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Routine EEG.doc.doc

  1. 1. CEC Website Section E: Programs and Services 1. Tests and Treatments a. Office Evaluation and Consultation b. EEG • Routine EEG • Ambulatory EEG • Video EEG Monitoring • Video or Routine EEG with additional electrodes 1. Sphenoidal Electrodes 2. Subdural and Depth Electrodes 3. Foramen Ovale Electrodes 4. Nasopharyngeal Electrodes c. Neuroimaging • MEG/MSI • CT Scan • MRI • MRS • SPECT • PET • fMRI d. Bain Mapping • Wada test
  2. 2. • Functional mapping through cortical stimulation e. Neuropsychology Testing (link to Neuropsychology main page) f. Surgical Therapy • Temporal Lobe Resection • Extra-temporal Epilepsy Surgery • Corpus Callosotomy • Lesionectomy • Hemispherectomy • Multiple Subpial Transections • VNS g. Sleep Center Testing 2. Pediatric Comprehensive Epilepsy Program 3. NYU Cognitive Neurology Program 4. Neuropsychology Service 5. Tuberous Sclerosis Center 6. Women’s Epilepsy Program 7. International Patient Services 8. FACES
  3. 3. 1. NYU Epilepsy Center Tests and Treatments The Comprehensive Epilepsy Center offers a broad range of neurophysiological studies for the diagnosis and treatment of epilepsy. These include electrophysiology studies such as electroencephalography (EEG) and magnetoencephalography (MEG), brain mapping studies, and neuroimaging, and they provide physicians with detailed information about abnormal electrical activity in the brain. These studies support the Center's leading role in the surgical treatment of adult and pediatric epilepsy. a. Office Evaluation and Consultation b. EEG • Routine EEG • Ambulatory EEG • Video EEG Monitoring • Video or Routine EEG with additional electrodes 1. Sphenoidal Electrodes 2. Subdural and Depth Electrodes 3. Foramen Ovale Electrodes 4. Nasopharyngeal Electrodes c. Neuroimaging • MEG/MSI • CT Scan • MRI • MRS • SPECT • PET • fMRI d. Bain Mapping • Wada test • Functional mapping through cortical stimulation e. Neuropsychology Testing
  4. 4. f. Surgical Therapy • Temporal Lobe Resection • Extra-temporal Epilepsy Surgery • Corpus Callosotomy • Lesionectomy • Hemispherectomy • Multiple Subpial Transections • VNS g. Sleep Center Testing
  5. 5. A. Office Evaluation and Consultation Includes a detailed medical history, a general medical examination, and a neurological examination (link to Diagnosing Epilepsy
  6. 6. B. EEG Electroencephalography (EEG), a neurophysiological study technique that has been in use for over 75 years, is a recording of the electrical potentials generated by firing neurons in the cerebral cortex. The EEG is used primarily for seizure diagnosis, although it can provide helpful information for other disorders. It is an important component of the evaluation for epilepsy surgery, which may require invasive monitoring to define the seizure onset zone and crucial functional areas. - Routine EEG - Ambulatory EEG - Video EEG Monitoring - Video or Routine EEG with additional electrodes: o Sphenoidal Electrodes o Subdural and Depth Electrodes o Foramen Ovale Electrodes o Nasopharyngeal Electrodes Routine EEG Preparation for the EEG: What to Expect The routine EEG is the most common test for epilepsy. The EEG technologist first measures the patient’s head so that the electrodes, which are small, metal, cup-shaped disks attached to wires, can be placed in the correct position. A wax crayon, which can be easily washed off later, is used to mark the points on the scalp. Next, the technologist applies the electrodes, usually using a paste that holds them in place for up to several hours. The technologist often scrubs each position on the scalp with a mildly abrasive cream before applying the electrodes. This will help improve the quality of the recording. The electrodes only record the brain waves. They do not stimulate the head with electricity, and pose no danger to the patient. The EEG machine then records the brain waves as a series of squiggly lines called traces. Recordings on paper are now commonly being replaced by computerized, paperless EEGs. During the EEG: What to Expect The patient may fall asleep briefly during a routine EEG, because the room is quiet and often dimly lit. That is fine and is often helpful, because an EEG obtained during both wakefulness and sleep may provide extra information. During the EEG, the technologist may ask patients to open and close their eyes several times, may shine flashing lights into their eyes (photic stimulation), or may ask them to breath rapidly or deeply (hyperventilation). Patients who have a medical problem, such as asthma or heart disease, which makes it unsafe to hyperventilate should tell the EEG technologist or the doctor. Similarly, pregnant women usually should not undergo hyperventilation or have photic stimulation. In some cases, the doctor may ask the patient to stay up the entire night before the EEG is performed. This sleep deprivation can increase the likelihood that epilepsy waves will be recorded. If the patient experiences any possible seizure symptoms during the test, he or she should tell the technologist. Routine EEG in Children: What to Expect Obtaining an EEG in children is usually easy, but it can pose a significant challenge. For babies, it is helpful to perform the EEG around naptime. Electrodes can be applied while the mother holds the child; a bottle may help to calm the baby. Then the baby is allowed to sleep naturally. Sedation is required for some babies and young children, to allow the technologist to apply the electrodes and to record sleep activity.
  7. 7. Children have difficulty lying still during EEG recordings, and the doctors who interpret these studies must separate the waves caused by movement and muscle activity from the brain waves. After the EEG: What to Expect After the EEG recording is done, the technologist will remove the electrodes from the patient’s scalp, and the patient is free to go home and wash the paste out of his or her hair. The paste is lanolin- or water-based, so it can be easily washed off. The doctor usually reads the EEG after the test is completed and the patient has left. Are there any risks to the test? The EEG has been used for many years and is considered a safe procedure. The test causes no discomfort. The electrodes only record activity and do not produce any electrical current. Skin irritation or redness may be present at the locations where the electrodes were placed, but this will generally wear off in a few hours.
