpa-
    tient setting
5. Nursing
  • Clinical nurse specialist/nurse clinician – qualifications
    to include nursing with experience in epilepsy. Responsi- bilities include providing patient and family education and coordinate nursing services for epilepsy center
  • Headnurse/staffnurse–qualificationsincludeR.N.with experience in epilepsy. Responsibilities include coordi- nating nursing functions for inpatient service
6. EEG Technologist(s) a. When intensive neurodiagnostic monitoring of patients
is performed, an EEG technologist, monitoring techni- cian, or epilepsy staff nurse must observe the patient and maintain recording integrity. An EEG technologist attaches electrodes, maintains integrity of the recording, is capable of observing for seizures and examining patients during seizures, and operates recording equip-
Epilepsia, 51(11):2322–2333, 2010 doi: 10.1111/j.1528-1167.2010.02648.x
ment. A monitoring technician is defined as an individual trained in seizure observation and capable of maintaining recording integrity in the temporary absence of an EEG technologist.
b. All technologists and technicians should be certified in basic life support. All technologists preferably would be board-eligible or certified by the American Board of Registration for EEG Technology (ABRET). All tech- nologists should meet American EEG Society long-term monitoring qualifications (Am EEG Society, 1994). The chief technologist should be ABRET-registered and have additional training in long-term monitoring.
c. At least one technologist should have experience with the technical and safety issues encountered during electrocorticographic recordings in the operating room.
d. Additionally, several technologists should have experi- ence with long term monitoring with intracranial elec- trodes and the safety and recording issues occurring during cortical stimulation. At least one technician should have experience with electrocorticographic recordings in the operating room.
7. RehabilitationServices(usuallybyconsultationor referral)
a. Registeredoccupationaltherapist b. Physicaltherapistsupervisedbyphysician c. Physiatrist with special interest in neurological dysfunc-
tion d. Speechtherapist e. Vocationalcounseling
8. Supportservices a. Biomedicalengineerand/orITspecialist
C. Outpatient video-EEG monitoring units
1. Layoutandfurnishingsshould a. Allow nursing or monitoring staff easy access to patients
to facilitate examination and first aid b. Minimizeriskofinjuryduetofalls.
2. Personnel a. Continuous observation by qualified providers such as
EEG technologists is mandatory. Additionally, physician or staff epilepsy nurse should be readily available.
3. Useful Protocols (modified as necessary to account for individual situations)
a. Examinationduringseizures b. Number or duration of seizures over given period requir-
ing physician notification c. Transportation and designated provider of emergency
services in the event of emergencies. d. Medication reduction to increase seizure yield is not
recommended in the outpatient setting. It should not be done without close supervision by a physician or extensively trained nurse clinician on premises.
4. Access to additional care.
  • Ready access to emergency resuscitative equipment in
    the monitoring unit
  • Arrangement with nearby hospital to provide emergency
    services when needed.
D. Inpatient units at fourth level epilepsy centers
1. Layout and furnishings should
  • Minimize risk due to injury and falls. Measures taken
    should be more thorough than in the outpatient setting because likelihood of seizures occurring is greater with medication reduction.
  • Decrease risks for leaving unit or confused wandering in the postictal state.
  • Allow continuous observation of patients for the pur- poses of safety and examination during video-EEG monitoring. Observation should be possible during wakefulness and sleep. Arrangements should assure privacy when appropriate, e.g. when patients use the bathroom but rapid access must be available at all times.
  • Additionally neurodiagnostic equipment and furnishings must meet electrical safety and other standard of the American EEG Society’s Recommendations for Inten- sive Neurodiagnostic Monitoring (Am EEG Society, 1994).
2. Personnel a. Forscalpvideo-EEGmonitoring,continuousobservation
by EEG technologists or epilepsy staff nurses is highly
Guidelines for Specialized Epilepsy Centers
recommended, supplemented as appropriate by fre- quently reviewed spike and seizure detection. Reliable and appropriately trained family members or nursing assistants may assist in some situations. A higher nurse to patient ratio than in standard care is necessary. For video- intracranial EEG monitoring, continuous observation by EEG technologists or epilepsy staff nurses is mandatory
b. Epilepsy staff nurses must be continuously present on site. EEG technologists must be continuously avail- able.
c. Twenty-four hour physician on site. Twenty-four hour availability of epileptologist.
3. MandatoryProtocols(modifiedasnecessarytoaccount for individual situations)
a. Examination of speech, memory, level of consciousness and motor function during and following a seizure.
b. Number or duration of seizures over given period requiring physician notification.
c. Measures to be taken if number, duration, or severity of seizures observed is excessive.
d. Care of head-dressings in patients studied with intracra- nial electrodes
e. Measures to prevent postoperative infections or other complications in patients studied with intracranial electrodes.
4. Accesstoadditionalcare a. Ready access to intensive care unit and anesthesia
services in the event of status epilepticus.
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