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Anterior callosotomy in the treatment of medically intractable epilepsies A study of 43 patients with a mean follow-up of 39 months.

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Anterior Callosotomy in the Treatment
of Medically Inmitable Epilepsies:
A Study of 43 Patients with a Mean
Follow-up of 39 Months
Hirokazu Oguni, MD, Andre Olivier, MD, PhD, FRCS(C), Frederick Andermann, MD, FRCP(C),
and Joseph Comair, MD
~~
We studied the effectiveness of anterior callosotomy in 43 patients whose follow-up period averaged 39 months. These
patients had intractable generalized seizures, characterized by a combination of seizure patterns, most frequently drop
attacks with generalized tonic-clonic, generalized tonic, and absence seizures. Overall, drop attacks were the most
frequent (31/43 or 7296) and the most disabling seizure pattern (27143 or 63%); they were also the most likely to
benefit from anterior callosotomy (70%). Patients with lateralized changes tended to have a better result than did
those without lateralization, but patients with synchronous and symmetrical spike and wave discharges also benefited.
The preoperative intelligence quotient and the etiological factors were not predictors of outcome. There was a
correlation between the extent of section and the results; patients with section of the anterior two thirds had a better
result, compared with those who had section of the anterior half.
Oguni H, Olivier A, Andermann F, Comair J. Anterior callosotomy in the treatment of medically intractable
epilepsies: a study of 43 patients with a mean follow-up of 39 months. Ann Neurol 1991;30:357-364
Over the last 10 years, there has been a considerable
resurgence of interest in the use of callosotomy for the
surgical treatment of intractable epilepsy. This operation was first carried out in the human in 1940 by Van
Wagenen and Herren [ l ]with encouraging results, but
the operation never became widely accepted. Bogen
and Vogel 12, 31 reintroduced it in the early 1960s,
but again, in spite of its demonstrated effectiveness,
it was never practiced routinely because of its high
morbidity. In the last 16 years, Wilson and his colleagues [4-61, using a microsurgical approach in selected patients with intractable epilepsies, have shown
satisfactory results in seizure control as well as an important reduction in morbidity. Since then, physicians
at several centers employed callosotomy for the treatment of patients with uncontrollable epilepsy and reported promising results in those patients who were
not candidates for classic resective surgery {7- 141.
The purpose of this report is to present the results of
anterior corpus callosotomy performed at the Montreal
Neurological Institute (MNI).
Materials and Methods
Patient Selection
From the Montreal Neurological Hospital and Institute and the Departrnent of Neurology and Neurosurgery, McGill University, Montreal, Canada.
ReceivedJan 5 , 1990,and in revised form July 12 and Dec 18, 1990,
Since 1981, we carried out a total of 63 anterior callosotomies for a variety of forms of intractable epilepsy. Fifteen
patients who had a combined frontal corticectomy and callosotomy were excluded from this study, leaving 48 patients.
One patient had the diagnosis of Lafora disease made after
surgery and was also excluded. Forty-three patients were followed for more than 1 year and are included in the analysis.
Twenty patients were male and 23, female. Their ages at
the time of surgery ranged from 7.8 to 60.0 years, with a
mean of 23.5 years. The duration of epilepsy ranged from
4.9 to 46.0 years, with a mean of 18.8 years. Follow-up
ranged from 15 to 98 months, with a mean duration of 39
months.
Selection criteria for anterior callosotomy were as follows
{ l 5 , 161: (1) the presence of intractable generalized or partial
seizures with secondary generalization, not responding to
medical treatment; (2) a malignant seizure pattern leading to
injury, deterioration, or both, more particularly consisting of
drop or akinetic attacks, especially of the tonic type, with
rigid unpreventable falling; and (3) absence of a single resectable epileptogenic area.
and Feb j,1091. Accepted for publication Feb 8, 1991.
Address correspondence to Dr Olivier, Montreal Neurological Institute, 3801 University Street, Montreal, PQ, H3A 2B4, Canada.
Copyright 0 1991 by the American Neurological Association
357
Surg-ev
All operations were carried out by the same surgeon (A. 0.).
The callosotomy procedure at the M N I has been described
in detail elsewhere [17]. Five patients had had a previous
temporal or frontal lobectomy without significant improvement. Thirty-two patients underwent division of the anterior
half of the corpus callosum and 2 patients underwent division
of only the anterior third. In 9 patients, division of the anterior two thirds (from the genu to just before the splenium)
was carried out in either one (n = 4), two (n = 4 ) , o r three
(n = 1) operations. No patient in this series had a total
callosotomy.
