General Principles

Candidates for epilepsy surgery are those patients with seizures refractory to appropriate medical management and a well-defined epileptogenic focus not involving eloquent cortex. Surgery is contraindicated in patients with generalized epilepsy, benign childhood epilepsy, progressive diseases, and significant noncompliance. Mental retardation, psychiatric disease, and the coexistence of epileptic and nonepileptic seizures are not absolute contraindications. Dominant hemisphere seizure origin, bilateral or multifocal epileptic discharges on EEG, and neurological deficits on examination should not preclude surgical consideration. Rarely, surgery is considered in patients with seizures arising from more than one epileptogenic focus. Surgery should be performed as early as possible, because intractable seizures portend a poor prognosis for seizure remission and psychosocial outcome. Once adequate trials of several first-line AEDs prove ineffective, the likelihood of improvement with adjunctive agents is low.

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