Is there a place for surgical treatment of nonpharmacoresistant epilepsy?

Epilepsy surgery has been shown to be the best possible treatment in well-defined and difficult-to-treat epilepsy syndromes, such as mesial temporal lobe epilepsy with unilateral hippocampal sclerosis, even early in the course of the disease if pharmacoresistance is proven. This review addresses the question if epilepsy surgery may be justified today even in nonpharmacoresistant cases. There are two possible groups of patients: first, there are epilepsy syndromes with a benign spontaneous course or with a potentially good treatment prognosis under appropriate antiepileptic drug (AED) treatment. Second, there are epilepsies with potentially worse AED treatment prognosis in which appropriate AED treatment has not yet been applied because of the short course of the disease, tolerability problems that prevented usually effective dosing, or adherence issues. In group one, the good spontaneous prognosis or the usually satisfying course under AED treatment in line with the commonly generalized underlying epileptogenesis does not suggest that epilepsy surgery is a realistic alternative, not even in cases with distinct focal clinical and/or electroencephalography (EEG) patterns like in Rolandic epilepsy with centrotemporal spikes. In the second group, the recent International League Against Epilepsy (ILAE) definition should allow assessment of individual pharmacoresistance early after the onset of the disease in order to avoid any delay. Concerns about a potential disease-specific or drug-specific cognitive decline that could be avoided in early surgery are speculative, a matter of controversial discussion, and certainly not relevant, if pharmacoresistance is consequently addressed in time according to the ILAE recommendations. One should also not forget that even in typically pharmacoresistant epilepsy syndromes that are suitable for surgical procedures, satisfying courses do exist that would not require early or any epilepsy surgery. Therefore, in almost any instance, epilepsy surgery as initial treatment or immediately after a first AED is still not recommended although, especially in cases with nonadherence to AEDs, it may be occasionally considered in order to outweigh the risks of ongoing seizures and epilepsy if surgery is not performed.