The extent of the callosal section was confirmed by midsagittal magfletic resonance imaging (MRI) in 11 patients. In 4
of these, the section was shorter than clinically expected, with
division of only 25 to 33% of the corpus callosum and in 3
of these patients, further division was undertaken.
Patient Evaluation
Neuroimaging (initially computed tomography [CT], more
recently MRI), electroencephalography (EEG), and neuropsychological studies were carried out pre- and postoperatively. Preoperative EEG studies included tracings after reduction or cessation of antiepileptic medication, recording
during sleep, and if possible, recording of ictal events. In 5
patients, chronic intracranial recording with depth electrodes
was carried out in order to localize or lateralize the epileptogenic area more accurately, but in none was a well-defined
focus identified. Patients were followed and examined at 6to 12-month intervals. Assessments of seizure frequency and
severity were obtained from the families, caregivers, and patients. Seizure types were classified according to the international classification of seizures [18},based o n review of videotaped attacks or descriptions in nurses’ notes or by family
members.
Classifcation of Results
The seizure outcome was defined by the following criteria:
A = Seizures completely eliminated.
B = Marked improvement; more than 75% reduction in seizure frequency or severity. Severity of drop or kinetic
attacks lessened at least to the extent that the patient no
longer falls, though head dropping may persist.
A and B combined was considered a good result.
C = Moderate improvement; 50 to 75% reduction in seizure
frequency, severity, o r both.
A, B, and C combined represented wortbuhile improvement.
D = No significant imprwement; less than 50% reduction in
seizure frequency, severity, or both.
E = Aggravation; increase in seizure frequency, severity, or
both. If the patient had more than one seizure type, we
used the most disabling seizure pattern for assessment of
outcome.
Statistical Methods
Student’s t tests and chi-square tests were used. W e defined
p < 0.05 as a significant difference.
Results
Overall Outcome
Eighty-five percent of the patients exhibited more than
one seizure type preoperatively (Table 1). Thirty-four
patients had frequent daily seizures and 9 patients had
clusters of seizures every several days. None of the
patients in this series had complete and lasting cessation of all seizures postoperatively.
The overall outcome according to the most disabling
seizure type is illustrated in Table 2. A good result was
obtained in 339% and a worthwhile improvement, in
56%. Almost half of the patients with drop attacks had
a good result. Half of the patients with generalized
tonic seizures, such as nocturnal axial tonic seizures,
had a worthwhile result.
Improvement of the seizures was usually maintained
over the follow-up period of up to 8 years. Some patients had a resurgence of seizures 6 to 12 months
postoperatively and then stabilized. All those with a
good result after 12 months remained stable. None
had worsening of the epilepsy after callosotomy.
EHects according to Each Seizure Type
Tonic or atonic drop attacks were observed in ?O% of
patients and generalized tonic-clonic seizures, in 5 3%.
The result of callosotomy according to different seizure
types is summarized in Table 3.
The patients with improved complex partial seizures
(CPSs) often had a combination of drop attacks preceded by an aura or staring, suggestive of secondary
generahation and an intrrictal epileptic abnormality
involving widespread or multifocal regions including
temporal as well as extratemporal regions. They did
Table 1. Anterior CallosotomyCombinations of Seizure Types (n
=
43)
No.
Combinations
+
+
+
Drop attacks
GTCSs
Drop attacks
GTCS or GTS
Drop attacks
GTCS
CPS
GTCS or GTS + CPS or SPS
GTCS or GTS
Drop attacks
Aty abs
GTCS + myoclonic seizures
Drop attacks
Other combinations
Total
+
+
+ Aty abs
11
7
4
4
3
3
2
2
7
43
GTCS = generalized tonic-clonic seizures;GTS = generalized tonic
seizures; Aty abs = atypical absence seizures;CPS = complex partial
seizures; SPS = simple partial seizures.
358 Annals of Neurology Vol 30 No 3 September 1991
--
Table 2. Anterior Callosotomy-Overall Outcome according t o the Patient's Most Disabling Seizure Pattern (n = 43)"
A
Drop attacks
B
C
D
Total
8
6
8
27
70%
0
2
10
2
4
5
48%
0
GTCS
0%
20%
0
0
GTS
Tonic adv sz
Myoclonic abs
Total
-
'
0%
L
50% A
0
0
0
1
0
1
0
0
5
3
I0
19
33% 2Good result
56% I
Worthwhile improvement
1
1
43
"See text for definitions for A, B, C, and D results.
