This study investigated long-term neuropsychological trajectories in children with epilepsy who underwent surgery. A retrospective cohort of 882 children who had epilepsy surgery at Great Ormond Street Hospital between 1990 and 2018 was analyzed. Neuropsychological functioning, including IQ and academic attainment, was assessed pre- and post-surgery. The results showed that children experienced declines in all neuropsychological domains before surgery, with some losing up to 4 points per year. At presurgical evaluation, most children scored below average on neuropsychological domains, with 37% meeting the threshold for intellectual disability. However, children who became seizure-free after surgery showed improved neuropsychological performance, with continued improvements over time. Children who discontinued antiseizure medication at 1 year post-surgery showed greater improvements in working memory, processing speed, and numeracy compared to those still on medication. The study suggests that epilepsy surgery may not only halt but reverse the downward trajectory in neuropsychological functioning in children with drug-resistant epilepsy. Early referral for surgery could help prevent or minimize this decline. The findings highlight the importance of considering epilepsy surgery for children with focal epilepsy as early as possible after diagnosis.This study investigated long-term neuropsychological trajectories in children with epilepsy who underwent surgery. A retrospective cohort of 882 children who had epilepsy surgery at Great Ormond Street Hospital between 1990 and 2018 was analyzed. Neuropsychological functioning, including IQ and academic attainment, was assessed pre- and post-surgery. The results showed that children experienced declines in all neuropsychological domains before surgery, with some losing up to 4 points per year. At presurgical evaluation, most children scored below average on neuropsychological domains, with 37% meeting the threshold for intellectual disability. However, children who became seizure-free after surgery showed improved neuropsychological performance, with continued improvements over time. Children who discontinued antiseizure medication at 1 year post-surgery showed greater improvements in working memory, processing speed, and numeracy compared to those still on medication. The study suggests that epilepsy surgery may not only halt but reverse the downward trajectory in neuropsychological functioning in children with drug-resistant epilepsy. Early referral for surgery could help prevent or minimize this decline. The findings highlight the importance of considering epilepsy surgery for children with focal epilepsy as early as possible after diagnosis.