Stereo-Electroencephalography-Recorded Interictal Epileptiform Discharges: Activation Pattern and Its Relationship With Surgical Outcome

Background Patients with drug-resistant epilepsy commonly undergo stereo-electroencephalography (SEEG) intracranial monitoring for surgical evaluation. Our current practice of defining the epileptogenic zone relies heavily on recognizing the seizure onset zone (SOZ), but the clinical significance of interictal epileptiform discharges (IEDs) is not well established. Methodology We retrospectively identified adult patients who underwent SEEG between January 2019 and May 2022. To study IED activation patterns, we classified IEDs as leading spikes (involved within the SOZ) and distant spikes (outside the SOZ). We calculated each patient's total number of brain subregions generating distant spikes. We correlated them with epilepsy type, duration, and surgical outcome (Engel I: good outcome and Engel II-IV: poor outcome). Results A total of 22 patients were identified during the study period, and 16 underwent surgical intervention (ablation or resection) with one-year post-surgery follow-up. The most common IED morphology was a single spike or sharp followed by periodic spikes or sharps. We found that 87% (n = 19/22) of leading spikes were activated during the first 24 hours of SEEG monitoring, whereas no activation pattern was observed for distant spikes. We found that a higher number of subregions generating distant spikes were associated with poor surgical outcomes (p = 0.002). However, we did not find any significant association between the number of subregions generating distant spikes with epilepsy duration (p = 0.67), temporal or extratemporal-onset epilepsy (p = 0.58), or the presence of an MRI lesion (p = 0.62). Conclusions IEDs involved within the SOZ were found to be activated during the first 24 hours of SEEG monitoring, which could aid in recognizing the pathological spikes and targeted mapping of the irritative zone. We also observed that a higher number of brain subregions generating IEDs outside the SOZ were associated with poor surgical outcomes, but this observation needs to be further studied with larger sample size prospective studies.