From Recommendations to Practice: Contextualizing the AES/CNS Epilepsy Surgery Guidelines for the Clinician

American Epilepsy Society/Congress of Neurological Surgeons Epilepsy Surgery Clinical Practice Guideline

Jobst BC, Bergey G, Roldán-Benítez YM, Hopp JL, Bauer D, Price A, Strickland SL, Bernat JL, Busch RM, Engel J, Gloss D, Husain AM, McGovern RA, McKhann G, Nordli DR Jr., Rolston JD, Shane R, Spencer D, Weiner HL, Nasif MB, Duda T, Eid A, Ghandour D, Hart S, Keserwan M, Martyniuk A, Lannon M, Saber G, Saouda C, Sharma S, Vinarsky V, Darzi A, Gonzalez-Martinez J. Epilepsy Curr . 2026.

This practice guideline from the American Epilepsy Society (AES) and the Congress of Neurological Surgeons (CNS) provides evidence-based recommendations for surgical treatment of epilepsy for adults and children. It is an update to previous practice parameters published by the Academy of Neurology in 2003. The multidisciplinary panel addressed resective procedures for mesial temporal epilepsy (MTLE), neocortical epilepsy, and resection/disconnection of hypothalamic hamartoma. It also examined evidence for callosotomy in developmental and epileptic encephalopathies. It did not intentionally address neurostimulation treatment. A comprehensive literature review was conducted using Grading of Recommendations Assessment, Development and Education (GRADE) methodology, and GRADE was also used for decision-making. This guideline considers not only seizure outcomes but also other critical and important outcomes. Seizures, quality of life, mortality, adverse events and verbal memory loss were considered critical outcomes, while other neuropsychological deficits besides verbal memory loss (ie, naming, fluency), neuropsychiatric and social outcomes were considered important outcomes. Following the GRADE process, the following strong recommendation was made based on moderate level of evidence: (1) anterior temporal lobectomy (ATL) is recommended for people with MTLE at low risk for cognitive decline. Due to very low to low certainty of evidence the panel suggested the following conditional recommendations: (1) ATL for people with MTLE at high risk for cognitive decline, (2) selective amygdalo-hippocampectomy (SAH) in MTLE, (3) interstitial thermal therapy (LITT) in MTLE, (4) neocortical resection in neocortical epilepsy, and (5) callosotomy in people with drop attacks, Lennox-Gastaut Syndrome (LGS) or developmental and epileptic encephalopathies. The panel recognized that conditional recommendations need to account for individual patient circumstances and mandate shared decision-making to ensure that decisions align with each person's values and preferences. For hypothalamic hamartoma, the panel strongly recommended LITT despite low levels of evidence due to a paradigmatic situation that open surgery has significant risks that outweigh the benefits. If LITT is not available, the panel suggested radiosurgery for hypothalamic hamartoma (conditional recommendation). The panel highlighted that every person with drug-resistant epilepsy should have access to a tertiary epilepsy care center that performs surgical procedures and advanced epilepsy diagnostics (good practice statement).