  8. 8. Ambulatory EEG What is the purpose of an ambulatory EEG? The brain’s electrical activity fluctuates from second to second. The routine EEG provides a 20- to 40- minute sample of brain electrical activity, which is often sufficient. In some patients with epilepsy, however, this recording is normal or shows only minor, nonspecific findings. In such cases, an extended recording that includes long periods of wakefulness and sleep is desired. For example, in some people, epilepsy waves occur only once every 3 or 4 hours or only after an hour of sleep, and a routine EEG will almost always be normal. An ambulatory EEG, on the other hand, can record up to 72 hours of EEG activity with a special recorder that is slightly larger than a portable cassette player. This recorder allows you to go about your normal routine while the EEG is being recorded. Why do I need the test? Your doctor may order an ambulatory EEG for you for a number of reasons: • To diagnose epilepsy and determine what type of seizures are occurring. EEG is the most useful and important test in confirming a diagnosis of epilepsy. • Distinguish fainting spells from seizures. • To quantify the number of abnormal discharges or seizures in patients with epilepsy. • Evaluate periods of unconsciousness or memory loss. • Monitor how effective medications are. • Study events that occur sporadically. How is the test done? The first day of an Ambulatory EEG set up procedure lasts one hour. The EEG technologist will attach 16 to 25 flat metal discs called electrodes to different places on your head, using a special glue called collodion to keep them in place. The electrodes are connected by wires to a small recorder that amplifies and records the electrical activity inside the brain. You can wear the recorder on your waist, with the wire running either under or outside of their shirt. For people with a full head of hair, the electrodes can be fairly well camouflaged. Even so, most of you may prefer not to go to work or school with the electrodes on their scalp. You will be asked to keep a diary of activities during the day. Most recorders have an “event” button for patients to press if they experience any of the symptoms for which they are being tested, such as episodes of feeling “spacey” or confused. A family member should press the button if the patient is unable to do it. An ambulatory EEG test may last anywhere from 24 to 72 hours. Please do not take a shower during this time as water will damage the machine. An appointment will be made for the technologist to remove the electrodes from your scalp with acetone or similar solutions at the end of the test. You still may wish to wash your hair when returning home to remove any remaining paste. Are there any risks to the test? The EEG has been used for many years and is considered a safe procedure. The test causes no discomfort. The electrodes only record activity and do not produce any electrical current. Skin irritation or redness may be present at the locations where the electrodes were placed, but this will generally wear off in a few hours. How do I prepare for the test? • Wash your hair with shampoo but do not use a conditioner the night before the test. Do not use any hair care products, such as hairspray or gels. • Please have clean hair without any hair styling products, braids or weaves. • Eat your usual meals and take any needed medication prior to testing, unless otherwise instructed by your physician. • Do NOT use any stimulants (coffee, tea, cola, etc.) starting the night before the test.
  9. 9. Video-EEG Monitoring Our understanding of epilepsy has been greatly advanced by video-EEG monitoring, which allows prolonged simultaneous recording of the patient’s behavior and the EEG. The video and EEG images are usually presented on a split screen, permitting precise correlation between seizure activity in the brain and the patient’s behavior during seizures (Fig. 15). Video-EEG recordings can be done on hospitalized inpatients or on outpatients. Figure 14 from page 101 Inpatient monitoring with close supervision allows the doctor to reduce and, in some cases, discontinue antiepileptic drugs safely. The medication reduction and possibly sleep deprivation, hyperventilation, exercise, or occasionally alcohol intake are used to induce seizures. Video-EEG is most helpful in determining whether seizures with unusual features are actually epileptic, identifying the type of epileptic seizures, and pinpointing the region of the brain from which the seizures begin. This last step is critical in assessing a patient for possible epilepsy surgery. A patient who is going to have video-EEG monitoring should bring clothing to the hospital that can be buttoned, not pullovers. The patient should also bring reading materials and things to keep busy, as a prolonged hospital stay for monitoring can be boring. Video or Routine EEG with Additional Electrodes When is an EEG with additional electrodes necessary? Depending on the information the doctor is trying to obtain, additional electrodes may be needed. These include:  Sphenoidal Electrodes  Subdural and Depth Electrodes  Foramen Ovale Electrodes  Nasopharyngeal Electrodes Sphenoidal electrodes Like many epilepsy centers, NYU Comprehensive Epilepsy Center routinely records the EEG with sphenoidal electrodes. The electrodes are inserted into the cheeks with a needle to record brain electrical activity from regions deep within the temporal and frontal lobes. Many doctors apply a topical anesthetic to the skin before inserting the electrodes. The needle is immediately withdrawn after insertion, leaving in place a thin wire that is bare at the tip. The patient feels some discomfort during the insertion and for several hours afterward, particularly when yawning or chewing. The risks of using sphenoidal electrodes are rare and almost always minor. A small amount of bleeding may occur during the needle insertion, but it is rarely a problem. Other risks include the possibility of infection or of a tiny piece of the bare wire remaining in the cheek. Subdural and Depth Electrodes What are subdural and depth electrodes used for? Subdural and depth electrodes are used to record electrical activity directly from the brain, and they are often used to map precisely the area from which seizures arise.
  10. 10. Whether subdural or depth electrodes must be used depends on the findings from the noninvasive studies and another test called the intracarotid sodium amobarbital test, which we’ll describe later. For example, if the routine scalp-recorded EEG, video-EEG recording, neuropsychological testing, PET scan, and amobarbital test all point to the same area of the brain as the focus of the seizures, most epilepsy centers will proceed without using invasive electrodes. If the information is inconsistent or indefinite, however, subdural or depth electrodes, which are invasive, are often used. For example, the MRI may appear normal, neuropsychological tests and the PET scan may suggest an abnormality in the left temporal lobe, but the video-EEG may suggest that seizures begin in the right temporal area. With the use of subdural electrodes, the brain can be stimulated electrically for mapping of brain areas involved in language, movement, and other important functions. Seizures can occur with the electrodes in place, and care must be used to protect the patient, and therefore the electrodes, during and after the seizures. In many centers, invasive electrodes are used in an intensive care unit or similar setting. The electrodes may be left in place for several days to weeks, depending on the specific case and how quickly seizures occur after they are placed. What does insertion of subdural electrodes involve? Subdural electrodes consist of a series of metal electrodes embedded in plastic and arranged as a strip or a large grid. They cover a large area and record directly from the brain, without interference from the scalp and skull. An operation is required for placement of these electrodes. The dura mater is one of the layers of tissue covering the brain, and the word subdural means that the electrodes are placed on the brain underneath the dura mater, but they do not penetrate the brain. In some cases, several strips of electrodes can be inserted through a small hole drilled in the skull, called a “burr hole.” In other cases, a section of the skull is removed, the electrodes are put in place, and the skull is replaced. If the skull section is not immediately replaced, it is kept sterile and frozen, and the electrodes are covered with the dura mater, the scalp, and a surgical dressing. After the testing is completed, the piece of the skull that was removed is then replaced. There is a moderate amount of discomfort for several days after the subdural electrodes are placed on the brain. In general, the greater the number of electrodes that are used (especially the