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

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>TSIPH appears to be a conservative alternative to classic hemispherotomy, leading to favorable outcome in this series.</jats:p></jats:sec>

Optimization of surgical intervention outside the epileptogenic zone in the Virtual Epileptic Patient (VEP)

“…However, given that our current work addresses network modulation outside of the EZ, it has challenges linked to clinical validation, because it is by definition outside the clinical routine. Extensive clinical data sets that have undergone surgery for areas other than EZ, in particular disconnection surgeries such as partial hemispherotomy [69], can be used to validate the proposed method. Individualized modeling for each data set and simulation results reflecting the actual surgical site can be directly compared with post-operative clinical outcomes (empirical data).…”

Epileptogenicity and surgical outcome in post stroke drug resistant epilepsy in children and adults

“…In cases where partial disconnection has been performed, it has always disconnected the motor cortex because there was a clear hemiplegia before the surgery. The disconnection procedure is detailed in a previous report (Scavarda et al, 2018). Mean follow up was 3.7 years (range 2 -7 y, SD±1.4 y).…”

“…In 6 of our patients, excellent outcome was observed after tailored suprainsular disconnection. This new technique has been recently reported (Scavarda et al, 2018) and is an efficient technique avoiding language, memory and visual consequences of classical hemispherotomy. A majority of patients who underwent TSIPH showed an improvement on their social behavior and no one presented a functional (motor or cognitive) degradation.…”

“…This information, along with other clinical and imaging data, allowed disconnection of the EZ to be performed according to the specific pattern in each case. This innovative approach tailors disconnections based on SEEG data in this way allows a truly functional surgical approach, targeting the epileptogenic zone and avoiding resection/disconnection of nonepileptogenic and functional areas (Scavarda et al, 2018).…”

“…These procedures have proved to induce seizure control, but not improve functional outcome (Scavarda et al, 2009). More recently, more selective deconnexion has been proposed to replace the classical hemispherotomy (Scavarda et al, 2018).…”