A multidisciplinary approach to posterior quadrant disconnective epilepsy surgery in pediatric patients

•TPO disconnection is a safe and effective, motor-sparing epilepsy surgery procedure.•TPO disconnection was selected for children with refractory focal or generalized seizures located in the posterior quadrant.•Stabilization of the cognitive profile and adaptive behavior are observed after disconnections.•No clinical differences were observed between T1 and T2 approaches. Extensive lesions of the posterior quadrant are a relevant cause of pediatric drug-resistant epilepsy. Early surgery is the best treatment in these cases, but conventional multilobar resections carry a significant risk in pediatric patients. Despite temporo-parieto-occipital (TPO) disconnection being the preferable technique due to the preservation of motor function, studies reporting long-term longitudinal outcomes are still limited. This study aims to analyze seizures and developmental outcomes after TPO disconnection. A prospective analysis was carried out on 12 children who underwent TPO disconnection. TPO disconnection was performed in 12 pediatric patients aged between 14 months and 18 years (median 6.29 years). The average age of seizure onset was 0.97 ± 1.22 years. Causes of TPO included perinatal ischemia in 4 patients and malformation of cortical development (MCD) in 8 patients. The presenting seizure types were focal motor impaired awareness seizures in 7 children and generalized in 5. The affected hemisphere was the right in 9 patients and the left in 3. In half of the patients, the temporal approach was performed through T1, and in the other 50%, it was performed through T2. After neuropsychological examination, 2 children improved, 7 remained stable, 2 patients presented stagnation and 1 declined. Regarding postoperative complications, nonresorptive hydrocephalus and an asymptomatic caudate nucleus infarct were observed. After a median follow-up of 2 years, 9 patients were in Engel’s Class I seizure outcome. TPO disconnection is a safe and effective motor-sparing epilepsy surgery for children with refractory seizures located in the posterior quadrant that prevents further cognitive deterioration.