grids), the greater the headache. Medicine can be given for pain relief. The mapping procedures performed with subdural electrodes involve stimulation of the brain with mild electrical currents to temporarily activate or shut down certain brain areas. For example, activating the left motor cortex controlling movement in the right thumb can cause a series of jerks in this finger, or stimulating language areas in the temporal or frontal lobes can cause a person who is counting to suddenly stop speaking. The mapping procedure is almost always painless. If pain occurs, it is momentary and caused by the electrical stimulation, which can be stopped immediately. The major risks of subdural electrodes are infection (which increases during prolonged use, especially after 6 to 8 days), bleeding, and brain swelling. What does insertion of depth electrodes involve? Depth electrodes are thin, wirelike plastic tubes with metal contact points spread out along their length. Unlike subdural and other invasive electrodes, depth electrodes are placed directly into the brain, but they do not require that a large opening be made in the skull, as is need to place a grid of subdural electrodes. Depth electrodes are inserted through burr holes drilled in the skull. The patient is usually awake while the electrodes are being placed, but may be sleeping. The placement of depth electrodes can be painful, depending on the exact procedure that is used. In some centers, the electrodes are placed using a frame that attaches to the skull and allows a computer to assist in calculating the exact course of the electrodes in the brain. Attaching the frame can be painful. The pain associated with depth electrodes is usually mild or moderate, however, and lasts only hours, or occasionally, several days. Medication can reduce the discomfort. Depth electrodes provide the best recordings of seizures arising in areas deep in the brain, but they also carry some additional risks, especially bleeding within the brain. They are less likely than subdural electrodes to cause infection or brain swelling. Foramen Ovale Electrodes The foramen ovale is an opening in the skull near the temporal lobe. Electrodes can be inserted
  11. 11. into this opening to provide recordings of electrical activity of the lower and middle portions of the temporal lobe, an area from which seizures often arise. These electrodes are intermediate between sphenoidal and subdural or depth electrodes in the information they provide, their invasiveness, and their risk of complications. Overall, foramen ovale electrodes are well tolerated, and in selected cases they can provide important information about the origin of the seizures. One of the problems with them is that they record information from a very limited area of the brain. Therefore, the actual area from which the seizures arise may be missed. Nasopharyngeal electrodes Nasopharyngeal electrodes are used occasionally to record deep brain electrical activity. These electrodes are plastic tubes with a wire inside, ending as a blunt metal tip. The electrodes are inserted through the nose (usually by the EEG technologist) and the metal tip is situated in the upper back part of the nose (the nasopharynx). There may be some discomfort while the electrodes are inserted and less discomfort while they are left in place for approximately 20 to 30 minutes during the study. Nasopharyngeal electrodes have been used less often during the past few decades, because regular electrodes placed in front of and slightly above the ears can often provide the same information with no discomfort to the patient.
  12. 12. C. Neuroimaging - MEG/MSI - CT Scan - MRI - MRS - SPECT - PET - fMRI - Magnetoencephalography (MEG) MEG MEG is a new technology that non-invasively measures brain activity across the entire head utilizing sensors called SQUIDs (superconducting quantum interference devices) to evaluate the natural magnetic fields generated by the brain. NYU is the only medical center in New York equipped with MEG. What is MEG? Magnetoencephalography or MEG is a technique for identifying and analyzing brain activity based upon the normal magnetic fields generated by the brain. Although this technique has been available for several decades, it is only recently that scanners involving the whole head have been available. Because the physical properties of magnetic waves differ from those of electrical waves, MEG provides different, complementary information than the EEG. MEG recording is achieved using detectors that are placed near the head. The test is non-invasive, painless and safe. Unlike MRI, the patient is not exposed to any magnets; metal objects do not pose any risk to the patient, however, metal (magnetic) objects can produce artifacts. Even metallic flakes in make-up and hairspray can alter the signal, so it is important to avoid using these products the morning of a test. Pacemakers and vagus nerve stimulators will not be harmed or altered in any way by this study, however, the wires can produce artifacts and the physician and technologist should be made aware of these devices prior to the test. Insert Figure A from page 102 of Orrin’s Book The magnetic waves recorded between seizures can be mapped in three dimensions onto an image of the patient’s brain derived from an MRI or CT, referred to as magnetic source images (MSI). Insert Figure B from page 102 of Orrin’s Book Is MEG covered by insurance? MEG has been approved for clinical use by Medicare as well as the Food and Drug Administration. Presently, many insurance companies are covering MEG. However, this is often on a case-by- case basis and may require efforts on the part of the patient, the patient’s epileptologist and the MEG center to coordinate this process. What is the primary reason MEG is used? MEG’s primary clinical use focuses on two areas: localizing the area or areas from which seizures arise in patients with epilepsy and identifying regions of normal brain function (e.g. vision, hearing, sensation, movement, language) in patients preparing to undergo brain surgery either for epilepsy
  13. 13. or removal of a tumor or other mass lesion. MEG plays an important role in identifying the seizure focus in patients with epilepsy, particularly in those with seizures arising from areas other than the mesial (inner) temporal lobe. MEG also plays an important role in facilitating the planning of surgery and preservation of normal brain functions. Computed Tomography (CT) CT was introduced in the United States in the early 1970s and revolutionized the practice of neurology and neurosurgery. What is CT Like? Like x-rays, CT scans expose the patient to radiation, although the amount is low and the procedure is safe even if it needs to be repeated several times over the years. The scanner is a large machine, but the patient’s head is not in a confined space as with MRI, which is discussed next. The CT scan is normal in most patients with epilepsy. Brain abnormalities that might be detected are atrophy (a decrease in brain substance), scar tissue, tumors, abnormal blood vessels or abnormal spinal fluid circulation. Insert Figure 17 page 104
  14. 14. Magnetic Resonance Imaging (MRI) What is an MRI? MRI was first introduced in the United States in the early 1980s and further revolutionized the practice of neurology and neurosurgery. MRI is the most important neuroimaging test in epilepsy, because it shows excellent detail of the brain’s structure, even more than CT. The MRI does not use x-rays, but rather uses a powerful magnet that changes the spin on atomic particles that are normally part of the body, and then measures the changes in the magnetic field as the particles resume their previous course. The patient does not feel anything. The images are a remarkably accurate representation of the brain’s structure. MRI is extremely helpful for identifying brain scar tissue, areas of abnormal brain development (dysplasia), small brain tumors, blood vessel abnormalities, and changes in the brain’s white matter. Insert Figure 17 page 105 What Is It Like? Although the MRI is safe and painless, most MRI machines require that the person’s head and upper body be placed in a very confined space. People with claustrophobia (fear of small places), and many who never knew they were claustrophobic, may become frightened and uncooperative when they see the confinement required for the test. Medications for relaxation can be given (children often require medications to put them to sleep), or a newer type of MRI machine (“open MRI”), which is not so confining, can be used. At present, however, the scans from open MRIs are not as detailed as those of the regular MRIs, and this difference can be important for patients being considered for epilepsy surgery. Also, patients will notice that MRI machines emit loud noises, and the MRI technician will often offer the patient earplugs for their comfort.
