Epicranial focal cortex stimulation (FCS) is a new CE‐certified treatment for pharmacoresistant focal epilepsy. In a multicenter observational trial, we report cognitive tolerability in 11 patients with pharmacoresistant epilepsy undergoing epicranial focal cortex stimulation (eFCS) over the predominant seizure focus (left temporal (N = 4), central (N = 2 right, N = 1 left), left frontal (N = 2), left temporoparietal (N = 1), and left frontoparietal (N = 1)). Extensive cognitive assessment focused on domains represented in the stimulated areas and was compared between baseline and first and last follow‐up (after a median 35 months of stimulation). Based on the reliable change index, the majority of patients remained cognitively stable; 3/11 patients showed improvements in more than one cognitive parameter at both follow‐up assessments. Isolated task parameters deteriorated exclusively at one time point; no patient revealed consistent worsening. Cognitive changes did not correspond to stimulation site or seizure outcome. Overall, the results from this case study provide preliminary evidence of stable cognitive functioning under focal cortical stimulation even if performed over eloquent brain regions. These findings are limited by the patient sample size and medication changes in part of the patients and need corroboration in larger patient cohorts.Plain Language SummaryWe report on preliminary results of a new brain stimulation treatment for epilepsy that doesn't respond to medication. Over about 3 years, 11 patients showed stable cognitive performance, some even improved, and no patient had lasting declines. These results provide preliminary evidence that the treatment is generally safe for brain function. However, larger studies are needed to confirm these findings.

ObjectiveTelemedicine can improve access and continuity of care for people with epilepsy (PwE), but its adoption across Italian epilepsy centers remains inadequately characterized. We conducted a nationwide cross‐sectional survey of all 75 epilepsy centers certified by the Italian Chapter of the International League Against Epilepsy (Lega Italiana Contro l'Epilessia, LICE) as of July 1, 2025.MethodsThe survey assessed center characteristics, telemedicine implementation, services provided, digital tool use, institutional recognition, satisfaction, barriers, advantages, and changes since COVID‐19. Associations with adoption were analyzed using chi‐squared or Fisher's exact tests.ResultsTelemedicine was currently used in 34 centers (45%), more frequently in higher‐level centers (p = 0.009), with no association to patient volume (p = 0.229) or geographic macroarea (p = 0.319). Adoption rates varied regionally: North (54.3%), Central (34.8%), South/Islands (41.2%). Follow‐up visits were the most common (91.2%), while first consultations (26.5%) and teleneurophysiology (23.5%) were less frequent. Messaging apps were widely used (median 4, IQR 3–5 on a 0–5 scale), whereas certified email and medical apps were less common (median 1). Nearly half of centers reported the absence of reimbursement. Satisfaction scores among professionals (five‐point Likert scale) were moderate to high (3.5 ± 0.9). Barriers included technical limitations, insufficient equipment, and inability to perform exams; perceived advantages included improved continuity of care, reduced outpatient visits, and enhanced patient's quality of life. Since the COVID‐19 pandemic, 38.2% reported reduced telemedicine use, 35.3% increased use, and 26.5% no change.SignificanceLess than half of LICE‐certified Italian epilepsy centers currently use telemedicine. Adoption remains uneven, with benefits recognized but important technical, organizational, and reimbursement‐related barriers limiting widespread and sustainable integration.Plain Language SummaryTelemedicine could help people with epilepsy get more consistent care, but fewer than half of Italian epilepsy centers currently use it. A national survey found that use varies by region and is more common in higher‐level centers. Most telemedicine activity involves follow‐up visits, while first appointments and remote testing are rare. Many centers rely on simple messaging apps, and reimbursement is often missing. Staff generally view telemedicine positively, but technical problems, lack of equipment, and the inability to perform exams limit its usefulness. Since COVID‐19, some centers have reduced telemedicine use, while others have increased or maintained it. Overall, adoption remains uneven and is held back by practical and organizational barriers.

