Search Results (258)

Background: Despite more than 30 licenced antiseizure medications (ASMs), approximately one third of people with epilepsy remain drug-resistant, and developmental and epileptic encephalopathies represent one of the greatest unmet needs in epilepsy therapeutics. The past decade has produced a substantial reorientation of ASM discovery, driven by epilepsy genetics, new disease models, advances in drug screening, and innovative therapeutic modalities. Objective: The objective of this study was to review the contemporary clinical-stage pipeline of ASMs with novel or differentiated mechanisms of action, organized by molecular target, while placing recent regulatory successes and instructive failures within the broader transition toward mechanism-based, precision, and potentially disease-modifying therapies. Findings: A 2024 pipeline analysis identified more than 200 epilepsy therapies in preclinical or clinical development; at the cutoff of the present literature search (30 June 2026), over 40 compounds had reached phase II or III, with the majority directed at DEEs. Functional-state-selective sodium channel modulation has emerged as a leading conceptual advance supported by converging mechanistic and early clinical evidence, exemplified by relutrigine (PRAX-562), a preferential persistent-current inhibitor for which a regulatory decision is pending in SCN2A/SCN8A-DEEs, and vormatrigine (PRAX-628), whose large open-label effect was not reproduced in a controlled (blinded) trial. Several of the efficacy figures summarized here derive from congress presentations, interim analyses, or open-label extensions and await full peer-reviewed publication. Parallel advances include the selective Kv7 opener azetukalner; the dual-mechanism benchmark cenobamate; cholesterol-24-hydroxylase inhibition (soticlestat); selective serotonergic agonism (bexicaserin); glutamatergic precision agents (radiprodil); subtype-selective GABA_A modulators (darigabat, ganaxolone); and gene-directed therapies (zorevunersen, elsunersen). Pre-symptomatic intervention in tuberous sclerosis complex provides an early, single-trial clinical proof of principle for delaying and reducing the incidence of epilepsy in a genetically defined population; this should not yet be equated with established disease prevention. Conclusions: The pipeline reflects an ongoing shift from broad symptomatic agents toward mechanism-led, genotype-matched, and potentially disease-modifying treatments. This shift is tempered by a persistent translational gap between early signals and randomized-trial confirmation, and by the preliminary status of much of the supporting evidence. Full article

Background/Objectives: In glioma patients, acute neurologic deterioration may reflect nonconvulsive status epilepticus (NCSE), peri-ictal pseudoprogression, treatment-related change, or true progression. As these entities share imaging features, misdiagnosis can delay therapy. This review synthesizes evidence relevant to a proposed electroclinical-imaging framework for distinguishing seizure-related deterioration from treatment-related change and true progression. Methods: This narrative review synthesized English-language literature on tumor-related epilepsy, NCSE, peri-ictal imaging abnormalities, pseudoprogression, radiation necrosis, Response Assessment in Neuro-Oncology (RANO) criteria, and advanced imaging in adult diffuse glioma. Results: Seizure recurrence after glioma treatment may indicate tumor activity, but it may also reflect radiation injury, postoperative gliosis, edema, metabolic disturbance, medication effects, or transient peri-ictal change. NCSE is particularly important because it may present with aphasia, confusion, impaired consciousness, behavioral change, or deficits without convulsions, making electroencephalography central for unexplained deterioration. Seizure activity can also produce transient magnetic resonance imaging (MRI) or positron emission tomography (PET) abnormalities, including enhancement, fluid-attenuated inversion recovery (FLAIR) hyperintensity, diffusion restriction, and perfusion changes that mimic recurrence. Conclusions: This review proposes a structured electroclinical-imaging framework incorporating early EEG, seizure history, treatment timing, corticosteroid and antiseizure response, multimodal imaging, and longitudinal reassessment for prospective evaluation in treated glioma patients with new neurologic decline. Full article

