Neurometabolic Epilepsies: A Practical Guide to Recognition, Diagnostic Workup, and Precision Treatment.

Neurometabolic epilepsies are a heterogeneous group of inherited metabolic disorders in which seizures are a major clinical feature and may be the presenting symptom. Although each disorder is rare, they are clinically significant because many are potentially treatable and early intervention can substantially improve neurological outcomes. The clinical spectrum includes neonatal epileptic encephalopathies, infantile spasms, developmental and epileptic encephalopathies, progressive myoclonic epilepsies, and late-onset epileptic syndromes. Epileptogenesis arises from diverse mechanisms, such as impaired cerebral energy metabolism, neurotransmitter dysfunction, accumulation of neurotoxic metabolites, cofactor deficiencies, and organelle dysfunction. Recognizing a metabolic etiology requires a high index of suspicion. Key diagnostic clues include early seizure onset, developmental delay or regression, episodic neurological deterioration, movement disorders, multisystem involvement, characteristic neuroimaging findings, and a suggestive family history. A structured diagnostic approach that integrates first-tier biochemical investigations, targeted metabolic testing, cerebrospinal fluid studies, neurophysiological assessment, neuroimaging, and molecular genetic testing is essential for timely diagnosis. In critically ill patients, empirical administration of pyridoxine, pyridoxal-5'-phosphate, folinic acid, biotin, and selected cofactors should be considered while diagnostic investigations are ongoing. Ketogenic dietary therapy is a disease-specific treatment for selected disorders of cerebral energy metabolism, particularly glucose transporter type 1 deficiency syndrome and pyruvate dehydrogenase complex deficiency.