The Video-EEG Monitoring Unit (v-EMU) has evolved over recent decades to aid the practitioner in the evaluation of people with recurrent transient neurologic events and the pre-surgical work-up of epilepsy patients. In this chapter, we discuss the various approaches to starting and operating a v-EMU at the various service levels recognized by professional organizations. Procedure and safety in the v-EMU is also reviewed.

Video-electroencephalography monitoring (VEM) units have been evolving for more than 40 years, with monumental progress since the early years of units, which relied on machines that used vacuum tube amplifier technology and recording on paper.¹ Many individuals and organizations contributed to this development. Albert and Ellen Grass and the Grass Instrument Company were pivotal in early technological progress, starting in the 1930s. This was complemented by Frederic and Erna Gibbs, who correlated specific electroencephalogram (EEG) patterns to seizures in limbic epilepsy in the 1940s.² The foundation for modern VEM units was laid at the Brain Research Institute of the University of California at Los Angeles through advances in epilepsy surgery in the 1960s and translational research conducted in the 1970s and 1980s.^3,4 This progress was partly supported by the U.S. National Aeronautics and Space Administration (NASA), which pioneered remote EEG monitoring during early missions in preparation for manned space flight.⁵ Multiple clinicians, researchers, institutions, and equipment manufacturers around the world continue to refine the process toward improved clinical evaluation.

VEM units have been shown to provide a definitive diagnosis in 88% of admissions, and the information obtained has been shown to influence the treatment plan in 80% of these cases.^6,7 Recent reports have highlighted the increasing numbers of admissions to hospital for seizures,⁸ which is likely to indicate increased numbers of patients undergoing VEM and related specialized clinical neurophysiology services.

The VEM unit has multiple functions, including classifying and characterizing changes in behavior and EEG that may represent epileptic seizures, with a primary role in the localization of seizures as a component of an epilepsy surgery evaluation.^9–15 Advancements in the technology used in VEM units have spawned an expansion in the use of monitoring services outside VEM units.¹⁶ Long-term quantitative EEG trending in the intensive care unit is one such adaptation of VEM technology. As a diagnostic resource for epilepsy, VEM units may be accredited by the National Association of Epilepsy Centers (NAEC). The NAEC has established guidelines for defining four levels of epilepsy care of progressively greater expertise and resources.¹⁷

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  Level 1: Care is provided by a primary care physician.

  
  
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  Level 2: Care is provided by a neurologist.

  
  
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  Level 3: Care includes basic services for patients with medication refractory seizures. This includes a range of medical, neurodiagnostics, neuropsychological, and psychosocial services, which may include implantation of vagus nerve stimulators. Third-level medical-surgical centers also provide straightforward resective epilepsy surgery based on noninvasive evaluations. Intracranial EEG monitoring is not provided. Physicians at third-level medical-surgical centers are able to identify when patients are not straightforward or may require intracranial EEG, and therefore should be referred to a level 4 center.

  
  
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  Level 4: As regional or national referral centers, care includes more complex forms of intensive neurodiagnostic monitoring and more extensive medical, neuropsychological, and psychosocial care. Fourth-level epilepsy centers offer intracranial monitoring and a wide range of surgical procedures.

The American Clinical Neurophysiology Society’s Guidelines for Long-Term Monitoring for Epilepsy¹⁸ requires that nonregistered EEG technicians be supervised by registered technologists in the VEM unit setting. Special training is required in the use and routine maintenance of VEM equipment, with an emphasis on techniques for monitoring the integrity of recorded data. Training and resultant expertise in the recognition of ictal and interictal electrographic patterns and differentiation from artifact should be emphasized. Specific nursing training and resultant expertise in the management of clinical seizures and seizure-related emergencies must be incorporated into the day-to-day operation of the VEM unit. Registered technologists and nonregistered technicians must have cardiopulmonary resuscitation certification. National competency skills standards for long-term monitoring in epilepsy are outlined by the American Society of Electroneurodiagnostic Technologists. Registered EEG technologists are eligible to take an exam recognizing additional skills in the long-term monitoring unit (CLTM exam). Exam eligibility requires at least 1 year as a registered EEG technologist and 1 additional year of VEM unit experience.

The actual physical layout of the VEM unit will vary depending on the physical space available. In general, several key elements are required, including some type of central monitoring station, where the patients are observed continuously either by remote video or by direct observation. Private individual rooms may have an advantage over multipatient rooms for several reasons. The extended length of VEM unit admissions (average ~5 days) is better served by private rooms, where patients may feel a greater sense of space, privacy, and accommodation for visitors and caregivers. This is especially important for pediatric patients, whose parents or other family members may accompany the patients throughout the admission, often becoming an integral part of the monitoring process. Space for caregivers and visitors is important because such individuals are often particularly helpful in alerting the staff when subtle spells occur. Space also allows more personal items, which can improve a patient’s comfort level during the admission and help the patient complete the testing instead of leaving prematurely. Additional items and services that facilitate the admission are listed in Table 5-1.

A common room where patients from the VEM unit may gather is found in some institutions. Such a room requires extra and often expensive hospital space and mainly serves to allow patients a relatively safe change in their immediate environment. Unlike most other hospital patients, VEM patients may be fully functional during the admission, which makes the restriction to a hospital room difficult. Furthermore, the restriction to one space may reduce the seizure frequency. Some patients have an increase in seizure frequency when they are more active, and this sensitivity to the level of activity and mobility affects the duration of the admission. A wireless monitoring system with strategically mounted cameras can serve essentially the same function as a day room, allowing the patient to be more mobile in hallways near the VEM unit. Whether such mobility is safe depends on the particular patient’s epilepsy history. In our unit at Mayo Clinic Hospital in Arizona, we incorporate such a wireless system, allowing patients to walk around the nursing station under supervision by the EEG technologist and nursing staff. Patients are also encouraged to bring in books, music, puzzles, laptop computers, and anything else that is considered safe to reduce boredom during their stay.