Minimum Technical Requirements for Performing Ambulatory EEG : Journal of Clinical Neurophysiology

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ACNS Guideline

Minimum Technical Requirements for Performing Ambulatory EEG

Tatum, William O.*; Halford, Jonathan J.; Olejniczak, Piotr; Selioutski, Olga§; Grigg-Damberger, Madeleine M.; Gloss, David; Acharya, Jayant#; Schuele, Stephan**; Sinha, Saurabh R.††; Tsuchida, Tammy‡‡; Drislane, Frank W.§§

Author Information
Journal of Clinical Neurophysiology: September 2022 - Volume 39 - Issue 6 - p 435-440
doi: 10.1097/WNP.0000000000000950
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Abstract

Ambulatory EEG (AEEG) monitoring provides prolonged interictal and potentially ictal recording in patients with recurrent paroxysmal neurological events in one's natural environment.1–4 Because AEEG is most often recorded for a few days, systematizing technical performance standards is necessary to ensure optimal recording quality and outcome data.5 Sources of environmental “noise” may degrade the signals of interest6 and hamper accurate EEG interpretation.7–10 The purpose of this technical guideline was to provide minimum standards for performance of AEEG.

AEEG is a form of diagnostic long-term EEG monitoring with several potential clinical indications. These include (1) differentiating epileptic and nonepileptic events, (2) prolonged interictal EEG sampling when standard EEG is nondiagnostic, (3) classifying seizure types and epilepsy syndromes, (4) quantifying seizure frequency and duration, (5) identifying seizure triggers that occur outside the hospital setting, and (6) making decisions regarding adjustment of antiseizure medications.11–15

The American Clinical Neurophysiology Society (ACNS) has previously provided minimum technical standards for performing in-hospital EEG with respect to equipment, electrode placement, montages, electrical safety, calibration, sensitivity, study duration, montages, and digital recording.16–19 The minimum technical standards for neonates, infants, and young children are separate from those required for older children and adolescents which differ little from adults.20 In general, these minimum technical standards have applied to the use of standard EEG.21 However, although there is information regarding the clinical use of AEEG, there are no formal guidelines that specifically address minimum technical standards. The International Federation of Clinical Neurophysiology provides clinical guidance for monitoring EEG in the diagnosis of patients with epilepsy and on EEG methodology in a commission report from the International League Against Epilepsy, but this report is outdated.22 Recently, the clinical practice guidelines by the International League Against Epilepsy and International Federation of Clinical Neurophysiology involving inpatient long-term video-EEG monitoring have become available but do not specifically include AEEG,23 and older guidelines involving long-term EEG are without technical specifications.11

The literature was searched for evidence to identify technical standards of AEEG. When available, it was limited to low-level evidence (primarily level III and IV studies) and expert opinion.24–28 In addition, no single agreed-on method exists for recording AEEG under all circumstances, and variations in performance were relative to individual patients and settings. As a result, a qualitative synthesis of the literature for technical aspects of AEEG recording was most appropriate. Therefore, in line with other technical guidelines established by the ACNS, we assimilated available evidence to inform discussion and develop standards based on expert consensus. The following standards are considered the minimum technical requirements for recording AEEG in adults and children, except for the very young, as a part of routine clinical practice.

EQUIPMENT

Essential components of an AEEG recording system are a portable light-weight battery-operated amplifier system capable of recording, EEG sensors, ECG, and event recorder. Ambulatory EEG amplifiers should meet minimum technical requirements previously established by the ACNS with input impedance >10 megaohms.12,18 We recommend equipment that uses a common-mode rejection ratio >90 dB to improve the signal-to-noise ratio. The digital EEG recorder should have a minimum resolution of 12 bits when recording from 32 electrodes and have the capacity to store a minimum of 24 hours of AEEG.29 Currently available AEEG systems using 16-bit analog-to-digital converters meet or exceed the 3-fold sampling rate and satisfy the Nyquist theorem and provide a resolution down to 0.3 µV at a maximum input range of ±10 mV used for recording clinical EEG.5,19

A minimum sampling rate of 256 Hz is necessary when recording AEEG, although rates of 512 Hz or higher are preferrable.19 Crosstalk between EEG channels should be <1%.30 Instrument calibration is routine to ensure the amplifiers are functioning appropriately.18,21 Optimal systems record and store data continuously. Recorded data are either stored locally or transferred in real time to the server. EEG data transfer from AEEG equipment requires connectivity from the amplifier to a remote computer or server for data review and storage, either by cable or wirelessly.

