Learning From Our Failures: When Anterior Temporal Lobectomies Fail

Anterior temporal lobectomy (ATL) remains the standard surgical treatment for drug-resistant temporal lobe epilepsy, yet 20% to 30% of patients experience persistent seizures and/or unfavorable neuropsychological outcomes. These results highlight that postoperative success is influenced not only by the technical execution of surgery but also by the accuracy with which epileptogenic networks are characterized. As such, we consider ATL failure through 2 broad mechanisms: incomplete treatment of the presumed epileptogenic network and limitations in the initial diagnostic understanding of the epileptogenic network. It is also becoming more evident that seizure outcomes alone do not fully capture surgical success, as cognitive, psychiatric, and functional consequences play a critical role in long-term quality of life. Drawing on contemporary evidence and discussions from the Temporal Lobe Club Special Interest Group at the 2025 American Epilepsy Society Annual Meeting, we present a framework for conceptualizing, reevaluating, and managing patients following ATL failure.