Porto Alegre Epilepsy Surgery Program, Neurology and Neurosurgery Services, Hospital São Lucas, Brazil.
Porto Alegre Epilepsy Surgery Program, Neurology and Neurosurgery Services, Hospital São Lucas, Brazil; School of Medicine, Pontificia Universidade Catolica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.
Epilepsy Res. 2021 Mar;171:106544. doi: 10.1016/j.eplepsyres.2020.106544. Epub 2021 Jan 5.
In a previous proof of concept study, selective posterior callosotomy achieved similar degree of control of drop attacks as total callosotomy, while sparing prefrontal interconnectivity. The present study aims to confirm this finding in a larger cohort and to provide anatomical and prognostic data.
Fifty-one patients with refractory drop attacks had selective posterior callosotomy and prospective follow up for a mean of 6.4 years. Twenty-seven patients had post-operative magnetic resonance imaging (MRI) and 18 had tractography (DTI) of remaining callosal fibers. Pre and postoperative falls were quantified and correlated with demographic, clinical and imaging data.
Mean monthly frequency of drop attacks had a 95 % reduction, from 297 before to 16 after the procedure. Forty- one patients (80 %) had either complete or greater than 90 % control of the epileptic falls. Age and duration of epilepsy at surgery correlated with outcome (p values, respectively, 0.042 and 0.005). Mean index of callosal section along the posterior-to-anterior axis was 53.5 %. Extending the posterior section anterior to the midbody of the corpus callosum did not correlate with seizure control (p 0.91), providing fibers interconnecting the primary motor (M1) and caudal supplementary motor areas (SMA) were sectioned. Only one patient had a notable surgical complication which resolved in two days.
This level III cohort study with objective outcome assessment confirms that selective posterior callosotomy is safe and effective to control epileptic falls. Younger patients with smaller duration of epilepsy have better results. A posterior section contemplating the splenium, isthmus and posterior half of the body (posterior midbody) seems sufficient to achieve complete or almost complete control of drop attacks.
在之前的概念验证研究中，选择性后连合切开术在控制坠落发作方面与全连合切开术达到相似的程度，同时保留额前连合的连通性。本研究旨在更大的队列中证实这一发现，并提供解剖学和预后数据。
51 例难治性坠落发作患者行选择性后连合切开术，并前瞻性随访平均 6.4 年。27 例患者术后行磁共振成像（MRI）检查，18 例行剩余连合纤维的示踪术（DTI）。术前和术后的跌倒次数进行了量化，并与人口统计学、临床和影像学数据相关联。
平均每月坠落发作的频率减少了 95%，从术前的 297 次减少到术后的 16 次。41 例（80%）患者的癫痫性跌倒完全或超过 90%得到控制。手术时的年龄和癫痫持续时间与结果相关（p 值分别为 0.042 和 0.005）。后连合沿前后轴的节段指数为 53.5%。将后连合节段向前延伸至胼胝体体部的前半部分与癫痫控制无关（p=0.91），这意味着连接主要运动区（M1）和尾侧补充运动区（SMA）的纤维被切断。只有 1 例患者出现明显的手术并发症，2 天后得到解决。
本研究为 III 级队列研究，采用客观结局评估，证实选择性后连合切开术安全有效，可控制癫痫性坠落发作。年龄较小、癫痫持续时间较短的患者效果更好。后连合节段包含胼胝体压部、结合部和后半部（后体部）似乎足以完全或几乎完全控制坠落发作。
