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.
Abstract
More than 25 years have passed since the first randomized controlled trial (RCT) established that surgery is superior to continued anti-seizure medication (ASM) for drug-resistant temporal lobe epilepsy, and nearly as long since a joint practice parameter urged that appropriate surgical candidates be referred to a specialized center for evaluation-guidance that subsequent consensus has since broadened to all patients with drug-resistant epilepsy. Despite Class I evidence and durable guidelines, epilepsy surgery remains one of the most underutilized effective interventions in medicine: fewer than 1% of potentially eligible patients are referred, and those who are referred reach a center on average two decades after seizure onset. This critical review, framed primarily around U.S. data and supplemented by a dedicated assessment of the global picture, examines the scope and burden of drug-resistant epilepsy (DRE), the foundational evidence and guideline history, and the magnitude, patterns, and causes of persistent underutilization, including a distinct discussion of pediatric care and of disparities by race, insurance, and geography. We then turn to grounds for optimism. Surgical candidacy has materially expanded through minimally invasive approaches to both monitoring (stereo-electroencephalography) and treatment (laser interstitial thermal therapy and neuromodulation), and indications have broadened to include selected generalized and multifocal epilepsies through thalamic neuromodulation. Contemporary International League Against Epilepsy (ILAE) recommendations go further still, extending referral even to selected patients who are seizure-free on medication but harbor a surgically accessible lesion. We also raise a counterbalancing concern: the welcome diffusion of minimally invasive options should not eclipse resective and disconnective surgery, which remain the only potentially curative options validated by RCTs. We conclude that, 25 years on, underutilization persists as a major and partly remediable problem, and we offer recommendations for closing the surgical gap.
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.
Debopam Samanta, A. Caraway, Andrew T. Knox et al.· Neurology Clinical Practice· 0 citations
The goal was to analyze the outcomes of patients undergoing epilepsy surgery at the authors' center, with a minimum follow-up of 15 years, and found Appropriate referral to a refractory epilepsy center permits a multidisciplinary approach that can result in long-term seizure freedom for most patients undergoing surgery.
Drug-resistant epilepsy (DRE) may lead to substantial morbidity, impaired quality of life (QoL), and increased mortality. Clinicians increasingly use surgical interventions to manage DRE, but uncertainty remains regarding their comparative benefits and harms across epilepsy syndromes. We conducted 4 systematic reviews and meta-analyses to inform the American Epilepsy Society (AES) and Congress of Neurological Surgeons (CNS) guidelines on surgical management of DRE. We searched MEDLINE, Embase, and CENTRAL from inception to August 2024 for randomized controlled trials (RCTs) and nonrandomized studies (NRS). We evaluated (1) resective or ablative surgery versus medical therapy in drug-resistant mesiotemporal lobe epilepsy (DR-MTLE); (2) resective or ablative surgery versus medical therapy in drug-resistant neocortical epilepsy (DR-NE); (3) callosotomy versus vagus nerve stimulation (VNS) in developmental and epileptic encephalopathies (DEEs) with drop attacks; and (4) ablative versus resective surgery in hypothalamic hamartoma (HH). The panel prioritized the following critical outcomes: seizure freedom, QoL, neuropsychological, neuropsychiatric, and social outcomes, and serious adverse events. We assessed certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. We included 47 studies comprising 4868 participants. In DR-MTLE, moderate-certainty evidence from RCTs showed that anterior temporal lobectomy (ATL), compared with medical therapy, probably increases seizure freedom and improves QoL. The evidence was very uncertain regarding the effects of selective amygdalohippocampectomy, laser interstitial thermal therapy (LITT), and radiosurgery in patients with DRE. In DR-NE, very low-certainty evidence suggested that seizure freedom may occur after resective surgery. However, we did not identify any eligible studies evaluating ablative surgery in this population. In DEE, very low-certainty evidence suggested that, when compared to VNS, callosotomy may improve seizure outcomes but may also increase serious adverse events. In HH, evidence for LITT and radiosurgery was found to be very uncertain. Across reviews, the most common reason for downgrading the certainty of evidence was risk of bias and imprecision. Moderate-certainty evidence supports ATL in selected patients with DR-MTLE. For other surgical approaches and epilepsy syndromes, the evidence remains very uncertain, highlighting the need for better comparative studies.
Y. Roldan, Barbara C. Jobst, Daniela Garcia-Aquino et al.· Epilepsy Currents· 0 citations
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
Every revision of the seizure classification-most recently the 2025 International League Against Epilepsy (ILAE) update-refines terminology, yet it is worth asking whether patients are treated better because their seizures were renamed. The focal versus generalized dichotomy has organized epilepsy classification since the 1960 s and is grounded in a pharmacologic rationale, but head-to-head data from the SANAD trials show that efficacy differences between individual antiseizure medications frequently equal or exceed differences across the focal/generalized boundary. Meanwhile, the distinction that is genuinely transformative-whether an epilepsy is surgically remediable-produces seizure-freedom differences of an entirely different order of magnitude, and yet epilepsy surgery remains among the most underutilized evidence-based treatments in medicine. We argue that classification should elevate therapeutic trajectory over electroclinical phenomenology, and we propose an Interventional Axis built around three pathways: focal resection, neuromodulation, and palliative surgery, operating in parallel with pharmacotherapy rather than after its serial failure. Refining terminology improves communication, but the ultimate metric of a classification is outcome, not taxonomic elegance.
Felix Benninger, Ilan Goldberg· Epilepsy & Behavior· 0 citations
It is suggested that establishing routine FLE services in countries with limited resources is feasible, and a streamlined surgery pathway should be introduced, together with strengthening national capacity and adopting cost-efficient technology.
Zainal Muttaqin, J. Bunyamin, Novanda Rizky Radityatama et al.· Surgical neurology internati...· 0 citations
