Structured testing during seizures: A practical guide for assessing and interpreting ictal and postictal signs during video EEG long term monitoring

Inpatient long-term video-electroencephalographic monitoring event capture audiovisual diagnostic quality

OBJECTIVES

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

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.

Implementation of a New Clinical Testing Tool to Assess Patients During Ictal and Postictal Periods

ABSTRACT

BACKGROUND: A seizure is a sudden, uncontrolled electrical disturbance of the cortical neurons in the brain, which can cause changes in behavior, movements, feelings, and consciousness. Clinical signs and symptoms before, during, and after a seizure can help to determine the seizure onset. The use of standardized clinical testing tools has been reported as being valuable, although also challenging, by some institutions. This study investigated the effectiveness of implementing a new clinical testing tool designed with an emphasis on simplicity for use during and after seizures. METHODS: A pre-and-post evaluation study was conducted from January 2020 to November 2020 in the epilepsy monitoring unit/neurology unit at a hospital in Sydney, Australia. The primary outcome of interest was the incidence of clinical testing during seizures. The secondary outcome of interest was nurse knowledge about clinical testing during a seizure. This knowledge was measured via testing before and after clinical education sessions. The third outcome of interest was nurse confidence regarding the use of the clinical testing tool. The confidence level was measured via posteducation session follow-up surveying. RESULTS: Forty-seven nursing staff (10 neurophysiology nurse technologists and 37 neurology unit nurses) participated in the education program. Forty-four seizures were evaluated. Clinical testing during ictal and postictal periods was performed by nursing staff 82% of the time during 2020, compared with 67% during the 2018 to 2019 preeducation comparison period. This difference was not statistically significant, but it was clinically relevant (P = .07). In addition, the time from seizure alarm to clinical testing improved significantly from a median of 30.5 seconds in 2018 to 2019 to 14 seconds in 2020 (P < .001). CONCLUSION: The tool is easy and convenient for nursing staff to perform clinical examinations accurately during ictal and postictal periods.

If seizures left speechless: CA-P-S C-A-R-E, a proposal of a new ictal language evaluation protocol

INTRODUCTION

We aimed to create standardized protocol for language examination in patients who underwent video-EEG recording and assessed its efficacy in the characterization of ictal language impairment, its ability to differentiate this from impaired awareness, and interobserver reliability in clinical practice.

METHODS

From our database of video-EEG recordings, we selected a representative sample of 63 focal seizures with presumed language impairment. A multidisciplinary team of epileptologists, EEG technicians, and speech therapists analyzed the selected videos to highlight the critical issues of ordinary ictal language evaluation. We subsequently followed a multi-step process to develop the protocol and assess its interobserver reliability.

RESULTS

A protocol based on seven tests in hierarchical succession was created, summed up in the acronym CA-P-S C-A-R-E (Closed Answers, Pro-speak question, Simple orders, Common object denomination, Audio repetition, Reading, Evoke). Following its preliminary administration for 5 months, we assessed the inter-observer reliability of 16 healthcare professionals in distinguishing between language impairment and impaired awareness among a sample of 10 seizures, finding a substantial agreement (kappa 0.61).

CONCLUSION

The proposed protocol, made of simple and easy to memorize tests, is an effective tool that evaluates multiple domains beyond language. Its use could help to recognize ictal aphasia effectively and differentiate it from impaired awareness, minimizing inter-examiner variability.