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Drug-Resistant TLE – Surgical Referral — SCE Neurology MCQ

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ModerateEpilepsy & Seizure DisordersDrug-Resistant TLE – Surgical ReferralSCE Neurology

A 32-year-old woman presents with episodes of altered awareness preceded by an unpleasant epigastric rising sensation. During episodes she stares, has lip-smacking automatisms, and is amnesic afterwards. Episodes last 1–2 minutes. She recently underwent video-EEG monitoring. The ictal EEG shows rhythmic theta activity originating from the right temporal region. MRI shows right hippocampal sclerosis. She has failed two appropriate antiseizure medications at adequate doses. Per NICE NG217, what should she be offered?

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Correct answer: C — Referral to a tertiary epilepsy surgery centre

NICE NG217 recommends referral to a tertiary epilepsy surgery centre for adults with drug-resistant focal epilepsy (defined as failure of two appropriate and tolerated antiseizure medications). This patient has mesial temporal lobe epilepsy with concordant semiology, EEG, and MRI (hippocampal sclerosis) — an excellent surgical substrate with >70% seizure-freedom rates after anterior temporal lobectomy. A: A third medication is unlikely to achieve seizure freedom (<5% chance). B: VNS is considered when surgery is not possible. D: Ketogenic diet has limited evidence in adults. E: TMS is experimental for epilepsy.

Reference: NICE NG217 (2025); ILAE Epilepsy Surgery Guidelines