2 2.1. Selection Criteria for Peri-Insular Hemispherotomy [9, 13– 15]. (a) Medical intractability. (b) Contralateral hemiparesis with weakness of distal musculature of the upper and lower limbs. (c) The hemisphere contralateral to the hemiparesis was shown by radiological (MRI/computerised tomog- raphy (CT)) and functional (scalp EEG/EEG video telemetry) imaging to have a unilateral diﬀuse abnor- mality and the remaining hemisphere was normal. 2.2. Selection Criteria for Peri-Insular Posterior Quadran- tectomy [6, 7]. When the epileptogenic zone encompassed large areas of the temporal, parietal and occipital lobes with sparing of the frontal lobe, a PIPQ was performed. The decision was dependant on good concordance between the imaging (MRI, CT, nuclear studies), EEG, clinical and neuropsychological evaluations, and a clear localization of the lesion to the unilateral-aﬀected region. The indications for PIPQ were the same as for hemispheric epilepsy, the pathology being localized to involve the temporal, parietal, and occipital lobes. The presence of residual voluntary motor function of the contralateral distal musculature, that is, ﬁnger opposition and foot tapping, was the indication for PIPQ preserving eloquent uninvolved sensorimotor cortex. 2.3. Presurgical Evaluation. All patients went through a presurgical evaluation including a study of the seizure semi- ology, neurological examination, multiple electroencephalo- gram (EEG) examinations (video telemetry), magnetic res- onance imaging (MRI), and neuropsychological evaluation. The focus of the evaluation was to identify a surgically remediable epilepsy syndrome with good electro-clinico- radiological concordance. If the structural lesion responsible for epilepsy could be safely removed without causing deteri- oration in the functional status, the patient was considered for epilepsy surgery. However, if there was no concordance in investigations in the Phase I evaluation, the patient would enter a Phase II evaluation which would include prolonged invasive EEG monitoring, nuclear medicine studies (positron emission tomography (PET) and single photon emission computerized tomography (SPECT)), and a WADA (Sodium amylobarbital) test. However, none of our patients required a phase II evaluation. 2.4. Surgery. A PIH was performed in all cases with hemi- spheric epilepsy. (Figure 1) This is a surgical method of func- tional hemispherectomy that enables disconnection of the hemisphere through peri-insular windows requiring limited removal of the fronto-parieto-temporal opercular cortices. Following the surgical principles of “anatomical subtotal removal of the hemisphere and complete disconnection,” the PIH is a radical hemispheric tractotomy based on the concept of maximum disconnection with minimal excision. It resulted from the demonstration that the hemisphere could be disconnected, made nonfunctional, through very small removal of brain tissue [9, 14, 15]. International Journal of Pediatrics Figure 1: Intraoperative photograph of peri-insular hemisphero- tomy (PIH) showing the supra- and infrainsular windows. Figure 2: Intraoperative photograph of peri-insular posterior quadrantectomy (PIPQ) showing the line of disconnection. A PIPQ was performed in all cases of subhemispheric epilepsy and the surgery tailored to encompass the whole epileptogenic lesion yet preserving the central region, which is still functional. (Figure 2) In this technical variant, there is a minimal removal of brain tissue but complete discon- nection of the remaining major part of the abnormal cortex, which is left anatomically intact and viable by preservation of the arteries and veins irrigating these lobes. The primary motor and sensory cortices are identiﬁed and recognized from the study of the MRI and correlation with intraop- erative surface anatomy, based on gyral pattern, arteries, and veins [6, 7]. The identiﬁcation of the functional cortex is also aided by electrophysiological means under general anaesthesia before the disconnection. This identiﬁcation maximizes both the extent of resection and the safety of surgery [6, 7]. In this variant, the mesial temporal structures are resected, but the temporal neocortex is disconnected and not resected followed by a parieto-occipital disconnection [6, 7]. 2.5. Statistical Analysis. The data was analyzed with non- parametric tests because of the small sample size among the children with poor outcome following surgery (Engel’s class II–IV). Nonparametric χ2 square test and Mann-Whitney U test was were to compare the categorical and continuous