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Easing the Journey to an Epilepsy Diagnosis

How one research team is taking an innovative approach to develop an epilepsy clinic using Telehealth and a portable EEG machine


From left to right: Chelsea Maskos EEG technologist at the Saskatchewan Epilepsy program (SEP), Pat Paulo administrative support at the SEP, Sareh Miranzadeh Master’s degree student involved in the project, Dianne Dash neurophysiology coordinator at Royal University Hospital, Dr. Lizbeth Hernández-Ronquillo epidemiologist at the SEP, Karen Waterhouse nurse at the SEP and Dr. José Téllez-Zenteno leader of the epilepsy research initiative

Facing a suspected epilepsy diagnosis can be complex and emotional for patients and their families and caregivers. Add in the need to travel long distances from rural and remote areas of Saskatchewan to reach specialists for diagnosis and treatment and this adds additional stress and costs to a patient’s journey.


Epilepsy is as common as five cases per 1,000 people and ranks as the second most commonly reported neurological condition worldwide. The incidence of new cases is also 2.1 times more frequent in northern Indigenous populations. These statistics outline a clear need for an innovative way for patients to access care in our province.


That’s where Dr. José Téllez-Zenteno and his research team come in to play. With funding from a Saskatchewan Health Research Foundation (SHRF) Collaborative Innovation Development grant, his team is investigating the use of Telehealth and a portable EEG device to see patients a little closer to home for the initial steps to diagnosis and decisions for an appropriate treatment plan.


The Saskatchewan Epilepsy Program (SEP) is located at Royal University Hospital (RUH) in Saskatoon. It is here that patients from across the province come for in-patient monitoring or possible surgical workups and to meet with neurologists and neurosurgeons for diagnosis and treatment.


“The time that it takes, not only the time the patient spends travelling, but the time it takes to arrange the travel, is a long time,” says Dr. Lizbeth Hernández-Ronquillo, epidemiologist in the epilepsy research initiative. “This Telehealth approach will mean that patients will be seen easier and faster. This research is working to prove the concept so that patients can be assessed, and they can have answers faster.”



Evolution of the electroencephalogram – EEG


“EEG is the gold standard test for epilepsy,” says Chelsea Maskos, EEG technologist in the SEP. “A lot of people don’t realize how limited of a resource that is.”


There is only one English-speaking school in Canada that trains technicians. To become a registered technician, it is a two-year program. Serving Saskatchewan is the SEP and one satellite lab located in Regina. The wait list to be seen by specialists is long.


So, what is an EEG and why is access an issue in our province?


EEG machines were once very large, sensitive machines that produced paper reports

Invented by German psychiatrist Hans Berger in 1924, an EEG, or electroencephalogram, catches the electrical activity, or brain waves, coming from our scalps. Traditionally recorded much like a polygraph, EEG machines historically were very large and used a lot of amplifiers and pens on paper to produce a large paper recording. These hefty reports would then need to be physically in front of a trained doctor to read and decipher. These machines were not portable, they were incredibly sensitive, and it would be difficult to get a nice clean recording. These large paper machines were used up until as recently as 2004.


Developments in technology have led to a somewhat more compact unit on a cart with a full CPU computer, an amplifier machine, a smaller headbox and about 30 wires that attach to the patient. The unit also includes a camera that records a video of the patients during EEG monitoring, allowing doctors to correlate the electrographic data with physical traits or symptoms that occur during the test. These units are still by no means portable and require the patient to come to the clinic for diagnosis.


Achieving the correct placement of the electrodes connected to each wire requires precise measurement by a technologist for each patient. Then you must apply a paste that scrubs the skin or causes micro-abrasions. This can be a source of infection and discomfort for the patient. The electrodes are then applied with a conductive gel and the patient’s head is wrapped up in a protective covering.


Pictured in the foreground is the new technology that replaces the need for all the materials pictured in the background currently needed to place wire electrodes on patients for an EEG.

