Published: May 8, 2026
Epilepsy surgery cures roughly 60% to 80% of children with focal, drug-resistant epilepsy, yet it is still commonly positioned as a treatment of last resort.That misconception, according to Ahmad Marashly, M.D., pediatric epileptologist and director of pediatric epilepsy at Norton Children’s Neuroscience Institute, affiliated with the UofL School of Medicine, can delay referrals for epilepsy surgery by years.Meanwhile, the preventable disease burden can accumulate: progressive cognitive and psychosocial impact, rising sudden unexpected death in epilepsy (SUDEP) risk and diminished quality of life.
“Current guidelines support surgical evaluation after failure of two anti-seizure medications — not after failure of every available one,” Dr. Marashly said. “Recognizing that threshold and acting on it earlier can make a big difference in patient outcomes.”
Epilepsy is among the most prevalent neurological disorders encountered in primary care. Approximately 10% of the general population will experience at least one seizure in their lifetime. This prevalence means most pediatricians will see children with seizure disorders. However, epilepsy is not a single disease, according to Dr. Marashly.“Epilepsy is a clinical umbrella term with widely varying etiologies — from genetic and metabolic causes to structural lesions, cortical malformations and post-injury sequelae,” he said. “Treating epilepsy as a single condition oversimplifies it and can impact both diagnostic workups and therapeutic decisions, including those surrounding epilepsy surgery.”
Roughly 70% of pediatric epilepsy patients achieve seizure control with anti-seizure medications (ASMs). The remaining 30% meet criteria for drug-resistant epilepsy (DRE), defined as failure of two appropriately chosen and tolerated ASMs to achieve sustained freedom from seizure.
These 30% of patients carry a disproportionate share of the disease burden:
The longer a patient remains in the DRE category, the more these risks compound, according to Dr. Marashly:“A parent once asked me, ‘Do I have a choice?’ and I said: ‘If you look at just this moment, yes. But expand the timeline. If your daughter doesn’t get surgery now, and she has a 90% chance of becoming seizure-free, she’ll live with this for decades which in itself will reduce the chances of surgery working. If you do it now, the epilepsy will be gone and a distant memory.’ Epilepsy may not be life-threatening in the immediate, but it can be life-threatening in the long run.”
Many providers assume that epilepsy surgery should be considered only after every available medication has failed. This is not what the evidence, or current guidelines, support, according to Dr. Marashly.
“Current guidance is clear: After two failed ASMs, the patient should be referred for surgical evaluation,” he said. “This is not an automatic recommendation to operate; it is a recommendation to assess surgical candidacy.”The field is also moving toward preemptive surgical consideration in select patients: for example, children with a well-defined congenital lesion in a non-functional region of the brain known to cause epilepsy, where surgical targeting may be appropriate before the patient formally meets DRE criteria.
Approximately half of children with drug-resistant epilepsy are responsive to surgical intervention.“A patient’s life can be turned around, and they can be cured. The disease burden, stigma and financial burden can all be reversed,” Dr. Marashly said.
Epilepsy surgery hesitancy often stems from an outdated understanding of modern procedures. Today’s surgical pathway bears little resemblance to the large craniotomies seen in previous generations.
Phase I evaluation is entirely noninvasive: video electroencephalography, high-resolution MRI, PET, functional MRI and neuropsychological testing.
Phase 2 evaluation, when needed, is now predominantly performed via stereoelectroencephalography. Small-diameter depth electrodes are placed through 1 millimeter to 2 millimeter openings rather than through open craniotomy and grid placement. Recovery is similar to minor dental procedures, and patients are typically discharged within 24 hours of electrode removal.
Definitive surgery may involve a traditional craniotomy in some cases, but an increasing number of procedures use minimally invasive approaches, requiring only 3 millimeter to 4 millimeter incisions. These include laser interstitial thermal therapy, responsive neurostimulation or deep brain stimulation. Any scars are generally small and hidden within the hairline. That said, even craniotomies are generally well tolerated in children undergoing surgery. Most scars are hardly noticeable after surgery.
Unlike emergency neurosurgery, epilepsy surgery is an elective, fully planned procedure with a comprehensive surgical plan. Recovery is significantly less morbid than that of open heart, transplant or major cancer surgery. Serious complications, while disclosed as part of informed consent, are increasingly uncommon with modern techniques.“Families rarely hesitate at the idea of cardiac surgery, cancer surgery or organ transplant, because the lifesaving benefit is understood,” Dr. Marashly said. “But epilepsy surgery is often met with far more resistance despite a risk profile that is, in many respects, more favorable.”
The threshold for referral should be lower than most providers assume:
Any diagnostic uncertainty about whether an event was a seizure is itself a reason to refer.