Approximately 1 in 26 people will develop epilepsy or recurrent seizures during their lifetime, with a prevalence of roughly 1% of the population. Beyond the direct effects of seizures, people suffering from epilepsy may have a number of challenges including diminished family and social support, impaired cognition, medical and psychiatric comorbidities and societal stigma – all leading to a reduced quality of life.
Critical to alleviating the impact of this condition is the correct diagnosis – minimizing both false negative and false positives. Failure to do so can produce significant negative consequences for individual patients, including physical, psychological and socioeconomic.
Continuous recording of the electroencephalogram (EEG) with time-locked video has been well-established as a critical tool in making the correct diagnosis. Advances in technology allow a patient to undergo this type of study in the home at much-reduced cost, increased convenience and equivalent diagnostic accuracy.
has been demonstrated with respect to serving as the gold standard for the diagnosis of many epilepsy syndromes, identifying mimickers of epilepsy and as the initial evaluation in preparation for eventual respective surgery.
The addition of video recording to long-term EEG recording provides multiple advantages over those done without. For recorded seizures, the video allows the delineation of whether the clinical onset of the event precedes, is concurrent with, or follows the electrographic onset.
At the most basic level, the concurrent video will allow differentiation of paroxysmal non-epileptic seizure-like events (PNES) from true epileptic seizures.
Conversely, if there are clinical events that are characteristic of seizures of frontal lobe origin that may have no scalp EEG correlate, the video may allow their identification where a standard EEG would not.
The ability to lower anti-epileptic drugs so that the patient is more likely to have one of their events. Because of the risk of triggering generalized convulsions (or rarely, even status epilepticus), this practice mandates observation and the ability to intervene immediately if necessary (frequent with the use of IV medications); one can only lower drugs safely in the inpatient setting.
The ability to have a skilled observer (nursing staff) directly interact with a patient during the event, allowing for assessment of orientation, the ability to speak, etc. -w that might not be evident otherwise.
Scheduling the inpatient stay may create a significant delay between when the study is ordered and when it is executed.
Admission to the hospital may be difficult for the patient for multiple reasons, including cost, distance to inpatient facility and family/home obligations. As previously noted, there is not only a worsening shortage of neurologists in the United States, but access is further hampered by the tendency for neurologists to cluster in major metropolitan areas creating “neurology deserts” over large areas of the country.14
Cost: the cost is artificially high for services that are either not medically necessary (e.g., 24-h nursing, vital signs every shift) or needs that are just as well available at home (e.g., bed, meals and medications).
The hospital is an artificial environment with little stress for the patient, and their activity is minimized. The result is that patients who may have been having seizures frequently when home may not even have an event recorded. This fact contributes to the need for drug reduction and activation procedures with inpatients in the first place.
The study is performed in the regular environment and stress where the episodes in question generally occur.
The study can generally be scheduled and executed much more quickly than inpatient studies. Alliance in most cases has “next day” and “next week” availability, resulting in a much higher level of patient compliance with completion of the testing, and a much faster turnaround of the final report getting to the ordering physician.
The expense is generally a fraction of a inpatient study, as low as 1/6th the cost for a 72 hour recording.
Patients can stay in the privacy and comfort of their own home, and do not have to travel to stay in an EMU (the distances in some cases may be significant). This results in less time off from work and away from family.
One cannot safely lower anti-epileptic drugs during the recording.
Studies that have evaluated the value of home video EEG monitoring in the past have also noted a decreased likelihood of the patient being on camera at the time of an event, and the inability to fix technical problems with the recording. With the advent of technology that allows for frequent web-based monitoring of the recordings, and the ability to either call the home (to fix patient position or pan/tilt/ zoom the camera position) or dispatch a technician to the home to fix technical problems, these are lessening concerns. The web-based software allows for remote real-time review of the study, so that the monitoring technician no longer needs to be on site, but is still able to contact medical or technical staff to intervene on a timely basis.
Indications for outpatient VEEG recording do not include the withdrawal of AED’s, therefore, no emergency / medical / nursing staff is available at the bedside.
In general, hospitalizations of epilepsy patients are more expensive in terms of hospital charges than routine medical patients, and the cost per day for hospitalization in dedicated epilepsy units and at the highest level, epilepsy monitoring units, is progressively more expensive.
The financial burden created for the patient is not insubstantial, on average more than $6,000 at a 20% co-pay.
When performed for the indications specified, the quality and diagnostic accuracy equals that of an inpatient EMU evaluation, and a report provided back to the ordering physician within 48 hours of completion (two business days).