VENI, VIDI, VICI: The advantage of early epilepsy surgery in drug-sensitive patients

Surgical intervention is frequently considered for drug-resistant focal structural epilepsy. However, the impact of early surgery on seizure control, cognitive performance, and quality of life (QoL) across drug-sensitive and drug-resistant patients remains incompletely characterized.

We conducted a prospective-retrospective study on 214 patients with age > 6 years with focal structural epilepsy (focal cortical dysplasia type II, hippocampal sclerosis, low-grade epilepsy-associated tumors) stratified as: drug-sensitive (DS, n = 72) and drug-resistant (DR, n = 112) patients undergoing surgery, and drug-resistant patients on pharmacological treatment (DRT, n = 30). Cognitive function (including language, verbal and visuospatial memory, attention/executive functions) and QoL (using the Quality of Life in Epilepsy Inventory [QOLIE] and 36-Item Short Form Survey [SF-36] questionnaires) were assessed at baseline and 1-year follow-up in patient subgroups. Statistical analyses included chi-square tests, t tests, analysis of variance (ANOVA), and multivariable regression models; p < .05 was considered statistically significant.

The DS patients demonstrated superior rates of complete seizure freedom (86%) compared with DR patients (69%, p = .009). At baseline, DS patients exhibited significantly fewer cognitive deficits compared with DR and DRT patients (p < .05). At the 1-year follow-up, no significant changes in neuropsychological performance were observed in any group, although a mild decline in verbal and/or visuospatial memory performance was observed in DRT patients. In a subset of patients (n = 59 adults) at baseline, DR and DRT patients reported significantly worse overall subjective QoL compared with DS patients (p = .047 and p = .036, respectively). Longitudinal analysis revealed significant improvements in QoL among surgically treated patients.

Early epilepsy surgery in symptomatic focal epilepsy yields excellent seizure outcomes, particularly in DS patients. Baseline preservation of cognitive function and QoL, together with the stability of these measures after surgery, suggests that timely surgery may help prevent deterioration in cognitive and psychosocial functioning. These findings support early referral for surgical evaluation in selected patients and highlight the need for larger studies with extended follow-up, to confirm surgical outcome, long-term neuropsychological, and patient-reported benefits.