Early Epilepsy Surgery in Drug-resistant Epilepsy: A Disease-modifying Therapy

Abstract Epilepsy is one of the most common neurological disorders. Many patients with epilepsy can achieve seizure freedom through optimized antiseizure medication therapy, dietary interventions such as the ketogenic diet, or epilepsy surgery. Not all patients with epilepsy are candidates for epilepsy surgery. Epilepsies that can potentially be cured or well-controlled through surgery are called surgically amenable epilepsy. Surgically amenable epilepsy needs to be recognized early so that the patients can benefit from this potentially curative treatment option. Any patient with drug-resistant epilepsy, especially those with a focal lesion(s) identified on MRI, should be referred for further evaluation and for consideration of epilepsy surgery. Despite robust evidence showing superior seizure freedom rates, and cognitive and quality-of-life outcomes with epilepsy surgery compared with continued medical therapy alone, referral for presurgical evaluation remains unacceptably low worldwide. On an average, patients spend more than a decade with uncontrolled seizures before being considered for surgery, leading to irreversible cognitive decline, psychosocial disability, and increased morbidity and mortality, including sudden unexpected death in epilepsy (SUDEP). One of the common myths among many doctors and patients about epilepsy surgery is that epilepsy surgery is a “palliative procedure” and it is the “last resort option” after all other treatments are exhausted. On the contrary, epilepsy surgery is potentially curative in well-selected patients and is the treatment of choice available to patients with surgically amenable epilepsy. This spotlight narrative review article highlights the current evidence in favor of epilepsy surgery and explores persistent barriers to referral, and provides practical guidance for neurologists and physicians to recognize patients who need timely referral for presurgical evaluation.