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Título

CALLOSOTOMY – SHOULD IT BE INDICATED EARLIER?

Apresentação do caso

Male 9 years and 9 months old patient with cerebral palsy (GMFCS5) and refractory epilepsy secondary to extensive and bilateral hypoxic ischemic encephalopathy started epileptic seizures in the first hours of life and after evolved with persistent and countless daily polymorphic seizures. He was diagnosed with West syndrome (WS) followed by Lennox-Gastaut syndrome (LGS). He got many treatments, with a total of more than 10 anti-crisis drugs (ACD), including rufinamide, explored in single or polytherapy and in the maximum tolerated doses. He also underwent alternative treatments with acetazolamide, corticosteroids, cannabidiol, and ketogenic diet. No therapeutic measure showed efficacy above 50%. At 9 years old, he was evaluated by the neurosurgery team after a video electroencephalography (EEG) showed an increase in interhemispheric synchronization and many spindle-like segments of rapid and rhythmic activity with record of countless tonic-type epileptic seizures and spasms in cluster. A total callosotomy was performed 4 months later. Two months after the surgery, the patient’s mother reported an 80% reduction in the number of attacks and a decrease in their duration. In the last performed EEG, no burst-suppression pattern was detected as in the EEG before surgery. There was persistence of multifocal epileptiform activity, with a left occipital and right frontocentral predominance.

Discussão

Callosotomy is an option for drug resistant epilepsies not amenable to focal resection. It best suits drop attacks cases, but is also relevant regarding WS, LGS and frontal epilepsy. Its rationale is based on the role of the fibers of corpus callosum on spreading the epileptic activity in both cerebral hemispheres. It is an invasive but effective intervention with low morbimortality. Possible complications are usually transient, such as aphasia, memory losses, or infections. In the palliative management of LGS, callosotomy is associated with a 50-90% reduction in the number of crises, better quality of life and high rates of family satisfaction.

Comentários finais

Our patient has had seizures since the first hours of life and went through an exhausting range of therapies with efficacy always below 50%. After callosotomy, there was a significant clinical improvement with corresponding EEG changes. Although it is a palliative, invasive and irreversible procedure, a discussion should be raised on the earlier indication of callosotomy in selected cases.

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