From the American Epilepsy Society 2009 Annual Course Identifying epilepsy surgery candidates in the outpatient clinic Frank G. Gilliam ⁎, Brenda Albertson Geisinger Epilepsy Program, Department of Neurology, Geisinger Health System, Danville, PA, USA abstract article info Article history: Received 15 December 2010 Accepted 15 December 2010 Available online 26 January 2011 Keywords: Epilepsy Surgery Refractory Pharmacoresistant Epilepsy surgery Presurgical Quality of life Mortality Seizures Magnetic resonance imaging Video-electroencephalography Epilepsy monitoring Epilepsy is the most prevalent disabling neurological disorder across the life span, and is not controlled by medications in more than one-third of patients. Epilepsy surgery is an accepted treatment, with guidelines supporting utilization in patients with recurrent temporal lobe seizures after two or more trials of antiepileptic medications. Unfortunately, the average delay in presurgical evaluation of appropriate candidates is more than 20 years, and this delay has not improved in recent decades. This offers the international neurological community the opportunity to improve disability, mortality, and quality of life by more effective application of epilepsy surgery and earlier identification of potential candidates. Optimal use of MRI and video/EEG monitoring should allow cost-effective screening of persons with recurrent seizures prior to more detailed presurgical evaluation when indicated. © 2010 Elsevier Inc. All rights reserved. 1. Introduction The accepted treatment for epilepsy is to sequentially prescribe medications appropriate for the syndrome until seizures are completely controlled. However, seizures in more than one-third of patients are not controlled by available antiseizure medications at tolerable doses [1]. Until recently the literature was unclear regarding the definition of a good outcome from pharmacotherapy. Terminology such as “acceptable seizure control,”“successful treatment,” and “adequate response” was inappropriately used in the past to describe improved outcomes with less than complete seizure control. Converging evidence from clinical and basic research indicates that serious adverse health consequences occur for a substantial proportion of persons with recurrent seizures. Health outcomes research in recent decades also has clarified the importance of complete seizure cessation for improved mortality, injury risk, and quality of life. Despite published recommendations by leading neurological orga- nizations that support surgical evaluation after two failed medica- tions during 2 years of treatment, most studies of epilepsy surgery indicate long delays of many years between failure of medical therapy and assessment for surgical candidacy. As characterized in Fig. 1, this delay may result from the unresolved tension between the estimation of the importance of reduction of disability and morbidity of uncontrolled epilepsy and the potential risk of surgical resection of the epileptogenic region. For example, a Letter to the Editor regarding the New England Journal of Medicine publication of the first randomized controlled surgical trial for temporal lobe epilepsy stated that, “I am going to continue to consider this kind of surgery a final, if not desperate, option when all other treatments have failed and my patients are willing to consider possible changes in their personality in order to improve their ‘quality of life’” [2]. This article is intended to consider the various components of the decision process for determining surgical candidacy, but not the specifics regarding the determination of the surgical procedure. Emphasis is placed on potential factors that may lead to delayed or even overlooked surgical candidacy, including current standards of care, difficulty in defining epilepsy severity, misperception of the relevance of limited remissions, and the importance of patient and family education, as summarized in Fig. 2. 2. Standards of care for identification of surgical candidates Understanding the current approach to pharmacoresistant epilepsy places the discussion of the determination of surgical candidacy into a contemporary context. Table 1 summarizes the duration of epilepsy prior to presurgical evaluation in several of the largest recent studies of epilepsy surgery. Multiple studies from single sites in different regions of North America found a range of mean duration of epilepsy from 19 to Epilepsy & Behavior 20 (2011) 156–159 ⁎ Corresponding author. 100 North Academy Avenue, Danville, PA 17822, USA. E-mail address: fggilliam@geisinger.edu (F.G. Gilliam). 1525-5050/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2010.12.022 Contents lists available at ScienceDirect Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh