There are many uncertainties in epilepsy. Most diagnoses are based entirely on the accounts which patients or seizure witnesses can give of their seizures (1). Even if clinicians do not only take note of factual information but also of interactional observations (such as whether patients focus on their subjective seizure experience – more in keeping with epilepsy – or the consequences of their seizures and the situations in which the seizures occurred – as one would expect if the diagnosis was one of Psychogenic Nonepileptic Seizures) (2), many epileptological diagnoses lack final certainty. Interictal tests are of little use. Frustratingly, this seems to be especially true when the diagnosis is unclear. Before the introduction of video-EEG, clinical work in epileptology was characterized by uncertainty. Health professionals unable to cope with uncertainty were well advised to choose other fields of medicine.
The introduction of Video-EEG has made a considerable difference to the amount of uncertainty in the working lives of epileptologists. Used appropriately (and in conjunction with other clinical information) Video-EEG allows us to make firm diagnoses in the patients with frequent seizures who we investigate. Video-EEG has also increased the certainty with which we are able to predict the success of epilepsy surgery. The experience gained with video-EEG has also helped us gain much more confidence about the diagnoses we have to make without ictal video-EEG recordings.
Having said that, the privilege of being able to wire up our patients, to record their behavior and EEG activity, and to increase the level of our diagnostic or therapeutic certainty comes with the obligation to ensure that our patients are safe. The national audit carried out in 27 UK video-EEG units by Kandler et al. demonstrates some significant deficits in this respect (3). Adverse events were observed in 12% of seizures and patients remained unattended after almost one half of all seizures recorded. There was a relationship between the availability of dedicated nursing staff and the rapidity and frequency with which patients were attended after the seizures.
The paper by Kandler et al. demonstrates that, if we take the safety of our patients seriously, staffing levels on video-EEG units do not provide a soft target for cost-cutting measures. It also suggests that it is essential for all video-EEG units regularly to audit the safety of their recording procedures (especially when they involve the use of intracranial electrodes and the tapering of antiepileptic drugs). Patients should be informed about the risks they can expect to encounter when they enter their local video-EEG unit.
 Malmgren K, Reuber M, Appleton R. Differential diagnosis of epilepsy. In; Shorvon S (editor), Oxford Textbook of epilepsy and epileptic seizures. Oxford, Oxford University Press, 2012,81-94.
 Reuber M, Monzoni C, Sharrack B, Plug L. Using Conversation Analysis to distinguish between epilepsy and non-epileptic seizures: a prospective blinded multirater study. Epilepsy and Behavior 2009; 16: 139-144.
 Kandler R, Lai M, Ponnusamy A, Bland J, Pang C. The safety of UK video telemetry units: results of a national service evaluation. Seizure 2013:22:872-880.