Epilepsy Surgery: Who Qualifies, What Risks Are Involved, and What Results to Expect

When medications stop working for epilepsy, many people feel stuck. They’ve tried one drug, then another, then a third-each with side effects, none with control. Seizures still come: sometimes daily, sometimes weekly, always unpredictable. For these people, there’s another path-epilepsy surgery. But it’s not for everyone. And it’s not as simple as just saying yes. Understanding who qualifies, what could go wrong, and what you can realistically expect is the first step toward making an informed choice.

Who is a candidate for epilepsy surgery?

Not every person with epilepsy is a candidate for surgery. The key is drug-resistant epilepsy. This isn’t just when a drug doesn’t work once. It’s when two properly chosen, well-tolerated medications have failed to stop seizures over time. The International League Against Epilepsy defined this in 2010, and it’s still the gold standard today. If you’re still having disabling seizures after trying two drugs, you’re already in the candidate pool.

But that’s just the starting point. The next step is proving the seizures come from one specific area of the brain-a focal onset. If seizures start in multiple places or spread too quickly from the start, surgery usually won’t help. The most common type of epilepsy that responds well to surgery is mesial temporal lobe epilepsy with hippocampal sclerosis. This is when a small area in the temporal lobe, often near the hippocampus, becomes the seizure trigger. MRI scans can show this damage clearly in many cases.

For children, the criteria are even more urgent. If a child has infantile spasms, tuberous sclerosis, or Rasmussen’s encephalitis, surgery may be considered even before trying multiple drugs. These conditions are often 80-90% resistant to medication from the start. Delaying surgery in these cases can mean permanent damage to developing brains.

The evaluation process is thorough. It usually takes 2 to 6 weeks and includes:

• 5 to 7 days of continuous video-EEG monitoring to capture seizures and map where they start
• High-resolution 3T MRI scans with special epilepsy protocols to spot subtle brain abnormalities
• FDG-PET scans to see areas of the brain with reduced metabolism-often the seizure focus
• Neuropsychological testing to assess memory, language, and thinking skills before surgery
• In some cases, electrodes placed directly on or inside the brain to get a more precise picture

Only about 15-20% of people who go through this full evaluation end up being cleared for surgery. The rest are ruled out because the seizure source can’t be pinpointed, or it’s too close to critical brain areas.

What are the risks of epilepsy surgery?

The idea of brain surgery scares people-and it should. It’s not a minor procedure. But the risks aren’t what most people imagine.

For a common surgery like a temporal lobectomy, the risk of permanent problems like weakness, vision loss, or language difficulties is only 1-2%. Transient issues-like temporary swelling, mild memory trouble, or mood changes-are more common, affecting 5-10% of patients. Most of these improve within weeks or months.

Memory problems are the biggest concern, especially for people having surgery on the left side of the brain. That’s where language and verbal memory are usually stored. If someone already has some memory weakness before surgery, they may notice it gets worse. But many patients don’t realize how much their memory was already affected by frequent seizures. After surgery, some actually report clearer thinking because seizures are no longer disrupting their brain.

The risk of death from epilepsy surgery is extremely low-less than 0.5%. That’s lower than the annual risk of sudden unexpected death in epilepsy (SUDEP), which affects about 1 in 1,000 people with epilepsy each year. For many, the real danger isn’t the surgery-it’s continuing to have uncontrolled seizures.

There’s also the risk of the surgery not working. About 20-30% of patients still have seizures after surgery, though often fewer and less severe. Some need to keep taking medication. Others may be candidates for a second surgery or a device like a responsive neurostimulator.

What outcomes can you expect?

Outcomes are measured using the Engel Classification. Class I means seizure-free. Class II means rare, non-disabling seizures. Class III means worthwhile improvement. Class IV means no change.

For people with temporal lobe epilepsy, 65-70% become seizure-free two years after surgery. That number stays stable over time-most who are free at two years stay free at five, ten, even fifteen years. For other focal epilepsies, like those from tumors or cortical dysplasia, the success rate is slightly lower but still around 50-60%.

These aren’t just numbers. They mean real life changes. In one study, 79% of patients who became seizure-free were able to drive again after years of being grounded. Many returned to work. Parents stopped missing school events. People stopped living in fear of the next seizure.

One patient on a support forum wrote: “After my left temporal lobectomy, I went from 15-20 seizures a month to zero. I got my license back. I started college. I didn’t think that was possible.”

But outcomes depend on timing. The longer you wait after becoming drug-resistant, the harder it becomes to recover lost function. Studies show that people who have surgery within two years of drug resistance have better cognitive outcomes than those who wait five or ten years. The brain adapts to seizures-and the longer it adapts, the less it can bounce back.

Why don’t more people have surgery?

About 1.2 million Americans have drug-resistant epilepsy. Only 5,000 get surgery each year. That’s less than 2% of those who could benefit. Why?

Fear is the biggest barrier. Half of patients referred for surgery turn it down because they’re scared of brain surgery. Many think they’ll lose their memory, their personality, or their ability to speak. Others worry about physical disability.

Another problem? Doctors don’t refer early enough. The guidelines say: refer as soon as two drugs fail. But a 2022 study found most patients wait over five years-some over ten-before being referred. Many neurologists still think surgery is a last resort, even though research shows early surgery leads to better outcomes.

Insurance is another hurdle. Nearly half of initial requests for surgery are denied. But 78% of appeals are approved. That means if you’re told no, don’t give up. Ask for help from your epilepsy center’s patient navigator program. These specialists handle insurance battles, schedule appointments, and guide you through every step.

What’s new in epilepsy surgery?

Surgery isn’t just about cutting out brain tissue anymore. Minimally invasive techniques are growing fast.

Laser interstitial thermal therapy (LITT) uses a thin probe inserted through a small hole in the skull. Heat is then applied to destroy the seizure focus. It’s less invasive than traditional surgery, with hospital stays of just one or two days. Seizure freedom rates are around 55% after one year-slightly lower than open surgery, but with far fewer complications. Only 2.3% of LITT patients have serious side effects, compared to 8.7% with traditional resection.

Another option is responsive neurostimulation (RNS). A device is implanted in the skull and monitors brain activity. When it detects a seizure starting, it delivers a tiny electrical pulse to stop it. The FDA expanded its use in 2022 to include some patients with generalized epilepsy, which opens the door for more people who weren’t candidates before.

These aren’t replacements for surgery-they’re alternatives. But they’re changing the game. For people who can’t have a resection, or who don’t want to lose brain tissue, these devices offer real hope.

Is surgery worth it?

The cost of epilepsy surgery is high-tens of thousands of dollars. But the long-term savings are even higher. One 2023 analysis found that a successful surgery pays for itself within three years. After that, patients save money on medications, ER visits, ambulance rides, lost work days, and caregiver support. Over ten years, the societal benefit per patient is an estimated $1.2 million.

But the real value isn’t financial. It’s freedom. The ability to wake up without wondering if today’s the day you’ll seize. To drive. To hold a job. To raise a child without fear.

If you’ve tried two or more medications and still have seizures, you’re not out of options. You’re at the beginning of a new path. Talk to an epilepsy center. Get evaluated. Don’t wait. The longer you wait, the more you risk losing-not just control over seizures, but control over your life.