Surgical and Other Nonpharmacologic Treatment
Core concepts
Drug-resistant epilepsy (failure of two appropriately chosen, tolerated ASMs) should prompt referral for presurgical evaluation. The goal is to identify a single epileptogenic zone that can be resected without unacceptable deficit. Evaluation includes MRI, video-EEG monitoring, neuropsychology, and often PET, SPECT, or magnetoencephalography. Invasive monitoring (subdural or depth electrodes, including SEEG) is used when noninvasive data are discordant.
Surgical options
- Resection (temporal lobectomy, lesionectomy) - best outcomes in mesial temporal sclerosis.
- Laser interstitial thermal therapy (LITT) - minimally invasive alternative.
- Disconnection (corpus callosotomy for drop attacks; hemispherectomy for hemispheric syndromes).
- Neuromodulation: vagus nerve stimulation (VNS), responsive neurostimulation (RNS), deep brain stimulation (DBS) of the anterior nucleus of the thalamus.
Dietary and other therapies
Ketogenic diet (classic and modified Atkins) is especially useful in children and specific syndromes (GLUT1 deficiency, Dravet). Avoid in certain metabolic disorders (e.g., pyruvate carboxylase deficiency, fatty acid oxidation defects).
Traps
- Offering surgery only after many drug trials - refer early once drug resistance is established.
- Assuming a normal MRI excludes a surgical lesion; focal cortical dysplasia may be subtle.
- Forgetting that corpus callosotomy is palliative, not curative, and targets drop attacks.
Rule of thumb
Two failed ASMs = drug-resistant = refer for surgical evaluation.