GTCS
=
generalized tonic-clonic seizures; GTS
=
generalized tonic seizures; Tonic adv sz
=
tonic adversive seizures; abs
=
absence seizures.
Table 3 . Efect of Anterior Callosotomy according to Seizure Types in = 431"
A
B
Drop attacks
6
GTCS
I
I
21%
Aty abs
1
I 3 3 %
GTS
C
D
E
Total
8
6
11
0
31
4
4
15
0
24
38%
3
1
7
0
12
42%
2
3
3
1
10
0
4
0
8
1
,
2
0
5
0
0
15
1
1
44
0
0
1
2
2
94
--
-1
30%
60%
CPS
3
50%
%
05;
0
-5
2
40%
Myoclonic seizures
Unclassified seizures
Total
1
1
14
60%
0
0
20
33% 2 GOO^ result
56%
Worthwhile improvement
"See text for definitions for A, B, C, D, and E results
GTCS = generalized tonic-clonic seizures; GTS
seizures; SPS = simple partial seizures.
=
g e n e d z e d tonic seizures; Aty abs
=
atypical absence seizures; CPS = complex partial
Oguni et al: Anterior Callosotomy for Epilepsy
359
Table 4. Effect of Anterzor Callosotomy according to Types of Interictal EEG Patterns (n
=
43)"
B
D
2
3
8
4
6
15
2
6
14
0
2
0% 1
33%
9
10
33% 1Good result
56% -Worthwhile
4
6
9
43
~~
1. Unilateral epileptic foci with or without small amounts of
2
1
~~
--
GSW
I-- 38%
2. Bilaterally asymmetrical independent discharges or GSW
with obvious lateralization
2
L 33%
3. Bilateral symmetrical independent discharges or GSW
without lateralization
2
Total
C
A
_I
63%
3
-_I
60%
4
L 43% --I
57%
4. Scanty shifting interictal epileptic abnormalities
?-
Total
5
improvement
'See text for definitions for A, B, C, and D results.
GSW
=
generalized bilateral synchronous spike and wave or sharp and slow wave discharges.
not have typical manifestations of temporal lobe seizures (characteristic temporal aura, or oroalimentary
automatisms). Both CPSs and drop attacks improved
simultaneously.
Postoperatively, significant modifications in seizure
manifestations were seen in 7 patients. In 3 who had
had characteristic drop attacks, postoperative seizures
involved only one hemibody with some retention of
consciousness, allowing them to prevent a fall or to
slump slowly to the ground. In a fourth patient, an
aura preceding the residual drop attacks appeared each
time. In the remaining 3 patients with generalized seizures, laterahzed or hemibody attacks developed.
After operation, one patient showed an increase in
frequency of generalized tonic seizures without falling,
but the drop attacks were completely abolished.
In addition, new seizure patterns, not clearly representing modification of previous attacks, were observed in 3 patients after surgery. In 1 patient with the
Lennox-Gastaut syndrome, mild focal motor seizures
involving the left arm appeared. Another patient with
frontal lobe epilepsy started to have CPSs, with the
head turning to one side followed by automatic movements. A third patient with partial epilepsy presented
CPSs with automatisms after surgery, which diminished progressively and then disappeared. In these 3
patients, the newly developed seizures were not as disabling as the preoperative ones.
EHects according t o D@rent Types
of Interictal EEG Patterns
Thirty of 4 3 patients had generalized, bilaterally synchronous spike or sharp and slow wave discharges
(GSWs). Most of these had slow spike and wave indicative of a secondary generalized epilepsy. We divided
these 43 patients into four groups according to the
amount of GSWs, lateralization of electrographic ab-
normalities, and the presence of interictal focal epileptic discharges (Table 4 , Fig).
The relationship between the surgery result and the
interictal EEG pattern showed similar results, except
for the patients with scanty shifting interictal epileptic
abnormalities who did less well. There was no statistical
correlation between outcome in these EEG criteria.