  15. 15. Magnetic Resonance Spectroscopy (MRS) This technique utilizes a standard magnetic resonance imaging (MRI) machine to analyze the molecular components of a region of tissue in the brain non-invasively. MRS techniques largely focus on the hydrogen or phosphorus atoms which are components of living tissue to characterize and quantify certain molecules within a tissue region which can, in turn, be utilized to gauge the energy stores or utilization in a region or the ratio of neuronal to non-neuronal tissue. This technique has been employed to non-invasively differentiate between tumors, strokes and other lesions (e.g. demyelinating lesions). It has also been utilized in patients with epilepsy to better identify the focus or foci of a patient’s seizures.
  16. 16. SPECT SPECT (single-photon emission computed tomography) shows the blood flow in the brain. A safe, very low-level radioactive compound is injected into the patient’s arm, and the particles it emits are measured. The more blood that flows through a certain area, the more particles are emitted. The result is displayed as a picture with different colors representing different levels of blood flow. This test is readily available in most hospitals, but it is seldom needed routinely in epilepsy. SPECT scans obtained during or immediately after a seizure may show increased blood flow in the area where seizures arise. Scans performed between seizures can be misleading, however. New computer techniques allow doctors to measure the differences between SPECT scans taken during (“ictal”) and those taken between (“interictal”) seizures to obtain "subtraction" SPECT images. These can be superimposed onto the patient's MRI in an effort to pinpoint the seizure focus. This technique may be most helpful when seizures begin outside the temporal lobe and MRI scans do not show a structural abnormality. What to expect? Your doctor may want you to undergo “ictal” SPECT—or a SPECT scan obtained during a seizure. The test isn’t actually performed during the seizure, but the goal is to have the tracer injected during a patient’s seizure. Therefore, this study usually occurs during the video EEG monitoring stay. Usually, the tracer can be used during a certain period of the day (most often between 9 am and 3 pm). The nurse is often instructed to hold all seizure medications to increase the likelihood that a patient will have a seizure. The patient will be very closely monitored during that period for any early signs of a seizure; as soon as the seizure occurs, the nurse will inject the tracer into the IV in the patient’s arm. The patient will then typically be given the morning dose of medications and will be sent to the radiology department for the scan. The SPECT machine is neither loud nor confining like the MRI machine and imaging is painless to the patient.
  17. 17. PET What is a PET SCAN? PET (positron emission tomography) is a technique that shows the brain's use of oxygen or sugar (glucose). As with SPECT, a very low, safe dose of a radioactive substance is injected into the patient’s arm and the scanner records its circulation. Not all types of PET scans look alike, but often different colors are used to show areas of higher or lower use of oxygen or sugar. What is A PET SCAN Used for? This test can help to identify the area of the brain from which partial seizures arise. It may be performed in the period between seizures, the interictal period. Unlike the SPECT, PET testing can be done on an outpatient basis, as it is not necessary to perform this test on a patient during or immediately after his or her seizure. ARE PET SCANS COVERED BY INSURANCE? PET scans are expensive, and are needed in very few patients with epilepsy. Many insurance companies will pay for PET scans for patients who are being evaluated for epilepsy surgery.
  18. 18. Functional Magnetic Resonance Imaging (fMRI) Functional magnetic resonance imaging (fMRI) utilizes a standard magnetic resonance imaging (MRI) machine to identify regions of cerebral function during specific tasks. The test measures changes in blood oxygen levels associated with increased blood flow to regions of active brain function during a particular task. Physicians and scientists design protocols in which a patient performs a task repetitively to activate a particular area of brain (for instance, lifting the left index finger). By analyzing this data, the region or regions of brain involved in performing the task can be identified. This test is increasingly being utilized, like magnetoencephalography (MEG), in the pre- operative planning of patients undergoing neurosurgical procedures in regions near functional cortex.
  19. 19. D. Brain Mapping Brain mapping procedures are undertaken to identify areas of functionally eloquent brain, to enable the epilepsy surgeon to remove epileptogenic brain safely. They can also provide clues to the location of the seizure focus.  Wada Test  Functional mapping through cortical stimulation The Wada Test What is the Wada test? The Wada test, officially know as the intracarotid sodium amobarbital test, looks at memory and language functions by putting one cerebral hemisphere to sleep with a short-acting anesthetic called amobarbital, and studying what functions are still working in the other hemisphere. What happens during the Wada test? The test begins with an angiogram, a test that examines the flow of a dye through the blood vessels. A thin plastic tube (catheter) is introduced through an artery in the inner portion of the upper thigh. A local anesthetic is given to numb the area, and a needle is then inserted into the artery. The tube is threaded through the needle, and the needle is removed. There is some mild discomfort during the local anesthesia, but the rest of the test is painless. The tube is guided up to the carotid artery in the neck. A small amount of contrast dye is injected through the tube into the artery, and x-rays are taken to study the flow of blood in the brain. Some warmth or flashing lights may be experienced with the injection of the dye. Next, the radiologist injects the amobarbital, which quite literally puts almost half of the cerebral hemisphere to sleep for several minutes. Immediately after the amobarbital injection, tests are given to see how well language and memory are working with half of the brain sleeping. This provides information on the functions of the cerebral hemisphere that is sleeping and the hemisphere that is awake. The same procedure is usually repeated on the opposite side after a delay to ensure that the patient’s level of alertness has returned to normal. Most centers wait 30 to 60 minutes, and some wait a day Is the Wada test safe? Like any other test involving a cerebral angiogram, this test has the possibility of causing a stroke, but the risk is extremely low. The risk is greatest, but still quite low, in older people with atherosclerosis (a disease in which arteries are partially or completely clogged). Functional Mapping Through Cortical Stimulation What is functional mapping through cortical stimulation? This type of mapping is intended to localize precisely areas of brain that are crucial for language, motor, sensory, and visual functions. What happens during functional mapping through cortical stimulation In this method, electrical current is applied for a few seconds to a small area of the brain surface, either through implanted intracranial electrodes or via a probe placed on the brain’s surface by the surgeon intraoperatively. While the current is on, specific functional testing is carried out to identify done which functions are compromised by the stimulation, thus creating a “map” of the brain’s surface that is used to determine the areas that are safe to remove. Testing can be done either at the bedside or in the operating room with the patient awake.
