Abstracts

Rationale: Paediatric epilepsy possess a different challenges to epilepsy surgeons, as the pathology or the epileptic zones are widespread sometime involving hemisphere requiring a hemispheric operations for children, but with consequent neurological deficits. We describe our experience of a case of modified functional subtotal hemispherectomy with preservation of central core of motor sensory area with functional disconnection, avoiding the complications of anatomical resection and weakness.Methods: Case descrption and illustration of new surgical technique ""Modified functional subtotal hemispherectomy ""Results: Six year old left handed child presented with right focal seizure from the age of 18 months evolving to drug resistant epilepsy, with current frequency of at least 4 seizure per day in spite of 3 AEDs. Episodes were characterized by chewing, right arm and face tonic-clonic episodes, rightward fencing posture with frequent clusters, usually with preserves consciousness and post-ictal weakness/Todd’s paralysis lasting hours. Neurological examination was non-focal. Electrophysiology, including LTE monitoring revealed continuous delta slowing over left hemisphere with abundant spikes recorded from left hemisphere (most notably in posterior quadrant), often continuous from posterior quadrant, left temporal intermittent rhythmic delta activity and symptomatic frontal lobe discharges. MRI brain revealed left hemispheric diffuse polymicrogyria and significant hemispheric heterotopia. Nuclear scan were suggestive of diffuse widespread abnormality in left hemisphere with discrete focal activity in frontal lobe. Epilepsy case conference favoured hemispheric operation, however, patients were not willing for neurological deficits associated with traditional hemispheric surgery. After detailed discussion with family and the team, we postulated and performed a modified functional subtotal hemispherectomy, consisting of posterior quadrant disconnection and frontal lobectomy guided with ECOG and DTI navigation of motor pathway. Post-operatively he is seizure free with no motor-sensory deficits at 3 months of follow up.Conclusions: Modified functional subtotal hemispherectomy is an addition to available surgical options available for hemispheric pathology, avoiding anatomical resection of temporal, parietal and occipital lobe of “subtotal hemispherectomy” and also avoiding dissection through white matter of traditional hemispherctomy and thus the neurological weakness. Proper case selection and appropriate use of adjunct technological tool can refine and minimize the anatomical resection with good seizure control and functional outcome. Our case highlights this new operative technique with good outcome, however, needs more cases to validate the technique and results.