Subcortical Structures and Epilepsy

Epilepsy is a network disorder characterized by dynamic interactions between cortical and subcortical circuits that collectively facilitate seizure initiation, propagation, maintenance, and termination. While cortical structures have traditionally dominated epilepsy research, diagnostic evaluation, and therapeutic targets, recent years have witnessed growth in exploring the role of subcortical structures beyond the well-studied limbic system for several decades. Structures such as the thalamus have emerged as critical nodes in epileptic networks, with growing evidence from neuromodulation studies underscoring its critical role in seizure dynamics. This shift reflects a paradigm change from localized cortical focus models to a more comprehensive understanding of distributed cortical-subcortical networks in epilepsy pathophysiology. In this review, we explore different subcortical structures and their involvement in both generalized and focal epilepsies, suggesting that there must be continued research into cortical-subcortical network dynamics. A more profound understanding of these networks holds promise for improving therapeutic strategies, enhancing patient outcomes, and reducing the risk of surgical failure.