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Epilepsy surgery is indicated in 30% to 40% of patients with refractory seizure disorders despite being on one year of therapy with an adequate dosage of two antiepileptic therapy. This activity outlines the role of epilepsy surgery in managing patients with a drug-resistant seizure disorder and highlights the role of the interprofessional team in improving care for patients with this condition. Objectives: Identify the indications and contraindications for epilepsy surgery. Describe the technique in regards to epilepsy surgery. Outline the clinical significance of epilepsy surgery. Access free multiple choice questions on this topic.

Epilepsy surgery is indicated in 30% to 40% of patients with refractory seizure disorders despite being on one year of therapy with an adequate dosage of two antiepileptic therapy.[1] Though the anterior temporal lobectomy has been the prototype epilepsy surgery, there has been a paradigm shift in the surgical principle of ensuring maximum disconnection of the epileptic neural pathways, in sharp contrast to the previous concepts of governing maximal surgical resection.

The major complications of the epilepsy surgery include:[6] Superficial hemosiderosis (anatomic hemispherectomy) Progressive hydrocephalus (anatomic hemispherectomy) Postoperative infarction from injury to the Sylvian vein Sinus thrombosis Memory decline and anomic aphasia (temporal lobe resection) Vasospasm and with contralateral superior quadrantanopia following the injury to Meyer's loop (amygdalohippocampectomy) Disconnection syndrome (corpus callosotomy) Hemiparesis and dysphagia (multiple subpial transections) Cough and hoarseness of voice (vagal nerve stimulation)

Surgical pearls in preventing complications: [8] Resecting insular block provides a window for subsequent disconnection procedures The most common reasons for seizure persistence include incomplete corpus callosotomy, frontoparietal disconnection, and incomplete insular resection. The early placement of cottonoid at the foramen of Monro minimizes, along with the prophylactic EVD placement, minimizes the risk of hydrocephalus. The osteoplastic bone flap ensures better cosmetic results with reduced risk of the surgical site infection. Surgical and functional outcomes: [8] Functional hemispherectomy/hemispherotomy provides equivocal seizure control (80% seizure-free Engel class 1 at two years) in comparison to that of the anatomical hemispherectomy. The pediatric population also shows significant neurocognitive and behavioral improvement following epilepsy surgery. Motor deficits also gradually improve, with 84% of patients eventually being able to walk independently or with minimal assistance.

The main reasons for the delayed or non-referral of suitable candidates for the epilepsy surgery include:[16][17] Unknown bias against the surgical mode of management Unawareness of proper dichotomization of patients Hesitancy for brain surgery by overestimating the operative risks

Early referral for epilepsy surgery is the key factor determining the outcome of the surgery. A multidisciplinary approach in a high-volume epilepsy center needs to be promoted for improved patient outcomes.[8] A significant proportion of patients, though not seizure-free, will at least have improved quality of life owing to the substantial reduction in their seizure frequency.[18] Since epilepsy surgery has shown to be cost-effective, even when the probability of being a suitable candidate is as low as 5%, harmonization and dissemination of the role of epilepsy surgery is the need of the hour.