Most currently available AEEG systems exceed minimum standards. They are light weight (∼0.5 kg) systems, worn at the waist or in a backpack, have 32 EEG channels or more,31,32 and higher input impedances, CMRR, and higher sampling rates. Most modern AEEG units have the capability to record and store up to 96 hours of data using compact flash memory cards. We recommend continuous AEEG recording systems as opposed to those that intermittently record scheduled samples and triggered events alone.

AEEG systems with video capabilities (AVEEG) can connect to computers and remote servers using cellular, wireless, or Bluetooth connection for “home (audio-video) telemetry,” which permit real-time access for adjusting video quality review, EEG lead impedance checks, and technical troubleshooting potentially encountered during AVEEG.33 The data review speed is limited by the resolution of the video, the network connection speed, and the stability of the network connection.19

Maintaining a cloud-based continuous AVEEG monitoring system requires substantial technical support. Overall, with these systems, the clinical usefulness may be compromised unless there technical support personnel and/or EEG technologists are available to troubleshoot technical problems remotely and/or ensure an optimal recording. This includes addressing artifactual interference, battery life, full-field video recording, and patient (and caregiver) cooperation.

AEEG Sensors

Conventional EEG recording uses standard surface disc electrodes secured with collodion or conductive paste, with the latter considered when patients express sensitivity to adhesives. Sixteen channels of simultaneous recording are the minimum number required to identify areas that produce most normal and abnormal EEG patterns.18 The International Federation of Clinical Neurophysiology recommends recording at least 25 electrodes for long-term EEG monitoring in adults and children to provide improved coverage of the anterior-basal and inferior-basal regions of the temporal lobe, which often include the voltage maxima from discharges propagating from the mesial temporal structures.8,34 Ambulatory EEG recording systems include 25 channels (19 EEG recording electrodes, a reference, a neutral (ground) electrode, two anterior temporal electrodes, and two ECG channels) and an event recorder. Sensors for recording AEEG use the International 10 to 20 System of electrode placement similar to that required for routine EEG.12 The common digital reference electrode placed in the FCz or CPz electrode position on the head helps limit artifact from head movement. Ear electrodes (A1 and A2) used in standard EEG recording are difficult to maintain in the home setting where artifacts may compromise the quality of AEEG recording.16,18,34 Disposable electrodes, silver–silver chloride, and gold cups are available. Electrode caps and dry electrodes for AEEG have the potential to reduce preparation time and maintenance,19,35 but during AEEG recording, they pose greater sensitivity to artifacts and rapid signal deterioration over time. Additional AC channel inputs recording electromyogram and electrooculogram signals, although optional, may be useful in certain circumstances especially for identifying sleep/wake states.36,37 A single channel of ECG recording modified lead II from left–right chest sensors during AEEG is essential because it is with standard EEG. Multimodal AEEG monitoring with DC channels that include oximetry, airflow respirometry, and band plethysmography is customizable to facilitate home sleep testing.38

Video and Audio

The use of a video camera is an optional feature that is available with most current AEEG systems. Synchronized video with AEEG is helpful to characterize events and to identify artifacts that may mimic interictal epileptiform activity and electrographic seizures. Recording video adds bulk, memory and power requirements and increases the cost of AEEG. Furthermore, there are limitations regarding FOV and mobility of the video equipment.

AEEG systems with video (ambulatory video EEG, AVEEG) such as long-term video-EEG monitoring in the hospital should include high-quality video cameras synchronized with the EEG recording to facilitate behavioral analysis.23 High-definition color video recording (1,920 × 1,080 or 1,440 × 1,080 pixels/inch resolution, >30 frames/seconds), with an audio channel, is necessary. The cameras should have a large FOV (wide-angle lenses) to maximize the likelihood of capturing events from a stationary camera. Using a camera, which can automatically switch to an infrared video recording mode in low-light situations, is important for recording events in dark or dim light conditions. Maintaining proper distance from the camera (to remain in focus) and remaining centered in the field are the responsibility of the patient or caregiver and crucial to quality AVEEG recording. Providing intermittent or continuous monitoring assists in keeping patients in full view of the camera and to address the presence of technical issues with video equipment, should they arise. The amount of data collected for AEEG without video is 1% to 2% of that in AVEEG recordings, which makes the task of streaming AEEG data to the Cloud using a cellular network more manageable. Depending on the ability to live-stream AEEG data to the Cloud in real time, patients may need to return to the EEG laboratory to download recordings on successive days to allow electrode maintenance and daily review.

