Introduction: Widespread epilepsy involving a large portion of a hemisphere is frequently treated by lobar resection, but this may be associated with a higher rate of postoperative complications such as hemorrhage or hydrocephalus. Based on clinical experience with hemispheric disconnection techniques as an alternative to hemispherectomy, we investigated the use of lobar disconnection to treat epilepsy distributed through the frontal or occipital lobes.
Methods: Patients with epilepsy arising diffusely from one frontal or occipital lobe were treated using lobar disconnection. To perform frontal disconnection, a frontal craniotomy was performed anterior to the precentral sulcus and the frontal horn of the lateral ventricle entered from above, then a cut was made in the white matter to the base of the anterior cranial fossa, following the pericallosal artery medially to end just in front of the hypothalamus, and extending to the surface in all directions. To perform occipital disconnection, a temporoparietal craniotomy was performed and a corticotomy made just posterior to the postcentral sulcus, extending to the temporal floor and deepened to the midline. All arteries and veins were preserved, and fluorescence using indocyanine green was used after disconnection to verify perfusion of the disconnected tissue.
Results: Four patients with medically intractable epilepsy were treated using this technique. Postoperative MRI demonstrated complete disconnection in all cases, and all patients experienced improvement to Engel Class I (3 patients) or Class III (1 patient) at mean 6 months follow-up. There were no complications.
Conclusions: Lobar disconnection surgery represents a minimally invasive alternative to lobar resection for patients with widespread epilepsy localized to one frontal or occipital lobe.
Patient Care: This technique will allow patients with widespread lobar epilepsy to undergo a less invasive disconnection surgery as an alternative to an extensive resection, which may reduce postoperative complications such as hemorrhage or hydrocephalus.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of disconnection techniques as an alternative to hemispherectomy, 2) Discuss, in small groups, the technique of lobar leukotomy, 3) Identify patients for whom lobar leukotomy would be appropriate for surgical planning.