More recently, there has been the invention of what is called a dry electrode system (ZETO-EEG). At first glance, the helmet holding these dry electrodes resembles a bike helmet. The embedded amplifiers and electrodes themselves look like small, soft, rubber-tipped wire probes. They are called dry electrodes because to ‘place’ the electrodes requires no abrasive paste or conductive gel. This new helmet also eliminates the need for measurement by providing a custom fit for each patient by simply tightening each section of the helmet.


“The helmet expands and contracts and still adheres to the standards for correct electrode placement,” says Maskos. “It’s much easier and quicker for the patient, requires less cleanup, and the helmet and its software have been developed in a way that it can be administered by an allied health professional.”


A Process of Validation


With any new technology or treatment approach, it’s important to validate that the method and results are consistent with traditional practice. The ZETO-EEG system is currently FDA approved in the United States, however, with differing standards in Canada, validation is the first step for the research team.


Karen Watherhouse, nurse coordinator of the SEP, explains that the plan to validate the technology and its potential use for Telehealth clinics in epilepsy in the future is to have 30 patients who had a single unprovoked seizure from the single seizure clinic, undergo the regular EEG, using the paste, gel and wire setup. These same patients will then have an EEG done using the dry electrode helmet and the results of both tests will be compared for accuracy.


In research, you need to start slow. That’s why the team is beginning the validation process before taking the technology further to rural and remote locations of Saskatchewan.


The research team is excited for the potential this innovative technology and approach holds for meeting the needs of patients across Saskatchewan. The transfer of information is a huge advantage with this new system. In real time, physicians and technologists with proper login can view the EEG and video recording at the same time that it is being administered.


“If you can see the patient via Telehealth and you have the EEG, you have everything you need for the initial assessment to plan further care and follow up,” says Téllez-Zenteno. “That is why we are working towards this.”


Benefits for the future


The increased accessibility is just the beginning of a long list of potential benefits that this innovative technology and approach could mean for the people of Saskatchewan. Looking at the big picture, using Telehealth for epilepsy will cut down on travel time and costs for individuals and for the health care system. It will lead to faster and easier diagnosis which in turn leads to reduced wait times to be seen in person by a specialist in clinic.


A second project, apart from the validation of the ZETO-EEG, includes patients who are referred to the SEP from Regina and the south of the province for a week-long stay in hospital to do continuous EEG for possible epilepsy surgery. These patients will be seen first trough Telehealth in order to assess the appropriateness of the investigation that cost $25,000.


“Though this approach won’t eliminate the need for further EEGs or visits to the clinic for further assessment, the accessibility of using Telehealth ensures that the patients coming in for these more thorough assessments are the right patients,” says Téllez-Zenteno.


“Another future goal is to train people from the community to be able to administer the portable EEG,” says Hernández-Ronquillo. “Techs from the north to be in the north.” This approach will help build the capacity of rural and remote communities in our province.


Most importantly is the impact this will have for patients. The ability to receive specialized care no matter your location in the province drastically reduce stress during what can be a complex time in a patient’s life. Telehealth for epilepsy can bring peace of mind and ease those first steps toward a diagnosis.


Telehealth could also increase safety for patients. Those who have had a seizure may have also had their license taken away or will have it taken away once they have been seen at the clinic. This further increases the difficulty of travelling for assessments and treatments.


“There can be a huge risk when you ask somebody with epilepsy or potential epilepsy to travel,” says Waterhouse. “If we can administer the initial assessment closer to home, that makes it much easier for the patient.”


“Epilepsy has been overlooked for a long time,” says Hernández-Ronquillo. “Epilepsy carries with it a lot of stigma and, though more common than other diseases, such as MS or Alzheimer’s disease, you don’t hear about it. One of the things that the SEP wants to do is remove the stigma around the disease.”


People who are facing a diagnosis of epilepsy can face problems with their jobs, in their personal lives, and in other areas. Adding travel can add stress. That is why this research and introduction of Telehealth for epilepsy could have a substantial impact on a patient’s quality of life during this time.


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