According to the latest epidemiological survey, the lifetime prevalence of epilepsy is 7.0‰, and the prevalence of active epilepsy (with seizures within 5 years) is 4.9‰. 70% to 80% of patients can have their seizures controlled or remitted with regular medical treatment, but 20% to 30% are patients with intractable/refractory epilepsy, so there are no less than 1 million patients with intractable epilepsy in China. Appropriate surgical treatment can alleviate and reduce the seizures in epileptic patients with a chance of complete control. Nowadays, surgical treatment of epilepsy is flourishing in China with certain achievements, but there are still significant shortcomings compared with foreign countries. The two key issues of screening epilepsy surgical patients, choosing the timing of surgery, and their misconceptions are discussed as follows: The concept of stage-refractory epilepsy emphasizes in principle that the timing of surgery must be reasonably well managed, with pharmacological treatment first for observation and then to determine whether it is intractable. Since the early 1980s, the principle of monotherapy for epilepsy has been gradually accepted. After failure with reasonable monotherapy (still more than 4 seizures per month), other antiepileptic drugs can be switched or added. Studies have shown that after failure of regular treatment with the application of two drugs, the likelihood of success with the application of a third drug will be less than 15% to 10%. In contrast, the likelihood of remission with further medication is less than 5% after failure of three medications. In addition, more than a dozen new antiepileptic drugs have emerged worldwide in recent years, and clinical trials have confirmed their effectiveness, but only about 1/3 of patients with refractory epilepsy have benefited from them, so one should not have complete hope. Failure of formal treatment with the application of two antiepileptic drugs will essentially establish refractory and initial consideration of surgical treatment. An important reason for failure of drug therapy is due to short- and long-term systemic and neurological toxicity caused by the drugs. Even if drug therapy is successful, adverse reactions may result in having to abandon drug therapy, and this group of patients is also suitable for surgical treatment. At present, the management of epilepsy medication in China is quite unregulated. The so-called “traditional Chinese medicine” that many patients take is often mixed with several western drugs, and the blood concentration does not reach the effective range. This is a very good way to get the most out of your life. It is important to note that a significant proportion of these patients can be effectively controlled. The definition of refractory epilepsy has a clear definition of seizure frequency, but does not take into account the severity of seizure symptoms. It is clear that there are significant differences in clinical severity between seizure types and seizures. For example, more aggressive treatment options need to be considered for patients with clinical seizures with loss of consciousness, convulsive seizures, drop seizures, seizures of long duration, seizures with psychiatric symptoms, seizures with the potential to cause accidental injury or death, and seizures during the day. In contrast, for those with relatively mild clinical seizure symptoms, surgery can be delayed appropriately. Deciding on surgery for adolescent and young adult patients with epilepsy should be done carefully and repeatedly. For most patients with epilepsy, refractoriness persists. However, for a small subset of patients, long-term follow-up, particularly in children and adolescent epileptics, has revealed a trend toward spontaneous remission of clinical seizures with age. For example, benign late-onset occipital lobe epilepsy in childhood is often refractory in childhood but can remit around adolescence. The concept of stage-refractory epilepsy has therefore been proposed, and this phenomenon is mainly due to the possible re-regulation of the function of excitatory and inhibitory systems in the brain with age to achieve homeostasis. On the other hand, persistent epileptiform discharges and frequent seizures during the interictal period in children and adolescents are capable of producing significant toxic effects on brain development, affecting cognitive function and susceptibility to further seizures. At the same time, brain tissue in this period is highly plastic and the function of surgically removed tissue can be compensated by other sites, thus greatly reducing the incidence of postoperative neurological deficits. The degree of seizures determines whether to operate Too early surgical treatment tends to lose the possibility of complete remission with non-surgical treatment, while too late intervention inevitably aggravates neurological damage, so if the seizures are still refractory after 2 years of observation with regular medication, only then can surgery be considered. If long-term seizures are producing or are about to produce serious psychosocial problems, surgery should be performed as early as possible. These include impact on school employability and marital status, depression, anxiety, poor psychological adjustment, and social isolation, in addition to language and cognitive impairment, which have been similarly identified in national and international studies. In the early stages, these are reversible, but as seizures persist, they gradually become irreversible and can be carried from childhood into adulthood. The application of the Quality of Life Scale for Epileptic Patients provides a more comprehensive evaluation of the effects of epilepsy on the patient. Aggressive and effective surgical treatment in the early stages of these effects can reduce long-term somatic and psychosocial problems and improve quality of life. Dynamic or progressive types of epilepsy require prompt surgery to prevent progression to refractory and serious consequences. Is the patient destined for a refractory outcome at the onset of the disease? Or does it change over time to eventually progress to refractory? The answer to this question has important clinical implications: if refractoriness is not predetermined, then it can be prevented from progressing to refractory by aggressive treatment early in the course of the disease. Further, if drug resistance is present, early surgery can prevent serious adverse outcomes. Certain types of epilepsy clearly do not progress to refractory status. For example, the prognosis for idiopathic epilepsy is generally good, and individual syndromes do not even require treatment. However, the latest “Recommendations for Seizure Classification” suggest that epileptic encephalopathy refers to a group of states in which progressive brain dysfunction is caused by epileptiform electrical activity. Highly refractory childhood epilepsies, such as WEST syndrome, infantile severe myoclonic epilepsy LennoxGastaut syndrome, and Rasmussen’s encephalitis, comprise progressive epilepsy syndromes. Medial temporal lobe epilepsy, perhaps the most studied epilepsy syndrome with the highest incidence, has been debated for over 100 years in relation to hippocampal sclerosis, and recent structural and functional imaging studies have shown that frequent clinical seizures can cause neuronal dysfunction and loss and exacerbate hippocampal sclerosis, suggesting that medial temporal lobe epilepsy may be progressive. The phenomenon of secondary epileptic foci also provides another evidence, despite the lack of direct human evidence, of this ignition phenomenon observed in animal models: the gradual generation of new epileptic foci, i.e. secondary epileptic foci, in the same locations of the contralateral cerebral hemisphere under the continuous stimulation of the primary foci. Initially, their epileptiform discharge events are closely linked to the primary epileptic focus, and after many seizures, the secondary epileptic focus can act as an independent foci producing seizure activity. The dynamic understanding of epilepsy progression for epilepsy progressivity allows for the recognition that appropriately early surgical intervention can strive for better outcomes without delaying to irreversible stages, such as secondary epileptic foci formation before surgical treatment, which can be less effective. In conclusion, given the short time of epilepsy surgery development in China, as the chief of the department and the leader of the epilepsy discipline, we should have an international vision and a high international starting point at the beginning. In order to avoid repeating some appropriate or even wrong methods and procedures from abroad, we should actively study some more standardized and reasonable standards from abroad, so that we can stand at the forefront of our discipline from the beginning, and guide our practice. At the same time, because the screening of patients by some epilepsy surgeons is not standardized enough at present, almost all epileptic patients are operated immediately, which directly affects the surgical effect, so it has not been recognized enough by neurologists. In the future, we need to strengthen the learning and mutual reference with our domestic counterparts, especially our counterparts in epilepsy medicine, so that the efficacy of epilepsy surgery can reach the international level, and win the recognition and cooperation of our neurology counterparts with our own efforts to push our epilepsy surgery forward to the world academic stage.