SURGICAL ANATOMY AND TECHNIQUE

Posterior Quadrant Disconnection: A Fiber

Dissection Study
Alexander Verhaeghe, MD∗
Thomas Decramer, MD∗
Wim Naets, MD∗
Wim Van Paesschen, MD,
PhD‡
Johannes van Loon, MD, PhD∗
Tom Theys, MD, PhD∗
∗
Department of Neurosurgery, University
Hospitals Leuven, Leuven, Belgium;
‡
Department of Neurology, University
Hospitals Leuven, Leuven, Belgium
Part of this work was presented in poster
form at the Belgian Neurosurgical Society
Annual Meeting, Brussels, March 23, 2016.
Correspondence:
Tom Theys, MD, PhD,
University Hospitals Leuven,
Department of Neurosurgery,
Herestraat 49,
3000 Leuven, Belgium.
E-mail: tom.theys@med.kuleuven.be
BACKGROUND: Posterior quadrant disconnection can be highly effective in the surgical
treatment of selected cases of refractory epilepsy. The technique aims to deafferent
extensive areas of epileptogenic posterior cortex from the rest of the brain by isolating
the temporoparietooccipital cortex.
OBJECTIVE: To describe this procedure and relevant white matter tracts with a specific
emphasis on the extent of callosotomy in an anatomic study.
METHODS: Twenty hemispheres were dissected according to Klingler’s fiber dissection
technique illustrating the peri-insular (temporal stem, superior longitudinal fasciculus,
corona radiata) and mesial disconnection (mesiotemporal cortex, cingulum, and corpus
callosum).
RESULTS: Extensive white matter tract disconnection is obtained after posterior quadrant
disconnection. Callosal fibers connecting the anterior most part of the parietal cortex
invariably ran through the isthmus of the corpus callosum and need to be disconnected,
while frontal lobe connections including the corticospinal tract and the anterior two-thirds
of the corpus callosum are spared during the procedure.
CONCLUSION: Our findings suggest the involvement of both the splenium and the
isthmus in interhemispheric propagation in posterior cortex epilepsies. Sectioning the
total extent of the posterior one-third of the corpus callosum might therefore be necessary
to achieve optimal outcomes in posterior quadrant epilepsy surgery.
KEY WORDS: Callosotomy, Disconnective surgery, Epilepsy surgery, Klingler’s fiber dissection, Neuroanatomy,
Posterior quadrant surgery, Posterior cortex epilepsy

Received, June 20, 2016. Operative Neurosurgery 0:1–6, 2017 DOI: 10.1093/ons/opx060
Accepted, March 1, 2017.

Copyright 
C 2017 by the

C
hildren and adults suffering from
Congress of Neurological Surgeons
intractable epilepsy due to widespread
unilateral areas of epileptogenicity can
be excellent candidates for surgical treatment.
Functional hemispherectomy is the treatment of
choice in many of these patients, especially in
catastrophic epilepsy cases in whom the whole
hemisphere is involved. Excellent outcomes have
been reported after hemispherectomy in both
children and adults.1-8
Specific patients however suffer from multi-
lobar posterior epilepsies with potentially
preserved frontal lobe functions. These patients
ABBREVIATIONS: AC, anterior commissure; AF,
arcuate fasciculus; CST, corticospinal tract; IC,
internal capsule; IFOF, inferior frontooccipital
fasciculus; PQD, posterior quadrant disconnection;
SLF, superior longitudinal fasciculus; UF, uncinate
fasciculus
with posterior quadrant lesions (temporal,
parietal, and occipital lobe) and concordant
electroclinical findings can benefit from multi-
lobar surgery instead of hemispherectomy,
thereby sparing frontal connectivity including
residual motor function of the hand. Extensive
posterior cortical resections have been shown to
be associated with good outcomes.9-11
Similar to the evolution from anatomic
hemispherectomy towards functional
hemispherectomy, there has been an evolving
trend from multilobar resections towards discon-
nective procedures for multilobar posterior
epilepsy. Disconnective techniques have been
introduced to reduce complication rates, which
is particularly important in smaller children. On
the other hand, an incomplete disconnection
can be responsible for residual propagation
of epileptic activity through intact white
matter connections and thus lead to surgical
failure.

