Combination of corpus callosotomy and VNS in refractory epilepsy

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Combination of corpus callosotomy and vagus nerve stimulation in the treatment of refractory epilepsy

E. Guillamón a, J. Miró b,  A. Gutiérrez a, R. Conde a, M. Falip b, S. Jaraba b, G. Plans b, M. Garcés a, V. Villanueva a
a Servicio de Neurología y Neurocirugía, Unidad Multidisciplinar de Epilepsia, Hospital Universitario y Politécnico La Fe, Valencia
b Servicio de Neurología y Neurocirugía, Hospital de Bellvitge, Barcelona , Spain

Purpose:

Tto investigate the efficacy of combined corpus calosotomy (CC) and VNS in patients with refractory epilepsy where the first surgery had not achieved adequate control.

Method:

retrospective review of 6 patients with refractory epilepsy in which both types of surgery were performed, CC and VNS. Variables such as age, sex, age at onset of epilepsy, seizure types, electroencephalogram and magnetic resonance imaging results, and number of pre- and postoperative seizures were analysed.

Results:

Three patients first underwent VNS and then CC, and 3 patients were treated in reverse order. All patients had some improvement after the first surgery, but they continued to experience persistent falls, so a second palliative technique was used. The mean improvement after both surgeries was 89% (90% in patients first receiving CC and 87% in patients who first underwent VNS).

Conclusions:

In adequately studied patients who are not optimal candidates for resective surgery, palliative surgery is a choice. The combination of VNS and CC shows good results in our series, although the right order to perform both procedures has not been defined. These results should be confirmed in a larger group of patients.

http://www.ncbi.nlm.nih.gov/pubmed/24334999

Comments reviewer, Prof Van Nieuwenhuizen:

This is an interesting regarding the included patients. All patients are adults at the time of surgery (CC and VNS), but suffer of “paediatric epilepsy”. In patient 1 traumatic brain contusion at the age of 4 years was mentioned, but neurological examination and MRI were normal. Patient 2 had suffered of birth asphyxia and traumatic brain injury at the age of 6 years. He was moderately retarded without other neurological defects. MRI revealed hyperintensity in the superior right frontal circumvolution as well as post-CC changes. Patient 3 had early psychomotor retardation; MRI showed Chiari malformation type I. Patient 4 had had prolonged birth. Soon after birth left hemiparesis was found. He turned out to be mentally retarded. Neurological examination showed moderate mental retardation, decreased visual acuity in the right eye, left facial paralysis, and left hemiparesis.MRI showed right brain atrophy. Patient 5 had Rethoré Syndrome which is associated with seizures, severe mental retardation, and gait ataxia. MRI was normal. Patient 6 showed mental retardation and behaviour disorder since the age of 5 years.

MRI was normal. In all patients with the exception of patient 4 a syndromal or genetic cause of epilepsy may be considered. Another interesting point is the sequence of surgical techniques. In three patients CC was performed first followed by VNS. In the other three the sequence was the other way around: first VNS and then CC. This did not influence final results. The additive efficacy after applying the second technique (regardless whether this was CC or VNS) was impressive: reduction of seizures of  33.52% after the first operation and 78.92% after the second. Although number of patients is limited, this study indicates efficacy of combination of CC and VNS in refractory patients.

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