Epilepsy Surgery: Who Qualifies, What Are the Risks, and What Can You Expect?

When Medications Stop Working, Surgery Becomes an Option

If you’ve been taking two or more anti-seizure medications for months or years and still have seizures, you’re not alone-and you’re not out of options. About 1 in 3 people with epilepsy don’t respond to drugs. This isn’t failure on your part. It’s a medical reality called drug-resistant epilepsy. The International League Against Epilepsy defines it clearly: if two well-chosen, properly dosed medications haven’t stopped your seizures, you’re in the drug-resistant group. And for many of these people, surgery isn’t a last resort-it’s the best chance for a real life change.

For decades, doctors waited two years after two failed medications before even considering surgery. Now, guidelines say: don’t wait. As soon as it’s clear drugs aren’t working, you should be referred to a specialized epilepsy center. The sooner you’re evaluated, the better your chances of becoming seizure-free-and the more likely you are to protect your brain from long-term damage caused by repeated seizures.

Who Is a Good Candidate for Epilepsy Surgery?

Not everyone with drug-resistant epilepsy is a candidate. Surgery works best when seizures start in one clear area of the brain, called a seizure focus. The most common type is mesial temporal lobe epilepsy with hippocampal sclerosis. In these cases, removing a small part of the temporal lobe can lead to seizure freedom in 65-70% of patients within two years.

To qualify, you need three things:

1. You or your caregiver must understand what surgery involves and agree to the process.
2. Your seizures must be disabling-frequent enough, severe enough, or disruptive enough to affect your job, school, driving, or relationships. Typically, that means at least one disabling seizure per month.
3. Tests must show a clear, localized seizure origin that can be safely removed or disconnected.

For children, the triggers are even clearer: if they have tuberous sclerosis, infantile spasms, or Rasmussen’s encephalitis, surgery may be recommended right away-even if they’ve only tried one medication. These conditions rarely respond to drugs, and delaying surgery can hurt brain development.

But surgery won’t help if seizures come from many areas at once-like in generalized epilepsy. In those cases, less invasive options like neurostimulators (RNS or VNS) might be better.

The Evaluation Process: What to Expect Before Surgery

Getting approved for surgery isn’t a quick appointment. It’s a deep dive into your brain’s activity. At a Level 4 epilepsy center, you’ll work with a team: epileptologists, neurosurgeons, neuropsychologists, and specialized nurses. The process usually takes 2 to 6 weeks and includes:

• Video-EEG monitoring: You’ll stay in the hospital for 5-7 days while your brain waves and seizures are recorded on camera. This helps pinpoint exactly where seizures start.
• High-resolution MRI: A 3T scanner with 1mm slices looks for subtle brain abnormalities like scar tissue or malformations.
• FDG-PET scan: This shows areas of the brain with low metabolism-often the seizure focus.
• Neuropsychological testing: Memory, language, and thinking skills are tested to predict how surgery might affect them.
• Intracranial EEG (sometimes): If non-invasive tests aren’t clear, electrodes are placed directly on the brain surface to map seizure activity with extreme precision.

Doctors use all this data to build a map of your brain. They don’t just look for where seizures start-they look for what areas are critical for speech, movement, or memory. The goal isn’t just to stop seizures. It’s to stop seizures without losing who you are.

What Are the Real Risks of Epilepsy Surgery?

Any brain surgery sounds scary-and it’s not without risk. But the risks need to be weighed against the risks of continuing seizures.

For a standard temporal lobectomy (the most common surgery), the risks include:

• Temporary side effects (5-10%): Swelling, headaches, or mild weakness that fades within weeks.
• Permanent deficits (1-2%): Trouble remembering names, finding words, or visual field loss (like missing part of your side vision). These are rare but real.
• Memory issues: Especially if the surgery is on the left side (where language and memory overlap in most people), some patients report trouble recalling new information. For others, memory improves because they’re no longer having seizures that disrupt learning.