Cowelation between Outcome of Eacb Seizure Type
and Laterahation of the lnterictal EEG Patterns
Drop attacks, generalized tonic-clonic seizures, generalized tonic seizures, and atypical absence seizures may
either have originated from a locahzed epileptic area
with subsequent secondary generalization or have been
generahzed from the beginning; this might influence
the outcome of surgery. Therefore, we compared the
outcome in these seizure types according to the lateralization of the interictal EEG patterns (interictal EEG
patterns types 1 and 2 with lateralization, versus types
3 and 4 without lateralization).
A good result was seen significantly more often in
the patients with lateralized interictal EEG patterns
than in those without such lateralization. Patients with
a lateralized EEG pattern were more likely to have a
worthwhile improvement but this did not reach statistical significance (Table 5).
EHect according to the Type of Epilepsy
According to the seizure types, the interictal EEG patterns, and the presence of mental retardation, we were
able to classify these 43 patients into five types of epilepsy as follows:
1. Lennox-Gastaut syndrome. Three of the 14 patients
with this diagnosis did not fulfill all the clinical criteria { 181but their EEG pattern was quite characteris-
360 Annals of Neurology Vol 30 No 3 September 1991
Typical examples of interictal EEG patterns. (A) Type I EEG
pattern: right-sided ongoing paroxysmal discharges and generulized bilaterally synchronous sharp and slow wave discharges.
(Bi Type 2 E E G pattern: generalized bihterally synchronous
sharp and slow wave discharges with right-sided predominance.
(Cj Type 3 EEG pattern: generalized bilateral synchronous
sharp and slow wave discharges without lateralization. (0)
Type 4 intm'ctal EEG pattern: only few interictal epileptic abnomlities without convincing localizations or lateralization.
Table 5. Anterior Callosotomy-Cowelution between
Seizure Types and Laterulizrztion of fnterictal EEG
Abnormalities in the Patients with Good Result
~
Seizure Types
Drop attacks
GTCS
tic. These patients had generalized tonic seizures,
drop attacks, or generalized tonic-clonic seizures
and bursts of GSW without lateralization.
Secondary generalized epilepsy with focal seizures,
lateralized interictal epileptic abnormality, and generalized seizures with strong focal accentuation.
These patients had a single seizure type (generalized tonic o r generalized tonic-clonic seizure) and
bilateral, asymmetrical, independent epileptic discharges or a large amount of GSW with lareralized
predominance.
Frontal lobe epilepsy with good localization to the
frontal regions but without clear or obvious lateralization.
Multifocal o r unlocalized regional epilepsy. Epileptic foci were difficult to lateralize or localize. The
most disabling seizure pattern consisted of drop attacks often preceded by staring or an aura. These
patients also had a combination of CPSs, generalized tonic-clonic seizures with focal onset, or simple
partial seizures.
Unclassifiable epilepsy. Patients had generahzed
Aty abs
GTS
~
Lateralized
Abnormalities
Nonlateralized
Abnormalities
56%'
(7116)
31%
33%
(5115)
0%
(5116)"
33%
(113)
(018)
33%
(319)
33%
(216)
0%
(014)
' x 2 < 0.05.
GTCS = generalized tonic-clonic seizures;GTS
seizures; Aty abs = atypical absence seizures.
= generalized tonic
seizures with focal signs and no good electroclinical
correlation. A depth electrode study in one such
patient disclosed multifocal and widespread onset
of seizures from frontal or temporal areas of either
hemisphere or both, with immediate secondary
generahation. Only frontal and temporal regions
were explored in this patient.
The results are summarized in Table 6.
Extent of the Anterior Callosotomy and Outcome
Both good results and worthwhile improvement were
seen significantly more frequently in the group who
Oguni et al: Anterior Callosotomy for Epilepsy
361
Table 6. Eflect of Anterior Callosotomy according t o Types of Epilepsy (n = 43)"
---A
1.
Lennox-Gastaut syndrome
L 43%
0
2. Secondary generalized epilepsy with focal features
L- 14%
3. Frontal lobe epilepsy
4. Multifocal epilepsy
B
C
D
Total
4
1
2
6
14
3
7
57% 2
1
3
1
57%
0
1
L 25% 1
75%
2
1
4
3
3
1
5
12
58%
0
2
4
6
10
19
43
509
0
5. Unclassifiable epilepsies
0%-
33%
Total
9
5
Good result
33%
I
569 2
Worthwhile improvement
"See text for definitions for A, B, C, and D results.
had resection of the anterior two thirds, compared to
those who had resection of the anterior half (Table 7).