Introduction. In recent years, cannabidiol (CBD) has been used as an adjunct therapy to anti-seizure medications for the control of seizures in patients with drug-resistant epilepsy. In addition to its anticonvulsant effect, CBD also has well-defined anti-inflammatory properties. Since neuroinflammation can trigger various pro-epileptogenic mechanisms, CBD could play an inhibitory role in this process. Epileptogenesis is the process by which epilepsy becomes a chronic disease following a brain injury, and one of its main characteristics is an increased susceptibility to seizures due to a reduced seizure threshold. However, the role of CBD in modulating this susceptibility remains poorly understood. Methodology. We developed an experimental protocol to discretely measure the seizure threshold (DMST) 7 or 14 days after lithium-pilocarpine-induced status epilepticus (SE) through the administration of small intraperitoneal (i.p.) doses of pentylenetetrazol (15 mg/kg/every 10 min). Results. Using the DMST, we observed a significant decrease in the seizure threshold after SE associated with a hypersensitivity state characterized by irritability and marked weight loss. A separate cohort of rats was treated with CBD (20 mg/kg) for 14 days following SE. Conclusions. Treatment with CBD did not improve the seizure threshold; moreover, it worsened the hypersensitivity state and delayed recovery following SE. Our results suggest that orally administered CBD, at a human-equivalent therapeutic and safe dose, does not improve susceptibility to seizure development after SE. Full article

Neuroprotection in childhood developmental and epileptic encephalopathies may require approaches, distinct from adult brain injury models of neuroprotection, with a primary focus on preservation of synaptic density rather than prevention of cellular necrosis. There is growing evidence to indicate early-life seizures activate complement cascade proteins C1q and C3. Subsequently, localized microglia may excessively phagocytose structurally intact synaptic neurons disrupting normal brain maturation. This review incorporates kinetic models of neuro-immune interactions based on human histopathology from epileptogenic tissues and quantitative neuro-immune biomarkers to provide suggestions that complement-mediated synaptic pruning may contribute to structural network disruption and cognitive decline in pediatric epilepsy. While standard anti-seizure medications effectively stabilize electrical activity, they do not mitigate underlying neuro-inflammatory responses. Consequently, targeted pharmacological inhibition of the complement microglia axis may provide a potential disease modifying strategy to protect developing neural circuits. The translational feasibility of using targeted complement inhibitors should be evaluated addressing critical challenges such as central nervous system drug delivery across the blood–brain barrier, immunosuppression management and the application of non-invasive biomarkers to define the precise therapeutic window for intervention. Full article

Background/Objectives: Epilepsy remains a major neurological disorder, with approximately one-third of patients continuing to experience pharmacoresistant seizures despite the availability of numerous antiseizure medications (ASMs). While current therapies primarily target neuronal hyperexcitability through modulation of ion channels and neurotransmitter systems, increasing evidence suggests that epileptogenesis arises from multiscale interactions involving molecular, cellular, circuit, network, neuroinflammatory, and neurovascular mechanisms. Although therapeutic strategies have diversified, this expanded mechanistic understanding has not yet been fully incorporated into therapeutic development and evaluation. This review integrates current knowledge of multiscale epilepsy pathophysiology with recent therapeutic advances and emerging experimental platforms. Methods: This narrative review synthesized literature identified primarily through PubMed and Google Scholar searches through January 2026, supplemented by targeted updates of therapeutic development and regulatory status through July 2026. Particular emphasis was placed on ion channel modulators, synaptic and neuromodulatory therapies, neuroinflammatory interventions, precision genetic approaches, and human-relevant experimental platforms, including induced pluripotent stem cell (iPSC)-derived models, brain organoids, multi-electrode arrays (MEAs), organ-on-a-chip systems, multi-omics technologies, and artificial intelligence (AI)-based analytical frameworks. Results: Current and emerging therapies target increasingly diverse molecular, circuit, neuromodulatory, and neuroinflammatory mechanisms. However, drug resistance remains multifactorial, and the long-term effects of therapeutic interventions on network remodeling, neuro-glial interactions, and sustained clinical response remain incompletely understood. NAMs provide complementary capabilities for patient-specific disease modeling, functional network phenotyping, neurovascular modeling, and the integration of molecular, electrophysiological, and computational data across biological scales. Conclusions: Epilepsy is increasingly recognized as a multiscale network disorder rather than solely a condition of neuronal hyperexcitability. The coordinated use of complementary human-relevant platforms may help incorporate multiscale mechanistic insights into therapeutic development and evaluation, narrow persistent translational gaps, and support more predictive and mechanism-informed treatment strategies. Full article

