Epilepsy Surgery Guidelines: What the AES and CNS Recommend

What was studied

This practice guideline reviewed evidence on epilepsy surgery for adults and children. It was developed by a multidisciplinary panel from the American Epilepsy Society and the Congress of Neurological Surgeons, rather than testing a treatment in a new group of patients. It updates practice parameters published in 2003. The panel used the GRADE method to assess evidence and develop recommendations.

The review covered surgery for mesial temporal lobe epilepsy, epilepsy arising in the brain’s outer layer, and hypothalamic hamartoma. It also covered callosotomy for developmental and epileptic encephalopathies. Seizures, quality of life, mortality, adverse events, and verbal memory loss were considered critical outcomes. Other thinking and language problems, mental health, and social outcomes were considered important outcomes. Neurostimulation treatments were not intentionally included.

What they found

The panel strongly recommended anterior temporal lobectomy (ATL) for people with mesial temporal lobe epilepsy who have a low risk of cognitive decline, meaning worsening thinking or memory abilities. This recommendation was supported by moderate-certainty evidence.

Based on very low- to low-certainty evidence, the panel made conditional recommendations for ATL in people with mesial temporal lobe epilepsy at high risk of cognitive decline; selective amygdalo-hippocampectomy (SAH) or laser interstitial thermal therapy (LITT) for mesial temporal lobe epilepsy; neocortical resection for neocortical epilepsy; and callosotomy for people with drop attacks, Lennox-Gastaut syndrome, or developmental and epileptic encephalopathies. Conditional recommendations require attention to individual circumstances and shared decision-making aligned with each person’s values and preferences.

For hypothalamic hamartoma, the panel strongly recommended LITT despite low levels of evidence because it judged that the significant risks of open surgery outweigh its benefits. If LITT is unavailable, the panel conditionally recommended radiosurgery.

The panel also issued a good practice statement that everyone with drug-resistant epilepsy should have access to a tertiary epilepsy care center offering surgery and advanced diagnostic testing.

Limits of the evidence

The abstract does not report the number of studies or patients reviewed, numerical seizure outcomes, or rates of complications and memory loss. Most procedure recommendations relied on low- or very low-certainty evidence. A strong recommendation does not necessarily mean the evidence is strong, as shown by the recommendation for LITT in hypothalamic hamartoma. The guideline does not establish which procedure is best for every person, and neurostimulation was not an intended focus.

For families and caregivers

For people with drug-resistant epilepsy, the guideline supports access to a specialized epilepsy center offering surgery and advanced testing. Decisions should consider seizure outcomes alongside memory, other thinking skills, quality of life, and potential harms. For conditional recommendations, the panel emphasizes shared decision-making that reflects the person’s circumstances, values, and preferences.

What to watch next

The abstract does not describe planned studies. Stronger evidence on seizure outcomes, memory, quality of life, and harms would help clarify the choices currently supported by low- or very low-certainty evidence.

Terms in this summary

Mesial temporal lobe epilepsy

Epilepsy in which seizures begin in the inner part of the brain’s temporal lobe.

Anterior temporal lobectomy (ATL)

Surgery that removes the front portion of the temporal lobe.

Selective amygdalo-hippocampectomy (SAH)

Surgery that removes the amygdala and hippocampus while leaving more surrounding temporal lobe tissue in place.

Laser interstitial thermal therapy (LITT)

A procedure that uses a laser to heat and destroy targeted tissue.

Callosotomy

Surgery that cuts some or all of the main nerve connection between the brain’s two halves.

Hypothalamic hamartoma

A noncancerous growth in a deep brain area called the hypothalamus.

Developmental and epileptic encephalopathies

Conditions in which both the underlying disorder and epileptic activity can affect development and learning.

Conditional recommendation

A recommendation that requires consideration of individual circumstances and shared decision-making to align treatment with the person’s values and preferences.