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Posterior quadrant disconnection for refractory epilepsy: how I do it

  • How I Do it - Functional Neurosurgery - Epilepsy
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Abstract

Background

Posterior quadrant disconnection (PQD) is intended to interrupt the propagation of intractable unilateral temporo-parieto-occipital epilepsy.

Method

An enhanced operative video presents the illustrative case of a total PQD indicated for a 15-year-old boy with Sturge-Weber syndrome suffering from seizure recurrence after a partial PQD. We describe the surgical procedure with emphasis on relevant anatomy and multimodal intraoperative guidance in three steps: (i) parieto-occipital disconnection, (ii) posterior callosotomy, and (iii) temporal disconnection/resection. Pearls and pitfalls of surgical management are discussed.

Conclusion

PQD is a less invasive surgical option to typical hemispherotomy and hemispherectomy for selected indications of posterior multilobar epilepsy.

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Acknowledgements

To the courtesy of Dr. Drew Bourn, curator of the David L. Bassett collection of human anatomical images from the Stanford Medical History Center.

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Authors and Affiliations

  1. Service de Neurochirurgie, Hôpital Erasme, Université Libre de Bruxelles, Anderlecht, Belgium

    Sami Barrit

  2. Neurodynamics Laboratory, Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA

    Sami Barrit, Eun-Hyoung Park & Joseph R. Madsen

  3. Division of Epilepsy Surgery, Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA

    Eun-Hyoung Park & Joseph R. Madsen

Authors
  1. Sami Barrit
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  2. Eun-Hyoung Park
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  3. Joseph R. Madsen
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Corresponding author

Correspondence to Joseph R. Madsen.

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This article does not contain any studies with human participants or animals performed by any of the authors.

Conflict of interest

The authors declare no competing interests.

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Key points

•Integrate data of interest from the presurgical planning with intraoperative mapping to enhance surgical guidance.

•Proceed to gentle subpial dissection while respecting subarachnoid sheath to protect underlying structures;

•Start the corticectomy at the opercular temporo-parietal junction to reach the atrium. Encounter the falx in the depth. Progress superiorly towards the sagittal sinus, posterior to the postcentral gyrus.

•Transect the posterior third of the corpus callosum comprising its isthmus as tracts from the anterior-most part of the parietal cortex run through it.

•Different temporal disconnection/resection approaches are valuable depending on the surgeon’s experience and preoperative findings.

•The role of partial PQD, staged surgical approaches, and intracranial EEG findings has yet to be determined.

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This article is part of the Topical Collection on Functional Neurosurgery—Epilepsy.

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Barrit, S., Park, EH. & Madsen, J.R. Posterior quadrant disconnection for refractory epilepsy: how I do it. Acta Neurochir 164, 2159–2164 (2022). https://doi.org/10.1007/s00701-022-05221-x

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  • DOI: https://doi.org/10.1007/s00701-022-05221-x

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