  20. 20. E. Neuropsychology Testing (link to Neuropsychology main page)
  21. 21. F. Surgical Therapy • Temporal lobe resection (link to section in “Epilepsy Surgery”) • Extra-temporal epilepsy surgery (link to section in “Epilepsy Surgery”) • Corpus Callosotomy (link to section in “Epilepsy Surgery”) • Lesionectomy (link to section in “Epilepsy Surgery”) • Hemispherectomy (link to section in “Epilepsy Surgery”) • Multiple Subpial Transections (link to section in “Epilepsy Surgery”) • VNS (link to VNS)
  22. 22. G. Sleep Center Testing Our center is affiliated with The New York Sleep Institute (NYSI), a state-of-the-art facility offering comprehensive testings and treatments for patients with sleep disorders. Specifically, the center provides epilepsy patients with a complete evaluation of their sleep problems by a board-certified specialist in sleep medicine with access to the most advanced diagnostic modalities. The NYSI can evaluate patients of all ages and works collaboratively with many other disciplines. Researchers at the NYSI are investigating different aspects of sleep in epilepsy patients with a special emphasis on children. Some of the testing services offered include: Nocturnal Polysomnography (Diagnostic) A polysomnogram or sleep study is a non-invasive test which records your sleep pattern, breathing, oxygen level, heart rate and rhythm, and muscle tone while you sleep overnight. Nocturnal Polysomnography with Nasal Continuous Positive Airway Pressure (CPAP) Overnight sleep testing performed in accordance with current standards of practice, with nasal CPAP added and adjusted to therapeutic pressures. Split-Night Polysomnography Overnight testing that is split between a diagnostic period, usually at the beginning of the recording, and a nasal CPAP period. Nocturnal Seizure Recording Multi-channel EEG recording performed in order to evaluate sleep-related seizures. Multiple Sleep Latency Test (MSLT) A test that involves a series of daytime nap opportunities in order to evaluate daytime sleepiness. The MSLT is desirable for evaluation of daytime sleepiness, and is particularly required for the evaluation of narcolepsy. Maintenance of Wakefulness Test (MWT) A daytime challenge test in which the patient is given multiple opportunities to nap, but instructed to remain awake during the recording period. The MWT often provides valuable information relevant to the patient’s ability to sustain wakefulness in occupational settings or when performing critical tasks (e.g., driving). For more information, please visit the New York Sleep Institute website. (link to
  23. 23. 2. Pediatric Comprehensive Epilepsy Program The Pediatric Comprehensive Epilepsy Program specializes in the evaluation and treatment of children with epilepsy. The program is committed to providing multidisciplinary care, recognizing that a child with epilepsy and his or her family often have complex and diverse problems that cannot be solved by a single person. The team includes pediatric epileptologists (neurologists who specialize in epilepsy), neurosurgeons, psychiatrists, nurses, social workers, psychologists, and child life therapists. The goal is a simple one: The restoration of quality of life to children and adolescents with epilepsy. Epilepsy is a common medical condition, affecting 0.5-1 percent of all children. Each year 150,000 children and adolescents in the United States will have a newly occurring single seizure. Thirty thousand of these individuals will be diagnosed with epilepsy (1), which is characterized by repeated seizures. The highest incidence of epilepsy is in the first year of life; often the seizures that occur in infancy are severe and damaging. Appropriate classification of the epileptic condition is the cornerstone of therapy. With appropriate classification, most children with epilepsy are well controlled on one antiepileptic medication without side effects. There are, however, a significant number of children whose epileptic conditions are resistant to medical treatment, in which case epilepsy surgery can be a highly effective option. Our Pediatric Epilepsy Team Our pediatric epileptologists, Dr. Daniel Miles, Dr. Josiane LaJoie, Dr. Rolando Sousa, Dr. Orrin Devinsky, Dr. Ruben Kuzniecky, and Dr. Blanca Vazquez, specialize in caring for children and teenagers who have seizures, and are renowned for their expertise. Our pediatric epilepsy team also includes world-renowned pediatric neurosurgeon, Dr. Howard Weiner. He is a pioneer in the field of surgery for children with epilepsy as well as for those with Tuberous Sclerosis. His surgical success rate demonstrates a track record of exceptional results and an extremely low complication rate. Due to the cosmetic techniques he uses, there is almost no visible scar from the surgery. Dr. Weiner was an award-winning medical student, has presented at National and International Conferences, and has published extensively in journals such as Epilepsia, the Journal of Child Neurology, Neurosurgery, Journal of Neurosurgery, Journal of Pediatric Neurosurgery, and Plastic and Reconstructive Surgery. Our pediatric epilepsy team also includes a pediatric pharmacist, pediatric neuroradiologists, a pediatric neuropsychologist, pediatric epilepsy nurses and EEG technicians. The Pediatric Epilepsy Unit operates year round and services are available in both English and Spanish. Our Pediatric Epilepsy Unit The Tisch Hospital Pediatric Epilepsy Unit features state-of-the-art technology. Children undergo video-EEG monitoring in a comfortable setting and are cared for by friendly and experienced staff. In addition to eight hospital beds dedicated to children and teenagers, the unit also has two neonatal beds for our youngest patients. The playroom is one of the few recreation areas in the United States where children can be monitored while they take a break from their hospital bed. Our part-time recreational therapist uses creative techniques like art therapy, music therapy, and horticulture therapy. Tutors can spend an hour or two with each child daily. A library in the unit also has books, videotapes, DVDs, and video game consoles for children to enjoy. Articles of Interest Behavioral Issues in Children with Epilepsy - By Nidia Ortiz, RN, PNP Are Seizures Bad for the Brain?- By Souhel Najjar, M.D. Ten Common Misconceptions About Childhood Epilepsy - by Daniel Miles, MD Talking To Your Child About Epilepsy - FACES Newsletter FACES Pediatric Resource Handbook
