The recent intense focus of attention on further characterization and management of infantile spasms is due, in part, to the resistant nature of these seizures and the frequently poor cognitive outcome, even when the seizures are controlled. Technological advances have increased our ability to diagnose specific brain disorders associated with infantile spasms, and have led to new therapeutic approaches. Most infantile spasms previously classified as cryptogenic have now been shown to be associated with various types of brain malformations and can, therefore, be reclassified as symptomatic. Infantile spasms are probably initiated by cortical epileptic discharges which propagate to the brainstem and other subcortical areas. When the epileptogenic cortex is unilateral in an infant with resistant spasms, resective surgery may be considered. For most infants, however, surgery is not a viable option, and the search for the most effective and least toxic anticonvulsant continues.