Epilepsy Service
The goal of the epilepsy/EEG rotation is to learn basic principles in clinical epileptology including evaluation, diagnosis, and treatment of seizure patients, and EEG interpretation. The epilepsy service gives you exposure to all aspects of epilepsy, from patients admitted to the EMU to patients that come in for evaluation in the clinic. 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. Jennifer Pritchard
Responsibilities: On the first day of the rotation, residents should contact Dr. Hopp to let her know you are on the rotation. Residents will provide initial assessment of new patients admitted to Epilepsy Monitoring Unit (EMU) service either in the EMU or on the floor. Most EMU patients are elective admissions, but some are urgent transfers. Residents will provide follow-up care to established patients. You will make daily rounds with the attendings/fellows. Residents will be responsible for the day to day management including the management of anticonvulsant medications. In addition, residents are expected to review routine EEGs daily and formulate an impression of the EEG. This will then be reviewed with the attending at the EEG reading session. You are also expected to participate in cEEG assessment with the fellows and attendings as time permits. It is expected that majority of your day will be spent in the EMU or working with fellows caring for epilepsy patients around the hospital.
Day 1
Please obtain sign out from outgoing epilepsy resident on existing patients on Friday prior to your rotation starting. You are expected to preround on existing patients on your first day and be ready to present at attending rounds.
Details about new admissions for the week are listed on the calendar in the EEG tech office on 4IMC. Please record when patients are arriving and chart review prior to the day of admission.
Touch base with epilepsy attending and fellow on EMU on the first day to see where the team will round. This will typically occur in the 12th floor reading room or the EMU tech office.
You should arrive to the hospital by 7 AM everyday. You will be primarily responsible for the EMU patients from 7 AM- 5 PM Monday-Friday.
Team Structure
EMU Attending: this attending is the attending of record for the patients admitted to the EMU and also oversees the epilepsy fellow that is responsible for reading cEEG.
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, reading routine EEG and in other meetings.
Epilepsy Fellows: there is typically one fellow assigned to the EMU, another assigned to read cEEG, and another who is in clinic. You will interact with all fellows during the rotation, but will likely spend most of your time with the fellows reading routine EEG and 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 EMU. Please use downtime in the afternoon to do some teaching.
Weekday Schedule
There are overlapping activities on our services but the fellows and attending will help you prioritize the day and week.
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 this time (see below).
9:00-12:00: The timing of morning rounds with the attending vary widely based on who is on service; 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 cEEG. 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.
11:30-12:30: Noon lecture/Lunch at Paca-Pratt
12:30-5PM: Clinical work including admission/discharges, reading routine EEG, reading continuous EEG, afternoon conferences (see below)
5PM: Sign out to on call resident
cEEG rounds typically occur in the morning and EMU rounds occur at 1pm daily (with some exceptions). You may attend cEEG rounds if you are not in other activities (seeing EMU patients) but otherwise may not be able to attend this. 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).
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 Tech Room to see the admission schedule during your rotation.
Check on Monday/Wednesday for the pre-admission folder in the reading room of the EMU. It will contain outpatient notes which can be helpful in obtaining history, outpatient meds, and what the referring physician was concerned about.
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. 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.
History and Physical
Use the EPIC template .UMHNEUROEMUHP to complete the history and physical note. Pay close attention to home antiepileptic 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 important 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 AEDs
Reasons for stopping medications
Current driving status
Is patient in contact with motor vehicle administration (MVA)
Monthly Conferences
Epilepsy Weekly Conference, every Monday at 830AM, Epilepsy Conference Room, 12th floor next to reading room
Two conferences are “general” and two are “surgical”
ICU EEG Case Conference typically 4th Thursday of the month at 3 PM
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 pseudoseizures.
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 antiepileptic (AED) medications and basic common side effects.
Know the basic concepts of AED 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 AED.
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, CC, Hemispherectomy, MST).
Understand the basic concepts of ketogenic diet treatment.
Know common medical and psychiatric comorbid conditions associated with epilepsy.
Know the basic regulations for driving and epilepsy.
Know the definition and basic algorithm for identification and treatment of status epilepticus (first line, second line, refractory status epilepticus).
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 (visual, SSEP, BAEP) and review one of each type of study with attendings
Review 25 EEGs (routine, cEEG, 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 and can be borrowed during the rotation.
Current Practice of Clinical Electroencephalography: Ebersole/Pedley
The Treatment of Epilepsy – Wylie
EEG teaching file – available in EEG lab
Last Updated: August 13, 2021