Supraorbital craniotomy for focal frontal epilepsy via eyebrow incision and guided by in situ stereo-EEG electrodes: illustrative case

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BACKGROUND: Focal cortical dysplasia (FCD) is a common cause of focal, pediatric, drug-resistant epilepsy. For FCDs in the frontal lobe, resection may be hampered by both difficult access and proximal eloquent cortex. Stereo-EEG (sEEG) can help define the boundaries of the suspected seizure onset zone (SOZ); however, subsequent epilepsy resections often rely on lateral approaches, requiring electrode removal before resection. Nevertheless, for some lesions, especially those in the frontopolar region, skull base approaches provide an in-line, minimally invasive trajectory that allows electrodes to remain in situ during resection as both anatomical landmarks and a source of intraoperative, continuous electrocorticography (ECoG). OBSERVATIONS: A 17-year-old, otherwise healthy male presented with 2 years of epilepsy secondary to a left frontopolar FCD. Left frontal and temporal sEEG confirmed a lesion-confined SOZ. The patient underwent a left supraorbital keyhole craniotomy via eyebrow incision for resection of the identified epileptogenic focus. All sEEG electrodes remained implanted during resection, serving as anatomical and electrophysiological surgical adjuncts. LESSONS: The authors present a case of frontopolar FCD-associated epilepsy resected using a supraorbital craniotomy via eyebrow approach. We highlight the utility of leveraging previously placed sEEG electrodes for intraoperative ECoG, resulting in gross-total resection and seizure freedom a year postoperatively. https://thejns.org/doi/10.3171/CASE25428.

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