Operculoinsular cortectomy for refractory epilepsy. Part 2: Is it safe?

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OBJECTIVE

Operculoinsular cortectomy (also termed operculoinsulectomy) is increasingly recognized as a therapeutic option for perisylvian refractory epilepsy. However, most neurosurgeons are reluctant to perform the technique because of previously experienced or feared neurological complications. The goal of this study was to quantify the incidence of basic neurological complications (loss of primary nonneuropsychological functions) associated with operculoinsular cortectomies for refractory epilepsy, and to identify factors predicting these complications.

METHODS

Clinical, imaging, and surgical data of all patients investigated and surgically treated by our team for refractory epilepsy requiring an operculoinsular cortectomy were retrospectively reviewed. Patients with tumors and encephalitis were excluded. Logistic regression analysis was used for uni- and multivariate statistical analyses.

RESULTS

Forty-four operculoinsular cortectomies were performed in 43 patients. Although postoperative neurological deficits were frequent (54.5% of procedures), only 3 procedures were associated with a permanent significant neurological deficit. Out of the 3 permanent deficits, only 1 (2.3%; a sensorimotor hemisyndrome) was related to the technique of operculoinsular cortectomy (injury to a middle cerebral artery branch), while the other 2 (arm hypoesthesia and hemianopia) were attributed to cortical resection beyond the operculoinsular area. With multivariate analysis, a postoperative neurological deficit was associated with preoperative insular hypometabolism on PET scan. Postoperative motor deficit (29.6% of procedures) was correlated with fewer years of neurosurgical experience and frontal operculectomies, but not with corona radiata ischemic lesions. Ischemic lesions in the posterior two-thirds of the corona radiata (40.9% of procedures) were associated with parietal operculectomies, but not with posterior insulectomies.

CONCLUSIONS

Operculoinsular cortectomy for refractory epilepsy is a relatively safe therapeutic option but temporary neurological deficits after surgery are frequent. This study highlights the role of frontal/parietal opercula resections in postoperative complications. Corona radiata ischemic lesions are not clearly related to motor deficits. There were no obvious permanent neurological consequences of losing a part of an epileptic insula, including on the dominant side for language. A low complication rate can be achieved if the following conditions are met: 1) microsurgical technique is applied to spare cortical branches of the middle cerebral artery; 2) the resection of an opercula is done only if the opercula is part of the epileptic focus; and 3) the neurosurgeon involved has proper training and experience.

ABBREVIATIONS fMRI = functional MRI; IL = ischemic lesion; MCA = middle cerebral artery; MEG = magnetoencephalography.

Article Information

Correspondence Alain Bouthillier: University of Montreal Hospital Center, Montreal, QC, Canada. alain.bouthillier@umontreal.ca.

INCLUDE WHEN CITING Published online September 20, 2019; DOI: 10.3171/2019.6.JNS191126.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Artistic representation of the 5 types of operculoinsular cortectomies (also termed operculoinsulectomies) (blue), based on the location of the periinsular resection. Image by Marc Briffaud. Copyright Alain Bouthillier, used with permission.

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    Artistic representation of regions resected with operculoinsular cortectomies. The insular cortex (purple) is divided into 4 quadrants: supero-anterior (SA), supero-posterior (SP), infero-anterior (IA), and infero-posterior (IP). As shown in the figure, 2 insular lines define these 4 quadrants. The vertical insular line descends from the superior periinsular sulcus midpoint, and the horizontal insular line is at the level of the posterior insular point. The frontal opercula (blue), parietal opercula (green), temporal opercula (yellow), and orbitofrontal cortex (gray) are shown. The limit of the opercular area is defined as a line 2 cm away and around the sylvian fissure. Image by Marc Briffaud. Copyright Alain Bouthillier, used with permission.

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    Segmentation of the corona radiata into anterior, middle, and posterior thirds. The reference is the superior periinsular sulcus segmented into 3 equal thirds.

  • View in gallery

    Typical examples of different types of ischemic lesions seen on MRI after operculoinsular cortectomies and temporal lobectomies (arrows).

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