Epilepsy Service
The goal of the epilepsy/EEG rotation is to learn basic principles in clinical epileptology including evaluation, diagnosis, and treatment of individuals with epilepsy, and EEG interpretation. The epilepsy service provides exposure to all aspects of epilepsy, from patients admitted to the EMU to patients that come in for evaluation in the outpatient setting. You will also become familiar with reading EEGs, both routine and continuous EEGs (cEEG)
Faculty Supervisors: Dr. Jennifer Hopp (Division Director), Dr. Stephanie Chen, Dr. Peter Crino, Dr. Camilo Gutierrez, Dr. Mehraneh Khadjevand, Dr. Tasleema Khan, Dr. Jennifer Pritchard, Dr. Susmit Tripathi
Responsibilities: Prior to or on the first day of the rotation, residents should contact the EMU attending to let them know you are on the rotation. Ideally, you should send an email the weekday before you start so you can get information on where to meet and how to prepare for your first day. The names of the EMU attending and fellow on service are available through EZCall under “Epilepsy Schedule”. Residents will provide initial assessment of (admit) new patients admitted to Epilepsy Monitoring Unit (EMU) service in the EMU, participate as part of the epilepsy team in the OR and during Wada tests, round on post-op epilepsy surgery patients in the PACU or ICU and on the floor. Most EMU patients are elective admissions, post-op epilepsy surgical patients, and rarely urgent transfers from other hospitals. Residents will provide follow-up care to established patients. They will make daily rounds with the attendings/fellows. Residents will be responsible for the day-to-day management including the management of antiseizure medications and other general medical and neurological care. In addition, residents are expected to review routine EEGs daily and formulate an impression of the EEG. This will then be reviewed with the EMU attending at the EEG reading session which is embedded into EMU daily rounds. They may participate in Continuous EEG study reading with the fellows and attendings or epilepsy attending outpatient clinic as time permits. It is expected that the majority of your day will be spent in the EMU or working with fellows caring for epilepsy patients around the hospital.
Day 1
Obtain sign out from outgoing epilepsy resident on existing patients on Friday prior to the start of the rotation. Residents are expected to pre-round on existing patients on the first day and be ready to present at attending rounds.
The schedule of new admissions for the week are listed on the calendar in the EMU control room on 4IMC. Patients are typically admitted on Tuesdays and Thursdays. Please review charts in EPIC prior to the day of admission to be prepared to take a history and admit the patient.
Contact the attending by email prior to the first day and text the fellow (or attending, if no fellow) by 8am to get details of when and where to meet for rounds. Rounding typically will occur daily in the EEG reading room on the 12th floor in the EEG lab.
Residents should arrive to the hospital by 7 AM every day. Residents are primarily responsible for the EMU patients from 7 AM- 5 PM Monday-Friday while on the rotation and will share care of the patients with the team. Residents are responsible for placing orders and communication with the fellow and attending.
Team Structure
EMU Attending: This attending is the attending of record for the patients admitted to the EMU and responsible for follow-up of any epilespy surgery patient admitted to the hospital. The EMU attending also may see outpatients during the time they are on service and may have administrative and teaching responsibilites during that time.
Epilepsy Faculty (Other): If faculty are not “on service”, then they are in the outpatient practice, doing research, teaching or in other administrative roles. You will interact with most of the faculty at weekly conference, in the outpatient setting, and in other meetings and conferences.
Epilepsy Fellows: There is typically one fellow assigned to the EMU, oone fellow assigned to read cEEG, and a third on their outpatient rotation. You will interact with all fellows during the rotation, but will likely spend most of your time with the fellows reading in the EMU.
EEG techs: There are EEG techs who work primarily in the EMU and those that typically set up and run routine and cEEG. You will interact with them in the EMU and outpatient setting in the EEG lab.
Medical student: There is typically one medical student on the EMU rotation. Residents are expected to assist with education of medical students. This includes teaching the neurologic examination, history taking and physical examination and presentation of patients and data on rounds. Residents may also be involved with basic EEG education if they are on their second rotation on the EMU, and with other general neurology and epilepsy concepts. Medical students rotating on the epilepsy service will often prepare a short presentation for the team on a topic relevant to epilepsy or EEG.
Weekday Schedule
There are overlapping activities in the Epilepsy Division on a daily basis, but the fellows and EMU attending will help you prioritize your involvement during your time on service.
7:00-9:00: Each morning, you will pre-round on the EMU patients, and see if they had any reported events overnight. This can be done by asking the patient directly and also by discussing any overnight or "push button" events with the EEG technician. On Tuesday and Thursday you can expect admissions to arrive at approximately 8am (see below).
10:00-11:30: The timing of morning rounds with the attending vary at times based on who is on service, but generally should start at 10am; check with the EMU fellow for more information. During rounds, the fellow and attending will read over the EEGs of the EMU patients as well as any routine EEG studies. Each attending has their own style of teaching; some may ask you to attempt to interpret the EEG, while others will point out findings as they come along. Routine EEG reading may occur before noon lectures but your team my reconvene in the afternoon to staff these studies. Outpatient EEG studies are staffed on the weekday after they are performed (i.e. Tuesday studies staffed on Wednesdays).
11:30-12:30: Noon lecture/Lunch at Paca-Pratt
12:30-5PM: Clinical work including admission/discharges, reading routine EEG, afternoon conferences (see below), and joining an epilepsy attending in outpatient epilespy clinic.
5PM: Sign out to on call resident
Note: Seeing your EMU patients takes priority. EMU rounds are mandatory, as is routine EEG reading (again, unless there is other conflict such as being in the OR – you can check with the attending on service about this daily). There may be opportunity to read some cEEG if you are on your second (advanced rotation) or if there is extra time and interest. There is also opportunity to join faculty in the outpatient practice. The EMU attending on service will discuss the specifics with you during the early part of the rotation.
