Joint military-civilian project allows 24/7 monitoring of patients with brain injuries

Army Col. Judith Lee, commander of Landstuhl Regional Medical Center, Germany, had electrodes connected to wires taped to her head on Aug. 28, 2014, while acting as the first test patient for the hospital's continuous electroencephalography, a tool neurologists can use to look for seizures in comatose patients.


By JENNIFER H. SVAN | STARS AND STRIPES Published: October 26, 2014

LANDSTUHL, Germany — Even to an untrained eye, it can be apparent when someone is having a seizure. A person falls to the floor, muscles may stiffen or twitch out of control; eyes may roll back or eyelids flutter.

But not all seizures are so dramatic or easily observed. “Silent” seizures can ripple across regions of the brain without any visible clues — and with potentially damaging effects.

Landstuhl Regional Medical Center in Germany recently became the first U.S. military hospital capable of detecting those nonconvulsive seizures through a diagnostic tool called continuous electroencephalography, or cEEG, thanks to a rare civilian-military medical partnership.

The digital recording of the electrical impulses in the brain gives neurologists a critical and early window into the cerebral function of patients after a traumatic brain injury, when they are in a state of altered consciousness — from mild confusion to a coma — and are thought to be more at risk of experiencing seizures.

Early seizure detection

Neurologists at Landstuhl say the tool will allow them to treat seizures that previously went undetected, an intervention they hope will stem further brain damage and improve a person’s long-term outlook.

“The idea is to use this advanced monitoring of the brain to detect seizures early on after a trauma,” said UCLA neurologist Paul Vespa, director of the brain injury program and neurocritical care unit at Ronald Reagan University of California, Los Angeles Medical Center and Operation Mend, a philanthropic group associated with the university that donated the $30,000 cEEG equipment to Landstuhl. “This technique is being done at our center and many civilian (neurointensive care) centers. It was not being done in the military at the time.”

“This isn’t necessarily a new technology but it’s a new application, a new approach to this,” said Army Maj. Anthony Frattalone, a neurointensivist and the chief neurologist at LRMC, “because Landstuhl for the past 12 years, we’ve been so busy, we have not been able to provide this round-the-clock sort of coverage.”

To pull off real-time, continuous monitoring, LRMC is teaming up with the neurology department at the UCLA medical center. The sharing of EEG data from LRMC through secure computer files will allow UCLA neurologists to monitor a Landstuhl patient’s brain activity in real time, 24 hours a day, if needed. If they saw something that looked like a seizure, they would immediately consult neurologists at LRMC to discuss the findings and come up with a possible treatment plan.

Vespa, who was the driving force behind the partnership, said UCLA began using cEEG in 1992. Over the years, the study of patients on cEEG has profoundly changed neurologists’ understanding of the injured brain, Vespa said.

About 20 percent to 25 percent of patients with a severe traumatic brain injury will have seizures, most likely within days after an injury, he said. “Most of those are silent.”

If left unchecked, seizures can further damage an already vulnerable brain. To what extent is not known, but doctors know that “seizures are bad for the brain over time,” Frattalone said.

They can lead to scarring of certain tissues and brain swelling, Frattalone said. Magnetic resonance imaging show the same types of changes in brain-injured patients who’ve had seizures as those with Alzheimer’s and other memory diseases, he said.

Studies that Vespa has been a part of back that up. “What we’ve seen in the civilian TBI world is that seizures make a big difference in terms of … physiology of the brain and long-term outcomes,” he said. “Patients who have early seizures have more brain cell loss long-term,” particularly in areas important for memory and language function, he said.

“We want to identify and stop these seizures,” Vespa said. “They are really a true secondary insult that can harm the brain after the initial trauma is over.”

Many obstacles

Vespa and others involved in the project chose LRMC for the cEEG partnership because of its proximity to the battlefield. The largest U.S. military hospital overseas is typically the first stop for servicemembers injured in the Middle East, Southwest Asia and Africa.

An earlier attempt to establish a cEEG study with TBI patients at Walter Reed National Military Medical Center in Washington in partnership with UCLA and Operation Mend failed because of concerns by the military about using servicemembers for research, Vespa said.

Setting up the cEEG program at LRMC took about two years. The slow-moving wheels of bureaucracy almost ground the effort to a halt, say those involved. A system giving civilian doctors access to military medical data, even though the only information to be shared were brain wave graphs — with patient identities kept anonymous — had to be vetted. Staff at UCLA involved in the project had to obtain security clearances, and there were technical issues to work through.

At one point, retired Army Gen. Peter Chiarelli, an outspoken supporter of Operation Mend and UCLA’s efforts to partner with military medicine, got involved.

Chiarelli said he offered to help after hearing about the project in 2013. “I have a Rolodex,” he said. “I put as much pressure as another person can put on anybody to have them look at this and have them move on this as quickly as possible.”

Chiarelli, the Army’s vice chief of staff for four years, said partnering with civilian hospitals needs to be easier. “We need to pull out all the stops to help our wounded warriors,” he said. “It really shouldn’t have taken as long as it did to get us to this point.”

In late August, LRMC successfully tested cEEG, with the hospital’s commander, Army Col. Judith Lee, standing in as the first test patient. Electrodes were stuck to her scalp, and her digital brain wave recordings were transmitted to a file that could be accessed by UCLA neurologists.

“I think it’s incredible,” Lee said. “There were a lot of obstacles. We hung in there, and here we are. It’s very exciting.”

Frattalone said UCLA is interested in how blast injuries affect the brain, which is different from the traumatic brain injury seen in the civilian population. Those more typically are TBIs from car accidents or gunshots.

“We see lots of different types of TBIs in the military environment than the civilian, and so that’s one of the reasons he was interested in collaboration,” Frattalone said of Vespa.

Whether LRMC will see those types of TBIs in significant numbers remains to be seen.

Medical staff at the hospital agree it would have been great to have cEEG capability a few years ago. During the height of the wars in Iraq or Afghanistan, LRMC was treating about 200 traumatic brain injuries per year, said Steven Cain, a certified physician’s assistant in general surgery and trauma, noting those numbers fluctuated depending on the situation downrange.

“Since the beginning of 2013, we’ve seen a fairly steady downward trajectory as far as trauma patients,” he said.

But cEEG is still valuable to LRMC, Cain said. “We don’t know what’s going to happen” regarding future conflicts.

Frattalone agrees.

“Even if we only help out a few people at the end of this conflict, that’s still good and worth it to me,” he said. “We’re trying to improve our care and provide something even better than what we’ve done before.”

The program isn’t just for TBI patients, Frattalone said. Just before the program was ready to go, a Special Forces soldier from Africa was treated at Landstuhl for cerebral malaria, a severe complication of malaria. He was in a coma for a short while and “would have been someone we could have used this machine on,” he said.

“Those kinds of patients are also the ones we’re going to be looking for,” he said. “Anybody who has an abnormal mental status, usually a depressed level of consciousness, and we don’t know why — those people deserve to be monitored with this sort of technology.”

He added: “There’s so little we can do to treat brain injury after it happens. This is one of those rare opportunities, I hope, where we can intervene and make a difference.”



The continuous electroencephalography uses color-coded strips and wires to guide in the placement of electrodes on a patient's scalp. Landstuhl Regional Medical Center is the first U.S. military hospital to be equipped with the device, which allows neurologists to monitor patients who are in a coma or an abnormal mental status for seizures.