Can Multimodal Large Language Models Understand Pathologic Movements? A Pilot Study on Seizure Semiology

While Multimodal Large Language Models (MLLMs) have demonstrated remarkable proficiency in general video understanding, their capacity to interpret involuntary, and spatio-temporally evolving pathologic motor behaviors such as seizure semiology remains largely untested. To address this gap, we introduce Seizure-Semiology-Suite, a clinically grounded dataset and benchmark for fine-grained, structured seizure semiology understanding. The dataset includes 438 seizure videos annotated with over 35,000 dense labels covering 20 ILAE-defined semiological features. Building on this dataset, we propose a seven-task hierarchical benchmark that systematically evaluates MLLMs from low-level visual perception to temporal sequencing, narrative report generation, and seizure diagnosis. To enable clinically meaningful evaluation of generated reports, we further introduce the Report Quality Index for Seizure Semiology (Seizure-RQI). Extensive baselines across 11 open-weight MLLMs reveal systematic weaknesses in laterality reasoning, temporal localization, symptom sequencing, and clinically faithful reporting. We show that seizure-specific fine-tuning substantially improves performance across tasks, and that a two-stage neuro-symbolic framework achieves an F1 score of 0.96 on epileptic versus non-epileptic seizure classification. Seizure-Semiology-Suite establishes a rigorous benchmark for evaluating multimodal models in safety-critical medical video understanding and guides the development of clinically reliable, domain-adaptive multimodal intelligence.

Reliable seizure detection in mouse models is essential for preclinical epilepsy research, yet manual review of synchronized video-EEG recordings is labor-intensive and single-modality systems fail for complementary reasons: video-based methods are easily confounded by benign behaviors, whereas EEG-based methods are vulnerable to ictal motion artifacts. We present EEGVFusion, a multimodal framework that combines self-supervised EEG representation learning, spatio-temporal video encoding, optimal-transport alignment, and bidirectional cross-attention to integrate neural and behavioral evidence. We also curate an expert-annotated dataset of synchronized EEG and video recordings comprising 93 sessions from 15 mice for training and evaluation. In the random-session split, EEGVFusion achieved a Balanced Accuracy of 0.9957 with perfect event sensitivity and an Event FAR of 0.6250 FP/h, indicating strong seizure detection performance with a low false-alarm burden. In a single held-out-subject evaluation with Subject 110 reserved for testing, EEGVFusion achieved a Balanced Accuracy of 0.9718 and reduced Event FAR from 2.7250 FP/h for the EEG-only counterpart to 0.4833 FP/h while preserving perfect event sensitivity. Targeted ablations further showed that EEG pre-training and OT alignment help reduce false alarms while preserving event sensitivity.

Multimodal Large Language Models (MLLMs) exhibit strong visual understanding, yet the internal features that cause these behaviors remain difficult to identify, audit, or control. While applicable to post-hoc inspection, hidden states that are decomposed into interpretable feature directions using sparse autoencoders (SAEs) neither readily isolate which features are changed by multimodal training, nor are they directly useful for targeted control. We introduce MMDiff, a multimodal model-diffing framework that trains multimodal SAEs and turns them into feature-level interfaces for discovering and controlling multimodal behavior. MMDiff supports three uses: (i) feature isolation, by diffing a base-LM SAE against its multimodal-adapted counterpart to identify features altered by multimodal training; (ii) task-specific feature detection, via per-token contrastive firing analysis that isolates causal features; and (iii) feature-level control, by causally removing or steering the discovered feature directions. We train multimodal SAEs for three MLLM families, LLaVA-MORE, PaliGemma 2, and InternVL3.5, and evaluate on visual-spatial understanding, multimodal safety, and OCR. MMDiff discovers sparse, causally specific features whose removal selectively degrades target behaviors by an average of 12% on spatial tasks and 17% on OCR, and reduces attack success rate by 24% on multimodal safety attacks, with no impact on VQA performance. Steering these features improves spatial and OCR accuracy by +3.6% and +1.8% on average over a standard single-layer steering baseline. These results show that multimodal SAEs can serve not only as interpretability tools, but as mechanisms for auditing, steering, and controlling MLLMs behavior toward safer and more capable generations.