EPILEPSY MONITORING UNIT (EMU) ADMISSION

What is the Epilepsy Monitoring Unit (EMU) at Nanavati Max Hospital?

The Epilepsy Monitoring Unit (EMU) is a set of specially equipped rooms at Nanavati Max Hospital. These rooms provide effective & safe video-EEG monitoring for 3-7 days.

How can the Epilepsy Monitoring Unit (EMU) help my patient?

An EMU admission can lead to dramatically better patient outcomes.

A common misconception is that EMU admission is needed only before epilepsy surgery. An EMU admission is much more helpful:

1) Seizure characterization: For example, if a focal onset is discovered - numerous medication choices & even epilepsy surgery become feasible.

2) Revealing the need for therapy escalation For example, frequent subclinical seizures at night causing cognitive decline, or an epileptic encephalopathy. The former needs anti-Epileptic Escalation, but the latter needs steroids.

3) Identifying Non-epileptic attacks: These can be caused by cardiac, psychogenic, and other causes. Identifying cardiac causes can save the patient's life. Acceptance and resolution of Psychogenic Seizures (PNES) are very high after an EMU admission.

4) Cost Effective:: EMU admissions decrease long-term patient expenses. For example, acceptance of PNES leads to fewer emergency room admissions.

Which patients should be referred for EMU admission?

1) All patients with medically refractory seizure-like spells:

As noted, these spells may be PNES, misclassified epilepsy, medically resistant epilepsy, cardiac events, or other events such as narcolepsy. Accurate diagnosis leads to effective treatment.

2) Many patients with non-epileptic events have uncontrolled episodes. Epilepsy monitoring helps these patients by:

a) Avoiding Misdiagnosis: Frontal lobe seizures frequently happen in sleep. Frontal lobe seizures have bizarre manifestations such as trashing in bed, running, shouting, etc., sometimes with partially retained awareness.

b) Increasing Acceptance: 2/3rd of patients with previously uncontrolled PNES achieve remission after EMU (Yadav et al 2015).

c) Ruling out co-existent Epilepsy: 30% of patients with Non-epileptic seizures also have co-existent epilepsy (Mellers et al 2005).

3) All patients in whom the seizure burden is unclear

a) Small events such as blank staring spells, noticed by the family may be epileptic or behavioral. EMU evaluation prevents the patient from being over-medicated.

b) Nocturnal events can be ruled out in patients who wake up feeling sore, with bruises, or unexplained tongue bite or incontinence.

4) Some patients with a decline in mental function:

a) To rule out an Epileptic Encephalopathy. For example, Landau-Kleffner syndrome which causes progressive loss of speech can occur without clinical seizures.

b) To rule out progressive neurological conditions such as CJD.

How much does EMU evaluation at Nanavati Max Hospital cost?

Currently, we are able to offer an all-inclusive daily package.

The all-inclusive cost includes:

• Room Charges
• EEG recording and interpretation charges
• Daily Nursing assessments
• Bed at night for the caregiver

Additional consultations (Psychiatrists, Cardiologists, etc.) or investigations (MRI, PET, etc.) are charged separately.

How long is the EMU admission?

Ideally, all types of events that the patient is having should be recorded. We try to record 2-3 events of each type. Here is a guide to estimate the duration of stay:

What if the patient's seizure frequency is low?

Depending on the clinical questions to be answered, we may try to provoke a seizure by:

• Reducing the dose of anti-epileptic medications
• Sleep deprivation
• Photic stimulation
• Hyperventilation

The majority of patients have a seizure with these measures. A minority of patients still do not have seizures during admission. This is called a "non-diagnostic EMU admission".

How is patient safety ensured?

Safety is the foremost priority at Nanavati Max Hospital's EMU.

Our safety practices match or exceed international standards. Detailed safety protocols have been made in consultation with administrators, nurses, and intensivists.

• All hardpoints are padded.
• Nurses in charge of the patient are senior nurses and are usually ACLS-certified.
• There is 24-hour availability of ACLS-certified doctors.
• When the patient or relative presses the "seizure alarm button", or when the nurse sees a seizure on the video, an alarm is sounded. Available nurses and the Neuro-ICU doctor(s) immediately rush to the patient's bedside.

Which reports are generated after EMU evaluation?

Two reports are generated after each EMU evaluation:

1) An Epilepsy Monitoring report: This is a technical report.

2) A summary letter: This is a less formal one-page letter summarising the history, EMU monitoring results, and suggestions for further treatment.

What are the report sent

After 2-3 days, the technical EMU monitoring report will be couriered to the patient. Both the EMU monitoring report and informal letter are used for further treatment.

The patient will follow up with the doctor after 5 days of discharge to discuss further action.

Which surgeries are possible after an EMU admission?

We provide the complete spectrum of epilepsy surgeries to patients with medically resistant epilepsy.

1) When the seizure onset zone can be precisely determined and safely removed: Resection (removal) is the most affordable and effective option. Seizure freedom rates for some surgeries are around 70-80%

2) When the above criteria are not met (e.g. multifocal epilepsy due to neonatal hypoxic-ischemic injury), other surgeries such as Vagus Nerve Stimulation and Corpus callosotomy can be helpful

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