A commentary on SCORE


This issue of Epilepsia hosts the important work of a group of eminent electroencephalographers/epileptologists and capable programmers (Beniczky et al., 2013) who created and propose an efficient computerized platform, optimally designed to register all important electroencephalography (EEG) graphoelements and patterns in the shortest possible time. It is predictable that such a combined effort can achieve all the crucial targets the authors set themselves (improvement of the quality of EEG assessment and reporting and compilation of multinational EEG database for research and training purposes), notwithstanding the very important benefit of standardization and homogenization of EEG terminology that will ease communication between clinical electroencephalographers and researchers, all so much needed for the electroencephalography of the twenty-first century.

I cannot see any reasons for which the Standardized Computer-based Reporting of EEG (SCORE) system may not be widely used. As the authors point out in their introduction, one of the main reasons previous systems of computerized EEG reporting failed to meet wider acceptance was because they were too time-consuming. In our times of extreme professional overregulation and added administrative work, particularly at the senior level, this risk is certainly not less than in the 80s and 90s when electroencephalographers (as all physicians) still had mainly their beloved métier to deal with. Nowadays, most electroencephalographers would still agree that, ideally, all background and paroxysmal graphoelements should be registered and quantified in the EEG report for all the good reasons mentioned above, but would particularly welcome a time-efficient, easy to use, versatile tool adaptable to different clinical needs. Presurgical EEG evaluation for instance, focuses on accurate localization and quantification of spikes and focal slow, attributes that are seldom required (at least at the time of the initial clinical decision) at the first seizure clinic level where the principal clinical question is: “do my findings support a diagnosis of epilepsy, and if yes, is it more likely to be focal or generalized?” Requirements are also different for the intensive care unit (ICU) recordings, which focus on identifying background rhythms and their reactivity, EEG/polygraphic signs of “awakening,” and nonconvulsive seizures and status, for neonatal EEG and other clinical uses. SCORE provides a comprehensive list of all clinically relevant EEG aspects, from background rhythms including sleep and changes encountered in the ICU recordings, to interictal and ictal findings complete with a full list of seizures (episodes) and relevant behavioral changes, which—crucially—can be scored in the least possible time. Its software has been designed in such a way that users can assess the clinically important parts of the recording without wasting time on features that do not occur. Such features make SCORE an all-inclusive but still flexible tool for EEG analysis, capable to swiftly and effectively satisfy all clinical requirements, and at any complexity level, from the standard EEG of the district hospital to the most sophisticated polygraphic video recording of the tertiary epilepsy center.

Some electroencephalographers may fear that any standardized computer-based EEG reporting system could “dry out” EEG reading and interpretation, compromising personal expertise, and removing the art from EEG reporting. Here is another strong point of SCORE that dispels any concern of this type: although its computerized part will “protect” electroencephalographers from missing important features (even the most experienced of the guild may sometimes be guilty of overlooking important graphoelements), the part of diagnostic significance (Table 10 in Beniczky et al., 2013) allows interpretation of the scored findings. Personal solutions to perennial dilemmas (for instance, focal or generalized?) can find a temporary home here. However, the major advantage that SCORE offers in this respect is its free-text parts that can be added and the text box for “summary” at the end of the reporting process. Here, personal opinions can be expressed, relevant arguments can be summarized, and the reasons for syndrome/type classification can be explained. At the same time, all important factual data will have been entered and stored in the SCORE platform, feeding a (hopefully) international database for training and research.

The possible selections in Beniczky et al.'s (2013) Tables 2–11 are detailed and thoroughly thought out, and lists are comprehensive and clear. Among them, Table 9 is particularly welcome, not only because polygraphy is one of the most important constituents of the EEG recording, but because it is the most neglected. After all, the SCORE lists can serve as reminders for the electroencephalographers not only “to score” but also (to ask their physiologists) “to do.”

SCORE is a dynamic tool endowed by the extra benefit of prospective periodical revisions aiming at further improvements. Such an ongoing task relies not only on its capable creators but, mainly, on the constructive feedback of its electroencephalographers/users from different areas of clinical electroencephalography. I am confident that its wide acceptance will lead to decisive improvements in our clinical practice, teaching, and research.


I have no conflicts of interest to disclose. I confirm that I have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.