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Hemispherical Procedures: Hemispherectomy/Hemispherotomy

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Surgical Treatment of Epilepsies

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Abstract

Hemispherectomy was primarily introduced for the treatment of malignant gliomas. Early experience with this procedure showed beneficial effects on seizures. Thus, already from the 1950s on, hemispherectomy has been recognized as a valuable tool for the surgical treatment of a subgroup of epileptic patients who show a diffuse pathology affecting one hemisphere which coincides with infantile hemiplegia. Hemispherical procedures have been improved over decades, all aiming at the best seizure control with the lowest morbidity. All techniques available follow common principles: disruption of the descending and ascending fibers through the corona radiata and internal capsule, removal of the mesial temporal structures, and callosotomy. Resective procedures include anatomical hemispherectomy and hemidecortication/hemicorticectomy. Disconnective strategies comprise transsylvian and vertical hemispherotomy. Combined resective/disconnective approaches include Rasmussen’s functional hemispherectomy and its modifications. Today, anatomical hemispherectomy and hemidecortication/hemicorticectomy have been largely abandoned. The transsylvian-transventricular key-hole approach is ideal for atrophic hemispheres and enlarged ventricles. Modified Rasmussen’s techniques are suitable for patients with atrophic, normal, and enlarged hemispheres. Vertical hemispherotomy constitutes a good alternative to combined resective and disconnective strategies that works well in almost all conditions. The value of resection of the insula is still unproven. It should be emphasized that the choice of the surgical approach within the limits given by different techniques and the patient’s situation depends to major parts on the individual training and experience of the surgeon. Systematic reviews and meta-analyses consistently demonstrate seizure-free (Engel I) outcome in around 70% of patients with best results achieved with acquired pathologies and Sturge–Weber syndrome mainly causing hemiatrophy, while seizure outcome with developmental pathologies, in particular hemimegalencephaly, is less favorable.

Do the difficult things while they are easy and do the great things while they are small. A journey of a thousand miles must begin with a single step.

Lao Tse

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    Josef Zentner

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Zentner, J. (2020). Hemispherical Procedures: Hemispherectomy/Hemispherotomy. In: Surgical Treatment of Epilepsies. Springer, Cham. https://doi.org/10.1007/978-3-030-48748-5_8

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