Standalone Video Review for Diagnosing Seizures

Andrew N. Wilner, MD; Selim R. Benbadis, MD


March 03, 2023

This transcript has been edited for clarity.

Andrew N. Wilner, MD: Welcome to Medscape. I'm your host, Dr Andrew Wilner. Today, I have the pleasure to welcome my old friend and colleague, Dr Selim Benbadis. Dr Benbadis is the author of a very interesting article that was just published in Neurology Clinical Practice, and he's here today to tell us about it. Dr Benbadis is a professor of neurology at the University of South Florida and director of the Comprehensive Epilepsy Center and EEG lab at the university.

Dr Benbadis, how many EEGs have you read? It's probably in the hundreds of thousands, right?

Selim Benbadis, MD: Has to be.

Wilner: At least. Tell us about the article.

Benbadis: Thank you for having me. It's nice to be here. The article was developed when — as articles often are — I became a little bit irritated at the way we tend to use and order EEGs because I think we have not adjusted to the times. I have run into many situations where neurologists order a routine EEG, for example, or a stat EEG when they want it now, when it really isn't the best way to diagnose seizures. We have a way that's easy and cheap and that everybody has, and that is the cell phone — we are moving toward using more and more cell phone videos for diagnosis.

Wilner: I read the article, and I thought you went through it very meticulously in anticipation that people were obviously going to jump on it and say, "Well, you can't diagnose seizures without the brainwaves." I guess, technically, that's true. Even experts make mistakes in that; when they watch a video, it could be pseudoseizures, for example.

On the other hand, if you saw a video of a tonic-clonic convulsion — a casual, spur-of-the-moment cell phone video — what do you think your sensitivity and specificity would be without the EEG?

Benbadis: For a generalized tonic-clonic convulsion, I would dare to say 100%. Even nonspecialists, I think, would be very close to 100%. As you said, there are more difficult situations and cases, and by no means, by the way, do I imply that it's either video or EEG. Those two things complement each other. I think the better way to look at cell phone videos is as an extension of their history.

When I wrote the article, I sent it to several colleagues whom I respect, and I asked them blindly, "Hey, I'm writing an article on — and I gave them the title — what is the best diagnostic tool for seizures?" All of them are experienced clinicians, so you are not going to be surprised that they said, "Well Selim, it's well known that the best way is the history." I agree 100%. Cell phone videos are nothing but an extension of the history, just more objective because histories are not that reliable.

It does not compete with EEG. They work together. As you know, the limitation of EEG is that we cannot perform EEG 24/7 for 3 months, so for people who have infrequent seizure-like events, good luck getting an EEG during the episode. With a cell phone, everybody has one right here. There are challenges to that, too, which are discussed in the article, but at least you can try to get a quick and dirty cell phone video. It's incredibly helpful — not instead of EEG, but to be complemented by EEG.

Wilner: To supplement the history.

Benbadis: I really think the best way to look at cell phone video is as an extension of the history.

Wilner: It's fair to point out that getting the history from a patient who had a seizure is usually impossible because the patient doesn't know what happened. He might have a memory of an aura. He might have had an aura and forgotten the aura.

It's always from a witness, if there is a witness, and that witness is usually not an epileptologist, right? It's their sister or their neighbor. They're not trained as to which signs to look for.

Benbadis: It's well known that histories are inaccurate because of the reasons you mentioned. In addition, they're oftentimes freaking out, they're not thinking of taking notes, and they don't remember well. That's been published, and I think that's referenced in the article.

Really, the cell phone video, again, has limitations but is a great tool, and I think neurologists need to start using fewer routine EEGs that oftentimes show nothing and instead obtain cell phone videos.

Wilner: What do you think should change?

Benbadis: One of the cases I give as an introduction is on a Saturday afternoon, when a patient is having an episode in the hospital. Instead of ordering a routine EEG or a stat EEG that is going to take 2 hours to get hooked up and may show nothing, take your cell phone out, take a video, and send it to me instead of sending me a routine EEG, which is likely to be normal.

There are many challenges to taking the videos, I get that, and they're discussed in the article, but it's a much better tool, and the examples I give illustrate exactly that. The EEG was not particularly helpful, but the video was.

