Frontal Lobe Epilepsy: Bermuda's Triangle

Despite great progress in imaging, genetics, surgery, and therapeutics, frontal lobe epilepsy (FLE) continues to be a challenge for neurologists and epileptologists. This manuscript summarizes the latest advancements in FLE discussed at the 2023 Epilepsy Specialist Symposium during the American Epilepsy Society Annual meeting. Correlation between stereoelectroencephalography and clinical symptoms has reinvigorated symptomatology literature in FLE, allowing for more precise aura anatomical localization. Neuropsychological assessments permit the identification of different FLE cognitive phenotypes, with language being the most prominent domain-specific impairment. These tests can help develop psychotherapeutic and cognitive support systems for these patients. Genetic and molecular studies have uncovered specific genes associated with FLE susceptibility, offering prospects for targeted therapies. Advanced neuroimaging techniques such as high field magnetic resonance imaging (MRI), functional MRI (fMRI), magnetoencephalography and colocalization of multiple imaging techniques have led to more precise localization of the epileptogenic zone providing insights into the dynamic neural networks underlying frontal lobe seizures. This has facilitated guided therapeutic surgical interventions that can be employed around the world, expanding access of these technologies to multiple populations. Despite many advances, prognosis of FLE remains poor for some patients. The biggest determinant for poor prognosis continues to be nonlesional FLE. Newer technological advancements aim to pass these barriers and offer FLE patients a better quality of life with lower seizure burden and higher cognitive outcomes.