The goal of epilepsy surgery may be to control seizures by resection of the epileptogenic lesion or region. In patients who are not candidates for cortical resection, surgery may be considered for palliation, as with disconnection procedures.
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85% of partial epilepsies arise from the temporal lobe and therefore the most common resective procedure is the anterior temporal lobe resection. This is performed as an en bloc resection, generally extending 4.5 cm from the temporal tip in the language dominant hemisphere and 5.5 cm in the nondominant hemisphere, or as a modified procedure involving a less extensive lateral temporal resection or selective removal only of the amygdala and hippocampus. Seizures remit in between 65-85% of patients treated with temporal lobe resection, depending on the seizure etiology, the epileptogenic region and the precise surgical procedure performed. Extratemporal resections are most commonly performed when the epileptogenic region coincides with a structural lesion. Outcome after lesional surgery is quite good (75 to 90% seizure free), although nonlesional extratemporal procedures are less successful (Van Ness, 1992). Complications of cortical resective surgery for epilepsy include hemiparesis (0.5-2%), homonymous hemianopsia and transient anomia.
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Corpus callosum section limits the ability for localization related seizures to spread to the contralateral hemisphere and can be a useful procedure for patients with atonic, tonic or convulsive seizures who are not candidates for cortical resection. Disconnection syndromes arise in some patients undergoing a complete callosal section but are less prevalent with the newer staged procedure in which the anterior two-thirds of the callosum is sectioned in a first surgery. Corpus callosotomy can lead to a reduction in injurious seizures in 75% or more, but can also increase simple and partial seizures in some patients.
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Outcome

Cognitive outcome is good after temporal lobectomy. There is no global cognitive decline after epilepsy surgery, although there may be relatively minor difficulties in specific areas, such as memory. Overall intelligence does not decline after surgery, and may even show a modest increase, particularly if the surgery occurs in the non-dominant hemisphere. Declines in verbal memory may occur after left temporal lobe resection but no consistent deficits in visual-spatial memory have been demonstrated after right temporal lobectomy. The most common language deficit is dysnomia after dominant temporal lobe resection. This risk can be lessened by intraoperative or extraoperative language mapping and by altering the extent of resection if language cortex is felt to be at risk.
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Surgery can lead to improvement in vocational and psychosocial status, particularly when good seizure control is achieved. Patients may attain their first or better employment. Children undergoing epilepsy surgery are less frequently absent from school and are often able to attend regular, rather than special classes.

Specific, directed rehabilitation efforts may be needed to improve psychosocial, psychiatric and vocational outcome in patients after epilepsy surgery. Patients may need help in the form of counseling, education, structured experience and vocational and occupational rehabilitation in order to learn new psychosocial and vocational skills. If rehabilitation of the patient with epilepsy can be accomplished in this broadest sense, then there will be tangible benefits to surgical therapy for the individual and society.
Summary
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Epilepsy is a heterogeneous condition which adversely affects many aspects of life, including psychosocial function and occupational achievement. The sudden unpredictable nature of seizures often leads to psychological distress, feelings of vulnerability and a sense of diminished competence. Seizures may not be completely controlled in nearly half of those with localization related epilepsy and many others will be troubled by side effects from AEDs. Medication response is optimized when the seizure type, epilepsy syndrome and common medication side effects are considered. Monotherapy is usually as effective as polytherapy and is better tolerated. Surgery is an important treatment option in patients with localization related epilepsy which is medically intractable.
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