ObjectiveTo characterize the neuropsychological profile and social cognition, particularly Theory of Mind (ToM), in 45 children and adolescents with temporal lobe epilepsy (TLE) compared with 56 age, gender, and schooling‐matched healthy controls. Within the original sample, we also evaluated a subgroup of patients who underwent epilepsy surgery, compared with those who were not surgically treated.MethodsThis is a prospective controlled study conducted between October 2020 and November 2022 at one center. We analyzed the study results for children (8–12 years old) and adolescents (13–18 years old) separately. We used univariate inferential statistical analyses (ANOVA or Kruskal–Wallis) and linear or logistic regression analyses.ResultsWe observed significant impairments in cognitive functions, social cognition, and ToM in children with TLE compared with controls, as confirmed also by logistic regression analyses. Conversely, we found lower scores in adolescents with TLE compared with controls only in the sub‐components of the Verbal Fluency test and Recognition of behaviors in the social situations test. Regression analyses adjusted for epilepsy‐related variables confirmed that children exhibit more severe neuropsychological and sociocognitive impairments than adolescents. ToM abilities were impaired in children who had been treated surgically compared with those who had not. This finding could be due to epilepsy‐related factors, such as earlier onset and longer disease duration, ablation of anatomic structures involved in ToM, or both.SignificanceA comprehensive neuropsychological and psychosocial assessment, including TOM, is recommended for children with TLE, especially if they are surgical candidates, to ensure timely psychoeducative and rehabilitative interventions.Plain language summarySocial cognition and ToM allow understanding of one's own and others’ thoughts and feelings. These skills are often impaired in children and adolescents with temporal lobe epilepsy (TLE). We compared the neuropsychological and social profiles of young people with TLE to healthy peers and examined differences between those who underwent epilepsy surgery and those who did not. Children with TLE showed significant impairments in cognitive functions, social cognition, and ToM, with surgically treated children facing greater ToM challenges. Our findings highlight the need for comprehensive neuropsychological and psychosocial assessments to provide timely support for children with TLE.

ObjectiveWe aimed to study the concordance of seizure semiology in direct electrical stimulation‐induced seizures (SIS) compared to spontaneous seizures during stereoelectroencephalography (SEEG) and to report on patient‐level variables associated with habitual and atypical SIS.MethodsWe retrospectively studied consecutive SEEG cases, performing a within‐patient comparison of semiology in spontaneous seizures versus SIS. We classified each patient's SIS as “habitual” or “atypical” using a new electroclinical definition. We then classified patients by maximum clinical expression of habitual SIS: “Aura,” “Fragment” (objective fragment ± aura), or “Full.” Patient groups with/without SIS and with/without atypical seizures were analyzed regarding demographics, clinical and SEEG characteristics. Reported patient‐level variables were categorically expressed as percentages or continuous.ResultsOf the 67 patients undergoing SEEG, all underwent 50 Hz stimulation. Prevalence of patients with SIS was 48/67 (71.6%); most patients had 1–2 SIS. Of 97 SIS, 91/97 (93.8%) were semiologically concordant with habitual spontaneous seizures. Patients' maximum clinical expression of habitual SIS was “Aura” in 14/47 (25.5%), “Fragment” in 16/47 (38.3%), and “Full” in 17/47 (36.2%). Patients presenting any atypical SIS (5/67) accounted for 7.5%; only 1 patient had atypical SIS as the sole SIS. Patients presenting atypical SIS had a tendency to a more widespread epileptogenic zone (EZ) (>1 lobe); none proceeded to surgery following SEEG. There was also a tendency toward female predominance. Rarely, patients with habitual SIS could report “old” habitual semiology triggered during stimulation.SignificanceThis within‐patient comparison of semiology of spontaneous versus cortical stimulation‐induced seizures (SIS), with semiologic stratification and a proposed electroclinical definition of atypical SIS, shows overall high semiologic concordance and a fairly low proportion (7.5%) of patients presenting atypical SIS at 50 Hz. Atypical seizures may occur in conditions where there is an altered stimulation threshold. No correlation was seen between dominant SIS semiologic subtype and surgical outcome.Plain Language SummaryThis study reports on semiology (clinical symptoms and signs of seizures) in people with epilepsy undergoing in‐depth brain exploration for presurgical evaluation. It compares the semiology in seizures occurring spontaneously with the semiology in seizures triggered by direct cortical stimulation. Semiologic similarity was high between spontaneous and stimulation‐induced seizures. Atypical seizures triggered by stimulation were fairly rare. Atypical seizures may occur in conditions of altered stimulation threshold. Some patients experienced past seizure semiology reactivated by cortical stimulation.

