Table 4.

Recommendations: Surgery

13. Recommendation: All epilepsy centers should regularly screen patients for drug-resistant epilepsy and refer such patients to multidisciplinary surgical conference for consideration of epilepsy surgery. CB   Remark: Referrals for epilepsy surgery evaluation should be made in a timely manner. CB   Remark: Epilepsy surgery includes resective, disconnection, ablative, intracranial and extracranial neurostimulation procedures, and placement of   intracranial electrodes. CB   Remark: Patients who were previously evaluated for epilepsy surgery but did not proceed to surgery should continue to be screened regularly. CB

14. Recommendation: All centers that perform epilepsy surgery should have a formal presurgical conference with the multidisciplinary team to evaluate and plan for each patient referred for epilepsy surgery. CB   Remark: The surgical epilepsy care team includes neurosurgeons, neuropsychologists, epileptologists, EEG technologists, nurses,   neuroanesthesiologists,   psychiatrists, neurophysiologists, neuroradiologists, case managers, and/or patient advocates. The neurosurgeon, neuropsychologists, epileptologists,   and neuroradiologists should attend the presurgical conferences consistently, with others attending as appropriate. CB

15. Recommendation: Multidisciplinary surgical conferences should be able to appropriately screen patients for all epilepsy surgery options and recommend the best procedure for controlling a patient's epilepsy without regard to whether it is performed at the center. Centers that do not perform specific epilepsy surgical procedures should refer patients to a center that performs those procedures, when appropriate. CB   Remark: Centers that only perform extracranial neurostimulation procedures (e.g., VNS) should have a referral arrangement whereby candidates for these   procedures are presented at a multidisciplinary conference at the partner center that performs the full range of epilepsy surgical procedures. CB   Remark: Centers that lack experience in performing certain procedures in children should refer patients to a center that regularly performs those   procedures. CB   Remark: Centers that receive referrals from other programs should not replicate the evaluation unnecessarily and should involve the referring provider in   decision-making. CB

16. Recommendation: All epilepsy centers that perform intracranial surgery should have the capability of performing 24-h video-EEG monitoring with intracranial electrodes, including stereo EEG and subdural electrodes. CB   Remark: All centers that perform intracranial monitoring should have epileptologists with sufficient volume of cases to maintain expertise in   interpretation   of intracranial EEGs. CB   Remark: All centers should have written protocols governing care for patients undergoing video-EEG monitoring with intracranial electrodes, including care   of head dressings and measures to prevent postoperative infections or other complications. CB   Remark: All centers that place intracranial electrodes should have capabilities for electrode localization, including the use of 3D reconstruction. CB

17. Recommendation: All centers that perform resective surgeries should have the ability to perform intraoperative electrocorticography to identify epileptogenic tissue. CB   Remark: Electrocorticography should be interpreted by epileptologists or neurophysiologists with sufficient volume of cases to maintain expertise. CB

18. Recommendation: Centers that perform intracranial surgeries should have the ability to perform functional mapping, including motor, sensory, language, and behavioral modalities. CB   Remark: Functional mapping procedures include cortical stimulation and evoked potential recording. CB   Remark: Centers should have written protocols for functional mapping that address methodology, safety, and risk of provoking seizures during mapping. CB   Remark: Center protocols for mapping language and behavioral modalities should be drafted in consultation with a neuropsychologist. When possible, a   neuropsychologist should be present during the mapping procedure. CB   Remark: Centers should have the capability of performing intraoperative functional mapping to maximize possibility of seizure freedom while mitigating   the risk of iatrogenic injury. CB   Remark: Centers that use intracranial electrodes should have the capability of performing extraoperative functional mapping for surgical planning. CB

19. Recommendation: All centers that perform surgery should have the ability to preoperatively assess language dominance and memory. CB

20. Recommendation: All centers that perform epilepsy surgery should have a neurosurgeon with specialized training and experience in epilepsy surgery. CB   Remark: Center neurosurgeons should be board certified or tracking toward certification in neurosurgery. CB   Remark: Centers that serve children should have a neurosurgeon with specialized training and experience in pediatric epilepsy surgery, including   hemispherotomy. CB

21. Recommendation: All centers that perform epilepsy surgery should have sufficient volume of cases to maintain expertise of the multidisciplinary surgical epilepsy care team. CB

22. Recommendation: All epilepsy centers that perform resective surgery should have surgical specimens analyzed by a neuropathologist who generates a formal pathology report. CB

Abbreviation: CB = consensus based; VNS = vagus nerve stimulation.