The optimal approach to analysis of seizures is to both see and record their onset and their spread. Such an approach is mandatory in situations in which surgery is being considered. When surgery is even an option, it is critical to know the exact area of the brain involved in the origin of the seizures. Video-EEG monitoring allows recording of the EEG from multiple areas of the brain and also simultaneous video recording of the seizures.Video-EEG monitoring can also be useful when there is a question about what the spells really are. The ability to see a spell that is said to be a seizure and to record the EEG at the same time is the definitive way to differentiate seizures from pseudo-seizures.Two examples will illustrate: Sasha was a fifteen-year-old with a severe behavior disorder and seizures. Despite several years of intensive outpatient psychotherapy, he was once again thrown out of school. His family was exasperated. It was clear to both his neurologist and psychiatrist that he used his seizures to manipulate his environment. He was taken off medication and these peculiar episodes, which did not sound like seizures, did not increase in frequency. The family was taught to ignore them and Sasha seemed able to control them. But their persistence and his abnormal EEG remained of concern to his psychiatrist.The only resolution to his problem was to send him to a residential institution where he could be taught better behavioral control. Since the psychiatrist at the institution was uncomfortable dealing with a child with seizures, we brought him into the monitoring unit to see whether all of his spells were pseudo-seizures.Much to our surprise, while most of his episodes were, indeed, pseudo-seizures, at night he had genuine tonic-clonic seizures. Placing him back on medication eliminated these true seizures and allowed the psychiatrist at the institution to concentrate on his behavioral problems.Simon’s seizures began when he was two. They would start in his left foot and spread up the left side. At times, he would have a weakness in the left leg that was thought to be post-ictal paralysis, but at other times the leg was quite normal. Despite intensive attempts with medication, seizures continued to occur several times each day. The EEG showed a focus near the motor strip on the right, and we faced the choice of operating to remove the focus (with the probability of causing paralysis at least of the leg) or of allowing him to continue to have seizures. We decided to wait. After several years, video-EEG monitoring allowed us to see the start of several seizures. The seizures actually began anteriorally in the frontal lobe and then spread into the motor strip. They began in an area that could possibly be removed without damaging his motor ability. Simon was, therefore, put on the list for evaluation with the grid  electrodes placed on the surface of his brain and eventually had successful surgery—without experiencing paralysis.Intensive monitoring allows us to make decisions we were never able to make before. It gives us the opportunity to separate true seizures definitively from pseudo-seizures and more successfully to identify children as prospects for surgery.*87\208\8*

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