Contemporary Management of Pediatric Intractable Epilepsy: Integrating Medical and Surgical Strategies

Abstract

Pediatric intractable epilepsy, defined as failure of two appropriately chosen and tolerated antiseizure medication (ASM) schedules to achieve sustained seizure freedom, remains one of the most consequential neurologic disorders of childhood because of its effects on cognition, behaviour, psychosocial development, academic attainment, and family quality of life. Over the past two decades, management has shifted from a predominantly pharmacologic model toward an integrated framework in which early referral to a comprehensive epilepsy center, precise localization of the epileptogenic zone, and individualized surgical or neuromodulatory treatment are considered central components of care rather than measures of last resort. Structural etiologies, particularly focal cortical dysplasia, hippocampal sclerosis, post-injury gliosis, and low-grade epilepsy-associated tumors (LEATs), comprise the most surgically remediable causes of pediatric drug-resistant epilepsy and illustrate the importance of linking lesion biology with network-level epileptogenicity. This scoping review maps current evidence on the medical and surgical management of pediatric intractable epilepsy, with particular attention to pre-surgical evaluation, lesion-directed and epilepsydirected surgery, minimally invasive ablative approaches, and neuromodulation. The available evidence consistently supports early multidisciplinary evaluation, recognition of surgical candidacy soon after pharmacoresistance is established, and individualized treatment pathways that prioritize seizure freedom, developmental preservation, and functional safety.