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However, given limited spatial sampling, it is possible that stereotactic electroencephalography (stereo\u2010EEG) may miss seizure onset elsewhere. We hypothesized that stereo\u2010EEG seizure onset patterns (SOPs) may differentiate between primary onset and secondary spread and predict postoperative seizure control. In this study, we characterized the 2\u2010year outcomes of patients who underwent single\u2010fiber SLAH after stereo\u2010EEG and evaluated whether stereo\u2010EEG SOPs predict postoperative seizure freedom.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>This retrospective five\u2010center study included patients with or without mesial temporal sclerosis (MTS) who underwent stereo\u2010EEG followed by single\u2010fiber SLAH between August 2014 and January 2022. Patients with causative hippocampal lesions apart from MTS or for whom the SLAH was considered palliative were excluded. An SOP catalogue was developed based on literature review. The dominant pattern for each patient was used for survival analysis. The primary outcome was 2\u2010year Engel I classification or recurrent seizures before then, stratified by SOP category.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Fifty\u2010eight patients were included, with a mean follow\u2010up duration of 39\u2009\u00b1\u200912\u2009months after SLAH. Overall 1\u2010, 2\u2010, and 3\u2010year Engel I seizure freedom probability was 54%, 36%, and 33%, respectively. Patients with SOPs, including low\u2010voltage fast activity or low\u2010frequency repetitive spiking, had a 46% 2\u2010year seizure freedom probability, compared to 0% for patients with alpha or theta frequency repetitive spiking or theta or delta frequency rhythmic slowing (log\u2010rank test, <jats:italic>p<\/jats:italic>\u2009=\u2009.00015).<\/jats:p><\/jats:sec><jats:sec><jats:title>Significance<\/jats:title><jats:p>Patients who underwent SLAH after stereo\u2010EEG had a low probability of seizure freedom at 2\u2009years, but SOPs successfully predicted seizure recurrence in a subset of patients. This study provides proof of concept that SOPs distinguish between hippocampal seizure onset and spread and supports using SOPs to improve selection of SLAH candidates.<\/jats:p><\/jats:sec>","DOI":"10.1111\/epi.17602","type":"journal-article","created":{"date-parts":[[2023,4,4]],"date-time":"2023-04-04T07:49:42Z","timestamp":1680594582000},"page":"1568-1581","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":21,"title":["Seizure onset patterns predict outcome after stereo\u2010electroencephalography\u2010guided laser amygdalohippocampotomy"],"prefix":"10.1111","volume":"64","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7401-8364","authenticated-orcid":false,"given":"Andrew J.","family":"Michalak","sequence":"first","affiliation":[{"name":"Department of Neurology Columbia University Irving Medical Center  New York New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adam","family":"Greenblatt","sequence":"additional","affiliation":[{"name":"Department of Neurology Hospital of the University of Pennsylvania  Philadelphia Pennsylvania USA"},{"name":"Department of Neurology Washington University in St. Louis  St. Louis Missouri USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2461-6323","authenticated-orcid":false,"given":"Shasha","family":"Wu","sequence":"additional","affiliation":[{"name":"Department of Neurology University of Chicago  Chicago Illinois USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9071-8398","authenticated-orcid":false,"given":"Steven","family":"Tobochnik","sequence":"additional","affiliation":[{"name":"Department of Neurology Brigham and Women's Hospital  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hina","family":"Dave","sequence":"additional","affiliation":[{"name":"Department of Neurology University of Texas Southwestern Medical Center  Dallas Texas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ramya","family":"Raghupathi","sequence":"additional","affiliation":[{"name":"Department of Neurology Hospital of the University of Pennsylvania  Philadelphia Pennsylvania USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yasar T.","family":"Esengul","sequence":"additional","affiliation":[{"name":"Department of Neurology University of Toledo College of Medicine  Toledo Ohio USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonio","family":"Guerra","sequence":"additional","affiliation":[{"name":"Department of Neurology University of Texas Southwestern Medical Center  Dallas Texas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7448-2183","authenticated-orcid":false,"given":"James X.","family":"Tao","sequence":"additional","affiliation":[{"name":"Department of Neurology University of Chicago  Chicago Illinois USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9247-1341","authenticated-orcid":false,"given":"Naoum P.","family":"Issa","sequence":"additional","affiliation":[{"name":"Department of Neurology University of Chicago  Chicago Illinois USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Garth R.","family":"Cosgrove","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery Brigham and Women's Hospital  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bradley","family":"Lega","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery University of Texas Southwestern Medical Center  Dallas Texas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Warnke","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery University of Chicago  Chicago Illinois USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"H. 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