What factors would prompt you to refer a patient for a surgical epilepsy evaluation who has not yet failed two anti-seizure medications?

This is a good question, and of course, the discussion with the patient regarding their diagnosis and treatment plan is important. There are also expert consensus guidelines that help to clarify this (Jehi et al., PMID 35842919) and that most of us would ascribe to in these cases. Specifically, when there is a brain lesion associated with their epilepsy (that would not otherwise require removal due to its malignant or life-threatening nature), that is resectable/surgically accessible, and not in the eloquent cortex, then referral for a surgical epilepsy evaluation is appropriate.

I agree with @Dr. First Last and would add that this may be especially true in cases where the epilepsy is due to a cavernous malformation. There is some evidence that longer duration of epilepsy or higher baseline seizure frequency prior to surgical resection is associated with worse outcomes, but this has not been shown consistently (at least not epilepsy duration).

Shoubash et al., PMID 36693619