The Therapeutic Loop: Closed-Loop Epilepsy Systems Mirroring the Read–Write Architecture of Brain–Computer Interfaces

Drug-resistant epilepsy (DRE) remains a major therapeutic challenge, as a considerable proportion of epilepsy patients fail to achieve seizure control with conventional anti-seizure medications or surgical therapy. Closed-loop systems have emerged as a promising alternative, offering patient-specific, on-demand neuromodulation. Despite notable advances in the academic domain, clinical translation has stagnated, and surgical resection remains the intervention with the highest probability of achieving seizure freedom. In this review, we delineate the principal limitations currently constraining progress in epilepsy neuromodulation and conceptualise these systems as instantiations of the read-write architecture characteristic of brain–computer interfaces. The read component entails the continuous acquisition and analysis of neurophysiological signals to predict or detect imminent seizures. In contrast, the write component involves the delivery of targeted interventions to disrupt epileptiform dynamics and prevent clinical seizure manifestation. We outline the closed-loop processing pipeline, survey the current state of the art, and discuss key methodological and translational challenges, particularly in algorithm validation and long-term reliability. Finally, we address patients’ and caregivers’ perspectives on the acceptance and practical integration of such technologies. This work synthesises current advances in the field and delineates the path toward fully autonomous clinically effective closed-loop neuromodulation as a viable treatment paradigm for DRE, aiming to improve patients’ quality of life.