Background/Objective: Status epilepticus (SE) is a life-threatening condition that requires immediate response to effectively control. Although benzodiazepines are the first-line treatment against SE, when treatment is delayed, benzodiazepine pharmacoresistance develops. In preclinical models of benzodiazepine refractory SE, the addition of antiseizure medications (ASMs) as adjunct to midazolam to reduce neuronal excitability and enhance inhibitory function is essential to protect against the neurodegeneration and epileptogenesis that follows prolonged seizure. Brivaracetam is a recently FDA-approved ASM to treat partial onset seizures in pediatric and adult patients as a monotherapy or adjunct therapy. We evaluated the potential of brivaracetam as monotherapy or in combination with midazolam and ketamine for efficacy against organophosphorus nerve agent (OPNA)-induced refractory SE in rats. Methods: Adult male rats were exposed to a seizure-inducing dose of soman and treated with atropine sulfate and the oxime asoxime chloride one minute after soman exposure and with brivaracetam alone or in combination with midazolam and ketamine 40 min after seizure onset. Multiple metrics of protection such as seizure severity, spontaneous recurrent seizure (SRS), neuronal loss, and neuroinflammation were evaluated. Results: Although brivaracetam monotherapy resulted in 100% survival, protection from the development of SRS and neurodegeneration only occurred when brivaracetam was administered as an adjunct to ketamine and midazolam. Initial seizure severity was also reduced by the combination of brivaracetam–midazolam–ketamine over monotherapy. Conclusions: Although further research is needed to determine optimal drug combinations, these preclinical findings provided further evidence that simultaneous polytherapy with ASMs improves OPNA-induced seizure outcomes. Full article

Objective: Voltage-gated potassium channel genes are among the most frequently implicated in epilepsy and antiseizure medication (ASM) response. In this pilot study, we aimed to identify rare and common variants by sequencing voltage-gated potassium channel (Kv) genes in epilepsy patients using ASM, and to reveal the potential drug responses of these variants. Methods: To investigate the role of genetic variants in Kv genes (KCNQ1, KCNQ2, KCNQ3, KCNA1, KCNA2, and KCNV2) in response to ASMs among 31 epilepsy patients, we used targeted next-generation sequencing (tNGS). Patients were classified as responders or persistent based on seizure control status. Selected variants in the genes were annotated, filtered, and analyzed for association with ASM response. Results: We identified 181 variants in the 6 channel genes, including missense, synonymous, intronic, UTR, and stop-gained variants. Six variants of uncertain significance (VUSs) were observed, including KCNA2c.*1314C>T, KCNQ1c.*976G>A, KCNQ2 (c.2613G>T p.Arg871Ser and c.1148+62T>G), and KCNQ3 (c.*6282A>G and c.*2860T>C). Two novel variants were identified in our study group, KCNA2:c.*1314C>T and KCNQ3:c.*2860T>C. Both were located in the 3′ UTR region and classified as VUSs according to ACMG guidelines. In the KCNV2 gene, the CG haplotype comprising rs7029012 and rs10967705 was observed more frequently in patients with drug-persistent epilepsy than in those with drug-responsive epilepsy (18.5% vs. 0.8%; χ² = 6.756, p = 0.009, BH-FDR q = 0.036), suggesting a potential association with pharmacoresistant epilepsy. Conclusions: Our haplotype analysis suggests the potential pharmacogenetic contribution of the KCNV2 gene to ASM response; however, these exploratory findings require validation in larger independent cohorts and functional studies. Full article

