Report-derived interictal epileptiform discharge burden is associated with 7-day antiseizure medication decisions after pediatric video electroencephalography

Objective To determine whether a three-level interictal epileptiform discharge (IED) burden abstracted from qualitative wording in issued pediatric video electroencephalography (VEEG) reports, rather than directly measured spike frequency, was associated with antiseizure medication (ASM) decisions within 7 days. Methods This single-center retrospective cohort included 216 VEEG report episodes from 181 children. Two reviewers independently classified each report as showing no, low, or moderate-to-high IED burden while unaware of the standardized 7-day outcome; disagreements were adjudicated. We separately analyzed a diagnostic/initiation cohort for new ASM initiation and an established-epilepsy cohort for exploratory treatment intensification. Associations were assessed using exact and trend tests and logistic regression with patient-clustered robust standard errors. Results Agreement was 211/216 (97.7%); linear-weighted Cohen κ was 0.975 (patient-clustered bootstrap 95% CI 0.947–0.995). The diagnostic/initiation cohort comprised 113 reports from 112 children, with 36 new ASM initiations. Initiation rates were 13.0%, 42.9%, and 70.0% for no, low, and moderate-to-high burden, respectively (trend p < 0.001). The adjusted odds ratio per higher burden grade was 2.89 (95% CI 1.58–5.30; p < 0.001). The established-epilepsy cohort comprised 103 reports from 76 children, with 13 intensification events. Moderate-to-high burden versus none/low yielded an odds ratio of 4.73 (95% CI 1.31–17.08; p = 0.018), but complementary analyses were not statistically significant. Conclusion Report-derived IED burden showed a strong graded association with new ASM initiation within 7 days. The treatment-intensification finding was exploratory. These data describe prescribing context and do not establish causality, treatment benefit, or an IED-based treatment threshold.