Summary- Long-term monitoring for epilepsy (LTME) refers to the simultaneous recording of EEG and clinical behavior over extended periods of time to evaluate patients with paroxysmal disturbances of cerebral function. LTME is used when it is important to correlate clinical behavior with EEG phenomena. EEG recordings of long duration may be useful in a variety of situations in which patients have intermittent disturbances that are difficult to record during routine EEG sessions. However, as defined here, LTME is limited to patients with epileptic seizure disorders or suspected epileptic seizure disorders. These guidelines do not pertain to extended EEG monitoring used in a critical care, intraoperative, or sleep analysis setting.
Although LTME can, in general, be considered to be longer than routine EEG, the duration varies depending on the indications for monitoring and the frequency of seizure occurrence. Because the intermittent abnormalities of interest may occur infrequently and unpredictably, the time necessary to document the presence of epileptiform transients or to record seizures cannot always be predetermined and may range from hours to weeks. Diagnostic efficacy requires the ability to record continuously until sufficient data are ob- tained. Consequently, long-term monitoring refers more to the capability for recording over long periods of time than to the actual duration of the recording. The term monitoring does not imply real-time analysis of the data.
Developments in digital technology have enhanced the ability to acquire, store, and review data in LTME to such a degree that digital systems are now the industry standard. These guidelines will therefore focus on these systems. It is expected that further advances in digital technology will make it necessary to review these standards on a regular basis.
INDICATIONS FOR LTME
This listing of indications is not meant to be all- inclusive, because special circumstances may warrant addi- tional considerations.
Diagnosis
1. Identification of epileptic paroxysmal electrographic and/or behavioral abnormalities. These include epi- leptic seizures, overt and subclinical, and documen- tation of interictal epileptiform discharges. EEG and/ or behavioral abnormalities may assist in the differ- ential diagnosis between epileptic disorders and condi- tions associated with intermittent symptoms because of nonepileptic mechanisms (e.g., syncope, cardiac ar- rhythmias, transient ischemic attacks, narcolepsy, other
Copyright 2008 by the American Clinical Neurophysiology Society ISSN: 0736-0258/08/2503-0170
sleep disturbances, psychogenic seizures, other behav-
ioral disorders).
2. Verification of the epileptic nature of the new spells
in a patient with previously documented and controlled seizures.
Classification/Characterization
1. Classificationofclinicalseizuretype(s)inapatientwith documented but poorly characterized epilepsy.
2. Characterization (lateralization, localization, distribu- tion) of EEG abnormalities, both ictal and interictal, associated with seizure disorders. Characterization of epileptiform EEG features, including both ictal dis- charges and interictal transients, is essential in the evaluation of patients with intractable epilepsy for sur- gical intervention.
3. Characterization of the relationship of seizures to specific precipitating circumstances or stimuli (e.g., nocturnal, catamenial, situation-related, activity-related). Verification and/or characterization of temporal patterns of seizure occurrence, either spontaneous or with respect to thera- peutic manipulations (e.g., drug regimens).
4. Characterization of the behavioral consequences of ep- ileptiform discharges as measured by specific tasks.
Quantification
1. Quantification of the number or frequency of seizures and/or interictal discharges and their relationship to naturally occurring events or cycles.
2. Quantitative documentation of the EEG response (ictal and interictal) to a therapeutic intervention or modifi- cation (e.g., drug alteration).
3. Monitoring objective EEG features are useful in pa- tients with frequent seizures, particularly with absence and other seizures having indiscernible or minimal behavioral manifestations.
QUALIFICATIONS AND RESPONSIBILITIES OF LTME PERSONNEL
Chief or Medical Supervisor of LTME Laboratory
Qualifications
1. A physician with appropriate qualifications to be chief of an EEG laboratory [e.g., as outlined in Guidelines for Laboratory Accreditation, Standard I, published by the American Clinical Neurophysiology Society (ACNS)].
2. Certification by the appropriate national certifying group in EEG.
3. Special training in the operation of LTME equipment,
ORIGINAL ARTICLE
  Guideline Twelve: Guidelines for Long-Term Monitoring for Epilepsy
170 Journal of Clinical Neurophysiology Volume 25, Number 3, June 2008

Journal of Clinical Neurophysiology Volume 25, Number 3, June 2008
Guideline Twelve
which is typically more complex than that used for routine EEG recording. Special knowledge of the tech- nical aspects of data recording, storage, and retrieval is required, and formal training or equivalent experience in electronics and/or computer science is strongly rec- ommended.
4. Special training in the interpretation of EEG and video data generated in an LTME laboratory. Experience beyond routine EEG interpretation is necessary, since much of the analysis involves complex ictal and inter- ictal features, as well as artifacts, seldom encountered in a standard EEG laboratory. Long-term monitoring systems can use methods of data display or formats of data review (e.g., discontinuous segments). The analysis of LTME data requires as well the simultaneous interpretation and correlation of EEG data and behavioral events.