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VERHAEGHE ET AL

Studies mostly report on posterior quadrant disconnection

(PQD) in children, with cortical dysplasia, porencephalic cysts,
and angiomatosis confined to the posterior quadrant repre-
senting the main indications. Postoperative seizure control
in temporoparietooccipital disconnection is generally good,
resulting in 50% to 90% of patients reaching Engel class I
outcome.12-18
The literature about the relevant anatomy is scarce with no
studies discussing the extent of posterior callosotomy. Most
reports describe a callosotomy at the level of the splenium or
use the general term posterior callosotomy, without defining the
extent of disconnection.12,13 We conducted an anatomic study to
illustrate the procedure, define relevant white matter tracts, as well
as the extent of disconnection at the level of the corpus callosum.

METHODS
Similar to previous studies we used the fiber-dissection technique
as described by Klingler19 in 20 hemispheres obtained from cadaveric
specimens. The specimens were fixed in a 10% formaldehyde solution
for at least 8 wk, followed by freezing at –10◦ C for at least 4 wk. After
thawing overnight and before the dissection was initiated, meticulous
attention was paid to the surface anatomy. Specific anatomic landmarks,
in particular the central and postcentral sulcus, represented essential
guides for dissection and disconnection. The dissection was performed
under magnification with the use of an operating microscope.
We performed the dissection in both a lateral and a medial fashion.
The lateral dissection was necessary to illustrate the long white matter
fibers disconnected by the PQD technique. White matter tracts
including the superior longitudinal fasciculus (SLF), the arcuate fasci-
culus (AF), the inferior frontooccipital fasciculus (IFOF), the internal
capsule (IC), the anterior commissure (AC), and the stratum sagittale can
be optimally visualized through a lateral approach, the medial dissection
was performed to visualize the commissural fibers and their crossing in
the corpus callosum.
The lateral disconnection line followed the inferior circular sulcus of
the insula and the postcentral sulcus (Figure 1). To assess the extent of
disconnection at the level of the corpus callosum, we applied Witelson’s
classification whereby 7 segments can be distinguished at the level of
the midsagittal plane: the rostrum, the genu, the rostral body, the
anterior midbody, the posterior midbody, the isthmus, and the splenium
(Figure 4).20 To determine the extent of callosal sectioning, the crossing
of the commissural fibers from the postcentral sulcus was determined
(Xpcs) and measured in relation to the total length of the corpus callosum
(lengthCC). An index between 0 and 1 was computed (Xpcs/lengthCC),
with an index between 0.67 and 0.80 representing a position in the
isthmus and an index above 0.80 representing a position in the splenium
of the corpus callosum.21
FIGURE 1. Disconnection line: lateral view. The dotted line marks the lateral
disconnection consisting of the peri-insular window (white arrowheads) and
the parietal disconnection (black arrowheads).
bundle comprises the fibers of the IFOF, the posterior limb of the
AC, the inferior longitudinal fasciculus, and the retrolenticular
part of the IC containing the optic radiation. In a next step, the
white matter at the level of the operculum was removed with fine
scissors to expose the insular cortex. The gray matter of the insula,
the capsula extrema, the claustrum, and the capsula externa were
peeled away up to the level of the putamen. At the limen insulae,
the uncinate fasciculus (UF) and the trunk of the IFOF were
exposed. The lateral dissection is illustrated in Figures 2 and 3.
Mesial Dissection
The dissection was started from the medial side in 10
hemispheres, and was executed in a similar fashion as previously
described.21 After blunt removal of the gray matter, the cingulum
and the surrounding U-fibers, the callosal fibers were exposed.
In all specimens, the location of the commissural fibers arising
from the mesial part of the postcentral sulcus was determined
and the total length of the corpus callosum was measured as
the maximal length parallel to the AC-PC (anterior commissure-
posterior commissure) line. These results are summarized in
Table. The average index (Xpcs/lengthCC) was 0.74 with an
index between 0.67 and 0.8 in all cases. Therefore, the commis-
sural fibers connecting the anterior parietal cortices were crossing
in the isthmus of the corpus callosum in all specimens. The mesial
dissection is illustrated in Figure 4.

