SEEG-guided therapeutic decision-making in drug-resistant epilepsy: retrospective analysis and clinical framework

BACKGROUND: Stereoelectroencephalography (SEEG) plays a central role in the presurgical evaluation of patients with drug-resistant epilepsy, particularly when noninvasive investigations are inconclusive. Beyond localization of the epileptogenic zone (EZ), its role in guiding therapeutic decision-making remains incompletely defined. OBJECTIVE: To evaluate the safety, clinical outcomes, and therapeutic impact of SEEG, including SEEG-guided radiofrequency thermocoagulation (RF-TC), and to develop a structured clinical decision-making framework based on SEEG findings. METHODS: We performed a retrospective analysis of 71 consecutive patients with drug-resistant epilepsy who underwent SEEG monitoring between 2016 and 2025. Clinical, neuroimaging, and electrophysiological data were analyzed, along with procedural variables, complications, and outcomes following RF-TC and resective surgery. SEEG findings were used to stratify patients into distinct therapeutic pathways. RESULTS: A total of 958 electrodes were implanted (mean 14 ± 4.5 per patient). SEEG confirmed the preimplantation hypothesis in 85% of cases. Based on SEEG findings, 52% of patients were candidates for resective surgery, while 48% were managed conservatively or with neuromodulation strategies. RF-TC was performed in 37 patients (52%), resulting in seizure improvement in 73% at 12 months, although complete seizure freedom was limi. Response to RF-TC influenced subsequent treatment decisions, favoring conservative management in responders and resective surgery in non-responders. Favorable outcomes (Engel I-II) after resective surgery were achieved in 71% of patients at 12 months. Complications were predominantly minor, with a 1% rate of permanent neurological deficit. CONCLUSIONS: SEEG is a safe and effective tool not only for localizing the EZ but also for structuring therapeutic decision-making in drug-resistant epilepsy. SEEG findings enable patient stratification into individualized treatment pathways and support a dynamic, staged approach in which RF-TC may serve as both a therapeutic and decision-modulating tool. This framework highlights the evolving role of SEEG as a central platform in modern epilepsy surgery.