Beyond focal and generalized: are we classifying seizures, or helping patients? A provocative reappraisal of epilepsy classification in the era of therapeutic pathways.
Aug 2026· Epilepsy & Behavior· Vol 184, pp.
111227
· 0 citations· 29 references
Medicine
TL;DR
It is argued that classification should elevate therapeutic trajectory over electroclinical phenomenology, and it is proposed an Interventional Axis built around three pathways: focal resection, neuromodulation, and palliative surgery, operating in parallel with pharmacotherapy rather than after its serial failure.
Abstract
Every revision of the seizure classification-most recently the 2025 International League Against Epilepsy (ILAE) update-refines terminology, yet it is worth asking whether patients are treated better because their seizures were renamed. The focal versus generalized dichotomy has organized epilepsy classification since the 1960 s and is grounded in a pharmacologic rationale, but head-to-head data from the SANAD trials show that efficacy differences between individual antiseizure medications frequently equal or exceed differences across the focal/generalized boundary. Meanwhile, the distinction that is genuinely transformative-whether an epilepsy is surgically remediable-produces seizure-freedom differences of an entirely different order of magnitude, and yet epilepsy surgery remains among the most underutilized evidence-based treatments in medicine. We argue that classification should elevate therapeutic trajectory over electroclinical phenomenology, and we propose an Interventional Axis built around three pathways: focal resection, neuromodulation, and palliative surgery, operating in parallel with pharmacotherapy rather than after its serial failure. Refining terminology improves communication, but the ultimate metric of a classification is outcome, not taxonomic elegance.
Underutilization persists as a major and partly remediable problem, and the welcome diffusion of minimally invasive options should not eclipse resective and disconnective surgery, which remain the only potentially curative options validated by RCTs.
This review examines the evolving landscape of pediatric OLE, highlighting the shift from syndromic to etiological classification and management strategies and the need to monitor cognitive comorbidities and syndrome evolution.
Preeti Srivastava, D. Nag, Shikha Swaroop et al.· World Journal of Clinical Pe...· 0 citations
Seizures after acquired brain injury pose distinct therapeutic questions: early seizure prophylaxis, treatment of acute symptomatic seizures, and late epilepsy prevention. These endpoints are often conflated, although early seizure suppression does not establish disease-modifying antiepileptogenesis, these end points are often confused. We performed a cross-sectional analysis of ClinicalTrials.gov records that were first posted from January 1, 2000, to June 18, 2026. Records retrieved through four disease-specific seizure-related searches were exported from the ClinicalTrials.gov web interface, deduplicated by NCT number, and adjudicated into a primary seizure-management or sensitivity/monitoring cohort. A purposively selected validation set of 269 potentially eligible or difficult-to-classify records underwent independent post-review classification by 2 reviewers who were blinded to each other’s responses. A prespecified secondary subset comprised completed primary-cohort trials evaluating pharmacologic interventions. The searches yielded 1,054 exported records and 878 unique records after deduplication. Final adjudication retained 85 primary cohort studies and 39 sensitivity/monitoring records. Brain tumor/neurosurgery (27/85, 31.8%) and traumatic brain injury (TBI) (23/85, 27.1%) predominated, whereas intracerebral hemorrhage and subarachnoid hemorrhage each had only 3 trials. Among the 44 completed or discontinued trials, 17 (38.6%) were discontinued. Among 26 completed trials eligible for results-reporting assessment, 11 (42.3%) had posted results, of which 10 (90.9%) were interventional drug trials. Only 3 of 15 completed pharmacologic trials had a late-prevention aim. Reviewer agreement ranged from 85.1% to 90.3%, with unweighted Cohen kappa values of 0.776–0.825. The seizure management pipeline after acquired brain injury registered on ClinicalTrials.gov is concentrated in brain tumor/neurosurgery and TBI, with sparse representation of hemorrhagic stroke and few completed pharmacologic trials targeting late epilepsy prevention. The registry findings support a clearer separation of the objectives of acute seizure prophylaxis, treatment of acute symptomatic seizures, and late epilepsy prevention. The etiology-specific design recommendations are presented as an author-proposed framework rather than empirical effectiveness conclusions. Not applicable. Only 3 of 15 completed pharmacologic trials had a late-prevention aim, indicating that the ClinicalTrials.gov-registered pipeline of completed antiepileptogenesis-oriented research remains limited. Of the 11 completed trials with posted ClinicalTrials.gov results, 10 were interventional drug trials, whereas completed nondrug trials rarely posted results. Intracerebral hemorrhage and subarachnoid hemorrhage each accounted for only 3 of 85 primary-cohort trials, and 17 of 44 completed-or-discontinued trials (38.6%) were discontinued.
The review emphasizes the need for further interdisciplinary collaboration to accelerate the translation of these findings into clinical practice, ultimately improving outcomes and quality of life for people with epilepsy.
Mirte Scheper, Zining Liu, A. Galanopoulou et al.· Epilepsia· 0 citations
EIMFS remains one of the most refractory epilepsy syndromes of infancy and international collaborative registries, standardized outcome measures, genotype-stratified biomarker studies, and rapid point-of-care genomic testing are urgently needed to advance evidence-based care.
Overall, the presence of SCSs alone was not associated with a poor outcome, but the spatial non-concordance with the seizure-onset zone was highly predictive for poor seizure outcome.
P. Bosque-Varela, Panagiota-Eleni Tsalouchidou, Petra Levicka et al.· Epilepsia· 0 citations
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