Posterior Quadrant Disconnection

RESULTS
Lateral Dissection
In 10 brains, dissection was performed in a lateral fashion:
after blunt removal of the cortex and the short association fibers
(U-fibers), the SLF and the AF were exposed. After removal of
the SLF and the AF, the sagittal stratum was visualized. This
The Sylvian fissure was opened and the inferior circular sulcus
was fully exposed. The temporal horn of the lateral ventricle was
reached and the white matter of the temporal stem (including
the UF, IFOF, AC, and optic radiation) was disconnected. The
disconnection was continued in a peri-insular fashion towards
the atrium of the lateral ventricle. The mesial temporal struc-
tures including the amygdala and hippocampus were removed

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 POSTERIOR QUADRANT DISCONNECTION

FIGURE 2. Lateral dissection: progressive steps. A, Arcuate fibers or U-fibers. B, SLF. C, After the gray matter and U-fibers,
the SLF, the arcuate fasciculus, the extreme capsule, the external capsule, and claustrum are removed, the following structures
can be appreciated: CR: corona radiata, IC: internal capsule, SS: stratum sagittale, LN: lentiform nucleus, +++: IFOF, ∗∗ :
UF.

TABLE. Corpus Callosum Measurements

LengthCC (mm) Xpcs (mm) Xpcs/LengthCC

1 56 39 0,70
2 65 49 0,75
3 72 55 0,76
4 66 50 0,76
5 70 54 0,77
6 68 48 0,71
7 68 47 0,69
8 73 57 0,78
9 67 49 0,73
10 68 50 0,74

FIGURE 3. PQD: lateral view after posterior disconnection. CR: corona
radiata, IC: internal capsule, Pu: putamen, IFOF: inferior fronto-occipital
fasciculus, UF: uncinate fasciculus, SS: stratum sagittale, Fo: fornix.
LengthCC represents the total length of the corpus callosum (measured parallel to the
AC-PC line). Xpcs refers to the crossing of the commissural fibers from the postcentral
sulcus. An Xpcs/LengthCC index between 0.67 and 0.80 represents a position in the
isthmus (according to the Witelson’s classification).

in a standard fashion. The former steps have been extensively
described.1,7,12,22,23 Alternatively, a disconnection of the mesial
temporal structures has been described.13 The parietal cortical
disconnection line was created, based on anatomic landmarks
(black arrowheads in Figure 1). The SLF and the corona radiata
posterior to the corticospinal tract (CST) were sectioned resulting
in the lateral disconnection. The mesial intraventricular discon-
nection could then be continued from the posterior hippocampus
towards the mesial parietal cortex, by following the tentorial edge

