The present letter aims to commend Hermann et al.1 for their significant contribution, “A user's guide for the International Classification of Cognitive Disorders in Epilepsy” (IC-CoDE). By establishing a consensus-based, empirically driven framework, the authors provide a robust solution to address decades of diagnostic heterogeneity in epileptology.2 This standardized lexicon, categorizing patients into Cognitively Intact, Single-Domain, Bi-Domain, or Generalized Impairment phenotypes,1 represents a major collaborative milestone, offering critical cross-cultural applicability across diverse cohorts. The guide provides the global neuropsychological community with an essential tool for pooling multinational data and standardizing clinical research. Building upon this robust framework, I respectfully suggest that a logical next step for the IC-CoDE taxonomy is its longitudinal application in patients with drug-resistant focal epilepsy undergoing resective surgery. Currently, the IC-CoDE provides a highly accurate, yet static, cross-sectional snapshot of cognitive morbidity. However, integrating this taxonomy into longitudinal surgical paradigms offers a valuable opportunity to track neuroplasticity3 and better understand the complex etiology of presurgical cognitive impairment. Transitioning from a baseline diagnostic classification to a longitudinal tracking metric would significantly enhance the ability to capture postsurgical cognitive trajectories and individualize patient counseling.4 A surgical candidate's preoperative cognitive profile is rarely driven by a single variable; it reflects a “dual hit”: irreversible structural damage and the reversible toxicity caused by the antiseizure medication (ASM) load and propagating seizure networks.5, 6 By applying the IC-CoDE before and after surgery, phenotypic transitions can be quantified. Following successful resection and the subsequent tapering of polytherapy,7 systemic cognitive suppression frequently lifts. For instance, a patient preoperatively classified with “Generalized Impairment” due to pharmacological burden may transition postoperatively to a “Single-Domain Impairment” (e.g., an isolated memory deficit). This dynamic tracking unmasks the patient's latent functional reserve, allowing clinicians to effectively differentiate fixed lesional damage from reversible systemic toxicity.3 This longitudinal perspective is particularly vital in public health systems characterized by high surgical latency, such as those in resource-limited settings.8 In these environments, prolonged wait times act as a chronicity modulator; years of unabating seizures and high-dose ASMs can irreversibly convert a reversible network dysfunction into a permanent structural trait.9 Applying the IC-CoDE longitudinally not only helps individualize expectations for postoperative cognitive rehabilitation but also provides potent objective data to advocate for the optimization of surgical timing. The foundational framework provided by Hermann et al. makes these dynamic clinical explorations possible, paving the way for a more comprehensive understanding of cognitive outcomes in epilepsy. The author declares no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
Cristian Blanco‐Inostroza (Mon,) studied this question.