Tailored suprainsular partial hemispherotomy: a new functional disconnection technique for stroke-induced refractory epilepsy

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OBJECTIVE

Hemispherotomy is currently the most frequently performed surgical option for refractory epilepsy associated with large perinatal or childhood ischemic events. Such an approach may lead to good seizure control, but it has inherent functional consequences linked to the disconnection of functional cortices. The authors report on 6 consecutive patients who presented with severe epilepsy associated with hemiplegia due to stroke and who benefitted from a new, stereoelectroencephalography-guided partial disconnection technique.

METHODS

The authors developed a new disconnection technique termed “tailored suprainsular partial hemispherotomy” (TSIPH). Disconnection always included premotor and motor cortex with variable anterior and posterior extent.

RESULTS

At a mean follow-up of 28 months, there were no deaths and no patient had hydrocephalus. Motor degradation was observed in all patients in the 2 weeks after surgery, but all patients completely recovered. The 6 patients were seizure free (Engel class IA) at the last follow-up. No neuropsychological aggravation was observed.

CONCLUSIONS

TSIPH appears to be a conservative alternative to classic hemispherotomy, leading to favorable outcome in this series.

ABBREVIATIONS EZ = epileptogenic zone; MCA = middle cerebral artery; mRS = modified Rankin Scale; SEEG = stereoelectroencephalography; TSIPH = tailored suprainsular partial hemispherotomy.

Article Information

Correspondence Didier Scavarda: Hôpital de la Timone, Marseille, France. didier.scavarda@ap-hm.fr.

INCLUDE WHEN CITING Published online August 24, 2018; DOI: 10.3171/2018.5.PEDS17709.

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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    Example of SEEG exploration. A: Axial MR images showing the stroke sequelae in the right MCA territory. B: Sagittal MR image showing SEEG implantation of the electrodes. C: SEEG traces of a typical seizure. The rapid discharge appears distributed over different regions but was prominent on the left side and in the premotor cortex (SMA′ electrode) and the central cortex (Sc′ electrode). D: MRI (sagittal plane) showing the disconnection (arrows). Electrodes implanted in the left side at the following locations: B′ = body of the left hippocampus; GCa′ = left anterior cingulum; GCp′ = left posterior cingulum; I′ = left oblique insular electrode; Lp′ = left paracentralis lobule; Of′ = left frontal operculum; Pa′ = left parietal area; PSMA′ = left premotor area; Sc′ = left central sulcus; SMA′ = left supplementary motor area. Figure is available in color online only.

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    Cortical exposure of the right hemisphere. The black arrows indicate the anterior and posterior disconnection lines. The white arrow indicates the sylvian fissure. The letters indicate the anterior and posterior limits of the disconnection lines.

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    Schematic of the operative procedure. A: First step. Under neuronavigation guidance, disconnection after localization of points A, B, C, and D is planned. The EZ is delineated by SEEG. B: Second step. Inferior disconnection (black arrow), coronal view. The suprainsular window to the lateral ventricle is along the inferior line (between points A and C). The trajectory must be ascending if the ventricle is not enlarged. C: Third step. Anterior and posterior disconnection. Transcortical coronal disconnection until the midline. Black arrows indicate the disconnection lines. D: Fourth step. Tailored callosotomy (black arrow). The inferior margin of the corpus callosum is visualized and disconnected from inside the ventricle between the inferior aspect of the anterior and posterior disconnection lines (white lines). The area of disconnection is drawn in black.

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    Case 1. Coronal, sagittal, and axial brain MR images showing anterior and posterior extension of stroke. Note that the posterior extension exceeds the central sulcus.

  • View in gallery

    Upper and Center: Sagittal MR images showing MCA stroke extension. Lower: Sagittal MR images showing the variability of the anterior and posterior limits of the TSIPH. Note the anterior complete disconnection in case 6.

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