Spontaneous fast‐ultradian dynamics of polymorphic interictal events in drug‐resistant focal epilepsy

Objective We studied the rate dynamics of interictal events occurring over fast‐ultradian time scales, as commonly examined in clinics to guide surgical planning in epilepsy. Methods Stereo‐electroencephalography (SEEG) traces of 35 patients with good surgical outcome (Engel I) were analyzed. For this we developed a general data mining method aimed at clustering the plethora of transient waveform shapes including interictal epileptiform discharges (IEDs) and assessed the temporal fluctuations in the capability of mapping the epileptogenic zone (EZ) of each type of event. Results We found that the fast‐ultradian dynamics of the IED rate may effectively impair the precision of EZ identification, and appear to occur spontaneously, that is, not triggered by or exclusively associated with a particular cognitive task, wakefulness, sleep, seizure occurrence, post‐ictal state, or antiepileptic drug withdrawal. Propagation of IEDs from the EZ to the propagation zone (PZ) could explain the observed fast‐ultradian fluctuations in a reduced fraction of the analyzed patients, suggesting that other factors like the excitability of the epileptogenic tissue could play a more relevant role. A novel link was found between the fast‐ultradian dynamics of the overall rate of polymorphic events and the rate of specific IEDs subtypes. We exploited this feature to estimate in each patient the 5 min interictal epoch for near‐optimal EZ and resected‐zone (RZ) localization. This approach produces at the population level a better EZ/RZ classification when compared to both (1) the whole time series available in each patient (p = .084 for EZ, p