Interictal and ictal video-EEG monitoring

Purpose : The purpose of this paper is to demonstrate the diagnostic efficacy and therapeutic relevance of video-EEG monitoring in an large patient population with long-term follow-up. Patients and methods: Between October 1990 and May 1997, 400 patients were monitored at the Epilepsy Monitoring Unit (EMU) of the University Hospital in Gent. In all patients, the following parameters were retrospectively examined : reason for referral, tentative diagnosis, prescribed antiepileptic drugs (AEDs) seizure frequency, number of admission days, number of recorded seizures, ictal and interictal EEG, clinical and electroencephalographic diagnosis following the monitoring session. During follow-up visits at the Epilepsy Clinic, we prospectively collected data on different types of treatment and post-monitoring seizure control. Results: 255/400 (64%) patients were referred for refractory epilepsy. 145/400 (36%) patients were evaluated for attacks of uncertain origin. Mean follow-up, available in 225 patients, was 28 months (range: 680 months). Mean duration of a single monitoring session was 4 days (range: 2-7 days). Prolonged interictal EEG was recorded in all patients and ictal EEG in 258 (65%) patients. Following the monitoring session, the diagnosis of epilepsy was combined in 217 patients. Pseudoseizures were diagnosed in 31 patients (8%) AEDs were started in 19 patients, stopped in 6 and left unchanged in 110. The type and/or number of AEDs was changed in 111 patients. Sixty patients underwent epilepsy surgery. In 48 surgery patients, follow-up data were available, 29 of whom became seizure-free, and 16 of whom experienced a greater than 90% seizure reduction. Vagus nerve stimulation was performed in 11 patients, 2 became seizure-free, and 7 improved markedly. Of the non-invasively treated patients in whom follow-up was available (n = 135), 70 became seizure-free or experienced a greater than 50% reduction in seizure frequency; 51 patients experienced no change in seizure frequency. Outcome was unrelated to the availability of ictal video-EEG recording. In patients with complex partial seizures, seizure control was significantly improved when a well-defined ictal onset zone could be defined during video-EEG monitoring. Conclusion: Prolonged intel ictal EEG monitoring is mandatory in the successful management of patients with refractory epilepsy. Ictal video-EEG monitoring is very helpful but not indispensable, except in patients enrolled for presurgical evaluation or suspected of having pseudoseizures.