Background: Volumetric absorptive microsampling (VAMS) is an emerging tool for therapeutic drug monitoring (TDM) of several drugs including antiseizure medications (ASMs). Here, we compared the concentrations of carbamazepine (CBZ), levetiracetam (LEV), lacosamide (LCS), topiramate (TPR) and the benzodiazepine (BZ) clobazam (CLB) in plasma and VAMS samples. Methods: VAMS samples were collected by fingerprick in pediatric patients followed at our center. Patients were also subjected to conventional venous blood sampling. Plasma and VAMS samples were analyzed by using a UHPLC-MS/MS validated kit for AEs and BZs (ClinMass LC-MS/MS Complete Kit^®). A cross-validation analysis was performed by using Spearman correlation (rho), Deming regression and Bland–Altman plots. Results: Two analytical methods for measuring selected AEs and BZs in VAMS samples were developed and validated in accordance with the ICH M10 guidelines. Based on Bland–Altman results, a satisfactory agreement was observed between VAMS and plasma for CBZ, LCS, TPR, LEV and N-CLB. Considering the absence of interchangeability between capillary blood and plasma levels for CBZ-Diol, -Epoxi and CLB, a blood to plasma ratio was used to convert VAMS values into estimated plasma concentrations. Comparison of estimated vs. observed plasma results showed a successful predictive performance for this conversion approach. Conclusions: A positive agreement between plasma and VAMS was found for CBZ, LCS, TPR, LEV and N-CLB. Conversely, a conversion factor based on blood to plasma ratio should be adopted to convert CBZ-Diol, -Epoxi and CLB VAMS results into estimated plasma concentrations. This study confirmed the utility of VAMS for TDM of selected ASMs in pediatric patients during routine clinical practice. Full article

Background/Objectives: Voltage-gated sodium channels (VGSCs) are among the most important molecular targets in epilepsy therapy. Unlike classical antiseizure medications (ASMs), newer sodium channel modulators selectively affect slow inactivation or persistent sodium currents, potentially improving seizure control while preserving physiological neuronal activity. This review summarizes the pharmacology, mechanisms of action, clinical efficacy, and therapeutic potential of eslicarbazepine acetate, lacosamide, and cenobamate. Methods: A narrative review of published clinical trials, meta-analyses, and real-world evidence was conducted. The analysis focused on sodium channel modulation, pharmacokinetic properties, efficacy in monotherapy and adjunctive therapy, and safety profiles in focal epilepsy. Main findings of the review: Eslicarbazepine acetate and lacosamide primarily enhance slow inactivation of VGSCs, suppressing pathological repetitive neuronal firing with limited effects on normal neuronal signaling. Both agents demonstrated efficacy in monotherapy and add-on therapy, with favorable pharmacokinetic properties and a relatively low potential for drug–drug interactions. Cenobamate represents a novel therapeutic approach through preferential inhibition of persistent sodium currents combined with positive allosteric modulation of GABA_A receptors. Clinical trials and real-world studies demonstrated high responder and seizure freedom rates, particularly in patients with drug-resistant focal epilepsy. The most common adverse effects across these agents included dizziness, somnolence, fatigue, and gastrointestinal symptoms, while notable safety concerns included hyponatremia with eslicarbazepine acetate and drug interactions or dose-dependent adverse effects with cenobamate. Conclusions: Recent advances in sodium channel modulation have expanded therapeutic options for focal epilepsy and support the development of more selective, mechanism-based ASM therapies. Eslicarbazepine acetate, lacosamide, and cenobamate demonstrate favorable efficacy and tolerability profiles and may improve seizure control in patients with drug-resistant epilepsy. Full article

