Early Surgical Referral Key in Pharmacoresistant Epilepsy
OTTAWA — Surgery can achieve improvements in seizure activity in patients (particularly younger patients) with epilepsy that is refractory to drug therapies, according to a presentation at the Canadian Neurological Sciences Federation (CNSF) Congress 2025.
Roy Dudley, MD, PhD, a pediatric neurosurgeon at Montreal Children's Hospital and Montreal Neurological Institute and associate professor of pediatric surgery at McGill University, Montreal, underlined the importance of early referral for surgery.
An ad hoc task force of the International League Against Epilepsy defined drug-resistant epilepsy as the persistence of seizures despite at least two syndrome-adapted antiseizure drugs used at efficacious daily doses. Many patients with pharmacoresistant epilepsy have tried more than two medications, said Dudley.
Age influences responsiveness to surgery, and very young pediatric patients are good surgical candidates because of their neuroplasticity, he stressed.
'Pretty aggressive surgery, such as an anatomical hemispherectomy, can be performed in a child,' said Dudley, noting a case of a 2-year-old child who became seizure-free after such a surgery. 'The goal is to make a child seizure-free, but if we can decrease seizures significantly, that is important. If a young child continues to have seizures, their neurological development will be poor.'
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Citing published research, Dudley pointed out that intraoperative MRI (iMRI) has not been helpful in surgical cases where lesions are poorly defined and the boundaries of the lesions are not apparent.
'These are lesions that extend beyond what is seen on iMRI,' he said. 'The iMRI does not help you to see these lesions, which is what drove us to using new tools.'
One of those new tools is robot-assisted stereoelectroencephalography (SEEG), which accurately pinpoints the locations from which epileptic seizures originate. 'Using a robot makes it more precise to implant the electrodes because human error is taken out of the procedure,' said Dudley. Robot-assisted SEEG pinpoints seizure locations more rapidly.
Other tools that are currently used for epilepsy surgery include magnetoencephalography, EEG, functional MRI, and advanced MRI voxel-based post-processing.
Pool of Surgical Candidates
Gerald A. Grant, MD, Allan H. Friedman Distinguished Professor of Neurosurgery and chair of Neurosurgery at Duke University School of Medicine in Durham, North Carolina, agreed that younger age increases the benefits of surgery in a patient with drug-resistant epilepsy.
'There is a greater chance for plasticity or rewiring of the brain if we treat as young as possible, which is also why it is so gratifying as a pediatric neurosurgeon to treat children with severe epilepsy, since we can have such enormous impact on their lives,' he told Medscape Medical News. 'We have advocated to identify the children who might benefit most from surgical intervention as young as possible, since the longer we wait, the greater the impact on long-term neurological development.'
Grant noted that working with neurologists is key to expanding the pool of candidates for epilepsy surgery. 'If a child fails two or more seizure medications, they may be a candidate for surgical intervention and should be referred early to a comprehensive epilepsy center. Partnering with the community neurologists is key, since there are many children with severe medically refractory epilepsy who are surgical candidates who, unfortunately, are not referred until much later in their course or even into adulthood.'
Artificial intelligence (AI) also might play a role in referrals to surgery. 'We are now testing an AI tool embedded in our electronic medical record at Duke to look at every child or adult getting evaluated by a neurologist and flagging the chart if, based on the AI algorithm, they potentially could benefit from a referral for surgical intervention,' said Grant.
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