Technical Neurosurgical Aspects of Pediatric Epilepsy Surgery Including Resections and Disconnections

Background: Epilepsy remains one of the most common neurological disorders in children, with approximately one-third of patients developing drug-resistant epilepsy (DRE) that may require surgical intervention. This review outlines the technical neurosurgical aspects of pediatric epilepsy surgery, focusing on resective and disconnection procedures. Summary: Successful epilepsy surgery relies on accurate identification of the hypothesized epileptogenic zone through comprehensive presurgical evaluation including clinical assessment, seizure semiology analysis, magnetic resonance imaging, electroencephalography (EEG), and neuropsychological testing. In complex cases, additional imaging modalities such as FDG-PET, SPECT, and MEG help establish the anatomo-electric-clinical network. Invasive monitoring using subdural grids or stereotactic EEG provides critical data for surgical planning in cases with discordant findings, potential involvement of eloquent tissue, or non-lesional epilepsy. Resective surgery is the primary intervention for focal, lesional epilepsy, with seizure freedom rates varying by location and etiology (70-80% for temporal lobe and tumor-associated epilepsy; 60% for extra-temporal lobe; 51% for non-lesional cases). Anterior temporal lobectomy, a cornerstone procedure, involves careful consideration of hemisphere dominance and selective approaches to mesial structures. Extent of resection is a critical determinant of outcome, with incomplete removal of epileptogenic tissue consistently identified as the leading cause of surgical failure. Disconnection procedures include anterior and posterior quadrant disconnections, hemispherectomy, and corpus callosotomy. Anterior quadrant disconnection isolates seizure foci within the frontal lobe, whereas posterior quadrant disconnection targets the temporal, parietal, and occipital lobes. Functional hemispherotomy has largely replaced anatomic hemispherectomy because it has a lower complication profile but maintains equivalent seizure freedom rates. Corpus callosotomy primarily targets generalized seizures, especially atonic seizures leading to drop attacks. Key Messages: Recent advances include minimally invasive techniques (such as laser ablation) and neuromodulation approaches (such as responsive neurostimulation and deep brain stimulation). Future directions will likely incorporate higher resolution imaging technologies and artificial intelligence driven signal processing to optimize outcomes and offer personalized treatment strategies that improve seizure control and quality of life for children with DRE.