Surgical treatment of epilepsy in polymicrogyria: A subject‐level meta‐analysis and decision‐making framework

Objective Polymicrogyria (PMG) presents a complex challenge in epilepsy surgery. The optimal surgical strategy and extent of resection, from hemispheric to more limited approaches, remain debated. We aimed to summarize subject‐level surgical outcomes and identify factors informing procedure selection. Methods We conducted a subject‐level pooled analysis of 161 patients across 20 retrospective studies, evaluating surgical outcomes (Engel classification), in relation to anatomic extent, surgical procedure, use of intracranial electroencephalography (ICEEG), and other decision‐influencing factors. Results At ≥12 months follow‐up, ~70% of patients achieved seizure freedom (Engel Class I). In our univariate analysis Engel Class I outcomes were associated with shorter epilepsy duration (8.05 vs 11.92 years, p = 0.009). Hemispheric PMG was linked to earlier seizure onset ( p = 0.02) and a higher incidence of epileptic encephalopathy with spike–wave activation in sleep ( p < 0.0005). Among unilateral non‐hemispheric and bilateral PMG cases, seizure‐freedom rates were similar between hemispheric and more limited resections, but the latter were associated with a lower incidence of new or worsened motor deficits. Mixed‐effects logistic regression ( n = 160) showed that hemispheric surgery increased the odds of seizure freedom but without statistical significance (odds ratio [OR] = 3.52, p = 0.055). ICEEG did not significantly influence seizure outcomes but may play a key role in identifying eloquent cortex and guiding safer, tailored resections. Significance In PMG‐related epilepsy, surgical strategy must balance seizure control with preservation of function. ICEEG (especially stereo‐EEG [SEEG]) remains a valuable tool for functional mapping and tailored resections.