Background/Objectives: Epilepsy treatment often continues long-term from childhood. However, evidence comparing long-term treatment persistence and adverse events (AEs) between levetiracetam (LEV) monotherapy and LEV-containing combination therapy in pediatric patients is limited. This study compared the retention rate and the rate of AEs, including irritability and insomnia, between these treatment strategies. Methods: A retrospective cohort study was conducted using data from the Pediatric Medical Information Collection System database. Patients aged ≥0 to <15 years who were diagnosed with epilepsy and prescribed with LEV, based on records registered between 1 April 2016 and 30 September 2025, were included in the study. Results: In total, 3576 patients were analyzed. Among them, 2936 were classified under the monotherapy group and 640 under the combination therapy group. The monotherapy group had a significantly higher retention rate than the combination therapy group. The two groups did not significantly differ in terms of the rates of irritability or insomnia. Conclusions: In pediatric patients with epilepsy, the retention rate of LEV monotherapy was higher than that of LEV-containing combination therapy. Meanwhile, the rates of irritability or insomnia did not substantially differ between the two groups. Based on these findings, adding LEV to other anti-seizure medications was not associated with an evident increase in the rate of irritability or insomnia. Although anti-seizure medication polytherapy has traditionally been considered to increase the risk of psychiatric and behavioral symptoms, the current study showed a different trend. Full article

Epilepsy is a multifactorial disorder, yet routine management still focuses on neuronal excitation and insufficient inhibition, with antiseizure medications (ASMs) as the primary therapeutic strategy. This approach fails in roughly one-third of patients who develop drug-resistant epilepsy (DRE). Converging evidence links DRE with neuroinflammation, oxidative stress (OS), and mitochondrial dysfunction—an interconnected distal pathophysiological triad that progressively lowers seizure thresholds yet remains peripheral to clinical epilepsy management. We map this triad mechanistically and show that ASMs modulate it beyond their anticonvulsant activity, while triad-targeting pharmacological, dietary, and botanical interventions independently reduce seizure susceptibility. Common precipitants are reinterpreted as acute activators of the distal triad, linking precipitant identification and patient agency to threshold elevation. Integrating these elements, we propose a threshold management framework for DRE, built on a revised reservoir model, and translate it into three structural priorities: mechanistic phenotyping to stratify patients by pathophysiological domain, dual-mechanism drug development, and trial designs suited to multicomponent, context-dependent interventions. Together, these proposals reframe epilepsy management from sequential pharmacological trials toward coordinated optimization of the full seizure threshold landscape. Full article

Background/Objectives: In resource-limited regions, limited access to genetic testing may delay etiological diagnosis in selected patients with epilepsy and complex neurological manifestations, particularly when the phenotype raises suspicion of an underlying genetic etiology. This study aimed to assess the diagnostic value and clinical utility of phenotype-guided WES in selected patients aged ≥17 years with epilepsy and complex neurological manifestations in Southern Kazakhstan and to characterize clinical, therapeutic, and molecular features associated with drug-resistant epilepsy (DRE). Methods: This observational cohort included 78 patients aged ≥17 years with epilepsy and complex neurological manifestations identified through 25 outpatient medical centers. After enrollment, all patients underwent structured HPO-based phenotyping, assessment of antiseizure medication exposure, seizure burden, treatment response, and proband-only WES. Variants were interpreted according to ACMG/AMP guidelines. Exploratory multivariable logistic regression was used to assess factors associated with DRE. Results: P/LP variants were identified in 12/78 patients, corresponding to a diagnostic yield of 15.4%. VUS were detected in 16/78 patients (20.5%). DRE was present in 41 patients (52.6%), all of whom were receiving polytherapy. Carbamazepine was the most frequently used antiseizure medication (52/78, 66.7%), followed by valproic acid (32/78, 41.0%) and levetiracetam (20/78, 25.6%). Patients with DRE had earlier seizure onset, more frequent definite structural MRI abnormalities, and a higher proportion of P/LP variants. In the adjusted model, P/LP variant presence and definite structural MRI abnormality were associated with DRE. Conclusions: Phenotype-guided proband-only WES provided clinically relevant diagnostic information in a real-world epilepsy cohort with complex neurological manifestations in a resource-limited outpatient setting. The observed burden of DRE and polytherapy supports the potential value of integrating therapeutic profiling, neuroimaging, and genomic testing in the etiological evaluation of patients with epilepsy and additional neurological features. Full article