ObjectiveTraumatic brain injury (TBI) can induce posttraumatic epilepsy (PTE), but early biomarkers for epileptogenesis are lacking. We aimed to investigate electrographic biomarkers before and during posttraumatic seizure development.MethodsWe used a repetitive diffuse TBI model in mice with continuous video‐EEG monitoring up to 4½ months postinjury.ResultsTwenty‐five percent of mice developed posttraumatic seizures (PTS) with highly variable latency (5–126 days postinjury). Most significantly, we identified fast ripple‐delta DOWN state coupling as an early biomarker that was detectable at 4 days post‐TBI and appeared before seizure onset in all seizure‐experiencing mice. This EEG signature distinguished seizure‐experiencing from seizure‐free TBI mice with high specificity. Power spectrum analysis revealed elevated delta and theta power, reduced physiological fast oscillations (alpha, beta, gamma), and increased pathological high‐frequency oscillations (fast ripples) in seizure‐experiencing animals, indicating network hyperexcitability. Spike analysis showed that while TBI itself increased cortical excitability, seizure onset triggered a dramatic further interictal activity escalation. These electrographic signatures were remarkably consistent across all seizure‐experiencing animals regardless of single or recurrent seizure pattern.SignificanceOur results demonstrate that fast ripple‐delta coupling represents a promising early biomarker detectable at 4 days post‐TBI, before seizure onset, offering potential for early identification of PTS susceptibility. Importantly, this biomarker identified all seizure‐prone animals regardless of whether they developed single or recurrent seizures, suggesting shared underlying mechanisms and clinical relevance for any PTS occurrence. These findings emphasize the utility of temporal EEG analysis for detecting early electrographic changes in posttraumatic epileptogenesis and may inform future intervention strategies.Plain Language SummarySome people develop epilepsy after a traumatic brain injury, but it is currently impossible to predict who is at risk. Using mice, we found that a specific brain wave pattern, brief bursts of very fast electrical activity occurring during deep sleep, appeared within days after injury in animals that later developed seizures. This pattern was not seen in injured animals that remained seizure‐free. Detecting this early warning sign could help identify at‐risk individuals and enable earlier treatment to potentially prevent epilepsy.

ObjectiveMagnetic resonance‐guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive technique that allows for real‐time magnetic resonance imaging (MRI) monitoring and precise ablation of epileptogenic lesions. This study reports our initial clinical experience with a domestically developed MRgLITT system in patients with drug‐resistant epilepsy (DRE) and evaluates its efficacy, safety, and learning curve.MethodsWe retrospectively reviewed 36 patients with focal DRE who underwent MRgLITT between October 2020 and May 2021. Clinical characteristics, operative variables, ablation rate, and length of hospital stay were analyzed. Prognostic factors were examined using univariate and Kaplan–Meier survival analyses. The surgical learning curve was evaluated using cumulative sum (CUSUM) analysis of the operative time.ResultsThe mean follow‐up duration was 40.86 months. At the last follow‐up, 66.7% patients (24/36) achieved seizure freedom (ILAE I–II), and the overall response rate (ILAE I–IV) was 94.4% (34/36). Single lesion (p = 0.002) and ablation rate of ≥90% (p = 0.009) were significant predictors of seizure freedom. CUSUM analysis identified a turning point in the 19th case, after which the operative time and total hospitalization, particularly the preoperative evaluation time, were significantly reduced. However, the ablation rate and seizure outcomes remained stable across phases. No long‐term postoperative complications were observed.SignificanceMRgLITT is safe and effective in patients with DRE, and adequate ablation and well‐localized single lesions predict a higher likelihood of favorable outcomes. We present the first evaluation of the MRgLITT learning curve in China and confirm that the technique can be readily adopted with consistent clinical outcomes.Plain Language SummaryThis study assessed the use of a domestic MRgLITT system of China in drug‐resistant epilepsy with more than 3 years of follow‐up. Seizure freedom was achieved in 66.7% of patients, and over 90% experienced significant improvement without long‐term complications. Single lesions and ablation rate above 90% predicted favorable outcomes. Surgical proficiency was reached after 19 cases, reflecting improved efficiency while maintaining stable efficacy and safety. MRgLITT is a safe, effective, and easily adoptable minimally invasive option for selected patients with drug‐resistant epilepsy.

