Nearly half of patients who underwent epilepsy surgery were seizure-free 10 years after surgery, but further improvements in preoperative evaluation and surgical treatment of patients with chronic epilepsy are needed to improve success rates, according to a prospective study published in the Oct. 15 issue of The Lancet. In this study, Drs. JanedeTisi and Gail S. Bel of the National Hospital for Neurological Surgery in the United Kingdom and colleagues followed 649 patients who underwent epilepsy surgery between 1990 and 2008 to observe patterns of seizure remission and recurrence. The investigators excluded 34 patients who died, were lost to follow-up, or underwent reoperation within the same year, and analyzed data from 615 patients (287 men and 328 women) aged 16-63 years. The median preoperative duration of epilepsy in these patients was 20.7 years. 497 anterior temporal lobes were resected, 40 temporal lobe lesions were resected, 40 extratemporal lobe lesions were resected, 20 extratemporal lobes were resected, 11 cerebral hemispheres were resected, and 7 palliative procedures (corpus callosotomy or submural transection) were performed. The investigators collected information annually by searching hospital records, direct questioning (of patients who kept prospective seizure diaries) and their general practitioners or relatives of the patients. The questioning included the occurrence of simple partial seizures (SPS), seizures with loss of consciousness, and the antiepileptic drugs taken. The median follow-up period was 8 years. The investigators defined seizure recurrence as a prognostic category on the International League Against Epilepsy Prognostic Scale.3 The results showed that the proportion of patients with no seizures at all or only SPS was 82% at 1 year, 63% at 2 years, 52% at 5 years, and 47% at 10 years after surgery. Forty percent of the patients were completely seizure-free for a long time after surgery, and 11% had only SPS. no patients had significantly worse epilepsy. Patients with SPS within 2 years of anterior temporal lobectomy were 2.4 times more likely to have seizures with reduced consciousness thereafter than those who did not have SPS within 2 years of surgery. Overall, those who had their anterior temporal lobes removed were more likely to be seizure-free than those who had other brain regions removed. The longer the duration of seizure-free time, the lower the risk of recurrence. Conversely, the longer the duration of seizures, the lower the odds of remission. Of 93 patients, 18 (19%) achieved late remission after application of a previously unused antiepileptic drug. At the final follow-up, 104 of 365 (28%) seizure-free patients discontinued their antiepileptic drugs. Limitations of the study include: I small sample size; II no randomized design; and III a higher proportion of patients with generalized epilepsy and lesions adjacent to the hippocampus underwent anterior temporal lobectomy than other patients. The investigators recommended that clinicians should refer appropriate patients for surgery as soon as possible, although they also said that patient selection procedures and surgical approaches could be improved. In an accompanying journal review, Dr Ahmed-Ramadan Sadek of University Hospital Southampton NHS Trust, UK, and Professor William Peter Gray of the University of Southampton noted that the study, with 19 years of postoperative follow-up on surgical prognosis, is the largest and longest-running prospective study of prognosis for epilepsy surgery to date. SPS occurring within 2 years of surgery is a significant risk factor for distant seizure recurrence, a finding that may influence the decision to discontinue antiepileptic drugs in those who present with SPS only. This study confirms the long-term effectiveness of epilepsy surgery, but raises important questions, such as whether the risk of being seizure-free is similarly low in patients who achieve sustained remission or late remission? Would improved patient selection and reselection strategies help to optimize control of the risk of distant seizures?