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VERHAEGHE ET AL
FIGURE 4. PQD: medial view. After removal of the cingulum and
surrounding U-fibers, the posterior callosal radiation is exposed. The crossing
of the callosal fibers from the depth of the postcentral sulcus was determined
and marked Xpcs (black arrowhead). The white asterisk represents the anterior
isthmus; the 2 white asterisks represent the splenium of the corpus callosum.
Small insert shows Witelson’s classification of the corpus callosum. CS: central
sulcus, PCG: postcentral gyrus, R: rostrum, G: genu, RB: rostral body, AMB:
anterior midbody, PMB: posterior midbody, I: isthmus, S: splenium.
towards the falx, thereby sectioning the posterior one-third of
the corpus callosum, ie, both the splenium and the isthmus. The
mesial deafferentation furthermore disconnected the cingulum.
Sectioned White Matter Tracts in PQD
The white matter tracts that were completely or partially
sectioned during PQD included association, commissural, and
projection fibers. Important disconnected long association fibers
(Figure 5) were the SLF, the cingulum, and the different fiber
tracts in the temporal stem (UF, IFOF, optic radiation). Commis-
sural fibers included the AC, the hippocampal commissure,
and the posterior corpus callosum. Mesial temporal structures
including the hippocampal formation were also disconnected or
resected. Projection fibers included the fornix and the corona
radiata fibers posterior to the CST.
DISCUSSION
PQD can be used in the treatment of posterior cortex
epilepsies. An anatomic study was conducted whereby a dissection
of the relevant white matter tracts was performed with an
emphasis on the extent of disconnection. An involvement of both
the splenium and the isthmus in the interhemispheric transcal-
losal propagation in posterior epilepsies is suggested. Since insuffi-
cient disconnection, eg, after corpus callosotomy for drop attacks,
or incomplete resection are the main causes of surgical failure in
epilepsy surgery, these findings could have implications in patients
with posterior cortex epilepsies.21
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FIGURE 5. Oblique posterior view. A coronal section was made through the
brain stem and the CST. After removal of the cingulum, the callosal fibers
have been dissected. IFOF: inferior fronto-occipital fasciculus, SLF: superior
longitudinal fasciculus, ILF: inferior longitudinal fasciculus, Th: thalamus,
CC: corpus callosum, LN: nucleus, HC: hippocampus, Cgc: Cingulate gyrus
part of cingulum, Cgh: Hippocampal part of cingulum.
Indications
PQD should be reserved for extensive posterior cortex abnor-
malities, in particular extensive cortical dysplasia or angiomatosis
in Sturge–Weber disease.11,13-15 In more restricted lesions, a
resection or less extensive disconnection might be preferable since
a very extensive white matter deafferentation is obtained after
PDQ. In case of more extensive unilateral hemispheric lesions,
a hemispherotomy might be the treatment of choice.
Technical Notes
Important steps of the procedure in PQD overlap with the
transsylvian peri-insular hemispherotomy: disconnection of the
temporal stem, mesial temporal disconnection or amygdalohip-
pocampectomy, disconnection of the corona radiata, transven-
tricular disconnection of the corpus callosum.22-28
In practice, a keyhole approach should be avoided since a
monitoring of the central cortex is performed during PQD and
therefore the bone flap should extend over the central area. Both
anatomic landmarks and functional intraoperative monitoring
will guide disconnection. By opening the Sylvian fissure, the
inferior and posterior part of the circular sulcus are exposed.
The removal of any temporal and/or parietal opercular cortex
is optional to facilitate surgical dissection. The temporal stem
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is disconnected29 and the temporal horn of the lateral ventricle
is exposed as well as the trigone. The mesial temporal struc-
tures including the hippocampus and the amygdala can be either
removed or disconnected. The parietal disconnection line runs
from the postcentral sulcus towards the opened ventricle. The
central cortex and the CST must be spared, a goal achieved by
the use of intraoperative mapping and monitoring. After resecting
the hippocampus, one can follow the choroid fissure along the
edge of the tentorium through the calcar avis and the medial wall
of the atrium. Callosal sectioning in PQD should include both
the splenium and the isthmus. In the literature, the extent of
callosotomy has not been extensively reported and if so, sectioning
of the splenium has been advocated.13 The anterior two-thirds of
the corpus callosum can be spared during PQD, in order to spare
frontal interhemispheric connectivity. The anterior extent of the
callosotomy can be marked preoperatively and is verified with the
use of neuronavigation during surgery.
A proper knowledge of the exact disconnection line and