ObjectiveFocal cortical dysplasia (FCD) is a leading cause of drug‐resistant epilepsy and is associated with sleep‐related seizures, yet the underlying electrophysiological mechanisms during different brain states remain poorly understood. We investigated whether fast oscillations (FOs) within the seizure onset zone (SOZ) and irritative zone (IZ) change significantly during sleep compared with wake in FCD patients. We analyzed multiple frequency bands—beta (14–20 Hz), gamma (40–80 Hz), ripple (80–250 Hz), and broadband BGR (14–250 Hz) to provide comprehensive information about sleep‐related changes. We hypothesized that sleep‐related FO changes would be associated with sleep‐related epilepsy, frontal location, or FCD type II.MethodsWe examined intracranial EEG (iEEG) recordings from 22 FCD patients undergoing presurgical evaluation between 2010 and 2023, with a mean age of 25.3 ± 12.8 years and a disease duration of 17.7 ± 12.3 years. Using semiautomated detection, we compared FO rates between wake and sleep epochs, focusing on contacts within IZ and SOZ. Distance‐based multivariate analysis of variance (MANOVA) was employed for patient‐level analysis, accounting for spatial organization and enabling multiband evaluation.ResultsAnalysis of 67 ± 28 bipolar iEEG contact pairs per patient revealed distinct sleep‐related patterns. In SOZ, gamma oscillations showed significant increases in 10/22 patients (45%), followed by BGR in 7/22 patients (32%). IZ exhibited stronger changes, with BGR and gamma showing significance in 13/22 patients each (59%) with high concordance. Gamma oscillation rates in SOZ increased in patients with confirmed sleep‐related epilepsy (p < 0.05), while no associations were found with frontal location or FCD type II.SignificanceGamma oscillations showed robust sleep‐related increases in SOZ, while gamma and BGR frequencies demonstrated strong changes in IZ, often occurring simultaneously. These findings suggest gamma oscillations, complemented by BGR analysis, may qualify as markers for characterizing sleep‐related changes in FCD patients, potentially advancing understanding of mechanisms underlying sleep‐related seizures.Plain Language SummaryFocal cortical dysplasia (FCD) is a brain malformation that causes difficult‐to‐treat epilepsy, with patients experiencing seizures mainly during sleep. We studied electrical brain waves in 22 FCD patients using electrodes placed directly within or on the brain during pre‐surgery evaluation. We compared brain wave activity between wake and sleep, focusing on fast brain waves. We found that fast brain waves, especially gamma waves, increased significantly during sleep in brain areas where seizures start, particularly in patients whose seizures occur mainly during sleep. These findings potentially help us better understand why seizures happen more often during sleep in FCD patients.

ObjectiveSudden unexpected death in epilepsy (SUDEP) is the leading cause of death in people with epilepsy with an incidence of 1:1000. The primary risk factors for SUDEP are generalized or focal to bilateral tonic–clonic seizures. Preventive measures like nighttime monitoring devices and resuscitation training address modifiable risk factors. Nevertheless, SUDEP awareness remains insufficient. This study aimed to analyze risk awareness and behavior and to evaluate the impact of a questionnaire.MethodsIn a monocentric cross‐sectional pediatric study, routinely used questionnaires were analyzed retrospectively regarding SUDEP awareness rates and monitor ownership.ResultsA total of 498 patient families completed the questionnaire between December 2023 and July 2024. At the time of the survey, 58% recalled having been informed about SUDEP before the questionnaire. The SUDEP questionnaire led to an education in the following outpatient clinic in 25%. A further 9% had been counseled within the following 6 months, leading to an education rate of 92%. Monitoring devices were used in 46% of patients, with nocturnal monitoring being most frequently used in children <4 years. Among those who did not use a monitor and provided reasons against monitoring, half had SUDEP risk factors. Additionally, one third of the responders reported not using their seizure detecting device, with false alarms (28%) being the most frequently cited reason.SignificanceAll patients with epilepsy should be counseled about epilepsy‐related risks and preventive measures. Our study highlights SUDEP education gaps and the need for targeted counseling strategies to contribute to SUDEP prevention. The findings show that a structured questionnaire can effectively identify education gaps, enhance counseling efforts, and improve health literacy. Furthermore, there is a need for the development of novel, reliable seizure detection devices.Plain Language SummarySudden unexpected death in epilepsy (SUDEP) remains the most common cause of death in people with epilepsy. That is why it is important to take steps to prevent it. We still do not fully understand why SUDEP occurs and how it can be completely prevented. But it is very important to be aware of the risk. This enables those affected and their families to take measures to reduce the danger. This text explains how to inform more people about SUDEP. It also shows a possible role of nighttime monitoring devices in the prevention of SUDEP.