  24. 24. Surgery for Children Quick Facts: • As many as 20% of children with epilepsy could benefit from epilepsy surgery. • More than 90% of children who have epilepsy surgery stop having seizures entirely or see a reduction in the number of seizures. • Studies have shown that the earlier in a child’s development that surgery is performed, the better the outcome. • The NYU Epilepsy Center has done more pediatric epilepsy surgeries with better results than any other epilepsy center in the Northeast. Pediatric Epilepsy Surgery at NYU The NYU Comprehensive Epilepsy Center is one of the largest medical treatment centers for children with epilepsy in the United States. During the past 6 years, more than 250 brain surgeries have been performed for children with epilepsy. The average age of these children is 5 years old. Due to our tremendous successes treating children that were not considered surgical candidates by other centers, we have earned an International reputation for taking on the most difficult cases. Types of Epilepsy Surgeries Performed Some of the types of surgeries performed at NYU include temporal lobe resections, corpus callosotomy, lesionectomy, hemispherectomy, extra-temporal resections, stereotactic ablations and stimulation, multiple subpial transections, surgery for patients with Tuberous Sclerosis and Vagus Nerve Stimulation Therapy (VNS). Pediatric Epilepsy Surgery Support Services Finding A Cure for Epilepsy and Seizures (FACES) is a non-profit organization within the NYU Comprehensive Epilepsy Center whose mission is to fund epilepsy research, education and awareness, and community building events for people with epilepsy, with a special emphasis on children and teenagers. FACES Respite Care Volunteers are available to allow parents to leave the child’s bedside for a few hours. The Respite Care Program is especially helpful for single parents and parents who need to run a few errands or to take a short break from the hospital. The FACES apartments are also available free of charge for the parents of children seeking treatment at the NYU Comprehensive Epilepsy Center. The apartments help families traveling from far distances for medical treatment lasting from one week to two months. The FACES apartments typically have 2-3 month waiting list, so please call early for best availability. For more information on the Respite Care Program and FACES, please contact: Finding A Cure for Epilepsy & Seizures (FACES) at NYUMC 724 Second Avenue, LL New York, NY 10016 (212) 871-0245 Additional Information For more information about the NYU Pediatric Epilepsy Surgery Program, please contact 212.263.8871.
  25. 25. 3. The NYU Cognitive Neurology Program Brain disease can cause intellectual impairments of profound complexity. The diagnosis and management of the cognitive and behavioral impairments accompanying diseases such as epilepsy, stroke, Alzheimer's disease, traumatic brain injury, or systemic illness often require an integrated approach by a team of multidisciplinary experts. The NYU Cognitive Neurology Program is an out-patient specialty clinic dedicated to providing state-of-the-art diagnosis and treatments for adults with brain-based memory, perceptual, cognitive, or emotional impairments. The NYU Cognitive Neurology Program is also committed to conducting varied clinical investigations in this area. The NYU Cognitive Neurology Program is staffed by a diverse group of specialists: neurologists with expertise in behavioral neurology and epilepsy, a neuropsychiatrist/ psychopharmacologist, senior clinical research neuropsychologists, clinical psychologists, clinical research nurse specialists supervising drug trials, and clinical social workers experienced in neurological disease. Our specialists work closely with other branches of the Department of Neurology at NYU Medical Center and have close ties with the Rusk Institute for cognitive rehabilitation and speech therapy. Patient Care Services Offered Referral Information Patient Care The NYU Cognitive Neurology Program specializes in the diagnosis and care of patients with the following conditions: Epilepsy Memory disorders Language impairments (aphasias) Alzheimer's disease Parkinson's disease and other degenerative disorders Problems with attention, memory, perception, language, personality, and emotions due to stroke, head trauma, multiple sclerosis, alcohol abuse, epilepsy, or systemic illness Tourette's syndrome and attention deficit disorder Psychological or psychiatric disorders due to brain disease Services Offered Behavioral Neurology A behavioral neurology evaluation at the NYU Cognitive Neurology Program includes: A thorough review of the patient's history, past neuroimaging, and present status. A neurological examination including assessment of higher cortical functions such as memory, language, attention, high level visual function, judgment, and comportment. Development of a treatment plan and provision of long-term follow-up when necessary. Further diagnostic testing as appropriate including MRI or CAT scanning, functional imaging with MRI or SPECT, EEG and/or long term monitoring.
  26. 26. Additional Cognitive Neurology Program core services include: Neuropsychology Formal evaluation of patients employing a series of quantitative tests of cognitive function. The neuropsychologic profile is used to confirm a diagnosis, assess potential for rehabilitation, and measure change over time in response to treatment. Neuropsychiatry Evaluation and determination of psychopharmacologic interventions for mood disorders and behavioral problems associated with neurological diseases. Individual and Family counseling Clinical psychologists address the management of cognitive deficits in daily living activities and the development of effective coping strategies. Cognitive Rehabilitation At the Rusk Institute, multi-dimensional cognitive rehabilitation is designed to maximize the functional status of the patient. Clinical Social Work Psychosocial assessment and treatment for patients and caregivers. A case manager networks parents and families to appropriate community resources and coordinated care planning. Ongoing Research The NYU Cognitive Neurology Program is actively recruiting patients with memory disorders due to traumatic brain injury and/or epilepsy that are otherwise healthy and are interested in participating in medication trials. Non-pharmacological approaches to cognitive remediation in epilepsy (i.e., education, yoga, behavioral strategies) are also being studied. Other areas of research interest include functional imaging of recovery of language, motor function, and visuospatial neglect from focal or traumatic brain injury. Referral Information Cognitive Neurology Program NYU Comprehensive Epilepsy Center 403 East 34th Street, 4th floor New York, N.Y. 10016 Orrin Devinsky, M.D. Oliver Sacks, M.D. Neuropsychiatry/Psychopharmacology Ken Alper, M.D. Neuropsychology
  27. 27. William Barr, Ph.D. Chris Morrison, Ph.D. William McAllister, Ph.D.