5. As a minimum, it is recommended that experience in the practical use of specialized LTME equipment and in data interpretation be gained by working in a major LTME laboratory, preferably under the direction of an individual who meets the qualifications for chief or medical supervisor of an LTME laboratory.
Responsibilities
1. The chief or medical supervisor of an LTME laboratory should have the same responsibilities and authority as the chief of an EEG laboratory. They must possess the training and necessary skills needed to care for a person having seizures.
2. Additional responsibilities include the final interpretive synthesis of LTME data with diagnostic and pathophys- iological formulations.
LTME Electroencephalographer
Qualifications
1. A physician with the qualifications to be a clinical electroencephalographer (e.g., as outlined in Guideline Four: Standards of Practice in Clinical Electroencepha- lography, published by the ACNS).
2. Specialized training and experience in the use of LTME equipment and in the interpretation of LTME data are necessary, preferably under the direction of an individ- ual who meets the qualifications for chief or medical supervisor of an LTME laboratory.
Responsibilities
Responsibilities include the analysis of, at minimum, pertinent segments of collected electrographic and behavioral data reviewed in all appropriate formats, the writing of LTME reports, and the final interpretive synthesis of LTME data with diagnostic and pathophysiological formulations in the absence or in lieu of the chief or medical supervisor.
LTME EEG Technologist I to III
Qualifications
1. A technologist with the minimal qualifications of an EEG technologist as set forth by the appropriate na-
2.
3. 4.
tional body (e.g., as outlined by the American Society of Electroneurodiagnostic Technologists). In the LTME laboratory EEG technologists should be supervised or managed by Registered EEG Technologist (R. EEG T.). Special training in the use and routine maintenance of LTME equipment in the laboratory of employment, with particular emphasis on techniques for monitoring the in- tegrity of data recording.
Special training and resultant expertise in the recogni- tion of ictal and interictal electrographic patterns and in their differentiation from artifacts.
Special training and resultant expertise in the manage- ment of clinical seizures and seizure-related medical emergencies. Successful completion of training in car- diopulmonary resuscitation is necessary.
Copyright 2008 by the American Clinical Neurophysiology Society
171
Responsibilities
1. LTME technologists I to III should have the same responsibilities and authority as EEG technologists. Competencies in EEG and LTME supported by The American Society of Electroneurodiagnostic Technolo- gists are embraced by LTME technologist. (These can be accessed online at http://aset.i4a.com/files/public/EEG_ National_Competencies.pdf and http://aset.i4a.com/files/ public/LTME_National_Competencies.pdf.)
2. Additional responsibilities include the technical opera- tion of LTME studies (e.g., patient preparation, equip- ment setup, and data recording). Overall management of these is the responsibility of a technologist III.
3. Under the supervision of the electroencephalographer in charge, data retrieval and reduction operations may be performed and EEG records prepared in a form suitable for interpretation, by LTME technologists II and III. This may include a prescreening of EEG and behavioral data to define segments for later analysis.
Monitoring Technician
Qualifications
1. Special training with resultant expertise in recognition of clinical ictal behavior and interaction with patients during seizures to elucidate specific ictal symptoms.
2. Special training and resultant expertise in aspects of use of monitoring equipment dependent on specific func- tions of technician.
3. If direct patient observation is involved, special training and resultant expertise in the management of clinical seizures, seizure-related emergencies, and cardiopulmo- nary resuscitation are necessary.
4. The monitoring technician position is exclusive of the operating room.
Responsibilities
1. Patient observation (direct or several patients at a time via video monitoring) to identify and note ictal events and interact with patients during seizures and to alert appropriate personnel (e.g., physician, EEG technolo- gist, nursing staff) to the occurrence of each seizure.

Westlake Journal of Clinical Neurophysiology Volume 25, Number 3, June 2008
2. Depending on specific training and requirements, the monitoring technician may also adjust video cameras to keep patient in view and in focus, oversee the adequate function of EEG recording equipment, administer or monitor continuous performance tasks, and otherwise maintain the integrity of the monitoring procedure, calling appropriate personnel to assist when problems occur.
3. Because of the need for continuous observation during most LTME procedures, monitoring technicians pro- vide essential specialized services that do not require the expertise of physicians, nurses, or EEG technolo- gists, but medical and technical personnel must be immediately available when called by the monitoring technician. If the monitoring technicians are the first responders on site, they must possess the training and necessary skills needed to care for a person having seizures.
4. Assess and respond to integrity of digital recording equipment including the integrity of electrodes.
LONG-TERM MONITORING EQUIPMEN.