Patients with cerebrovascular disease frequently require concomitant antiplatelet and antiseizure therapy. However, experimental evidence regarding potential pharmacodynamic interactions between these medications remains limited. The present study investigated whether clopidogrel affects the anticonvulsant effects of valproic acid (VPA) or levetiracetam (LEV) in a pentylenetetrazol (PTZ)-induced seizure model. Forty-two male Wistar rats were randomly allocated to seven groups (n = 6/group): Control, PTZ, clopidogrel (CLP), VPA, LEV, VPA + CLP + PTZ, and LEV + CLP + PTZ. Electroencephalographic recordings, passive avoidance testing, histopathological examination, and glial fibrillary acidic protein (GFAP) immunohistochemistry were performed to evaluate seizure activity, behavioral performance, neuronal injury, and astroglial activation. Both VPA and LEV significantly reduced spike–wave discharge frequency and duration compared with the PTZ group (p < 0.05). Clopidogrel alone did not exhibit anticonvulsant activity, and co-administration with either VPA or LEV did not significantly alter electrophysiological, behavioral, histopathological, or GFAP-associated immunohistochemical outcomes. Overall, these findings indicate that clopidogrel did not significantly affect the anticonvulsant efficacy of VPA or LEV under the experimental conditions of this acute PTZ-induced seizure model. Full article

Stroke is a major cause of acquired epilepsy in adults, particularly in older individuals. However, seizures after stroke should not be regarded as a single clinical entity. Acute symptomatic seizures (ASyS) occur within the first seven days after stroke and are considered provoked events, whereas remote symptomatic seizures carry a higher recurrence risk and may fulfill the practical definition of post-stroke epilepsy (PSE). This narrative review provides a clinically oriented synthesis of current evidence on definitions, epidemiology, pathophysiology, risk factors, predictive scores, EEG and biomarker-based risk stratification, seizure prevention, and antiseizure medication (ASM) management. Current evidence does not support routine primary antiseizure medication prophylaxis for all stroke patients. In contrast, documented clinical or electrographic seizures require appropriate treatment, and established PSE often requires long-term individualized therapy. Predictive tools may help guide surveillance, EEG indication, counseling, and follow-up, but should not be used as automatic triggers for prophylactic treatment. ASM choice should account for seizure type, age, comorbidities, cognitive and psychiatric vulnerability, drug interactions, and secondary vascular prevention. Future research should focus on validated biomarkers and preventive strategies capable of modifying epileptogenesis after stroke. Full article

Background/Objectives: Adult epilepsy is clinically heterogeneous, and individual clinical predictors may not fully capture the multidimensional burden associated with drug-resistant epilepsy (DRE). This study aimed to identify latent clinical phenotypes in adults with epilepsy and examine their cross-sectional associations with DRE and broader disease burden. Methods: This regional observational cohort study used a source database of 1100 patients with epilepsy. After excluding two patients aged <18 years, the adult analytic cohort included 1098 patients. Complete-case latent class analysis (LCA) was performed in 1054 patients using age at onset, disease duration, seizure type, seizure frequency, serial seizures/status, postictal confusion, neurological status, neuroimaging category, and number of antiseizure medications. Model selection was based on statistical fit, class size, and clinical interpretability. Internal clinical validation outcomes included DRE, quality of life, cognitive screening, and stigma scores. Post hoc characterization described the classes by epilepsy etiology, derived epilepsy type, and seizure categories aligned with current terminology. Results: A three-class solution was selected, with class sizes of 314, 465, and 275. DRE prevalence increased stepwise across classes: 5.7%, 14.2%, and 33.1%, respectively (p < 0.001). In adjusted analysis, Class 2 had higher odds of DRE than Class 1 (odds ratio 2.70, 95% confidence interval 1.56–4.67), while Class 3 showed the strongest association (odds ratio 8.19, 95% confidence interval 4.15–16.16; both p < 0.001). Higher-burden classes showed lower quality-of-life and cognitive scores and higher stigma scores. Conclusions: LCA identified three clinically interpretable, burden-enriched phenotypic profiles associated with a stepwise gradient in DRE and broader multidimensional disease burden. These cross-sectional profiles may provide a useful framework for describing clinical heterogeneity in adult epilepsy and generating hypotheses for future validation studies. Full article