Prepare, don't scare: Rethinking cognitive readiness before epilepsy surgery

Epilepsy surgery is an effective but underutilized treatment for drug-resistant epilepsy, and concerns about postsurgical cognitive change are a prominent barrier. Refinements in surgical technique can reduce cognitive impact, but cognitive change cannot always be avoided, and approaches carrying lower cognitive risk are often less effective for seizure control. Cognitive change therefore needs to be addressed directly rather than minimized through surgical strategy alone. This article proposes cognitive prehabilitation, a structured presurgical intervention combining individualized risk-benefit education, compensatory strategy training, and recovery planning, as a potential advancement in presurgical care. A central conceptual shift is reframing potential postsurgical cognitive decline from an outcome to be feared to a cost that patients can prepare for, adapt to, and weigh against the benefits of seizure freedom. The literature specific to cognitive prehabilitation in epilepsy surgery is too limited to support systematic review; thus, we draw on adjacent evidence bases, including cognitive rehabilitation in epilepsy, prehabilitation in other surgical populations, and literatures on shared decision-making and risk communication, to outline complementary frameworks. We detail theoretical components of cognitive prehabilitation, including risk communication and expectation setting, cognitive compensatory training, attention to mental and physical wellbeing, planning for postsurgical recovery, and peer support. Clinical and structural barriers to implementation are discussed, including patient engagement challenges and healthcare constraints. Priorities for future research include standardization of prehabilitation protocols, identification of patient-level moderators of benefit, and scalable delivery formats. Cognitive prehabilitation represents an opportunity to move toward empowerment-based presurgical care and to expand access to epilepsy surgery. PLAIN LANGUAGE SUMMARY: Many people with drug-resistant epilepsy avoid surgery because of the risks associated with declines in memory and thinking. This article describes the concept of cognitive prehabilitation, which is a presurgical program that gives patients personalized information about what may change with surgery, teaches practical strategies for managing memory and thinking difficulties should they arise, and helps them plan for recovery. The aim is for patients to prepare for possible memory and thinking changes rather than simply fear them. Research is still early, and studies are needed to test whether prehabilitation improves outcomes.