Contemporary disconnection and neuromodulation treatments for generalized drug-resistant epilepsy: A narrative review and clinical decision-making framework.

Abstract

Surgical treatment of generalized drug-resistant epilepsy (DRE), lacking a clearly resectable epileptogenic focus, presents a formidable clinical challenge. Inadequately treated generalized DRE is associated with neurological deficits, impaired neurodevelopment, poor quality of life, and lifelong educational and occupational difficulties. Over the last half-century, various neurosurgical interventions have been introduced for the management of generalized DRE. These include longstanding and well-established disconnection procedures, which have evolved over time to reduce surgical morbidity, as well as more recent options such as neuromodulation through surgically implanted devices. As technological advances and evidence for their use continues to grow, clinical decision-making has become increasingly nuanced. In this article, we review contemporary neurosurgical approaches for managing generalized DRE, including the most common disconnection and neuromodulation-based interventions, and provide a framework to guide patient selection and presurgical counselling at specialized epilepsy centers. We conclude with an overview of current and emerging technological advances in this rapidly evolving field, providing an up-to-date resource for clinicians to inform practice.