  28. 28. 4. Neuropsychology Service - Landing Page - Memory Disorders - Frequently Asked Questions - What is a Neuropsychologist - What is Neuropsychology Testing? - Neuropsychology Training - Neuropsychology Lectures and Seminars - Neuropsychology Research Neuropsychology Service (on landing page) The Neuropsychology Service provides a range of services to adults and children receiving treatment at the Comprehensive Epilepsy Center. Services for adults with epilepsy include neuropsychological testing and a group- oriented approach to memory treatment. Information from standardized testing helps identify difficulties in cognition and/or behavior that might influence a patient's diagnosis and treatment. Pediatric services include assessment of cognitive and behavioral disorders related to epilepsy, in addition to evaluations of learning and communication issues relevant to performance in a school setting. Neuropsychological testing also provides detailed information for adults and children who are considered surgical candidates. The test results will help determine strengths and weaknesses and provide a baseline to measure postsurgical functioning. Members of the neuropsychology service also perform a range of specialized procedures for surgical candidates, including the Wada Test (link to wada test in “testings and services”) and Brain Mapping (link to brain mapping in “testings and services”) of language zones. All of these services are offered in both English and Spanish. Other Clinical Services The Neuropsychology Service welcomes referrals from neurologists, psychiatrists, and other medical professionals from NYU Medical Center and the community at large. All of our staff neuropsychologists have extensive training in neuropsychological assessment of a variety and are board certified through the American Board of Clinical Neuropsychology. Services are provided to patients receiving treatment through this center’s Cognitive Neurology Program. These include neuropsychological testing of memory disorders, dementia, and other neurobehavioral syndromes. Our adult neuropsychologists accept referrals from the community for evaluation of similar issues. Specialized services involving forensic evaluations and assessment of sports concussion are also available. Our pediatric specialist also accepts referrals from local schools and pediatricians, for assessment of language, learning, and attention deficits in children.
  29. 29. Diagnosis and Treatment of Memory Disorders in Epilepsy Many people with epilepsy experience memory difficulties. The symptoms are typically caused by a combination of neurobiological factors, including the underlying cause of the epilepsy and side effects resulting from treatment. In some cases, the memory disturbance may become severe enough to disrupt the individual’s ability to function in the workplace or to perform common activities in the home. In these cases, a referral to a behavioral neurologist or a clinical neuropsychologist may be required for further delineation of the problem and to establish a treatment plan. An examination by a behavioral neurologist involves more detailed evaluation of memory than what is typically received in a routine neurological visit. In some cases, the patient is referred for neuropsychological testing, which involves another appointment for completion of a 4-6 hour battery of standardized tests. This testing provides an objective means for measuring the severity of the disorder by determining how the individual’s scores on memory tests differ from what is expected, given their age and demographic background. Many ask the question of whether any drugs have been found to be effective for improving memory. At this time, there is no evidence of any “wonder drug” that has been found to effectively reverse the effects of memory decline. The only FDA-approved medications for memory are limited to the treatment of elderly patients at risk for developing Alzheimer’s disease. Preliminary evidence suggests that these drugs are not likely to be effective for treating memory difficulties in younger patients with conditions such as epilepsy. However, there is a possibility that other drugs, such as the psychostimulants used to treat narcolepsy and/or ADHD, will prove to be more effective for treating memory disorders in younger age groups. Cognitive remediation is the term that is used to describe a type of therapy emphasizing enhancement of cognitive skills and development of strategies for adapting to impairments in functions including memory. This therapy is conducted either individually or in a group format by a neuropsychologist or another qualified health professional. Most of the existing cognitive remediation techniques have been developed for use with victims of traumatic brain injury. Very little information exists on whether these techniques are helpful for patients with other neurologic conditions, including epilepsy. Efforts are now underway to develop group remediation techniques aimed at treating the specific types of memory difficulties experienced by people with epilepsy. Participants in these groups are encouraged to share their experiences with memory and epilepsy. Group activities include a psychoeducational program on memory, brain functions, and the various ways that epilepsy may affect one’s memory. There is also specific instruction on the use of external memory devices, including notebook systems, calendars, electronic organizers, and alarms and on the use of internal strategies, including association techniques and the use of imagery for helping memory. Patients receive homework assignments based on techniques learned in the group. For more information about memory groups for patients with epilepsy, call NYU Comprehensive Epilepsy Center at 212-263-8317. Frequently Asked Questions What is a Neuropsychologist? A neuropsychologist is a doctoral level psychologist who has received specialty training in evaluating and treating patients with various neurologic and psychiatric conditions. Neuropsychologists at the Comprehensive Epilepsy Center have particular experience in working with patients with epilepsy. They provide important information to the neurologist and the treatment team regarding the patient's cognitive and behavioral functioning. Services offered by neuropsychologists at the Comprehensive Epilepsy Center include neuropsychological testing, the intracarotid sodium amytal procedure (Wada Test), and Brain Mapping. Neuropsychology staff members also provide a range of treatments including individual
  30. 30. psychotherapy, group psychotherapy, and cognitive remediation. What is Neuropsychological Testing? Neuropsychological testing involves taking a battery of standardized of attention, memory, language, and other cognitive functions. The tests also include more general measures of intellectual functioning and behavior. The tests provide important details about cognitive and behavioral functioning. The results provide the doctor and treatment team with objective information regarding level of performance and the presence of any specific strengths or weaknesses in cognitive functioning or areas of concerns in other aspects of behavior. The nature of the testing depends on a number of factors, including the nature of the epilepsy and the treatment plan. The types of tests administered are also determined by the age, level of development, and background of the patient, as well as the ability to become engaged in the testing. A neuropsychological evaluation includes an interview, testing, and an opportunity to obtain feedback on the results. The examination typically takes between 3-5 hours to complete. These evaluations are performed routinely on patients undergoing inpatient monitoring at the Comprehensive Epilepsy Center. It can also be completed on an outpatient basis by appointment. For more information about neuropsychologists and neuropsychological testing (link to: Brochure from Division 40 (Clinical Neuropsychology) of the American Psychological Association on testing for adults. (link to: Brochure from Division 40 (Clinical Neuropsychology) of the American Psychological Association on testing for children. (link to Neuropsychology Training We offer a course of intensive training to graduate students enrolled in doctoral training programs who are interested in gaining specialized experience in neuropsychological assessment. Graduate students interested in internship training can receive supervised experience at our center through applying to the NYU/Bellevue Psychology Internship Program. We also offer a two-year full-time fellowship in clinical neuropsychology for individuals who have already received the doctorate degree. Click below to download additional information on our neuropsychology training programs: Externships in Clinical Neuropsychology (download PDF - NYU_Externship_2007.pdf) Epilepsy Center Rotation – NYU/Bellevue Psychology Internship Program Postdoctoral Residency in Clinical Neuropsychology (download PDF - NYU_Residency_2007.pdf) Neuropsychology Lectures and Seminars Weekly Seminars and Lectures in Clinical Neuropsychology at NYU Medical Center
