Cossu Giulia, Lebon Sebastien, Seeck Margitta, Pralong Etienne, Messerer Mahmoud, Roulet-Perez Eliane, Daniel Roy Thomas
1Department of Neurosurgery and.
2Unit of Pediatric Neurology and Neurorehabilitation, Department of Pediatrics, University Hospital of Lausanne; and.
J Neurosurg Pediatr. 2018 Feb;21(2):124-132. doi: 10.3171/2017.8.PEDS17339. Epub 2017 Dec 8.
Refractory frontal lobe epilepsy has been traditionally treated through a frontal lobectomy. A disconnective technique may allow similar seizure outcomes while avoiding the complications associated with large brain resections. The aim of this study was to describe a new technique of selective disconnection of the frontal lobe that can be performed in cases of refractory epilepsy due to epileptogenic foci involving 1 frontal lobe (anterior to the motor cortex), with preservation of motor function. In addition to the description of the technique, an illustrative case is also presented. This disconnective procedure is divided into 4 steps: the suprainsular window, the anterior callosotomy, the intrafrontal disconnection, and the frontobasal disconnection. The functional neuroanatomy is analyzed in detail for each step of the surgery. It is important to perform cortical and subcortical electrophysiological mapping to guide this disconnective procedure and identify eloquent cortices and intact neural pathways. The authors describe the case of a 9-year-old boy who presented with refractory epilepsy due to epileptogenic foci localized to the right frontal lobe. MRI confirmed the presence of a focal cortical dysplasia of the right frontal lobe. A periinsular anterior quadrant disconnection (quadrantotomy) was performed. The postoperative period was uneventful, and the patient was in Engel seizure outcome Class I at the 3-year follow-up. A significant cognitive gain was observed during follow-up. Periinsular anterior quadrantotomy may thus represent a safe technique to efficiently treat refractory epilepsy when epileptogenic foci are localized to 1 frontal lobe while preserving residual motor functions.
难治性额叶癫痫传统上通过额叶切除术进行治疗。一种离断技术可能会带来相似的癫痫发作控制效果，同时避免与大脑大面积切除相关的并发症。本研究的目的是描述一种新的额叶选择性离断技术，该技术可用于因致痫灶累及一个额叶（运动皮层前方）而导致的难治性癫痫病例，同时保留运动功能。除了对该技术进行描述外，还展示了一个说明性病例。这种离断手术分为4个步骤：岛叶上窗、胼胝体前部切开、额叶内离断和额叶底部离断。对手术的每个步骤都详细分析了功能神经解剖结构。进行皮质和皮质下电生理图谱检查以指导这种离断手术并识别明确的皮层和完整的神经通路非常重要。作者描述了一名9岁男孩的病例，该男孩因致痫灶位于右侧额叶而患有难治性癫痫。MRI证实右侧额叶存在局灶性皮质发育异常。进行了岛周前象限离断术（象限切开术）。术后过程顺利，在3年随访时患者的癫痫发作结果为恩格尔I级。随访期间观察到显著的认知改善。因此，当致痫灶局限于一个额叶时，岛周前象限切开术可能是一种安全有效的治疗难治性癫痫的技术，同时保留残余运动功能。
