which is a consultation with a general neurologist or possibly a specialized epilepsy center if considered necessary and locally available. Many, and perhaps most, patients with seizures can be initially evaluated and managed at the first or second level of epilepsy care by a primary care physician or a general neurologist in their local community. If seizure control is obtained, no further specialized epilepsy evaluation may be necessary. If seizures persist and cannot be brought under control by the primary care provider within 3 months, further neurological intervention is appropriate; the neurologist should assume full management of the patient’s care at this point (Scheuer and Pedley, 1990). Once seizures are under control, care can be transferred back to the primary care provider.

NAEC recommends that referral to a level 3 or 4 specialized epilepsy center should occur when a patient’s seizures are not fully controlled with the resources available to the general neurologist after 1 year. This recommendation was included in a technical assistance document supported by a grant from the Centers for Disease Control and Prevention for state Medicaid programs in contracting with managed care plans for epilepsy services (GWUMC, 2002).

Level 3 and 4 epilepsy centers provide an interdisciplinary and comprehensive approach to the diagnosis and treatment of patients with epilepsy. The team typically includes neurologists and neurosurgeons, neuropsychologists, nurse specialists, electroencephalography (EEG) technologists, and other personnel with special training and experience in the treatment of epilepsy. The primary goal of the team is to achieve complete control or at least a reduction in the frequency of seizures and/or medical side effects in patients with refractory epilepsy. This is accomplished through a comprehensive epilepsy evaluation, which provides epilepsy specialists with the necessary information to formulate a treatment plan, whether medical, surgical, or through use of an implanted stimulator.

A comprehensive epilepsy evaluation may require an inpatient admission to the epilepsy center’s epilepsy monitoring unit (EMU). The evaluation is done to confirm a diagnosis of epilepsy seizures, to classify the type of seizures, and/or to determine if the patient would be a candidate for epilepsy surgery. It can include EEG monitoring with video (vEEG), cognitive testing, specialized brain imaging, and other procedures to determine the diagnosis and to prepare the most effective medical or surgical treatment plan. During hospitalization, withdrawal of seizure medications is often necessary to precipitate seizures in order to characterize them. In some cases, this may precipitate generalized tonic-clonic or severe seizure types that the patient is otherwise unlikely to experience, or it could precipitate status epilepticus. Balancing the need to provoke seizures but not induce status epilepticus requires expertise and intensive care. Seizures are recorded with vEEG and analyzed by an epileptologist and other members

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