Central neocortical epilepsy: Hypothesis and surgical approach

Abstract

From a large series of epilepsy surgeries, we identified a spectrum of epileptogenic infarctions involving central neocortex. The severest end of this spectrum includes patients with the well-known syndrome of infantile hemiplegia. On magnetic resonance imaging (MRI), they show major hemispheric damage in the middle cerebral arterial distribution with or without involvement of other vessels. They usually have widespread EEG abnormalities and are best treated with hemispherectomy. The middle of this spectrum includes patients with infarction involving one or two branches of the middle cerebral artery (MCA) with varying degrees of hemiplegia. They can be treated with focal resection of only the infarcted tissue. The mildest form of this spectrum is represented by patients showing minimal to no MRI evidence of cerebral infarction and minimal to no neurologic deficit, but with histopathologic cortical abnormalities consistent with mild infarction. Such patients are candidates for multiple subpial transections (MST) when the epileptogenic focus involves indispensable cortex.