Oct 2026· Neurology Clinical Practice· Vol 16 5, pp.
e200641
· 0 citations· 35 references
Medicine
TL;DR
Delays from DRE diagnosis were independently associated with reduced seizure freedom, supporting presurgical evaluation within 1 year as an evidence-based quality benchmark, and DRE-to-evaluation interval, not total epilepsy duration, predicted outcomes.
Abstract
Background
AND
Objectives
Despite its proven effectiveness, epilepsy surgery for drug-resistant epilepsy (DRE) remains underutilized and frequently delayed. Previous studies of epilepsy duration before surgery-using variable delay thresholds (2-20 years)-were small, single-center cohorts focused mainly on temporal/frontal lobe epilepsy, showed better seizure freedom with earlier surgery, but did not distinguish total epilepsy duration from DRE duration. As contemporary epilepsy surgery now includes broader indications and emphasizes faster evaluation, the timing and impact of evaluation across this wider population remain unclear. We examined factors associated with evaluation timing from DRE diagnosis and its effect on surgical outcomes in a large multicenter cohort.
Methods
Using a prospective database across 29 US centers, we analyzed associations between patient and epilepsy factors and DRE-to-evaluation interval-defined as the interval from DRE diagnosis to phase 1 video-EEG admission, categorized as shorter (<1 year) or longer (≥1 year)-and compared seizure freedom between groups using multivariable logistic regression adjusted for etiology, seizure type, neuroimaging, and surgical factors.
Results
Among 1,310 children, 720 (55%) had shorter and 590 (45%) longer DRE-to-evaluation intervals. Shorter interval was associated with lesional epilepsy (OR 1.65, 95% CI 1.30-2.08), focal seizures (2.80, 2.13-3.70), and normal neurologic exams (1.86, 1.49-2.33). Structural congenital and acquired etiologies were linked to shorter interval, while genetic etiologies (1.73, 1.30-2.32) were linked to longer interval. Among 624 surgical patients (357 shorter, 267 longer), seizure freedom occurred in 53% vs 27% (3.04, 2.17-4.29; p < 0.01). After adjustment, longer interval remained independently associated with lower seizure freedom (0.59, 0.35-1.00; p = 0.0497). DRE-to-evaluation interval, not total epilepsy duration, predicted outcomes.
DISCUSION
In this first large multicenter study across diverse epilepsy types applying a 1-year benchmark, nearly half of pediatric patients experienced delays, particularly those with MRI-negative, generalized, or genetic epilepsies. Delays from DRE diagnosis were independently associated with reduced seizure freedom, supporting presurgical evaluation within 1 year as an evidence-based quality benchmark.
Similar children evaluated at different institutions had significant differences in the odds of not being recommended surgery, suggesting that institutional decision-making contributes importantly to surgical candidacy.
A. Caraway, Nancy A Mcnamara, Andrew T. Knox et al.· Epilepsia· 0 citations
Underutilization persists as a major and partly remediable problem, and the welcome diffusion of minimally invasive options should not eclipse resective and disconnective surgery, which remain the only potentially curative options validated by RCTs.
OBJECTIVE
Epilepsy duration is a modifiable risk factor in the outcome of definitive epilepsy surgery; however, an analogous effect in palliative procedures has not been shown. We reviewed the Pediatric Epilepsy Surgery Database data for an association between epilepsy duration and seizure reduction in palliative procedures.
METHODS
Patients enrolled between January 2018 and April 2025 who underwent their first epilepsy surgery with palliative intent with 6 months of follow-up were included. Procedures included neuromodulation, corpus callosotomy, hemispherotomy, lesionectomy, and lobectomy where surgical intent was not seizure freedom. Outcomes of seizure freedom, 90% seizure reduction, and 50% seizure reduction were considered at 6-12 months and >12 months from surgery. Duration from epilepsy onset to surgery was compared for patients above and below each outcome threshold at each time point. Logistic regression analysis for the association between epilepsy duration and seizure reduction adjusted for potential confounders including procedure type, etiology, and other clinical factors. Logistic regression analysis was performed on the overall cohort and subgroups of patients with each procedure.
RESULTS
A total of 588 patients were included. Initial univariate analysis suggested that epilepsy duration at time of surgery was significantly associated with seizure freedom and 90% seizure reduction at both 6-12 months and >12 months. After adjusting for confounders, only seizure freedom at >12 months was significantly associated with duration of epilepsy. When individual procedures were considered, only lobectomy was sensitive to duration of epilepsy in multivariate analysis, with significant impacts on >50% and >90% seizure reduction at >12 months. Lesional epilepsy predicted seizure freedom at >12 months. Neuromodulation and corpus callosotomy were less likely to achieve seizure reduction than other procedures.
SIGNIFICANCE
We did not find an association between early epilepsy surgery and seizure reduction. This reflects the heterogeneity of our population, including different types of surgical procedures and lesional and nonlesional epilepsies.
Robert M Crutcher, David E. Horvat, A. Caraway et al.· Epilepsia· 0 citations
The findings suggest that referring children for surgery sooner rather than later can meaningfully improve their chances of living seizure‐free and underscore the importance of achieving complete lesion removal to optimize postoperative seizure control.
Hua Li, Yao Wang, Qiang Guo et al.· Epilepsia Open· 0 citations
Drug-resistant focal epilepsy remains one of the most challenging problems in modern epileptology and functional neurosurgery, since delayed referral for presurgical evaluation increases the duration of uncontrolled seizures, worsens quality of life, and may reduce the likelihood of a favorable surgical outcome. A prospective single-center observational study was conducted and included 86 patients examined at a specialized epileptology and neurosurgical center. All patients underwent clinical and semiological seizure analysis, brain MRI, routine EEG, long-term video-EEG monitoring, neurological assessment, and neuropsychological evaluation. The stratification criteria included the presence of a structural lesion on MRI, localized seizure onset, concordance of seizure semiology with the presumed epileptogenic zone, local epileptiform activity, MRI/EEG concordance, seizure frequency, secondary bilateral tonic-clonic generalization, progressive cognitive decline, and the functional significance of the presumed intervention zone. Based on the total clinical and diagnostic score, patients were divided into low, intermediate, and high surgical eligibility groups. High surgical eligibility was identified in 29 patients, intermediate eligibility in 36, and low eligibility in 21. The most significant factors associated with the possibility of localizing the epileptogenic zone were an MRI-positive structural lesion, local ictal or interictal onset on video-EEG, concordance of clinical semiology with the presumed anatomical zone, and MRI/EEG concordance. The proposed algorithm may be used as an accessible model for primary stratification of patients requiring standard follow-up, extended presurgical evaluation, or discussion of invasive monitoring.
Bobur Abduvoyitov· Research Focus International...· 0 citations
