Current challenges in the practice of epilepsy surgery

The accurate prediction of individual outcomes after epilepsy surgery represents a key challenge facing clinicians. It requires a precise understanding of surgical candidacy and the optimal timing of surgery to maximize a range of outcomes, including medical, psychosocial, cognitive, and psychiatric outcomes. We promote careful consideration of how epilepsy has affected an individual's developmental trajectory as key to constructing more differentiated profiles of postsurgical risk or resilience across multiple outcome measures. This life span approach conceives surgery as a crucial “turning point” in an individual's development from which varied outcome trajectories may follow. This helps clinicians understand the expectations patients and families bring to surgery, and emphasizes the interplay of factors that determine a patient's outcome. It also promotes comprehensive, longitudinal assessment of outcome using data analytical techniques that capture individual differences and identify subgroups with similar trajectories. An ongoing challenge facing clinicians is the development of an outcome classification system that incorporates outcomes other than seizures. We illustrate two emerging areas of research shaping how we define surgical candidacy and predict outcome: (1) using cortico-cortical evoked potentials to identify pathways of seizure propagation and cortico-cortical networks mediating cortical functions, and (2) predicting postoperative depression using a model that incorporates psychosocial and neurobiological factors. The latter research points to the importance of routine follow-up and postoperative psychosocial rehabilitation, particularly in patients deemed at “high risk” for poor outcomes so that early treatment interventions can be implemented. Significantly more research is needed to characterize those patients with poor outcomes who may require re-surgery.

► Surgery is a ‘turning point’ in life leading to varied outcome trajectories.
► We need a classification system that captures more than seizure outcome.
► Accurate prediction of individual outcomes represents a key challenge.
► CCEP can aid detection of seizure propagation pathways and cognitive networks.
► Mood outcome can be predicted by psychosocial and neurobiological factors.