Comparative Review of Seizure and Cognitive Outcomes in Resective, Ablative, and Neuromodulatory Temporal Lobe Epilepsy Surgery.

Resective surgery for drug-resistant temporal lobe epilepsy remains underutilized in the United States. While anteromesial temporal lobectomy consistently achieves the highest rates of long-term seizure freedom, it comes with greater risks for memory and language decline. Magnetic resonance imaging-guided laser interstitial thermal therapy and neuromodulation have gained popularity due to perceived lower surgical risk and faster recovery, although they yield lower rates of sustained seizure freedom. Neuromodulation with vagus nerve, deep brain, or responsive neurostimulation provides an option for patients ineligible for resection or ablation, but overall seizure outcomes remain modest. Balancing improved seizure control with open resection against the potential cognitive advantages of less invasive treatments is complex, requiring careful patient selection. Future research must refine these approaches to optimize results. Thoughtful, individualized decision-making, guided by each patient's clinical scenario and goals, is paramount for achieving the best balance between seizure freedom, cognitive preservation, and overall patient outcome.