Why You Should Order an MCT with an EEG

In the 2009 paper, A consensus-based approach to patient safety in epilepsy monitoring units: Recommendations for preferred practices, Shafer et al. reviewed the results of a 2007 meeting of 51 experts in epilepsy care, monitoring and qualitative research(1). The result was a series of consensus guidelines with 30 recommendations designed to maximize patient safety. One area where consensus was not reached concerned the need for concurrent cardiac monitoring. The group conclusion was to recommend at least 1 lead of ECG monitoring, but there was controversy:

Strategies for the use of cardiac monitoring showed that at the time of the rating (2009), consensus was only achieved on the use of single‐ lead ECG monitoring. However, since that time, there has been more attention given to cardiovascular disorders that may mimic epilepsy as well as to the cardiovascular and respiratory consequences of seizures. Many centers already use more extensive cardiac and/or respiratory monitoring in patients during EEG telemetry; thus, the consensus on this item may be different if tested today.

Reasons to Consider the Use of Concurrent Mobile Cardiac Telemetry

Syncopal episodes and other symptoms triggered by cardiac arrhythmias may mimic seizures, and conversely, seizure activity may involve the autonomic nervous system triggering arrhythmias. In particular, sinus tachycardia accompanies roughly 90% and bradycardia or asystole occurs with 0.5% of all seizures(2, 3). More recent work suggests that chronic epilepsy, with recurrent seizures, may over time damage the heart so that there is an increased risk of heart disease independent of the seizures themselves(4). This suggests more aggressive cardiac monitoring in the medically refractory epilepsy population will identify previously unsuspected cases of heart disease, ideally in time for successful intervention. Taken all together, the current state of published evidence suggests having a low threshold for adding mobile cardiac telemetry for those undergoing continuous video EEG monitoring for evaluation of possible seizures/epilepsy.

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About the Author

Jeremy Slater, M.D., has worked in the field of epilepsy for more than 27 years and currently serves as the Chief Medical Officer for Stratus. He served as the director of the Texas Comprehensive Epilepsy Program from 2004 through 2017, growing the center from a single neurologist and neurosurgeon to one of the largest epilepsy surgery programs in the country. Dr. Slater earned his medical degree at the University of Pittsburgh School of Medicine, in Pittsburgh, PA. He completed his residency in neurology followed by a fellowship in epilepsy and clinical neurophysiology at the University of Miami School of Medicine in Miami, FL.

References

1. Shafer PO, Buelow JM, Noe K, Shinnar R, Dewar S, Levisohn PM, Dean P, Ficker D, Pugh MJ, Barkley GL. A consensus-based approach to patient safety in epilepsy monitoring units: recommendations for preferred practices. Epilepsy Behav. 2012;25(3):449-56. Epub 2012/09/25. doi: 10.1016/j.yebeh.2012.07.014.
2. Oppenheimer SM, Cechetto DF, Hachinski VC. Cerebrogenic cardiac arrhythmias. Cerebral electrocardiographic influences and their role in sudden death. Archives of neurology. 1990;47(5):513-9. Epub 1990/05/01. doi: 10.1001/archneur.1990.00530050029008
3. Nei M, Ho RT, Sperling MR. EKG abnormalities during partial seizures in refractory epilepsy. Epilepsia. 2000;41(5):542-8. Epub 2000/05/10. doi: 10.1111/j.1528-1157.2000.tb00207.x.
4. Verrier RL, Schachter SC. Is heart disease in chronic epilepsy a consequence of seizures or a fellow traveler? Epilepsy & Behavior. 2018;86:211-3. doi: 10.1016/j.yebeh.2018.06.027