This retrospective study characterized epileptic arousals (EAs) — seizures manifesting solely as arousal from sleep — in 20 focal epilepsy patients undergoing presurgical monitoring (2010–2023), using simultaneous intracranial EEG, scalp EEG, and ECG to define seizure-onset/propagation zones and autonomic signatures.
133 of 507 seizures (26.2%) were EAs; 66.9% were undetectable on scalp EEG alone. Broader seizure-propagation zones predicted scalp detectability (OR 3.16, AUC 0.891). Heart rate rose during both EAs and physiological arousals, but modulation was significantly greater during EAs (p = 0.007, AUC 0.995) with a multimodal distribution, suggesting a distinct autonomic signature.
Small single-center cohort (n = 20) limits generalizability. Retrospective design introduces selection bias. EAs are not yet formally classified, so identification relied on visual review without a standardized definition.
Scalp EEG alone misses roughly two-thirds of EAs, so clinicians should not rely on it to rule out a high EA burden in focal epilepsy patients. Heart rate dynamics during arousals may serve as a useful bedside signal to distinguish epileptic from physiological arousals pending formal validation.
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