Response to: "Early benzodiazepine treatment and electrographic seizures after febrile status epilepticus"

We appreciate Inui et al.'s comments regarding the divergent prognostic outcomes of patients with electrographic seizures (ESz) between our studies. The poorer prognosis in their cohort compared to ours likely stems from three key differences. First, baseline disease severity significantly differed. Our cohort predominantly consisted of milder cases, such as febrile seizures, with only 17.2% requiring pediatric intensive care. Conversely, Inui et al. evaluated critically ill patients with acute encephalopathy, whose severe ESz EEG features-such as periodic discharges-inherently indicate a poorer prognosis. Second, the timing of EEG recordings varied. We evaluated EEGs during the hyperacute phase in the emergency department (median 77.5 min post-onset). In contrast, Inui et al. assessed patients 7-96 h post-onset, reflecting a substantially delayed timeframe. Third, diverging interpretations and treatments of evolving rhythmic delta activity (RDA) likely contributed to the prognostic gap. Our institution's protocol treats evolving RDA as a seizure equivalent, warranting immediate therapeutic intervention in the emergency setting. We have previously demonstrated that this early, RDA-targeted intervention yields better clinical outcomes. These discrepancies highlight the necessity for future studies incorporating comprehensive, early EEG evaluations. Further investigation is essential to clarify the precise prognostic implications of post-ictal evolving RDA and to establish a clinical consensus on the necessity of active therapeutic intervention.