Mesial-to-lateral patterns of epileptiform activity identify the seizure onset zone in mesial temporal lobe epilepsy.

Mesial temporal lobe epilepsy (mTLE) is a common localization of drug-resistant epilepsy in adults. Patients often undergo intracranial EEG (iEEG) monitoring to confirm localization and determine candidacy for focal ablation or resection. Clinicians primarily base surgical decision-making on seizure onset patterns, with imaging abnormalities and information from interictal epileptiform discharge (spikes) used as ancillary data. How the morphology and timing of spikes within multi-electrode sequences may inform surgical planning is unknown, in part due to the lack of measurement methods for large datasets. We hypothesized that patients with mTLE have a distinct mesial-to-lateral spike pattern that differentiates them from other epilepsy localizations. In a multicenter study at the University of Pennsylvania and the Medical University of South Carolina, we analyzed the timing and morphology of spikes and seizure high frequency energy ratio (HFER) in 75 patients with drug-resistant epilepsy. We compared these features across patients with mTLE, temporal neocortical epilepsy, and other localizations. A logistic regression model combining all features predicted a clinical localization of mTLE in unseen patients with an AUC of 0.82 (compared to an AUC of 0.70 for seizure-only features, DeLongs test p = 0.08). Spike rate was the most important feature in the combined model. Modeled probability of mTLE was similar between patients who had a good versus a poor 12-month outcome after undergoing a mesial temporal resection or ablation (p = 0.34). These findings support quantitative spike analysis to supplement analysis of seizures for use in surgical planning.