Multiple Subpial Transection

This operation is also referred to as the Morrell procedure. Parallel rows of 4-5 mm deep cortical incisions are ploughed perpendicular to the cortical surface. This is done on the theoretical basis that the transections sever horizontal cortical connections and thus disrupt the lateral recruitment of neurones, which is essential for the production of synchronized epileptic discharges (Figure 5.23). At the same time normal function is preserved, as this is supported largely by vertically oriented afferent and efferent connections. There are many critics of this theory, and it is not clear whether or not this is a valid explanation of the postoperative consequences. The procedure has, theoretically, one major advantage—it can be used when the epileptogenic zone involves eloquent brain cortex, in which resection would result in significant neurological deficit. It has thus been principally applied to patients with epileptic foci in language, or primary sensory or motor cortex. In many cases it has been combined with a lesion resection in or adjacent to the eloquent cortex.

The procedure has been the subject of only a rather limited evaluation, and its true role is yet to be defined. A meta-analysis of data in 211 patients from six centres has been published. Fifty-three underwent the procedure without resection. In those in whom it was combined with resection, a short-term excellent result (> 95% reduction in seizures) was observed in 87% of those with generalized seizures and 68% of those with simple and complex partial seizures; in those who underwent the procedure without resection the figures were 71%, 62% and 63%, respectively. Neurological deficits occurred post-operatively in 23% of those operated with resection and 19% of those who had multiple subpial transection alone. These results are certainly encouraging, but only limited information regarding long-term seizure

Multiple Subpial Transection

Figure 5.22 MRI showing sagittal cuts through the corpus callosum in a 9-year-old patient. (a) Pre-operative, (b) after anterior two-thirds corpus callosotomy and (c) after callosotomy completion.

Figure 5.22 MRI showing sagittal cuts through the corpus callosum in a 9-year-old patient. (a) Pre-operative, (b) after anterior two-thirds corpus callosotomy and (c) after callosotomy completion.

control is available, and at present the procedure should be reserved for patients with severe frequent seizures arising from the eloquent cortex in whom all alternative strategies have been exhausted. The operation, however, has a particular role in EPC and in the Landau-Kleffner syndrome.

Multiple subpial transection has been successfully carried out in Broca's area, the pre-central and post-central gyrus, and in Wernicke's area without noticeable loss of function. There is also a risk of haemorrhage, and a proportion of patients will experience severe motor, sensory, and language deficits. The overall morbidity of this opera tion in routine surgical practice has not been clearly established, and its use seems to be declining.

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