Frontiers in EEG as a tool for the management of pediatric epilepsy: Past, present, and future

Electroencephalography (EEG) has evolved into an indispensable tool in pediatric epilepsy, fundamentally transforming the diagnosis, classification, and management of this condition. This review chronicles the historical journey of EEG from its groundbreaking inception to its current pivotal role in delineating distinct pediatric epilepsy syndromes. Early observations of epileptiform patterns paved the way for the classification of pediatric epilepsy syndromes, such as Childhood Absence Epilepsy, West syndrome, and Lennox-Gastaut syndrome, marking a significant leap in understanding pediatric epilepsy. Over the decades, EEG's application has advanced from mere observation of brain activity to a systematic analysis that not only identifies abnormal patterns but also guides targeted treatment decisions. Currently, EEG assists clinicians in differentiating epileptic events from nonepileptic phenomena, which is crucial for accurate diagnosis and appropriate intervention. By localizing epileptogenic zones, EEG informs surgical planning in drug-resistant epilepsy. Continuous EEG monitoring in pediatric critical care settings enables real-time seizure detection, which can significantly reduce morbidity. Furthermore, EEG plays a critical role in evaluating the efficacy of pharmacological therapies, ensuring that treatments are both timely and tailored to individual patient needs. Emerging conceptual and technological advancements-including quantitative biomarkers for genetic epilepsies, high-frequency oscillations from scalp EEG, network-based analyses, and real-time seizure detection combined with closed-loop stimulation-hold tremendous potential to transform the diagnosis and treatment of pediatric epilepsy. Concurrently, the rapid integration of artificial intelligence is pushing the boundaries of EEG analysis in ways previously unimaginable. These innovations allow for earlier detection of subtle or subclinical pathological EEG signatures and provide prognostic insights that can inform long-term management strategies. As these techniques mature, they promise not only to refine current clinical approaches but also to foster personalized interventions that optimize outcomes for children with epilepsy. PLAIN LANGUAGE SUMMARY: EEG has evolved from Hans Berger's first recordings in 1924 to a critical tool for diagnosing and classifying childhood epilepsy. Noninvasive scalp and video-EEG now distinguish true seizures from other events, monitor treatment response, forecast risk, and guide ICU care. When needed, invasive EEG pinpoints seizure sources for surgery. Cutting-edge methods-like detecting high-frequency oscillations, network analysis, AI-driven interpretation, and closed-loop stimulation-are creating personalized therapies and improving outcomes for children with epilepsy.