landmarks will become even more important with minimally
invasive techniques such as laser thermal ablation and MR-guided
focused ultrasound.
CONCLUSION
PQD is a technique in epilepsy surgery that can be applied
to extensive unilateral posterior cortical epileptogenic zones.
This anatomic study discusses the white matter tracts relevant
in posterior quadrant surgery in general. More specifically, the
technique of PQD is illustrated and the importance of discon-
necting both the splenium and the isthmus of the corpus callosum
is stressed. Failure to disconnect the isthmus could leave parietal
epileptogenic cortex connected resulting in worse outcomes.
Disclosures
Tom Theys is supported by the Clinical Research Foundation of UZ Leuven,
Belgium. The authors have no personal, financial, or institutional interest in any
of the drugs, materials, or devices described in this article.
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Acknowledgements
We thank Jo Verbinnen and Kristof Reyniers for technical assistance.
COMMENTS
A n in-depth understanding of the topographical and functional
anatomy of white matter tracts is essential to perform disconnective
procedures in epilepsy surgery. White matter fiber dissection technique
was originally described by Klingler in 1950s,1 and then revitalized
by Yasargil and Ture et al.2,3 Since then we have been witnessing the
VOLUME 0 | NUMBER 0 | 2017 | 5
VERHAEGHE ET AL
publication of many excellent anatomical studies using white matter
fiber dissection technique. Along these publications, recent advances in
modern MRI techniques such as diffusion tensor imaging as well as
evolution of intraoperative cortical/subcortical mapping techniques also
dramatically increased our understanding and appreciation of surgical
anatomy of white matter tracts.
This paper is another example of the many recent contributions in this
field. Authors use Klingler’s white matter fiber dissection technique to
illustrate posterior quadrant disconnection procedure to define relevant
white matter tract disconnections. They assess the extent of the discon-
nection at the level of corpus callosum using Witelson’s classification
to determine ideal length of the corpus callosotomy for optimal seizure
control. They state that disconnecting the splenium and isthmus of the
corpus callosum (posterior one-third of the corpus callosum) is critical for
good outcome. This is a well-written paper and a welcome contribution
to this topic. However, we still should not forget that both white matter
fiber dissection technique and diffusion tensor imaging are investigator
dependent techniques and also has inherent limitations in details.
Oguz Cataltepe
Worcester, Massachusetts
1. Ludwig E, Klingler J: Atlas Cerebri Humani, Basel, S. Karger, 1956.
2. Ture U, Yasargil MG, Pait TG. Is there a superior occipitofrontal fasciculuc? A
microsurgical anatomic study. Neurosurgery 40: 1226-1232, 1997.
3. Ture U, Yasargil MG, Friedman AH, Al-Mefty O: Fiber dissection technique:
Lateral aspect of the brain. Neurosurgery 47:417-427, 2000.
P osterior quadrant disconnection can be very effective for widespread
epilepsy localized in the temporoparietooccipital cortices by
6 | VOLUME 0 | NUMBER 0 | 2017
isolating epileptic brain tissue without a large resection. To evaluate
the ideal location of the callosal dissection, the authors of this study
used Klinger’s fiber dissection technique on 20 cadaveric human brains,
10 from the medial side and 10 from the lateral side, in order to
identify relevant structures to be disconnected. They found that commis-
sural fibers from the most anterior cortex disconnected (just behind
postcentral sulcus) invariably decussated in the callosal isthmus, anterior
to the splenium of the corpus callosum. They conclude that the location
of the dissection within the corpus callosum should not be posterior to
a point one-third in front of the posterior part of that structure in order
to ensure adequate parietal disconnection.
Minimally invasive disconnection procedures for epilepsy require
meticulous attention to the location of the dissections since epileptogenic
brain is left in place and the disconnection will be rendered pointless
if commissural pathways arising from epileptic brain are preserved.
However, the precise location of the cut within the corpus callosum is less
important than the concept that white matter underlying epileptic cortex
must be disrupted at some location. For example, it is possible to perform
a complete disconnection of the anterior parietal cortex with minimal
callosal disruption as long as the cortical dissections are in the right place
and a complete disconnection is made in the corona radiata. Although
it is logical that fibers from anterior parietal cortex will decussate nearby,
this study demonstrates that attention to the location of the corpus
callosum dissection is important in order to avoid incomplete discon-
nection.
Jonathan P. Miller
Cleveland, Ohio
www.operativeneurosurgery-online.com