Not All Spikes Are Equal.

EEG remains the primary diagnostic tool for evaluating seizures in children, with interictal epileptiform discharges (IEDs) serving as key biomarkers of epileptogenic activity. However, not all IEDs have the same prognostic significance. Variations in IED topography, morphology, frequency, and timing influence outcomes in pediatric epilepsy. The developing brain's maturation affects IED location and features, creating age-specific patterns with distinct implications. For example, occipital and midline IEDs are common in young children, with midline IEDs strongly linked to increased seizures and developmental delay than control patients. Morphological features provide additional prognostic stratification. While centrotemporal IEDs with tangential dipoles are well-established as favorable prognostic markers, IEDs exhibiting tangential dipoles in any brain region are associated with more benign clinical courses than control patients. Conversely, positive sharp waves persisting beyond the neonatal period signal less favorable prognosis, including developmental delay, abnormal neurological examination, and structural brain abnormalities. Additionally, IEDs occurring on ripples have been shown to serve as more reliable interictal biomarkers of the epileptogenic zone than IEDs or ripples alone. Topography, frequency and sleep-state dependence also carry clinical significance, as frequent IEDs during slow-wave sleep may impact cognition. Furthermore, the temporal context of IED occurrence during seizure onset, treatment, activation procedures, medication withdrawal, or after epilepsy surgery provides valuable prognostic information. Recognition of these nuanced electrophysiological distinctions enhances clinicians' ability to predict clinical trajectories and optimize long-term management strategies.