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High-frequency oscillations (HFO) are promising EEG biomarkers of epileptogenicity. While the evidence supporting their significance derives mainly from invasive recordings, recent studies have extended these observations to HFO recorded in the widely accessible scalp EEG. Here, we investigated whether scalp HFO in drug-resistant focal epilepsy correspond to epilepsy severity and how they are affected by surgical therapy. In eleven children with drug-resistant focal epilepsy that underwent epilepsy surgery, we prospectively recorded pre- and postsurgical scalp EEG with a custom-made low-noise amplifier (LNA). In four of these children, we also recorded intraoperative electrocorticography (ECoG). To detect clinically relevant HFO, we applied a previously validated automated detector. Scalp HFO rates showed a significant positive correlation with seizure frequency (R 2  = 0.80,  p  < 0.001). Overall, scalp HFO rates were higher in patients with active epilepsy (19 recordings,  p  = 0.0066, PPV = 86%, NPV = 80%, accuracy = 84% CI [62% 94%]) and decreased following successful epilepsy surgery. The location of the highest HFO rates in scalp EEG matched the location of the highest HFO rates in ECoG. This study is the first step towards using non-invasively recorded scalp HFO to monitor disease severity in patients affected by epilepsy.

High-frequency oscillations in scalp EEG mirror seizure frequency in pediatric focal epilepsy