Epilepsy outcomes following single and repeat epilepsy surgeries in tuberous sclerosis complex

Epilepsy surgery in tuberous sclerosis complex (TSC) is underutilized but associated with improved seizure control and better neurocognitive outcomes. Here we focus on utilization of repeated surgeries to improve seizure control.

We performed a retrospective chart review of 62 pediatric patients with TSC, who underwent a total of 120 epilepsy surgeries at Boston Children's Hospital and Stanford University from 2011 to 2025. We collected patient seizure control over time, following single or multiple surgeries, details of the surgery performed, the location(s) and timing of post-operative seizure recurrence.

Twenty-nine patients (47%) had a single surgery and 33 (53%) underwent repeat epilepsy surgeries. There were no significant differences in surgical approaches (laser vs open) or demographic or clinical factors between patients with single vs repeated surgeries. Patients with one or two surgeries had similar rates of seizure freedom from the targeted epileptic foci: 76% single and 66% two or more surgeries. Overall seizure freedom from all foci was 69% for a single surgery and 55% for two or more surgeries. Seizure freedom rates for the targeted foci decreased following the third through fifth surgeries, but some patients still achieved overall seizure freedom: 33% following the third and 40% the fourth surgery. Seizure recurrences were primarily from prior targeted foci (57%), but 29% were from new foci that became clinically apparent after the first surgery. The presence of interictal epileptiform activity prior to surgery had modest sensitivity 75% (25/33) for prediction of an eventual seizure focus. Timing of surgery had some impact on outcome, with earlier surgery associated with increased seizure freedom.

Repeat surgeries whether near a prior surgical site or addressing a novel seizure focus have the potential to render most children with TSC seizure-free. Earlier surgery had some evidence for improving outcomes and timing of surgery should be studied in greater detail.