Frontal Lobe Decortication (Frontal Lobectomy with Ventricular Preservation) in Epilepsy-Part 1: Anatomic Landmarks and Surgical Technique

BackgroundAn extensive frontal resection is a frequently performed neurosurgical procedure, especially for treating brain tumor and refractory epilepsy. However, there is a paucity of reports available regarding its surgical anatomy and technique.ObjectivesWe sought to present the anatomic landmarks and surgical technique of the frontal lobe decortication (FLD) in epilepsy. The goals were to maximize the gray matter removal, spare primary and supplementary motor areas, and preserve the frontal horn.Material and MethodsThe anatomic study was based on dissections performed in 15 formalin-fixed adult cadaveric heads. The clinical experience with 15 patients is summarized.ResultFLD consists of 5 steps: 1) coagulation and section of arterial branches of lateral surface; 2) paramedian subpial resection 3 cm ahead of the precentral sulcus to reach the genu of corpus callosum; 3) resection of gray matter of lateral surface, preserving the frontal horn; 4) removal of gray matter of basal surface preserving olfactory tract; 5) removal of gray matter of the medial surface under the rostrum of corpus callosum.The frontal horn was preserved in all 15 patients; 12 patients (80%) had no complications; 2 patients presented temporary hemiparesis; and 1 Rasmussen syndrome patient developed postoperative fever. The best seizure control was in cases with focal magnetic resonance imaging abnormalities limited to the frontal lobe.ConclusionFLD is an anatomy-based surgical technique for extensive frontal lobe resection. It presents reliable anatomic landmarks, selective gray matter removal, preservation of frontal horn, and low complication rate in our series. It can be an alternative option to the classical frontal lobectomy.