Safety

Performing EEG is a noninvasive and safe procedure.8,39 Because AEEG recording is without the continuous presence of onsite-trained personnel, and with limited ability to intervene, unique patient safety issues exist. During AEEG recording outside the hospital setting, sleep deprivation, antiseizure medication taper, and provocative maneuvers avoidance limit the safety risk that could occur from provoking seizures. However, diagnostic video-EEG for seizure classification performed in the patients' home is safe and poseses no security risks for staff.33 When reusable electrodes or electrode caps are used, all electrode sensors must be thoroughly disinfected after each use to prevent transmission of infection.18

Electrical injury during standard EEG is rare.40 Cutaneous injuries and burns rarely occur during standard EEG recording.40–43 However, if the patient has electrical contact with the AEEG device while it is being charged (and plugged into an AC power source), there is a potential risk of electrical injury. However, currently available AEEG equipment does not require charging the recording unit during recording thereby avoiding the patient–equipment connection with the AEEG equipment when the internal battery is charging. As with any electrically powered device, exposure to water will damage the AEEG equipment, so showering, bathing, swimming, or exposure to water is prohibited during AEEG recording.

PERFORMANCE IN PRACTICE

Setup

During the setup process for AEEG, technologists should teach patients and caregivers proper use of the equipment and to ensure that event recording is optimal. The setup may be hospital-based or clinic-based or even performed at the patient's home. This requires travel time and portable equipment and adds expense.44 Ambulatory EEG monitoring should be maintained by a qualified EEG technologist and preferably someone who is credentialled (R. EEG T) by the American Board of Registration of EEG and Evoked Potential Technologists, Inc, to ensure optimal technical performance.

In accordance with standards established for recording clinical EEG, the initial setup begins by obtaining patient demographic and clinical informations. Information regarding current types and frequency of events is especially important. Electrodes adhere to the scalp using collodion adhesive or a combination conductive/adhesive gel. Checking electrode impedances ensures that scalp electrodes at the start of the recording session have impedances less than 10 kΩ. For AEEG recordings lasting more than one day, impedances should be less than 10 kΩ12,13,18 and calibration of the signal should be performed.16–18,34,45

A baseline sample of EEG serves as a baseline before outpatient AEEG without the 60-Hz notch filter applied to assess the quality of recording. Common activities (e.g., eye movement, chewing, talking, and swallowing) should be performed during AEEG setup to reproduce and document artifactual waveforms for postrecording comparison designed to facilitate accurate interpretation. Activating procedures (i.e., intermittent photic stimulation and hyperventilation) are patient-specific when performed during baseline AEEG recording.

AEEG quality may be poor in children because of difficulty maintaining electrode integrity.46 Restricting patient activity to limit movement improves recording quality and outlined during setup. Depending on the intended duration of the recording, patients may also need instructions on battery charging or replacement. If the system has video recording capabilities, clear written instructions regarding setup of the video system should be available and reviewed with patients. Instruction for the patient push-button event activation and diary documentation is also necessary.

Activity Log

A patient daily activity log or diary is a simple, practical way to track activities during AEEG. A written record of the times and descriptions of behavioral episodes should be maintained as part of the medical records.

Patients and caregivers should document and be encouraged to detail push button events in the diary. This information should include (1) the date and time of event occurrence (which should correspond to the same date and time displayed on the AEEG monitor), (2) a detailed description of the event and how it compares with the patient's habitual attacks, (3) the presence or absence of any direct interaction with the patient (questions asked or commands given and the responses), and (4) whether the patient's awareness of the event is maintained or impaired. Emphasis on recording the event that is typical for the patient needs emphasis during baseline setup to focus on the importance during AEEG.

Push-Button Activation

Push-button activation indicates that a patient-specified or observer-specified event has occurred and creates a time stamp in the EEG tracings, prompting the interpreter to closely review these segments for any ictal EEG changes. This is an essential component of AEEG. Evaluating the push-button event marker during setup ensures system integrity and educates the patient (and caregivers) on how to effectively use the event recorder. Despite adequate education, a significant minority of patients are self-unaware of their events during seizures, and in this case, events must be recognized and marked by others using the push-button activation system.

Voice recording may supplement push-button activations during AEEG recording. Patient vocalization or verbalization (in addition to that of witnesses who can interact with the patient and describe the event) can help clarify the observed semiology. Push-button activations also prompt the reader to review that portion of AEEG for paroxysmal events. Identifying a typical event by push-button activation during AEEG can provide useful information about the electrographic onset of a seizure, although it may not indicate the precise timing of the electro–clinical correlation unless video recording is also performed.47 During the setup for AEEG, event characterization may be more detailed when simple testing protocols performed during events clarified by technologists are understandable to patients and caregivers. Both the push-button activations and the activity log should be reviewed by the patient and technologist on return of the recording to clarify details regarding marked events and distinguish intentional from unintentional push-button activations.

