Hemispherotomy and Other Disconnective Techniques

Sandrine de Ribaupierre, M.D.; Olivier Delalande, M.D.

Disclosures

Neurosurg Focus. 2008;25(3):E14 

In This Article

Abstract and Introduction

Abstract

The surgical treatment of intractable epilepsy has evolved as new technical innovations have been made. Hemispherotomy techniques have been developed to replace hemispherectomy in order to reduce the complication rates while maintaining good seizure control.

Disconnective procedures are based on the interruption of the epileptic network rather than the removal of the epileptogenic zone. They can be applied to hemispheric pathologies, leading to hemispherotomy, but they can also be applied to posterior quadrant epilepsies, or hypothalamic hamartomas.

In this paper, the authors review the literature, present an overview of the historical background, and discuss the different techniques along with their outcomes and complications.

Introduction

Horror vacui ("nature abhors a vacuum") wrote Aristotle in 350 BC. Complications from a dead space will arise after epilepsy surgery when a large part of the brain is removed. Since the first hemispherectomy for epilepsy was done in 1938, surgical techniques have evolved to try to minimize the extent of resection while maintaining the same seizure outcome. In the past, patients died of hydrocephalus and hemosiderosis following anatomical hemispherectomies. Those late complications discouraged surgeons from performing this surgery in patients with refractory epilepsy. New surgical techniques, as well as a better understanding of the complications leading to appropriate treatment, have brought hemispheric epilepsy back to surgeons' hands.

Disconnective procedures are based on the concept that interrupting the epileptic discharge-spreading pathway, by isolating the primary epileptogenic zone, would have the same effect as removing the focus. This is true for hemispherotomy as well as for multilobar disconnection, hypothalamic hamartoma disconnection, or corpus callosotomy.

A continual evolution of the disconnective techniques has helped improve outcome in epileptic lesions that are not well delimited from the surrounding structures, such as hypothalamic hamartomas or multiple unilateral foci that are responsible for intractable epilepsies. We will describe here some of the disconnective techniques, focusing on their different surgical techniques, with their outcomes and complications. Hemispherotomy, posterior disconnection, and hypothalamic hamartoma disconnection will be reviewed. Corpus callosotomy is described in another article in this issue.

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