Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 13 Sept 2026Clinical review pending
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Ongoing or clustered seizure during assessment
A seizure lasting five minutes or more, repeated seizures without recovery, new persistent focal deficit, serious injury or pregnancy-related deterioration is an emergency independent of elective surgical evaluation.
Action: Follow the acute seizure or status pathway, protect airway and safety, give time-critical rescue treatment according to the applicable protocol, identify reversible causes, and contact neurology or critical care without waiting for presurgical tests.
Synopsis
Identify who should be referred promptly for tertiary epilepsy-surgery evaluation, distinguish referral from final eligibility, integrate multimodal localisation and functional risk, and explain resection, ablation and neuromodulation outcomes honestly.
Refer drug-resistant epilepsy for consideration of resective-surgery assessment even when routine MRI is normal; referral opens evaluation and does not guarantee an operation.
Drug resistance generally means failure of two tolerated, appropriately chosen and used antiseizure medication schedules to achieve sustained seizure freedom.
NICE also supports early tertiary assessment when MRI abnormalities predict a high risk of drug resistance; years of additional seizures are not a prerequisite.
Key red flags
A prolonged seizure, incomplete recovery, recurrent events without recovery or new focal deficit requires emergency treatment and imaging when indicated.
Apparent worsening after medication change demands adherence, interaction, toxicity and withdrawal review; do not label drug resistance until regimens were appropriate and used adequately.
A lesion with mass effect, haemorrhage, infection features or rapidly progressive neurology requires its own urgent pathway rather than routine epilepsy conference timing.
Depression, suicidality, injury risk, safeguarding concerns and sudden-unexpected-death risk need active management while referral proceeds.
Acute override
Status epilepticus, new persistent neurology or serious injury is treated immediately and should not wait for an elective presurgical pathway.
Reasoning priorities
01
Prolonged video-EEG telemetry
Capture habitual events with simultaneous behaviour and electrical activity, confirm whether they are epileptic and contribute to onset localisation.
Scalp ictal onset is integrated with semiology and imaging; deep or rapidly propagating seizures may be poorly localised and a captured non-epileptic event does not exclude coexisting epilepsy.
Worked reasoning
Worked caseFocal seizures after two appropriate regimens
Disabling focal seizures persist after two tolerated, appropriately chosen and adequately used medication schedules, with or without an MRI lesion.
Verify seizure diagnosis, habitual semiology, adherence, dose and duration, medication appropriateness, adverse effects and the person’s goals; address immediate safety and rescue planning.
Refer promptly to a tertiary epilepsy service for consideration of surgical assessment rather than waiting for additional routine drug failures or a visible MRI lesion.
Build a concordant hypothesis from video EEG, epilepsy-protocol MRI and neuropsychology, adding functional imaging or intracranial recording only when it answers a defined decision.
At conference, compare resection or ablation, neuromodulation and non-surgical options using seizure, cognitive, neurological and psychosocial outcomes.
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 13 Sept 2026; clinical approval remains outstanding.
NICE NG217 tertiary epilepsy referralPublished 27 April 2022 and updated 30 January 2025; current body read 13 September 2026. Recommendations 3.1.1 to 3.1.4; tertiary service capabilities; urgent and routine referral criteria. Supports: Timely tertiary referral for diagnostic uncertainty, drug resistance, intolerable treatment effects and need for video-EEG, neuropsychology, specialised imaging or surgery. Limits: Children, young people and adults with epilepsy in UK care; referral is assessment, not a promise of resection. Chapter-specific use: epilepsy-surgery-assessment.
NICE NG217 resective epilepsy surgeryPublished 27 April 2022 and updated 30 January 2025; current body read 13 September 2026. Section 8 resective epilepsy surgery recommendations and rationale links. Supports: Refer drug-resistant epilepsy for consideration of resective-surgery assessment even without an identified MRI lesion; consider early referral for high-risk MRI abnormalities. Limits: Referral recommendation across ages; final treatment depends on concordant localisation, benefit-risk assessment and informed preference. Chapter-specific use: epilepsy-surgery-assessment.
ILAE timing of referral for epilepsy surgery consensusEpilepsia 2022; full body read 13 September 2026. Drug-resistance definition; consensus statements; age, comorbidity and lesion scenarios; limitations. Supports: Offer surgical evaluation promptly after failure of two tolerated, appropriately chosen and used antiseizure regimens, without waiting years or requiring an MRI lesion. Limits: International expert consensus; the age-up-to-70 statement is not an NHS exclusion above 70, and referral does not equal eligibility. Chapter-specific use: epilepsy-surgery-assessment.