Real Time Tele-Epilepsy Consultants - RTTC

09/16/2026

In the ICU, artifact is often the loudest signal in the room—and sometimes the most misleading. Device-related and physiologic artifact can closely mimic epileptiform activity, especially:
• IV pumps / infusion devices → rhythmic, repetitive discharges that can resemble periodic patterns
• Ventilators / respiratory cycles → slow, rhythmic deflections time-locked to breathing
• ECG contamination → sharp transients that may be mistaken for spikes
👉 These patterns can be particularly deceptive in critically ill patients, where the clinical threshold for seizure concern is already high.

👉 Always correlate with:
• Raw EEG signal (not just compressed trends or automated detections)
• Physiologic rhythms (heart rate, respiratory rate, ventilator timing)
• Video + bedside activity when available
• Clinical timing (Was a pump cycling? Was the patient being repositioned?)

💡 Key insight:
• True epileptiform activity typically demonstrates evolution—in frequency, amplitude, or spatial distribution.
• Most ICU artifact is time-locked, repetitive, and non-evolving once you recognize the source.

09/09/2026

Check out this excellent educational opportunity featuring RTTC's own Nabil Azar, MD!

Learning Objectives:
1. The differential diagnosis of nonepileptic seizures
2. The peri-ictal and ictal semiology of epileptic vs nonepileptic seizures
3. The discriminative features of epileptic vs nonepileptic seizures

Register now:

Access free continuing education for EEG technologists. Live webinars, on-demand courses, and CEU credits. Register for EEG U and ELEVATE U programs today.

09/07/2026

Time to kick back and relax! Happy Labor Day!

09/03/2026

The ketogenic diet has been used to reduce seizures since the 1920s. The mechanism by which the seizures are regulated is poorly understood. Both the low sugar component and high fat component uniquely alter the ‘excitability’ of the brain, thereby reducing the tendency to generate seizures.

The keto diet has proven effective over time to help epilepsy. About 40% to 50% of children who start the keto diet have 50% fewer seizures. And roughly 10% to 20% of children achieve more than 90% reduction in seizures.

The ketogenic diet is high in fat, adequate in protein, and very low in carbohydrates (carbs). Learn More: https://www.epilepsy.com/treatment/dietary-therapies/ketogenic-diet

08/26/2026

Real Time Tele-Epilepsy Consultants (RTTC) is a physician-led organization focused on delivering expert, high quality EEG interpretation and customizable tele-epilepsy consultation services via telehealth to hospitals, outpatient facilities and ambulatory EEG companies, regardless of geographical location.

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08/19/2026

Pediatric is not just “adult EEG in smaller heads.” Normal findings vary significantly with:
• Age
• Sleep state
• Developmental stage

👉 Examples:
Posterior dominant rhythm evolves over time. Sharp transients in neonates may be normal. Sleep architecture differs dramatically.

💡 Key insight:
Misinterpreting age-appropriate patterns as abnormal is one of the most common pitfalls—even among experienced readers outside pediatrics. Pattern recognition must always be calibrated based on a patient’s age.

08/12/2026

🧠 Electrode Integrity Still Drives Everything!
💡 Even with advanced software and AI-assisted review, signal quality starts at the scalp.
❌ High impedance doesn’t just add noise, it can mask focal abnormalities and distort amplitude relationships.
👉 Consistency tip: Aim for balanced impedance across electrodes, not just “below 10kΩ.”

08/06/2026

Triphasic Waves vs. Ictal Patterns: It’s About Behavior, Not Just Morphology.

Triphasic morphology alone doesn’t define encephalopathy—and it doesn’t exclude ictal activity. Both triphasic waves and nonconvulsive seizures can:
• Be rhythmic
• Be generalized or frontally predominant
• Occur in altered patients

👉 What separates them:
• Reactivity → triphasic waves often attenuate or change with stimulation
• Consistency → triphasic waves are often stereotyped and stable
• Evolution → ictal patterns tend to evolve in frequency, amplitude, or distribution

💡 Clinical layer:
When in doubt, this is where meets medicine—trend over time + clinical response (including trial of treatment) can be decisive.

07/29/2026

Don’t Ignore the Background.

📊 Background tells the story before the seizure does.

💡 Tech Tip: Before focusing on events, assess:
✔️ Symmetry
✔️ Reactivity
✔️ Continuity
✔️ Posterior dominant rhythm (if present)

⚠️ Subtle background changes can be the earliest sign of deterioration or seizure risk.

07/23/2026

Case Study: Flame Pattern on the Density Spectral Array
A 60-year-old woman with severe hepatic encephalopathy and hyperammonemia developed intermittent facial twitching, raising concern for metabolic myoclonus vs seizures. EEG review was limited by significant artifact, and imaging showed a chronic hemorrhagic lesion—adding further complexity.

Instead of relying on raw EEG alone, density spectral array (DSA) was used. This revealed repeated “flame patterns”—abrupt increases followed by gradual declines in frequency—suggestive of seizure evolution. Correlation with EEG (in Laplacian montage) confirmed electrographic seizures arising from the left parietal region. As sedation was reduced, the activity progressed clinically, confirming status epilepticus.

💡 Key takeaway: Trend tools like DSA can reveal seizure evolution when the raw EEG is obscured by artifact or subtle findings.

📚 Reference: https://doi.org/10.1212/WNL.0000000000214485