EMU Admissions
EMU admissions are scheduled, and thus are considered elective admissions. There are typically 2 admissions scheduled every Tuesday, and 1 scheduled on Thursdays. Refer to the admission calendar located in the EMU Control Room on 4IMC to see the admission schedule during your rotation.
There are two types of admissions: Phase 1 monitoring (characterization of episodes; helps to distinguish epileptic and non-epileptic episodes; may be used for medication titration in a controlled setting) and Phase 2 monitoring (localization of seizures; helpful in pre-surgical evaluation).
Nurses will notify you of patient arrival. This usually occurs at 8-10 AM. Please be proactive to go to the EMU to see if patients have arrived. When the patient arrives, obtain EMU Consent initially. These are the points to discuss:
Safety: Notify nurse prior to getting up from bed due to risk of tripping over long EEG cord
Water: Not allowed to shower or get the “head box” wet
Since UMMC is a teaching hospital their EEG and corresponding video may be shown to people in the healthcare field for education purposes, even though they are not taking part in their care
Obtain patient signature and witness the document
Let EEG technician know when consent is complete, so they may hook them up to EEG.
Natus is the EEG program utilized to record and review EEG studies at UMMC.
History and Physical
Use the EPIC template .UMHNEUROEMUHP to complete the history and physical note. Pay close attention to home antiseizure medications, and in particular these factors:
Generic vs. Brand Name
Normal vs. Extended Release
Size of tablet, and quantity taken with each dose
Timing of doses, as they can be different from norms
Here is other essential information to ask about related to seizures:
Seizure risk factors: Family history of seizures, CNS infection (meningitis/encephalitis) history, history of complex febrile seizures as an infant, significant head trauma, (+/- LOC), prior skull fractures/defects
Prior EEG
Routine vs. Ambulatory vs. previous EMU admission
Prior MRIs
Prior antiseizure medications (ASMs)
Reasons for stopping antiseizure medications
Current driving status
Is patient in contact with motor vehicle administration (MVA)
Review of contraception and folic acid supplementation when appropriate
Monthly Conferences
Epilepsy Weekly Conference, Monday at 2:00pm, Epilepsy Conference Room, 12th floor next to reading room. This will vary based on the Monday of the month and may include Epilepsy Research Meeting and educational conferences. Once a month these are Divisional meetings which are not for residents.
Please reach out to attending and fellow on service for additional learning opportunities such as surgical cases, VNS interrogation, etc.
Goals/Objectives
At the end of the rotation, residents will be expected achieve the following competencies and milestones.
Develop the ability to obtain an accurate seizure/epilepsy history that includes risk factors, prior history of seizures, and family history.
Understand basic pathophysiological mechanisms including the anatomic localization of epileptic seizures, the relevant neurochemical features that lead to hyper- excitability, and the known neurophysiological consequences on brain function that leads to seizures.
Understand the difference between epileptic and non-epileptic seizures as well as the differential diagnosis and evaluation of “spells” for example, seizure vs. syncope.
Develop the ability to explain to patients and families the diagnosis of epilepsy and PNES.
Know the basic precipitants of a seizure and know the difference between a provoked and unprovoked seizure.
Know the basic pathophysiology behind an epileptiform discharge and a seizure.
Understand the basic classification scheme for epilepsy (seizure types and syndromes) based on ILAE Classification.
Know the names of all antiseizure medications (ASM) and common side effects.
Know the basic concepts of ASM mechanisms as they relate to drug interactions (induction vs. inhibition of metabolism, protein binding, interactions with hormonal contraception).
Know the basic concepts of when to start and when to discontinue an ASM.
Know the basic evaluation and treatment of a first seizure.
Know the basic management of a pregnant woman with epilepsy (and the basic management of issues related to pregnancy – folate, discuss teratogenic risks)
Know the indications for epilepsy surgery and basic testing needed in epilepsy surgery evaluation.
Know the basic types of epilepsy surgery (resection, VNS, RNS, DNS, CC, Hemispherectomy, MST).
Understand the basic concepts of dietary therapy for epilepsy.
Know common medical and psychiatric comorbid conditions associated with epilepsy.
Know the basic regulations for driving and epilepsy.
Understand the definition and risk of SUDEP.
Know basic first aid for seizures.
Develop basic EEG reading skills:
Be able to read a normal wake/sleep EEG
Recognize epileptiform discharges (spikes, sharps, etc)
Recognize common EEG artifacts
Recognize common EEG normal variants
Recognize periodic patterns
Understand the utility of various EEG techniques.
Understand the concept of an evoked potential (SSEP) and review one of each type of study with attendings
Review 25 EEGs (routine, EMU).
Observe 1 EEG hookup with the EEG technicians.
Key READINGs
Evidence-based Guideline: Management of an Unprovoked First Seizure in Adults
Practice guideline summary: Sudden unexpected death in epilepsy incidence rates and risk factors
Wiebe S A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med. 2001 345(5):311-8.
Early identification of refractory epilepsy. Kwan P, Brodie MJ. N Engl J Med. 2000 Feb 3;342(5):314-9.
ADDITIONAL ROTATION REFERENCES
Primer of EEG: With Mini-Atlas by A James. Rowan MR: This is kept in the EMU or EEG lab as well as the library.
Current Practice of Clinical Electroencephalography: Ebersole/Pedley
The Treatment of Epilepsy – Wylie
EEG teaching file – available in EEG lab
Last Updated: August 2, 2024