  31. 31. A. Neuropsychology Case Conference Tuesdays, 11:00 AM @ Neurology Conference Room - 7th Floor, New Bellevue B. Neuropsychology Didactic Lecture Thursdays, 12:00 Noon @ NYU Child Study Center, First Floor Conference Room Schedule for additional conferences through the Department of Neurology Neuropsychology Research Neuropsychology staff members hold faculty appointments in the medical school’s Department of Neurology [link] and have active research programs with studies on the cognitive and behavioral issues related to epilepsy and other neurological and psychiatric conditions. A listing of our staff’s recent publications and presentations is provided below: Neuropsychology Faculty Studies – 2006 (link to “Neuropsychology Publications” pdf) Further information about Clinical Neuropsychology can be found at the following links: American Academy of Clinical Neuropsychology (AACN) American Psychological Association (APA) - Division 40 (Clinical Neuropsychology) National Academy of Neuropsychology (NAN) New York State Association of Neuropsychology (NYSAN) New York State Psychological Association (NYSPA) - Neuropsychology Division New York Neuropsychology Group (NYNG)
  32. 32. 5. The Tuberous Sclerosis Center The NYU Comprehensive Epilepsy Center has developed a comprehensive program that provides well-coordinated, multidisciplinary care for individuals with tuberous sclerosis. The Tuberous Sclerosis Center at NYU, organized under the direction of Dr. Daniel Miles and Dr. Orrin Devinsky, strives to work closely and collaboratively with the patient's pediatrician, internist, family practitioner and neurologist to provide the best possible care. Dr. Miles, the director of the pediatric epilepsy program at the NYU Medical Center, is a board-certified pediatric neurologist with particular interest in the treatment of epilepsy who has worked with children with TS for over a decade. Dr. Devinsky, the director of the NYU Comprehensive Epilepsy Center, is recognized as one of the top adult epileptologists in the country. Together with the eight neurologists, two neurosurgeons, four neuropsychologists, and five nurse practitioners of the epilepsy center, Drs. Devinsky and Miles have joined a dozen other specialists in the areas of child development, cardiology, dermatology, genetics, nephrology, ophthalmology, neuroradiology and psychiatry to guarantee complete care of all aspects of the tuberous sclerosis complex. The goal of the Tuberous Sclerosis Center at NYU is to assist the patient, the patient's family and the patient's primary care physician in managing the many needs of individuals with TS. The program ensures appropriate and timely follow-up care for patients in all specialty areas. The Tuberous Sclerosis Center is located within the NYU Comprehensive Epilepsy Center at 403 East 34th Street in Manhattan. To learn more about the center or to refer a patient for evaluation, please call (212) 263-8318. Tuberous Sclerosis Research Articles The Journal of Child Neurology 2004 Sep;19(9):687-9. Epilepsy Surgery in Young Children with Tuberous Sclerosis: Results of a Novel Approach Weiner HL, Ferraris N, LaJoie J, Miles D, Devinsky O. The Journal of Child Neurology 2004 Nov;19(11):847-52. Cognitive and Behavioral Correlates of Tuberous Sclerosis Complex. Zaroff CM, Devinsky O, Miles D, Barr WB. Parents who would be willing to discuss their child's surgery for Tuberous Sclerosis: Kyla Burns (daughter Haileigh) Haileigh's Story: Surgery for a Child affected by Epilepsy and Tuberous Sclerosis, by Linda Viscardis Alessandra Smeraldi (son Ricardo Maffi) Ricardo had multiple lesions, one near motor cortex, two separate tumors removed from left temporal and right parietal regions. Judy and Peter (daughter Hannah) Hannah’s Story
  33. 33. 6. Women Epilepsy Program A Comprehensive Approach The goal of the Women’s Epilepsy Program at NYU is to manage the many needs of women with epilepsy. Physicians at our center collaborate closely with the primary care physician, obstetrician/gynecologist and other specialists to provide comprehensive, multifaceted care to women with epilepsy. Highest Level of Care Women referred to the program—whether for diagnosis, treatment, or both—are seen by a full complement of specialists, including epileptologists, neuropsychiatrists, endocrinologists, and obstetrician/gynecologists. This team approach assures the patient of comprehensive, coordinated care in a safe and comfortable environment. Our goal is to promote the health and well-being of women with epilepsy. Expert Attention to Issues facing Women with Epilepsy Menstruation Contraception Preconception counseling Pregnancy Menopause Bone health Mental health Sexuality Antiepileptic drug management Faculty and Staff of the Women’s Epilepsy Program Epilepsy & Neurology Blanca Vazquez, MD Katherine Mortati, MD Epilepsy, Neurology and Psychiatry Siddhartha Nadkarni, MD Nursing Mary Miceli, RN
  34. 34. 7. Finding a Cure for Epilepsy and Seizures (FACES) Finding A Cure for Epilepsy and Seizures (faces), the non-profit arm of the NYU Comprehensive Epilepsy Center, has a vitally important mission – improve the quality of life of those affected by epilepsy through research initiatives, education and awareness, community-building events and more. We welcome you to learn more. Please visit our website to download our educational materials and newsletters, learn about research underway, view the upcoming lecture and fun community building event schedules, or give a tax-deductible donation.(Link to:
  35. 35. 8. The International Epilepsy Program The NYU Comprehensive Epilepsy Center has developed a worldwide reputation for epilepsy care. We provide multidisciplinary care for patients with epilepsy from around the world. The International Epilepsy Program at NYU is co-Directed by Ruben Kuzniecky, M.D. and Blanca Vazquez, M.D. with participation by all members of the NYU Comprehensive Epilepsy Center. The International Epilepsy Program strives to offer the international patient specialized care in accordance with their cultural background. Several of our staff are multi-lingual and have established excellent relationships with multiple epilepsy centers and neurologists around the world. The center is a referral source for patients from Latin America, the Caribbean and Europe. In addition to patient care, the International Epilepsy Program aims to facilitate the continuing medical education for physicians from other countries. The program organizes a symposium every year that brings neurologists from around the world to NYU. The program offers the most sophisticated and up to date neurological care including outpatient consultations, outpatient EEG, ambulatory EEG monitoring, video-EEG monitoring, high resolution MRI, magnetoencephalography, neuropsychological assessment and epilepsy surgery. The International Epilepsy Program is associated with the New York Sleep Institute - a dedicated facility for the study of sleep disorders in children and adults. Patient admissions, patient care, VISA requirements, and patient services are coordinated by the NYU Office of International Patients. The International Epilepsy Program is closely associated with several international government agencies that facilitate the referral of patients to NYU. The International Epilepsy Program is located within the NYU Comprehensive Epilepsy Center at 403 East 34th Street in New York, New York. To learn more about the center please call (212) 263-8327.