Rethinking the electrographical boundaries of status epilepticus: controversies and paradoxes of the ictal-interictal continuum

The ictal-interictal continuum (IIC) challenges the traditional dichotomous classification of electroencephalographic activity into ictal and interictal states and represents a major zone of diagnostic and therapeutic uncertainty in status epilepticus (SE). IIC is defined by rhythmic and periodic electroencephalographic (EEG) patterns that do not fulfill formal seizure criteria and occupies a gray zone in which the interpretation of what is ictal, treatment responsiveness, and risk of neuronal injury remains controversial. In this narrative review, we explored the boundaries between SE and the IIC, focusing on key controversies and paradoxes that emerge across electroclinical scenarios and neuroimaging findings. More specifically, we examine the time-locked electroclinical correlates and antiseizure medication responsiveness as markers of ictality, ongoing controversies in EEG-based definitions, and the role of peri-ictal neuroimaging abnormalities as complementary markers of metabolic burden. This review aims to summarize these topics and discuss key gaps for future research in the management of IIC.