Overall effectiveness between surgical approaches was clinically similar, with neither demonstrating clear superiority; the model suggests epilepsy etiology, rather than expected effectiveness alone, should guide procedure selection between MRgLITT and open resection.
Abstract Background Drug-resistant epilepsy (DRE) remains a major cause of neurological morbidity worldwide, affecting approximately one-third of patients with epilepsy despite advances in antiseizure medications. Persistent seizures are associated with increased mortality, cognitive decline, psychosocial impairment, and reduced quality of life. Surgical intervention represents the most effective treatment for carefully selected patients; however, substantial delays in referral and underutilization of epilepsy surgery continue to be reported globally. This study is done to provide a contemporary evidence-based review of patient selection, presurgical evaluation, surgical decision-making, and outcomes across the spectrum of epilepsy surgery modalities. Methods A narrative review of the current literature was performed, focusing on the definition of DRE, indications for surgical referral, presurgical investigations, resective and disconnective surgical procedures, minimally invasive techniques, and neuromodulation strategies. Emphasis was placed on practical clinical decision-making and contemporary developments influencing patient selection. Results Successful epilepsy surgery depends primarily on accurate localization of the epileptogenic zone and careful multidisciplinary evaluation. Temporal lobe epilepsy remains the most favorable indication for resective surgery, while advances in stereoelectroencephalography, neuroimaging, laser interstitial thermal therapy, and neuromodulation have expanded treatment options for patients previously considered unsuitable for surgery. Contemporary presurgical assessment integrates clinical semiology, prolonged video-electroencephalographic monitoring, high-resolution magnetic resonance imaging, functional imaging, and neuropsychological evaluation to optimize patient selection and maximize postoperative seizure control. Conclusion Appropriate patient selection remains the cornerstone of successful epilepsy surgery. Continued advances in imaging, electrophysiology, minimally invasive techniques, and neuromodulation are transforming the management of DRE and facilitating increasingly individualized treatment strategies.
Vartika Gupta, Pankaj Gupta· Asian Journal of Neurosurger...· 0 citations
Similar children evaluated at different institutions had significant differences in the odds of not being recommended surgery, suggesting that institutional decision-making contributes importantly to surgical candidacy.
A. Caraway, Nancy A. Mcnamara, Andrew T. Knox et al.· Epilepsia· 0 citations
Delays from DRE diagnosis were independently associated with reduced seizure freedom, supporting presurgical evaluation within 1 year as an evidence-based quality benchmark, and DRE-to-evaluation interval, not total epilepsy duration, predicted outcomes.
Debopam Samanta, A. Caraway, Andrew T. Knox et al.· Neurology Clinical Practice· 0 citations
The available evidence supports earlier referral for surgical evaluation in children with DRE and suggests that prompt intervention may preserve neurodevelopment, improve long-term functional outcomes, and maximize quality of life.
Tyler L. Williams, Spencer Collins, Edgar Sanchez et al.· Journal of Surgical Research· 0 citations
Complete resection of the epileptogenic zone offers the best chance of seizure control in patients with drug-resistant epilepsy. However, surgical management remains challenging when the epileptogenic zone is located within or adjacent to eloquent brain regions. Awake craniotomy (AC), combined with intraoperative functional mapping, has the potential to maximize resection while preserving neurological function. Despite its increasing use, evidence regarding its safety and efficacy in epilepsy surgery remains limited. This study aimed to systematically evaluate the feasibility, reported safety, and reported seizure outcomes of awake craniotomy in patients undergoing surgery for drug-resistant non-oncological epilepsy.
A systematic literature search was conducted in PubMed, Scopus, and Web of Science databases in accordance with PRISMA guidelines.
Seven retrospective studies comprising 231 patients from six countries were included; 120 patients underwent AC. Four studies (57.1%) included mixed adult and pediatric populations and three (42.9%) included adults only; however, none provided age-stratified seizure or complication outcomes, precluding separate pediatric analysis. Reported seizure duration ranged from 2 to 39 years. The frontal lobe was the most frequently involved region (
n
= 52; 43.3%), followed by the temporal lobe (
n
= 27; 22.5%), and cortical dysplasia was the most common underlying pathology (
n
= 30; 25.0%). Language and sensorimotor functions were the most commonly mapped eloquent areas, each reported in five studies (71.4%). Seizure outcomes were predominantly assessed using the Engel classification. Complete seizure freedom (Engel class I) was reported in 69 of 120 AC patients (57.5%); a random-effects single-arm synthesis estimated an Engel I proportion of 59.3% (95% CI: 46.3–71.2%; I2 = 31.9%). Comparisons with surgery under general anesthesia (GA) were available in only two non-randomized studies and should be interpreted cautiously. No study reported conversion from AC to GA. Postoperative neurological deficits were largely transient, with a low reported incidence of permanent morbidity. Owing to substantial differences in patient selection, surgical indications, and study design, these findings should be considered exploratory and should not be interpreted as demonstrating comparable seizure outcomes or treatment effectiveness.
In carefully selected patients with drug-resistant non-tumor epilepsy involving or adjacent to eloquent cortex, AC with intraoperative functional mapping appears feasible and may help preserve neurological function while enabling tailored resection. The current evidence base remains limited by retrospective designs, heterogeneous populations and techniques, inconsistent outcome reporting, and sparse comparative data; therefore, efficacy and equivalence with surgery under general anesthesia should not be inferred.
M. Mofatteh, M. Mashayekhi, Sho Giersztein et al.· BMC Surgery· 0 citations
Current and emerging pharmacotherapeutic options for selected representative pediatric focal epilepsies are summarized using a syndrome- and localization-oriented approach, highlighting conventional antiseizure medications, newer agents, and investigational or repurposed treatments.
L. Perilli, G. Dell’Isola, Pietro Ferrara et al.· Expert Opinion on Pharmacoth...· 0 citations
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