Table 7 . Extent of Callomtomy and Outcome ( n = 43)"
Clinical Correlations
1. The full scale intelligence quotient (IQ) was evalu-
Anterior
ated in all patients preoperatively. Ten were severely
retarded (Group 1, I Q < 30); 15, moderately retarded
(Group 2, 30 < IQ < 60); 12, mildly retarded (Group
3, 60 < IQ < 80); and 6 functioned within the normal
or low average range (Group 4, I Q > 80). There was
no consistent relationship between preoperative intelligence and effectiveness of operation. A good result
was seen in 18% of Group 1, 36% of Group 2 , 50%
of Group 3, and 17% of Group 4. Worthwhile improvement was seen in 4596, 65%, 58%, and 50%,
respectively.
2. The presence of lateralized structural abnormalities on CT or MRI scan did not significantly contribute
to a good result.
3. Fourteen patients had minimal or mild hemiparesis. Some correlation was seen between the presence
of hemiparesis and good outcome, but this was not
statistically significant (good result: 47% among the
patients with hemiparesis versus 29% without hemiparesis, x2> 0.05; worthwhile improvement: 80% versus
43576, 0.05 < x2 < 0.1).
4. There was no correlation between the effect of
anterior callosotomy and age at onset or duration of
the epilepsy, nor with the age at the time of surgery.
5. Comparison among prenatal (n = ll), perinatal
and postnatal (n = lo), and unknown etiological factors (n = 22) showed no consistent relationship to
the effectiveness of anterior callosotomy (good result:
55% versus 40% versus 23%, x2 > 0.05; worthwhile
A
two thirds
Anterior
one half
Total
3
B
C
D
Total
3
2
1
9
-- 67%
8 9 % l b
6
8
18
34
L 249% -I
47910
5
9
10
19
43
L 3394 1Good result
56% 2Worthwhile
2
improvement
"See text for definitions for A, B, C , and D results.
bBoth good and worthwhile improvements were seen significantly
more frequently in the group who had anterior two thirds section
(X* < 0.05).
improvement: 555% versus 70% versus 50%,
0.05).
xz >
Surgical Complications
Early postoperative complications occurred in 16 of
the 43 patients. There was no mortality in this series.
One patient developed an epidural hematoma with
transient hemiparesis. Another patient had a cranial
infection and an intracranial abscess that was evacuated
later; a third had a collection of blood between the
galea and the bone flap without residual neurological
deficit. Two patients had transient contralateral (left
after right craniotomy) weakness of the leg. One patient had a venous thrombosis of the leg. Decreased
output of speech was noticed in 4 patients and disappeared within 1 to 2 weeks. In severely retarded individuals, such reduction in speech output was difficult
362 Annals of Neurology Vol 30 No 3 September 1991
Table 8. Postoperative IQ Score 4-36 Months afrer
Anterior Callosotomy according to Outcome (n = 10)
Full scale IQ
Verbal IQ
Performance IQ
2x2
Worthwhile
Improvement
(n = 6)
No Significant
2+-5
-2 f 8
8 4"
-3
-4
*
Improvement
(n = 4 )
2
8
4
-8? 9
k
< 0.01.
to evaluate. The remaining complications were minor
and consisted of a transient minor confusional state,
mild fever, or drowsiness.
Postoperative IQ Change
Small increases in full scale, verbal, and performance
IQ scores were seen in the group who had worthwhile
improvement and a similar decrease in those who did
not improve (Table 8).
Discussion
The results of this study are in agreement with our
previous findings [151 and confirm the effectiveness of
callosotomy in the treatment of some patients who are
not candidates for resective surgery. Although the attacks did not cease completely in any of the patients,
anterior callosotomy led to a good result in 33% and
a worthwhile improvement in 56%.
The aim of callosotomy is to limit the spread of convulsive discharges from one hemisphere to the other
{I, 2, 3, 19, 201, and therefore patients with mainly
lateralized foci with secondary generalization should
benefit the most. Indeed, the outcome of callosotomy
with regard to both drop attacks and generalized tonicclonic seizures was different according to the interictal
EEG and the overall seizure profile, results being generally better in patients in whom the interictal epileptogenic abnormality was lateralized and in patients with
partial seizures. We considered this improved outcome
to be due to differences in the mechanism of seizure
propagation, with secondary generalized seizures that
arose from lateralized epileptogenic areas being better
controlled than seizures generalized from the outset
(generalized epilepsy). However, improvement was
seen not only in this group, since 57% of the patients
with bilateral independent focal epileptogenic discharges without lateralized predominance or bilateral
slow spike and wave discharges without lateralization
also exhibited worthwhile improvement.
