Hemispherotomy leads to persistent sleep-like slow waves in the isolated cortex of awake humans

Abstract

Hemispherotomy is a neurosurgical procedure for treating refractory epilepsy, which entails disconnecting a significant portion of the cortex, potentially encompassing an entire hemisphere, from its cortical and subcortical connections. While this intervention prevents the spread of seizures, it raises important questions. Given the complete isolation from sensory-motor pathways, it remains unclear whether the disconnected cortex retains any form of inaccessible awareness. More broadly, the activity patterns that large portions of the deafferented cortex can sustain in awake humans remain poorly understood. We address these questions by exploring for the first time the electroencephalographic (EEG) state of the isolated cortex during wakefulness before and after surgery in 10 pediatric patients, focusing on non-epileptic background activity. Post-surgery, the isolated cortex exhibited prominent slow oscillations (<2 Hz) and a steeper broad-band spectral decay, reflecting a redistribution of power toward lower frequencies. This broad-band EEG slowing resulted in a marked decrease of the spectral exponent, a validated consciousness marker, reaching values characteristic of deep anesthesia and the vegetative state. When compared with a reference pediatric sample across the sleep-wake cycle, the spectral exponent of the contralateral cortex aligned with wakefulness, whereas that of the isolated cortex was consistent with deep NREM sleep. The findings of prominent slow oscillations and broad-band slowing provisionally support inferences of absent or reduced awareness in the isolated cortex. Moreover, the persistence of unihemispheric sleep-like patterns years after surgery provides unique insights into the long-term electrophysiological effects of cortical disconnections in the human brain.