Review

Once AEEG recording is complete, the device is removed, data are downloaded and processed, and the EEG is reviewed at a workstation monitor on site or remotely.48 Ideally, the entire EEG recorded should be available to the interpreter for review. A log of all activities and behaviors during AEEG should be available to the interpreter. Technical requirements for review of AEEG are similar to those for routine EEG. Customizable reformatting of AEEG montages, digital filters, and channel sensitivities should be available to adjust the EEG for clinical display.17,18,34 Typical filter settings should include a high-pass filter of 0.5 Hz and low-pass filter of 70 Hz. Montage selectors allow data reorganization of the AEEG to clarify waveform visualization.49 A 60-Hz notch filter may be necessary during review because of ambient exposure to line noise during AEEG.7,50 Viewing AEEG on a monitor should allow varying scrolling speeds. A standard horizontal screen display scaling should be available for EEG review, in which 1 second occupies between 25 and 35 mm (30 mm in the older guidelines), and has a minimum resolution of 128 data points/second on the screen for a 10-second page, requiring a horizontal resolution of at least 1,280 pixels.19,44 The review device should permit split-screen review and an ability to compare the data over different times of recording using a variety of preprogrammed or customized montages, sensitivities, and filter settings.

Contemporary AEEG systems also offer software options51 which include artifact reduction, spike and seizure detection, and compressed spectral array and other quantitative EEG measures.52–55 These have been adapted for AEEG from the same software used for inpatient video-EEG monitoring.56 The AEEG data are subsequently processed for clinical interpretation post hoc. Ambulatory EEG services may incorporate on-call technical support and on-line troubleshooting. Therefore, the entire raw AEEG data should be available for the physician interpreter to ensure that all clinically significant findings are available for review.

Archiving and Storage

AEEG should retain clips of relevant sections for secured archiving and storage in compliance with HIPAA requirements. Local practices govern routine data disposal, reuse, backup, archiving, and storage. Video of all events captured on AVEEG, interictal epileptiform activity, ictal EEG, and other waveforms of concern are relevant data that is stored for the duration of time specified by law.12,18–20 Along with hospital supported storage options, various interfaces offer AEEG viewing, archiving, and secure transfer for data sharing. Twenty-four hours of AEEG recording require an average of 8 to 30 GB of internal memory (mostly for video storage) and depend on the video resolution recorded. Data are off-loaded from the AEEG or AVEEG system to secured storage in the clinical neurophysiology laboratory or are streamed to a cloud server. Manufacturers should provide a method to export deidentified files of AEEG recordings in nonproprietary, publicly available EEG data formats (such as European Data Format).45 Ambulatory EEG data, such as standard EEG data, should be archived and stored in accordance with institutional and state regulations for record retention of personal health care information.18

CONCLUSIONS AND RECOMMENDATIONS

AEEG systems provide long-term EEG monitoring outside the hospital setting as an independent technique with unique technical standards. This guideline should serve as a minimum standard for the performance of AEEG for clinical purposes. The strength of the conclusions for this guideline would benefit from higher levels of evidence, in addition to expert consensus. Developments and forms of AEEG monitoring are evolving. New systems include increasing availability of simultaneous audio–video recording and opportunities for real-time monitoring, review, and troubleshooting. As one form of long-term EEG recording, despite its technical similarities, AEEG is not an equivalent technique or substitute for inpatient long-term video-EEG monitoring. Future technological advances will increase the quality and utility of AEEG in the diagnosis and management of patients with seizures and other paroxysmal neurological disorders.

DISCLAIMER

This guideline is provided as an educational service of the ACNS. It is based on an assessment of current scientific and clinical information. It is not intended to include methods of care for a unique disease or medical condition nor incorporate all legitimate indications for choosing to use a specific EEG procedure. Neither is it intended to exclude any reasonable alternative methods. American Clinical Neurophysiology Society recognizes that specific patient care decisions are the prerogative of the patient and the physician caring for the patient, based on all the circumstances involved. Formal practice recommendations are not intended to replace clinical judgment. This guideline will be revised as science, evidence, and technology evolve.

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Keywords:

Ambulatory; EEG; Video; Technical; Guideline

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