Surgery May Help Some People With Severe Ongoing Seizures

What was studied

This paper was a structured narrative review, not a new clinical trial. The authors looked at published reports since 2000 about surgical or neuromodulatory treatments for super-refractory status epilepticus (SRSE), a severe form of ongoing seizures that continues despite standard treatment. They also included some evidence about refractory status epilepticus (RSE) when it was relevant to timing of intervention, patient selection, or progression toward SRSE.

The review searched several databases and included 33 studies. These included case reports and systematic reviews involving both children and adults. The treatments reviewed included resective or disconnective surgery and neuromodulation approaches such as vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS).

What they found

The review suggests that resective or disconnective surgery in selected patients with a clearly identified epileptogenic lesion appeared to be associated with the most rapid and consistent termination of SRSE. This appeared most relevant when a well-defined focal lesion could be identified.

Neuromodulation treatments showed more variable and often delayed responses, but they appeared to provide meaningful clinical benefit in some selected patients, especially when seizures were linked to diffuse or poorly localized epileptogenic networks or when resection was not feasible. VNS was the most commonly reported neuromodulation strategy, while RNS and DBS showed promising results in focal and network-related epilepsies.

Among surviving patients, favorable longer-term seizure outcomes were reported in a substantial proportion, but the exact benefit is difficult to interpret because the studies were very different from each other and outcomes were reported inconsistently.

Limits of the evidence

This review is based mostly on low-quality evidence such as case reports and systematic reviews of limited underlying data, not large controlled studies. That means it cannot show with confidence that surgery or neuromodulation led to better outcomes.

There is a risk of publication bias, since successful or dramatic cases may be more likely to be published than unsuccessful ones. The patients, treatments, timing, and outcome measures varied a lot across studies, making it hard to compare results or know which approach may be best.

Because both adults and children were included together, the review does not clearly show whether results differ by age group. It also cannot firmly answer the best time to intervene, which patients are most likely to benefit, or what the long-term risks and benefits are.

For families and caregivers

For families facing SRSE, this review suggests that surgery or implanted stimulation devices may sometimes be considered when medicines are not enough. The clearest signal in this review was for surgery in carefully selected patients when there is a clear epileptogenic lesion or focal seizure source.

It also suggests that device-based treatments may be options when seizures are more widespread or the seizure source cannot be removed. Because the evidence is limited, these treatments may be best considered in specialized epilepsy surgery centers with multidisciplinary expertise.

What to watch next

Stronger evidence would come from larger multicenter prospective studies that track which patients get these treatments, when they are used, and how patients do over time.

Terms in this summary

status epilepticus

A seizure, or repeated seizures, that lasts too long and is a medical emergency.

super-refractory status epilepticus (SRSE)

Status epilepticus that continues or comes back even after strong standard treatments, including anesthesia medicines.

refractory status epilepticus (RSE)

Status epilepticus that does not stop after first-line and second-line seizure medicines.

neuromodulation

Treatment that uses an implanted device to send electrical signals to nerves or brain areas to help control seizures.

vagus nerve stimulation (VNS)

An implanted device that sends regular electrical pulses to the vagus nerve in the neck.

responsive neurostimulation (RNS)

An implanted device that detects seizure activity and gives electrical stimulation in response.

deep brain stimulation (DBS)

An implanted device that sends electrical stimulation to specific deep parts of the brain.

epileptogenic lesion

A brain abnormality that may be causing seizures.