Tailored multilobar disconnective epilepsy surgery in the posterior quadrant

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  • 1 “C. Munari” Center for Epilepsy Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan;
  • 2 Institute of Neuroscience, CNR, Parma;
  • 3 Section of Neurosurgery, Department of Neurosciences and of Sense Organs, University of Milan;
  • 4 Cognitive Neuropsychology Centre, Department of Neuroscience, ASST Grande Ospedale Metropolitano Niguarda, Milan;
  • 5 Clinic of Neurosurgery, Polytechnic University of Marche, Ancona; and
  • 6 Neurological Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

OBJECTIVE

Surgical treatment of drug-resistant epilepsy originating from the posterior quadrant (PQ) of the brain often requires large multilobar resections, and disconnective techniques have been advocated to limit the risks associated with extensive tissue removal. Few previous studies have described a tailored temporoparietooccipital (TPO) disconnective approach; only small series with short postoperative follow-ups have been reported. The aim of the present study was to present a tailored approach to multilobar PQ disconnections (MPQDs) for epilepsy and to provide details about selection of patients, presurgical investigations, surgical technique, treatment safety profile, and seizure and cognitive outcome in a large, single-center series of patients with a long-term follow-up.

METHODS

In this retrospective longitudinal study, the authors searched their prospectively collected database for patients who underwent MPQD for drug-resistant epilepsy in the period of 2005–2017. Tailored MPQDs were a posteriori grouped as follows: type I (classic full TPO disconnection), type II (partial TPO disconnection), type III (full temporooccipital [TO] disconnection), and type IV (partial TO disconnection), according to the disconnection plane in the occipitoparietal area. A bivariate statistical analysis was carried out to identify possible predictors of seizure outcome (Engel class I vs classes II–IV) among several presurgical, surgical, and postsurgical variables. Preoperative and postoperative cognitive profiles were also collected and evaluated.

RESULTS

Forty-two consecutive patients (29 males, 24 children) met the inclusion criteria. According to the presurgical evaluation (including stereo-electroencephalography in 13 cases), 12 (28.6%), 24 (57.1%), 2 (4.8%), and 4 (9.5%) patients received a type I, II, III, or IV MPQD, respectively. After a mean follow-up of 80.6 months, 76.2% patients were in Engel class I at last contact; at 6 months and 2 and 5 years postoperatively, Engel class I was recorded in 80.9%, 74.5%, and 73.5% of cases, respectively. Factors significantly associated with seizure freedom were the occipital pattern of seizure semiology and the absence of bilateral interictal epileptiform abnormalities at the EEG (p = 0.02). Severe complications occurred in 4.8% of the patients. The available neuropsychological data revealed postsurgical improvement in verbal domains, whereas nonunivocal outcomes were recorded in the other functions.

CONCLUSIONS

The presented data indicate that the use of careful anatomo-electro-clinical criteria in the presurgical evaluation allows for customizing the extent of surgical disconnections in PQ epilepsies, with excellent results on seizures and an acceptable safety profile.

ABBREVIATIONS AED = antiepileptic drug; DRE = drug-resistant epilepsy; EA = epileptiform abnormality; EEG = electroencephalography; EZ = epileptogenic zone; FCD = focal cortical dysplasia; MPQD = multilobar PQ disconnection; PQ = posterior quadrant; SEEG = stereo-EEG; TO = temporooccipital; TPO = temporoparietooccipital; VEEG = video-EEG.

Supplementary Materials

    • Supplementary Figure and Tables (PDF 757 KB)

Contributor Notes

Correspondence Michele Rizzi: “C. Munari” Center for Epilepsy Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy. michele.rizzi@ospedaleniguarda.it.

INCLUDE WHEN CITING Published online April 26, 2019; DOI: 10.3171/2019.1.JNS183103.

Disclosures Dr. Cardinale was a consultant (paid expert testimony) to Renishaw Mayfield, the manufacturer of Neuromate robotic system, until February 2019. Dr. Rizzi is a consultant to WISE Srl, a start-up manufacturing implantable leads for neuromodulation and neuromonitoring.

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