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Objective: The aim was to compare the outcomes of subdural electrode (SDE) implantations versus stereotactic electroencephalography (SEEG), the 2 predominant methods of intracranial electroencephalography (iEEG) performed in difficult-to-localize drug-resistant focal epilepsy. Methods: The Surgical Therapies Commission of the International League Against Epilepsy created an international registry of iEEG patients implanted between 2005 and 2019 with ≥1 year of follow-up. We used propensity score matching to control exposure selection bias and generate comparable cohorts. Study endpoints were: (1) likelihood of resection after iEEG; (2) seizure freedom at last follow-up; and (3) complications (composite of postoperative infection, symptomatic intracranial hemorrhage, or permanent neurological deficit).Results: Ten study sites from 7 countries and 3 continents contributed 2,012 patients, including 1,468 (73%) eligible for analysis (526 SDE and 942 SEEG), of whom 988 (67%) underwent subsequent resection. Propensity score matching improved covariate balance between exposure groups for all analyses. Propensity-matched patients who underwent SDE had higher odds of subsequent resective surgery (odds ratio [OR] = 1.4, 95% confidence interval [CI] 1.05, 1.84) and higher odds of complications (OR = 2.24, 95% CI 1.34, 3.74; unadjusted: 9.6% after SDE vs 3.3% after SEEG). Odds of seizure freedom in propensity-matched resected patients were 1.66 times higher (95% CI 1.21, 2.26) for SEEG compared with SDE (unadjusted: 55% seizure free after SEEG-guided resections vs 41% after SDE). Interpretation: In comparison to SEEG, SDE evaluations are more likely to lead to brain surgery in patients with drugresistant epilepsy but have more surgical complications and lower probability of seizure freedom. This comparativeeffectiveness study provides the highest feasible evidence level to guide decisions on iEEG.

Background Ictal asystole is a rare, serious, and often treatable cause of syncope. There are currently limited data to guide management. Characterization of ictal syncope predictors may aid in the selection of high-risk patients for treatments such as pacemakers. Methods and Results We searched our epilepsy monitoring unit database from October 2003 through July 2013 for all patients with ictal asystole events. Clinical, EEG, and ECG data for each of their seizures were examined for their relationships with ictal syncope events. In 10 patients with ictal asystole, we observed 76 clinical seizures with 26 ictal asystole episodes, 15 of which led to syncope. No seizure with asystole duration ≤6 seconds led to syncope, while 94% (15/16) of seizures with asystole duration >6 seconds led to syncope (P=0.02). During ictal asystole events, 4 patients had left temporal seizure onset, 4 patients had right temporal seizure onset, and 2 patients had both. Syncope was more common with left temporal (40%) than right temporal seizures (10%; P=0.002). Treatment options included anti-epileptic drug changes, epilepsy surgery, and/or pacemaker implantation. Eight patients received pacemakers. During follow-up of 72±95 months, all patients remained syncope-free. Conclusions Ictal asystole >6 seconds is strongly associated with ictal syncope. Ictal syncope is more common in left than right temporal seizures. A permanent pacemaker should be considered in patients with ictal syncope if they are not considered good candidates for epilepsy surgery.

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Background: Brain activity is constrained by and evolves over a network of structural and functional connections. Corticocortical evoked potentials (CCEPs) have been used to measure this connectivity and to discern brain areas involved in both brain function and disease. However, how varying stimulation parameters influences the measured CCEP across brain areas has not been well characterized. Objective: To better understand the factors that influence the amplitude of the CCEPs as well as evoked gamma-band power (70e150 Hz) resulting from single-pulse stimulation via cortical surface and depth electrodes. Methods: CCEPs from 4370 stimulation-response channel pairs were recorded across a range of stimulation parameters and brain regions in 11 patients undergoing long-term monitoring for epilepsy. A generalized mixed-effects model was used to model cortical response amplitudes from 5 to 100 ms poststimulation. Results: Stimulation levels <5.5 mA generated variable CCEPs with low amplitude and reduced spatial spread. Stimulation at !5.5 mA yielded a reliable and maximal CCEP across stimulation-response pairs over all regions. These findings were similar when examining the evoked gamma-band power. The amplitude of both measures was inversely correlated with distance. CCEPs and evoked gamma power were largest when measured in the hippocampus compared with other areas. Larger CCEP size and evoked gamma power were measured within the seizure onset zone compared with outside this zone. Conclusion: These results will help guide future stimulation protocols directed at quantifying network connectivity across cognitive and disease states.

Summary Purpose:  To describe five patients with ictal aphasia and one patient with ictal amnesia, who had focal positron emission tomography (PET) hypermetabolism but no clear ictal activity on electroencephalography (EEG). Methods:  18F‐Fluorodeoxyglucose (FDG)–PET scans with concomitant EEG were obtained in five patients with suspected ictal aphasia or ictal amnesia without ictal activity on EEG. We reviewed medical history, EEG, imaging data, and treatment outcome. Results:  Brain magnetic resonance imaging (MRI) showed no structural abnormalities in any of the patients. EEG showed left temporal irregular delta activity in three patients, with aphasia and nonspecific abnormalities in two other patients, all without clear ictal pattern. All patients demonstrated focal hypermetabolism on PET scan. The hypermetabolism was in the left frontotemporal region in patients with ictal aphasia and in the bilateral hippocampal region in the patient with amnesia. Three patients who received intravenous benzodiazepines during their episodes had transient clinical improvement. With antiepileptic drug (AED) treatment, symptoms gradually resolved in all patients. Concomitant resolution of PET hypermetabolism was documented in three patients who had follow up scans. One patient with ictal aphasia later developed recurrent episodes, each with recurrent PET hypermetabolism. This patient and one other patient required immune‐modulating therapy in addition to AEDs. Discussion:  FDG‐PET imaging should be considered as a diagnostic tool in patients with suspected ictal aphasia or amnesia, who fail to show clear evidence of ictal activity on EEG.

The incidence of new-onset epilepsy is high among elderly patients. Seizures can present differently to and with more subtle semiology than those in younger adults. This difference in presentation frequently poses a diagnostic challenge. Elderly patients also often have comorbidities, are usually on multiple medications that can interact, have altered medication pharmacokinetics, and tend to be particularly sensitive to adverse effects of medication. Seizures in the elderly tend, however, to respond better to antiepileptic drugs than those in younger individuals, and can often be appropriately controlled with monotherapy. After the diagnosis of epilepsy is confirmed, treatment should be started with a single medication at a low dose, with subsequent gradual upward titration until seizures are controlled. First-generation antiepileptic drugs should be avoided in the elderly in view of poor tolerability. A large trial has shown that lamotrigine and gabapentin are better tolerated than carbamazepine. In elderly patients whose seizures remain uncontrolled on antiepileptic medications, surgery can be considered if excellent results are predicted and the risks are low.