Seizure pathways change on circadian and slower timescales in individual patients with focal epilepsy

Personalised medicine requires that treatments adapt to not only the patient, but changing factors within each individual. Although epilepsy is a dynamic disorder that is characterised by pathological fluctuations in brain state, surprisingly little is known about whether and how seizures vary in the same patient. We quantitatively compared within-patient seizure network dynamics using intracranial recordings of over 500 seizures from 31 patients with focal epilepsy (mean 16.5 seizures/patient). In all patients, we found variability in seizure paths through the space of possible network dynamics, producing either a spectrum or clusters of different dynamics. Seizures with similar pathways tended to occur closer together in time, and a simple model suggested that seizure pathways change on circadian and/or slower timescales in the majority of patients. These temporal relationships occurred independent of whether the patient underwent antiepileptic medication reduction. Our results suggest that various modulatory processes, operating at different timescales, shape within-patient seizure dynamics, leading to variable seizure pathways that may require tailored treatment approaches.