Wilner: I'm on your side, and I'm going to give another example. I'm very interested in eye movements. In eye movements, abnormalities are often transient, and so the best thing is to get a video.

I've got the video on my cell phone that is not HIPAA certified, so already I've committed a federal crime if I video the patient — even if I get their written consent, which they're often not in a position to do because they're in a coma or something like that.

Then I can't upload it. How do I put it in the electronic medical record? This is part of the history. It should be in the electronic medical record. Is there a way to do it?

Benbadis: More and more, there is a way, and I mentioned that in the article. That's improving a little bit. With the electronic medical record, we have a system, which is called EPIC, a way to upload media such as pictures, which are used routinely. You also can upload videos. They're limited in size for now, but that's going to change. That's part of the challenge, as I discussed in the article.

It's too new and too recent. Those things are going to evolve if we are enthusiastic about them. Yes, there are ways to do that, but you're absolutely right about HIPAA and other things. We don't know how to deal with this because it's too new.

By the way, you're also correct that the use of cell phone videos, even though my article focuses on seizures, is well beyond that. They can be used with movement disorders, eye movement disorders that are transient, probably also psychiatry for episodes of behavior that might be transient, and in other areas of medicine as well.

I start with the seizure point of view — that's the one you and I are familiar with — but the applications are much broader than that. We need to move, again, toward solving the problems that you mentioned, such as regarding HIPAA. Is it illegal to take it? How do we transmit it? How do we store it?

I don't pretend to have the solution to all of that. I just wanted to start the discussion.

Wilner: There's another part of the discussion that I think is germane. I have patients that come to the office, and I say, "Well, what happened?" "Oh, Dr Wilner, I have a video. Let me find it." They're still poking around in their phone 5 minutes later trying to find it. I'm ready to move on to the next patient, and then, finally, they find it.

Now, I must watch it. Well, it's not an edited video on Final Cut Pro. They say, "Wait, Dr Wilner, it's going to start soon." I'm waiting, I finally see the video, and it might be very valuable or it just might be the guy's foot and part of the ceiling. I've now invested 10 minutes, which is already 9 minutes more than my usual visit. What is the compensation for that?

Benbadis: That's a very good question, and I touch on it briefly about getting a CPT code for this. There should be a code as it becomes a true diagnostic tool. I have no illusion that it's going to be quick, but we should gradually move toward getting a CPT code for standalone video review.

Also, there is another issue here. The beauty of videos is that you don't have to review it this minute. For this patient, you could send him home and say, send me the video when you get home. I don't need to see it this minute. Send it.

Again, how are they going to send it? Is it protected? Is it HIPAA compliant? I don't have a solution to these questions. For example, we might have an email address that we dedicate to this, where our patients can send their episodes or even their side effects of a tremor, for example. We don't necessarily need to bring them in for this. Upload your video. Send it, of course, through secure ways, and there are secure ways to do that.

This is all evolving, and it's new. The point of the article was to start this discussion, but I totally agree, and it's the subtitle of the article. It's time to look into getting a CPT code for this. As we know, this is going to be like moving the Earth, and it's going to take forever. It's time to start this discussion, and that was my purpose.

Wilner: Maybe I'm not the best person to ask the questions because I agree with you 100%. I think it's an incredibly useful tool.

Benbadis: I have yet to communicate with any epilepsy specialist who tells me, "You know what, Selim, I don't think those are helpful." Not one. More often than not, the answer I've received is, "Oh, we've been doing this for years." Especially pediatric neurologists, for example, and all kinds of epileptologists.

Wilner: The American Academy of Neurology meeting is coming up in April. Is there a committee assigned to work on this problem?

Benbadis: No, nothing moves that quickly, as you know.

Wilner: All right, I'm going to nominate you.

Benbadis: All right.

Wilner: If you get an email, that's what it's about. Anything you'd like to add before we wrap up, Selim?

Benbadis: No. You asked me all the right questions, as usual. Like I said, my goal was to start a discussion. It opens many other questions, but let's go forward and tackle them.

Wilner: Dr Selim Benbadis, thank you very much for joining us on Medscape.

Benbadis: Thanks for having me.

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