In-Home Ambulatory EEG

How In-Home Ambulatory EEG with Video Fits into My Practice

Author:
Dr. Andrew Lerman, First Choice Neurology, Miami Epilepsy Specialists

In my practice at First Choice Neurology, we regularly use in-home ambulatory EEG with video monitoring for patients who experience clinical episodes suspicious for seizures or episodes which cannot be fully explained. In-home Video AEEG has become an important diagnostic tool in my practice and in the lives of so many of my patients.

AEEG Results Can Now Rival EMUs
In the past, AEEG was horribly ineffective and 90% of the study was artifact, rendering the study basically uninterpretable. Today’s recording systems are much improved and the study results can now rival the quality of a hospital-based epilepsy monitoring unit or EMU. Advances in video and AEEG technology now allow the seamless capture of real time data.

I find the video component to be very helpful in seeing exactly what happened before, during and after an event, allowing for electro-clinical correlation, and confirming a diagnosis. Since only until recently this technology was felt to be subpar and usually not very helpful, there is a general lack of knowledge and experience with its use. Now that we are able to obtain high quality studies, this tool provides a means of obtaining an accurate diagnosis in a minimally invasive environment, hopefully leading to effective treatment and recovery.

How I Use AEEG with Video in My Practice.
You would be amazed at how helpful the video is in telling me the story, confirming clinical events, and evaluating suspicious artifact, such as tooth brushing, hair combing etc. A 99% confirmed diagnosis can be obtained by seeing the events on video and correlating them with real time EEG. For example, I had a patient tell me that she would wake up in the morning with her sheets kicked off the bed, at times even on the floor or in another room. The video showed this patient having complex motor behaviors out of sleep, including bicycling movements with both legs. This correlated with a burst of ictal activity lasting several minutes over the left and b-frontal regions out of sleep.

Ways that Video AEEG Help to Clarify a Diagnosis
Video AEEG helps to clarify diagnosis and eliminate unnecessary treatment for patient’s suffering from seizure mimics, and is able to accurately quantify events and response to treatment. It has helped to correctly diagnose various sleep disorders, non-epileptic events, exercise induced dizziness, migraine syndromes, convulsive syncope, panic disorder, and various other conditions of altered consciousness or sensorium.

Ambulatory EEG has been extremely helpful for these types of cases:

• To clarify diagnosis and allow for EEG correlation by using longer recordings aimed at capturing interictal abnormalities and increasing the chances of capturing the patient’s typical event or the clinical event in question.
• Unclear or mysterious events that are not life threatening.
• Patient events which are not frequent enough to be approved for a hospital inpatient stay.
• To localize a patient’s seizure onset zone for determining the origin of interictal discharges or seizures.
• Capturing nocturnal events when the patient is comfortable at home and exposed to natural triggers.

Three Cases where AEEG was an Effective Diagnostic Tool
Three different cases quickly come to mind where in-home AEEG with video was an effective diagnostic tool:

• Quantification of interictal spike burden as well as non-life threatening—often simple partial or absence—seizures
• Paroxysmal non-epileptic (psychogenic) events
• Nocturnal frontal lobe epilepsy with subtle motor automatisms vs. REM behavior disorder

Overall, we use AEEG with video for non-critical patients in whom a routine EEG is not helpful and we do not have a clear idea of the underlying etiology due to either variable semiology or atypical history or clinical events. We always recommend admission to an epilepsy monitoring unit for prolonged inpatient monitoring during medication changes, if critical events like generalized tonic-clonic seizures are suspected or there is suspicion that the device won’t be well-tolerated or handled by the patient.

The Patient Perspective
There are various other non-medical reasons that are felt to be medically indicated and several valid reasons to refer a patient for an in-home AEEG with video. In home AEEG has been useful for patients who:

• Refuse to come into the hospital for 3-5 days for various reasons.
• Have obligations to family/work that do not allow them to spend that amount of time in the hospital.
• Are agoraphobic or have extreme anxiety or stress by being in the hospital.
• Cannot afford a hospital stay (in-home AEEG is 50-60% less expensive versus inpatient).
• Object because their commute to the closest EMU is inconvenient and costly.

Many patients prefer an in-home ambulatory EEG with video to an inpatient EEG when their situation allows for it. One of RSC’s patients, Dan, recorded three videos about his experience so others can understand how what it is like to have a prolonged in-home VEEG study. Read RSC’s blog, “Dan the Man! A Patient’s Viewpoint of an Ambulatory EEG” to watch his short videos and read Dan’s personal story.

It’s not uncommon for AEEG patients to report that they are much more comfortable and at ease when they stay in their own home. The high quality of home video EEG allows for clear and readable electroencephalographic recordings combined with high definition video. We are now able to monitor and diagnose many patients that would have otherwise not been good candidates or not-tolerated an inpatient admission.