To characterize intraoperative neurophysiological monitoring in pediatric epilepsy surgery in a single tertiary center.

We reviewed intraoperative neurophysiological monitoring procedures during pediatric epilepsy surgeries at Meyer Children’s Hospital, Florence, Italy, from 2018 to 2025.

We analyzed 39 procedures in 37 children with lesional epilepsy. Mean age at surgery was 9.4 years. All patients underwent a comprehensive presurgical workup. Frontal lobe resection was the most frequent surgery, and focal cortical dysplasia was the most common histopathology. Total intravenous anesthesia and neuronavigation were used routinely. Brain activity was monitored using intraoperative electroencephalography; motor function was assessed using motor evoked potentials, direct cortical and subcortical stimulation, and continuous electromyography; somatosensory and visual function were evaluated using somatosensory and visual evoked potentials, respectively. All responses remained stable throughout all procedures. We reached high mean transcranial (164.4 mA) and cortical (21.7 mA) stimulation thresholds, however, we observed only one intraoperative seizure (2.6%) following intraoperative bleeding. Mean follow-up after surgery was 30.9 months. Expected postoperative deficits occurred in 38.5% procedures (permanent in three patients). At last visit 66.7% of patients were seizure-free.

In pediatric epilepsy surgery, intraoperative neurophysiological monitoring is safe even at high stimulation thresholds. Combining presurgical planning and intraoperative neurophysiological monitoring optimizes pediatric epilepsy seizure and functional outcomes.