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Epilepsy surgery can achieve seizure freedom in selected pediatric candidates, but reliable postsurgical predictors of seizure freedom are missing. High frequency oscillations (HFO) in scalp EEG are a new and promising biomarker of treatment response. However, it is unclear if the skull defect resulting from craniotomy interferes with HFO detection in postsurgical recordings. We considered 14 children with focal lesional epilepsy who underwent presurgical evaluation, epilepsy surgery, and postsurgical follow-up of ≥ 1 year. We identified the nearest EEG electrodes to the skull defect in the postsurgical MRI. We applied a previously validated automated HFO detector to determine HFO rates in presurgical and postsurgical EEG. Overall, HFO rates showed a positive correlation with seizure frequency ( p  &lt; 0.001). HFO rates in channels over the HFO area decreased following successful epilepsy surgery, irrespective of their proximity to the skull defect ( p  = 0.005). HFO rates in channels outside the HFO area but near the skull defect showed no increase following surgery ( p  = 0.091) and did not differ from their contralateral channels ( p  = 0.726). Our observations show that the skull defect does not interfere with postsurgical HFO detection. This supports the notion that scalp HFO can predict postsurgical seizure freedom and thus guide therapy management in focal lesional epilepsy.

Scalp HFO rates decrease after successful epilepsy surgery and are not impacted by the skull defect resulting from craniotomy