MGH Epilepsy Surgery Program: For Physicians
Epilepsy surgery: information for referring physicians.
This section is for neurologists, epileptologists, pediatricians, and other physicians who care for patients with drug-resistant epilepsy. It explains why we consider every patient with drug resistance a surgical candidate, how our program uses thalamic stereo EEG to build a network hypothesis, and what the published evidence shows for the therapies we offer. The patient-facing version of this material is in the Epilepsy Surgery Guide and on the pediatric program page. For centromedian RNS in idiopathic generalized epilepsy, see RNS for IGE.
Surgery is underused.
About 1.2 million people in the United States live with drug-resistant epilepsy. Each year roughly 110,000 are admitted to an epilepsy monitoring unit at an NAEC accredited center, and about 7,400 are treated with surgery of any kind, counting resection, laser ablation, RNS, and VNS together. That is a utilization rate below one percent.
Bars are to scale. Sources: Richardson RM, Neurologic Clinics 2022; Chen Z, et al., JAMA Neurology 2017; NAEC Center Annual Report, May 2025.
Every patient with drug-resistant epilepsy is a surgical candidate.
The 2022 ILAE expert consensus recommends offering a surgical evaluation to every patient with drug-resistant epilepsy up to age 70, as soon as drug resistance is confirmed by the failure of two appropriate medication trials, regardless of epilepsy duration, seizure type, epilepsy type, localization, or comorbidity. Patients who do not look like resection candidates are referred because other options exist. Candidacy means evaluation. It does not commit the patient to a particular operation.
The consensus also names circumstances that should not delay referral:
Other therapies have not been tried.
Surgery may be palliative.
A prior resection failed.
Medications failed because of side effects.
The patient was nonadherent in the past.
The patient is reluctant. Counseling is part of the evaluation, so a reluctant patient is still a referral.
Jehi L, et al. Timing of referral to evaluate for epilepsy surgery: expert consensus recommendations from the Surgical Therapies Commission of the International League Against Epilepsy. Epilepsia 2022;63:2491-2506.
The cost of delay.
Surgery cuts mortality by about two thirds. In the series summarized by the ILAE consensus, mortality was 8.6 deaths per 1,000 person-years after surgery and 25.3 per 1,000 person-years without surgery. A second series of 590 surgical and 122 nonsurgical patients confirmed lower all-cause and SUDEP mortality after surgery. Patients who become seizure free have mortality indistinguishable from the general population.
Data from the mortality series summarized in Jehi L, et al., Epilepsia 2022, citing Bjellvi 2019 and Lewis 2021.
Longer epilepsy duration predicts worse outcome. Patients who became seizure free had epilepsy for 2.8 fewer years at the time of surgery than those who did not. In children, delay forfeits developmental windows; early surgery can halt or reverse regression.
Think like a surgical epileptologist.
Neurologists and neurosurgeons both need to learn to think like one.
Five paradigm shifts in drug-resistant epilepsy.
Richardson RM. Closed-loop brain stimulation and paradigm shifts in epilepsy surgery. Neurologic Clinics 2022;40:355-373.
Putting hypotheses into practice.
Refer early and broadly. Every drug-resistant patient deserves evaluation for surgery. Build the team and the workflow. Think like surgical epileptologists. Implant to test a hypothesis. RNS therapy should validate the hypothesis confirmed by SEEG.