The good outcome seen here in 4 of the 8 patients
with CPSs has also been reported in other studies
[9-11, 13, 141. Evidence from the interictal EEG, the
lack of typical manifestations of temporal lobe seizure
(no typical auras or oroalimentary automatisms) 1217,
the association of drop attacks, and the fact that 2 of
the patients failed to respond to temporal lobectomy
suggested that these CPSs might originate from extratemporal regions such as the frontal lobe or be due to
multilobar involvement E133.
Anterior callosotomy produced significant improvement in other seizure types, too. Worthwhile benefit
was seen in 5794 of patients with the Lennox-Gastaut
syndrome, 75% of patients with frontal lobe epilepsy,
and 58% of patients with multifocal or unlocalized focal epilepsy; 33% of patients with unclassifiable epilepsy were improved but none had a good outcome.
Preoperative low intelligence did not correlate with
poor outcome in this study or in that from Geoffroy
and colleagues (221 despite reports to the contrary 113,
141. Most patients with the Lennox-Gastaut syndrome
had low intelligence, but some of their most disabling
drop attacks improved significantly after callosal section.
Spencer and colleagues 1231 reported an increase in
focal seizures after callosal section and suggested that
the procedure might disrupt an inhibitory mechanism
in patients with asymmetrical frontal or bilaterally synchronous frontal foci. In the current series, only 3 patients developed new seizure patterns and in none
were these as severe or disabling as their preoperative
attacks, which had been helped.
In no patient in this series were the seizures completely arrested by callosotomy. However, patients
who fulfilled the criteria or had the clinical indications
for functional hemispherectomy were treated by this
method, with excellent outcome in many, and are not
included here (241.
The results published here suggest that drop attacks
of atonic or tonic type are specifically improved by
callosotomy. They are similar to those of Gates and
associates (121 but do not reach their almost 100%
success rate in abolishing or improving drop attacks
and generalized tonic-clonic seizures over a 2-year
follow-up period. This discrepancy may reflect the
greater extent of callosal section (total or near total) in
their patients, compared to our own.
The ideal extent of callosal section required to bring
about optimal seizure control is still unclear [ll, 13,
14,251. Wada and coworkers 1251 concluded that section of the anterior two thirds was sufficient to eliminate contralateral spread of discharges in an experimental model of frontal kindled seizures. In humans,
Purves and colleagues 1131 confirmed the benefit of
callosotomy of the anterior two thirds in a variety of
intractable epilepsies. However, a significantly improved outcome has been claimed after total callosotomy, with more than twice the benefit seen in the
control of secondarily generalized seizures, when compared to partial section [14}.
In the present study, patients who had section of the
anterior two thirds showed significantly better results
Oguni et at: Anterior Callosotomy for Epilepsy
363
than those who had section of the anterior half. Possibly, section of the anterior half might be sufficient for
patients with anteriorly situated foci with secondary
generahation, but patients with more widespread epileptogenic areas require a more extensive procedure.
Since, theoretically, division of the anterior half is
less likely to lead to a disconnection syndrome, the
strategy used was to perform section of the anterior
half initially and if there was insufficient improvement,
to extend the division to a point just anterior to the
splenium. However, no clinically significant manifestations of a disconnection syndrome occurred in any of
the patients, regardless of the extent of section, and it
is now our policy to perform section of the anterior
two thirds in all patients.
Patients considered for callosotomy are unsuitable
for other forms of epilepsy surgery. They are a severely
disabled group with a very destructive form of epilepsy, and even partial control of seizures may improve
the quality of their life and is worthwhile.
Certain clinical features suggest a good outcome
from anterior callosotomy. These are: (1) drop attacks
irrespective of the type of epilepsy or the EEG findings
(although patients with lateralized EEG abnormalities
showed greatest benefit); (2) CPSs, especially in patients who also have drop attacks and demonstrable or
presumed frontal epileptogenic abnormalities; and (3)
atypical absence seizures, though these have a less predictable outcome. When considering this operation,
the treating physician must thoroughly assess the expected benefits, limitations, likelihood of residual seizures, and the risks, and explain them to the patient,
his family, and other caregivers.
We thank Dr Geoffrey Wright for his generous help in the preparation of the manuscript.
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