Stimulation devices are considered in patients with drug-resistant epilepsy and who are not surgical candidates. Responsive neurostimulation (RNS) is a cortically based stimulator activated by electrocorticography (ECoG) patterns. Stimulation is applied directly to the seizure focus. The vagal nerve stimulator AspireSR 106 is also a responsive device which, in addition to basal stimulation, is activated by tachycardia. Deep brain stimulation of the anterior nucleus of the thalamus is used in Europe for intractable epilepsy and yields similar response rates to RNS using duty cycle stimulation. Chronic subthreshold cortical stimulation is an experimental form of constant, low-level stimulation applied to a seizure focus. These modalities are discussed and compared in this review.

Aim. To determine whether there is added benefit in detecting electrographic abnormalities from 16–24 hours of continuous video‐EEG in adult medical/surgical ICU patients, compared to a 30‐minute EEG. Methods. This was a prospectively enroled non‐randomized study of 130 consecutive ICU patients for whom EEG was requested. For 117 patients, a 30‐minute EEG was requested for altered mental state and/or suspected seizures; 83 patients continued with continuous video‐EEG for 16–24 hours and 34 patients had only the 30‐minute EEG. For 13 patients with prior seizures, continuous video‐EEG was requested and was carried out for 16–24 hours. We gathered EEG data prospectively, and reviewed the medical records retrospectively to assess the impact of continuous video‐EEG. Results. A total of 83 continuous video‐EEG recordings were performed for 16–24 hours beyond 30 minutes of routine EEG. All were slow, and 34% showed epileptiform findings in the first 30 minutes, including 2% with seizures. Over 16–24 hours, 14% developed new or additional epileptiform abnormalities, including 6% with seizures. In 8%, treatment was changed based on continuous video‐EEG. Among the 34 EEGs limited to 30 minutes, almost all were slow and 18% showed epileptiform activity, including 3% with seizures. Among the 13 patients with known seizures, continuous video‐EEG was slow in all and 69% had epileptiform abnormalities in the first 30 minutes, including 31% with seizures. An additional 8% developed epileptiform abnormalities over 16–24 hours. In 46%, treatment was changed based on continuous video‐EEG. Conclusion. This study indicates that if continuous video‐EEG is not available, a 30‐minute EEG in the ICU has a substantial diagnostic yield and will lead to the detection of the majority of epileptiform abnormalities. In a small percentage of patients, continuous video‐EEG will lead to the detection of additional epileptiform abnormalities. In a sub‐population, with a history of seizures prior to the initiation of EEG recording, the benefits of continuous video‐EEG in monitoring seizure activity and influencing treatment may be greater.

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Background. Video-EEG (VEEG) monitoring is a vital diagnostic tool, but there are no guidelines for withdrawal of antiepileptic drugs (AEDs). Aim. The main objectives of this study were to understand the different withdrawal strategies used in the EMU, how strategies are chosen, and the efficacy and safety of different withdrawal strategies in producing seizures. Materials and methods. We retrospectively analyzed 95 consecutive patients and measured time to first seizure, incidence of status epilepticus, and need for rescue medications. Results. We found that AED withdrawal strategies can be divided into four categories based on level of aggressiveness. The main factors which impacted choice of strategy was number of AEDs on admission and frequency of pre-admission seizures. Abrupt cessation of medications was correlated with longer time to first seizure compared to other methods (hazard ratio (HR) 0.36, 95% confidence interval (CI) 0.20-0.65, p = 0.0007). Patients remaining on medications had shorter time to first seizure (HR 2.98, 95% CI 1.22-7.24, p = 0.016). Withdrawal technique was not correlated with need for rescue medications (OR 5.0, 95% CI 0.77-43, p = 0.20). No patients had status epilepticus in the study. Conclusions. Pre-admission seizure frequency and number of AEDs are the main factors which drive choice of withdrawal strategy on the epilepsy monitoring unit (EMU). Counterintuitively, least aggressive strategy is associated with highest risk of seizures. Results of this analysis suggest that disease factors, not choice of withdrawal strategy, determine seizure frequency on the EMU.