Less common procedures like laser ablation (LITT) have lower complication rates-around 2.3%-but also slightly lower success rates (55% seizure freedom at one year vs. 65-70% with traditional removal). The trade-off is smaller incisions, shorter hospital stays, and faster recovery.

And then there’s the risk of doing nothing. People with uncontrolled epilepsy face a 1 in 1,000 chance each year of sudden unexpected death (SUDEP). Seizures can cause falls, injuries, drowning, or accidents while driving. For many, surgery isn’t about avoiding a 2% risk-it’s about avoiding a 1% annual risk of dying.

What Are the Chances of Being Seizure-Free?

Success depends on the type of epilepsy. For temporal lobe epilepsy with hippocampal sclerosis, about 60-80% of patients become completely seizure-free after surgery. That’s compared to less than 5% who ever become seizure-free with medication alone.

For other focal epilepsies-like those caused by cortical dysplasia or tumors-success rates are 50-70%. But if your seizures start in multiple areas or spread quickly across the brain, surgery may only reduce seizures by half, not eliminate them.

Long-term data shows that if you’re seizure-free for one year after surgery, you’re likely to stay that way. Studies following patients for 10+ years show that 60-70% remain seizure-free. That’s not a guarantee, but it’s a strong chance.

And it’s not just about no seizures. People report life-changing improvements: driving again after 15 years, returning to work, going out without a caregiver, or finally sleeping through the night. In one study, 79% of patients regained the ability to drive after surgery.

Why Don’t More People Have Surgery?

Here’s the shocking part: only about 2% of people who could benefit from epilepsy surgery actually get it. In the U.S., an estimated 1.2 million people have drug-resistant epilepsy. Less than 5,000 surgeries are done each year.

Why? Three big reasons:

1. Fear: Half of patients who are referred decline evaluation because they’re terrified of brain surgery. Many think it means losing their memory, personality, or ability to speak.
2. Delayed referrals: A survey found 63% of patients waited over five years after becoming drug-resistant before even being evaluated. Some waited a decade.
3. System gaps: Most neurologists aren’t trained to recognize surgical candidates early. Only 52 centers in the U.S. are certified as Level 4 epilepsy centers-and most are in big cities. Insurance denials are common, and the approval process can take 27 days on average.

And yet, the cost of not acting is higher. A 2023 study found that successful epilepsy surgery pays for itself in three years through fewer hospital visits, less medication, and increased work productivity. Over 10 years, each successful surgery saves society over $1.2 million.

What Comes After Surgery?

Surgery isn’t the end-it’s the start of a new phase. You’ll still take anti-seizure medications at first. Doctors slowly reduce them over 6-12 months if you’re seizure-free. Some people stay on low doses forever. Others get off them completely.

Follow-up care is critical. You’ll need regular EEGs, MRI scans, and neuropsychological check-ins. Many centers offer patient navigators who help with insurance, transportation, and emotional support. Since 2020, programs like this have cut no-show rates for evaluations by more than half.

And if surgery doesn’t fully stop seizures? That doesn’t mean failure. Many patients go from 20 seizures a week to 1 or 2 a month. That’s still a huge improvement. And for those who don’t qualify for resection, newer devices like responsive neurostimulation (RNS) are now approved for more types of epilepsy than ever before.

Final Thoughts: It’s Not About Risk-It’s About Potential

Epilepsy surgery isn’t for everyone. But if you’ve been told your seizures are just something you have to live with, that’s outdated thinking. The science is clear: if you have drug-resistant epilepsy with a well-defined focus, surgery offers your best shot at freedom.

The risks are real, but they’re small compared to the daily dangers of uncontrolled seizures. The success rates are high. The quality-of-life improvements are profound. And the longer you wait, the harder it becomes-not just to stop seizures, but to recover from the damage they’ve already done.

You don’t need to rush into surgery. But you do need to get evaluated. One phone call to a specialized epilepsy center could change the next 20 years of your life.