4 Neurology India | Jan-Feb 2009 | Vol 57 | Issue 1 Abstract This review traces the evolution of epilepsy surgery in India from the beginning to the present state. During the last one and half decades, surgical treatment of epilepsies has made resurgence in this country and at present a few centers have very active and sustained epilepsy surgery programs. Within a 14-year period, the R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Trivandrum, has undertaken over 1000 epilepsy surgeries. However, in the whole country, annually, not more than 200 epilepsy surgeries are currently being performed. This number is a miniscule when compared to the number of potential surgical candidates among the vast population of India. The enormous surgical treatment gap can only be minimized by developing many more epilepsy surgery centers in different parts of our country. Key words: Developing countries, epilepsy, epilepsy surgery Address for correspondence: Dr. Kurupath Radhakrishnan, Senior Professor and Head, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum - 695 011, Kerala, India. E-mail: krk@sctimst.ac.in DOI: 10.4103/0028-3886.48791 Epilepsy surgery in India Kurupath Radhakrishnan R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India Indian Perspective Introduction Nearly one-third of the patients with newly diagnosed epilepsy on long-term follow-up will have their seizures unsatisfactorily controlled by treatment with available antiepileptic drugs. [1] A majority of these patients with difficult to control seizures have focal epilepsies. The remarkable advances in neuroimaging technologies during the past two decades have allowed detection of a variety of brain lesions in over half of the patients with medically refractory focal epilepsies such as hippocampal sclerosis, malformations of cortical development, benign neoplasms, vascular malformations and focal gliotic lesions that are amenable to surgical resections. [2] Epilepsy surgery was considered until recently to be an expensive high- technology therapy restricted to the industrialized world. The understanding that a majority of patients with substrate-directed intracranial lesions associated with chronic focal epilepsies can be selected for surgery based on relatively simple and affordable non-invasive presurgical evaluation strategies has resulted in recent years in the creation of epilepsy surgery programs in developing countries. [3] A recent survey revealed that, in 26 of 142 (18.3%) economically disadvantaged nations, at least one center regularly conducted epilepsy surgeries, compared with 18 of 24 (75%) developed countries. [4] Out of 50 million people with epilepsy globally, 80% live in resource poor countries. [5] India with over one billion people will have over one million people with medically refractory epilepsies, of which nearly one half are potential surgical candidates. The success of an epilepsy surgery depends upon the early identification of potential surgical candidates, and selecting from them, ideal candidates destined to have a postoperative seizure-free outcome. Since epilepsy surgery centers in developing countries will lack the full range of state-of-the-art technologies usually available in the developed world to perform presurgical evaluation and surgery, the success of epilepsy surgery programs in a developing country set-up will depend upon the ability to select ideal surgical candidates using locally available technology and expertise without compromising on patient safety. [6,7] Despite major challenges, in the last one and half decades, a handful of epilepsy surgery centers in India have not only successfully implemented epilepsy surgery programs, but have also produced results comparable to those from developed countries at a fractional cost. On January 14, 2009, the R. Madhavan Nayar Center for Comprehensive Epilepsy Care (RMNC) at Trivandrum, Kerala, performed the 1000 th epilepsy surgery. Through this brief review, I intend to trace the evolution of epilepsy surgery in India and discuss its present state.