Epilepsy Surgery Referral: Why Evaluation Remains Underused

What was studied

This article was a critical review, not a new clinical trial, and the abstract does not report enrolling participants. It examined more than 25 years of evidence, guidelines, and referral patterns for epilepsy surgery, primarily using U.S. data and supplemented by an assessment of the global situation.

The review addressed surgery for drug-resistant epilepsy, including pediatric care, resective and disconnective surgery, minimally invasive monitoring and treatment, and neuromodulation. It also examined disparities related to race, insurance, and geography.

What they found

Despite randomized trial evidence and long-standing guidelines, epilepsy surgery remains substantially underused. The review reports that fewer than 1% of potentially eligible patients are referred for evaluation and that those referred reach a specialized center an average of about two decades after seizure onset.

Options for evaluating and treating patients have expanded through stereo-electroencephalography, laser interstitial thermal therapy, and neuromodulation. Selected people with generalized or multifocal epilepsy may be considered for thalamic neuromodulation. Current International League Against Epilepsy recommendations also extend referral to selected patients who are seizure-free on medication but have a surgically accessible lesion.

The authors caution that wider use of minimally invasive options should not eclipse resective or disconnective surgery. According to the review, these remain the only potentially curative approaches validated by randomized controlled trials.

Limits of the evidence

This was a critical review rather than a new clinical trial. The abstract does not describe a systematic search strategy or formal assessment of study quality. The discussion is based primarily on U.S. data, so referral patterns, delays, and barriers may differ elsewhere, although the review also assessed the global picture. The abstract does not provide detailed findings for particular ages, procedures, or patient groups and cannot determine the best option for an individual patient.

For families and caregivers

The review indicates that many people with drug-resistant epilepsy may wait years or may never reach a specialized epilepsy center for evaluation. Referral for evaluation does not necessarily mean that surgery will be performed; it allows specialists to assess whether resective or disconnective surgery, laser treatment, neuromodulation, or another approach might be appropriate. The abstract emphasizes broader and earlier referral for appropriate patients.

What to watch next

The authors identify persistent underuse as a major, partly remediable problem and offer recommendations for closing the gap in surgical referral and care. Families may wish to ask a clinician what drug-resistant epilepsy means, whether evaluation at a specialized epilepsy center is appropriate, and how different surgical or minimally invasive options compare for the individual patient.

Terms in this summary

drug-resistant epilepsy

Epilepsy that continues despite treatment with anti-seizure medication.

resective surgery

An operation that removes brain tissue involved in generating seizures.

disconnective surgery

An operation that interrupts pathways through which seizures spread, without necessarily removing the affected tissue.

stereo-electroencephalography

A monitoring method that uses electrodes placed within the brain to help identify where seizures begin.

laser interstitial thermal therapy

A minimally invasive procedure that uses laser-generated heat to treat targeted brain tissue.

neuromodulation

Treatment that uses targeted stimulation of the nervous system to help manage seizures.

randomized controlled trial

A study that assigns participants to treatment groups by chance to compare outcomes.

surgically accessible lesion

An abnormal area in the brain that specialists consider reachable for potential surgical treatment.