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

For many people with epilepsy, taking pills every day doesn’t stop the seizures. No matter how many medications you try, the convulsions, blackouts, or strange sensations keep coming. If you’ve tried two or more antiseizure drugs and still have disabling seizures, you might be a candidate for epilepsy surgery. It’s not a last resort-it’s often the best chance to live seizure-free. Yet most people never even get evaluated for it.

Who Is a Candidate for Epilepsy Surgery?

Epilepsy surgery isn’t for everyone. But if you’ve had drug-resistant epilepsy, you’re likely closer to eligibility than you think. The medical definition is clear: if two well-chosen, properly dosed antiseizure medications haven’t controlled your seizures, you meet the basic criterion for drug-resistant epilepsy. That’s not a suggestion-it’s the global standard set by the International League Against Epilepsy since 2010.

But meeting that definition doesn’t automatically mean surgery is right for you. Three things must line up:

• You or your family understand what the process involves and are willing to consider surgery.
• Your seizures are disabling-meaning they interfere with driving, working, learning, or daily safety. A seizure once a month that causes you to fall or lose consciousness counts.
• Doctors can pinpoint where in your brain the seizures start. This is critical. Surgery works best when seizures come from one clear spot, like the temporal lobe.

Some conditions make surgery more likely to help. Mesial temporal lobe epilepsy with hippocampal sclerosis is the most common and successful target. People with this condition have a 65-70% chance of becoming seizure-free after surgery. Others, like those with tuberous sclerosis complex or Rasmussen’s encephalitis, are also strong candidates-even if they’re children.

On the flip side, surgery rarely helps if seizures start in multiple areas at once or spread too quickly across the brain. Generalized epilepsy, like absence seizures or myoclonic epilepsy, usually doesn’t respond to resection surgery. But new options like responsive neurostimulation (RNS) are changing that for some.

What Does the Evaluation Process Look Like?

Before any cut is made, you’ll go through a detailed, weeks-long evaluation. This isn’t a quick checkup-it’s a full neurological detective job. You’ll need:

• At least five days of continuous video-EEG monitoring in a specialized unit. Doctors watch your brainwaves while recording your seizures to map exactly where they begin.
• A high-resolution 3T MRI scan with special epilepsy protocols. This can spot subtle scars, malformations, or shrinkage in the hippocampus that standard scans miss.
• A PET scan using FDG to see areas of low brain metabolism-often the seizure origin.
• Neuropsychological testing to assess memory, language, and thinking skills. This helps predict what might change after surgery.
• In some cases, electrodes placed directly on or inside the brain to get even clearer signals.

This isn’t done at every hospital. Only Level 4 epilepsy centers-there are fewer than 100 in the U.S.-have the full team: epileptologists, neurosurgeons, neuropsychologists, and nurses trained in epilepsy care. These centers must perform at least 50 evaluations a year to stay skilled. If your neurologist hasn’t referred you to one, ask why.

Insurance is often the biggest hurdle. Nearly half of initial requests get denied. But 78% of appeals succeed. Keep pushing. Keep documentation. A seizure diary with dates, times, triggers, and descriptions is essential.

What Are the Real Risks?

Fear of brain surgery is normal. But the risks are often misunderstood. For a standard temporal lobectomy-the most common procedure-the chance of a permanent, serious problem like paralysis or loss of speech is only 1-2%. Most complications are temporary.

Common short-term risks include:

• Swelling or infection at the surgical site
• Headaches or fatigue for a few weeks
• Temporary memory issues, especially if the left side is operated on (affects verbal memory)
• Mood changes or depression in the first few months

Long-term risks are more specific. If the seizure focus is in the part of the brain that handles language or memory, those functions might be affected. About 10-15% of patients report mild memory changes after surgery. For most, it’s a trade-off: losing a little memory to stop 20 seizures a month. Many say it’s worth it.

One of the biggest surprises? The risk of dying from epilepsy is higher than the risk of dying from surgery. Sudden unexpected death in epilepsy (SUDEP) affects 1 in 1,000 people with epilepsy each year. Surgery can cut that risk dramatically-if it works.

What Are the Expected Outcomes?

Success isn’t always total freedom from seizures. But even a 75% reduction can change your life. Here’s what real data shows:

• 60-80% of people with temporal lobe epilepsy become seizure-free after surgery.
• 70-80% of all surgery candidates see at least a 50% reduction in seizures.
• For those who are seizure-free for a year, 90% stay that way for five years or longer.

And it’s not just about seizures. People who go surgery report:

• Regaining the ability to drive-something they lost years ago.
• Going back to school or work without fear of having a seizure.
• Reducing or stopping antiseizure medications entirely.
• Improved mood, confidence, and relationships.

One patient from a 2021 study said, “I had 15-20 seizures a month. After surgery, I’ve been seizure-free for three years. I got my license back. I started college. I never thought that was possible.”

But not everyone succeeds. About 15-20% of people who go through the full evaluation are told surgery won’t help because their seizure origin can’t be pinpointed. Others have seizures that return after a few years. That’s why ongoing care matters-even after surgery.

Why Isn’t More People Getting Surgery?

Here’s the shocking part: an estimated 300,000 Americans with drug-resistant epilepsy could benefit from surgery. But only about 5,000 surgeries are done each year. That’s less than 2% of those who might be helped.

Why? Three big reasons:

• Doctors don’t refer early enough. Many still wait two years after two failed meds. New guidelines say: refer immediately.
• Patients are scared. Half of those referred decline evaluation because they fear brain surgery or memory loss.
• Access is limited. Most specialized centers are in big cities. If you live in a rural area, getting to one can mean driving hours.

And misinformation is common. A 2023 survey found nearly half of neurologists couldn’t correctly define drug-resistant epilepsy. If your doctor doesn’t know the standard, they won’t refer you.

What’s New in Epilepsy Surgery?

The field is evolving fast. Traditional open surgery still works best for many. But new techniques are making it safer and more accessible.

Laser interstitial thermal therapy (LITT) is one example. Instead of opening the skull, a thin laser probe is inserted through a small hole. It heats and destroys the seizure focus. Recovery is faster-most go home in 2-3 days. Seizure freedom rates are around 55% after one year, slightly lower than open surgery, but with fewer complications.

Neurostimulators like RNS and VNS are also expanding options. RNS detects seizures as they start and delivers a tiny pulse to stop them. It’s now approved for some generalized epilepsies, opening doors for people who used to be told surgery wasn’t an option.

And the cost? It pays for itself. A 2023 study found that for every person who becomes seizure-free, society saves $1.2 million over ten years-through fewer hospital visits, emergency rides, lost wages, and caregiving costs.

What Should You Do Next?

If you’re still having seizures despite trying two or more medications:

• Ask your neurologist: “Am I a candidate for epilepsy surgery?”
• Request a referral to a Level 4 epilepsy center.
• Start keeping a detailed seizure diary-dates, times, what happened before and after.
• Don’t wait. The longer you delay, the more your brain and life are affected.

There’s no magic pill for drug-resistant epilepsy. But there is a proven, life-changing option-and it’s not as scary or far off as you think. Surgery isn’t about fixing your brain. It’s about giving your life back.