Timely Surgical Approaches for Pediatric Epilepsy Resistant to Medication.
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Meckel's Pediatric drug-resistant epilepsy (DRE) is a significant neurological disorder that develops when seizures persist despite treatment with two appropriately selected antiseizure medications. Although only a subset of children with epilepsy develops DRE, prolonged uncontrolled seizures during childhood can result in irreversible cognitive, behavioral, and developmental impairment. Over time, growing evidence has demonstrated that epilepsy surgery is an effective treatment for appropriately selected patients and that earlier surgical intervention is associated with improved relief from seizures and long-term neurodevelopmental outcomes. This review examines the mechanisms underlying pharmaco-resistance, including network reorganization, neuroinflammation, blood-brain barrier dysfunction, and structural abnormalities that contribute to epileptogenesis. Common surgically remediable causes of pediatric DRE, including focal cortical dysplasia, mesial temporal sclerosis, tuberous sclerosis complex, hemimegaloencephaly, and tumor-associated epilepsy, are discussed along with current surgical approaches, including resective, disconnective, and minimally invasive procedures. The evidence comparing early versus delayed surgical intervention is reviewed with emphasis on seizure control, cognitive development, language, behavior, and quality of life. Finally, this review highlights persistent barriers to timely surgical referral, including socioeconomic, geographic, and racial disparities, while exploring emerging advances in neuroimaging, artificial intelligence-assisted lesion detection, and imaging biomarkers that may improve early diagnosis and patient selection. Collectively, the available evidence supports earlier referral for surgical evaluation in children with DRE and suggests that prompt intervention may preserve neurodevelopment, improve long-term functional outcomes, and maximize quality of life.