Corpus Callosotomy
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Who Performs the Procedure and Where Is It Performed? Corpus callosotomy is performed by a neurosurgeon in a hospital operating room. Questions to Ask the Doctor
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Definition
Corpus callosotomy is a treatment for epilepsy, in which a group of fibers connecting the two sides of the brain, called the corpus callosum, is cut.
Purpose
Corpus callosotomy is used to treat epilepsy that is unresponsive to drug treatments. A person with epilepsy may be considered a good candidate for one type of epilepsy surgery or another if he or she has seizures that are not adequately controlled by drug therapy, and has tried at least two (perhaps more, depending on the treatment center's guidelines) different anti-epileptic drugs.
The seizures of epilepsy are due to unregulated spreading of electrical activity from one part of the brain to other parts. In many people with epilepsy, this activity begins from a well-defined focal point, which can be identified by electrical testing. Surgical treatment of focal-origin seizures involves removal of the brain region containing the focal point, usually in a procedure called temporal lobectomy. In other people, no focal point is found, or there may be too many to remove individually. These patients are most likely to receive corpus callosotomy.
The purpose of a corpus callosotomy is to prevent spreading of seizure activity from one half of the brain to the other. The brain is divided into two halves, or hemispheres, that are connected by a thick bundle of nerve fibers, the corpus callosum. When these fibers are cut, a seizure that begins in one hemisphere is less likely to spread to the other. This can reduce the frequency of seizures significantly.
The initial surgery may cut the forward two-thirds of the corpus callosum, leaving the rest intact. If this does not provide sufficient seizure control, the remaining portion may be cut.
Demographics
Corpus callosotomy is most often performed for children with "drop attacks," or atonic seizures, in which a sudden loss of muscle tone causes the child to fall to the floor. It is also performed in people with uncontrolled generalized tonic-clonic, or grand mal, seizures, or with massive jerking movements. Of the 20,000 to 70,000 people in the United States considered candidates for any type of epilepsy surgery, approximately 5,000 receive surgery per year. Between 1985 and 1990, more than 800 corpus callosotomies were performed, and the number has increased since then. Corpus callosotomy is performed by a special neurosurgical team, at a regional epilepsy treatment center.
Description
During corpus callosotomy, the patient is under general anesthesia, lying on the back. The head is fixed in place with blunt pins attached to a rigid structure. The head is shaved either before or during the procedure.
Incisions are made in the top of the skull to remove a flap of bone, exposing the brain. The outer covering is cut, and the two hemispheres are pulled slightly apart to expose the corpus callosum. The fibers of the corpus callosum are cut, taking care to avoid nearby arteries and ventricles (fluid-filled cavities in the brain).
Once the cut is made and any bleeding is controlled, the brain covering, bone, and scalp are closed and stitched.
Diagnosis/Preparation
The candidate for any type of epilepsy surgery will have had a wide range of tests prior to surgery. These include electroencephalography (EEG), in which electrodes are placed on the scalp, on the brain surface, or within the brain to record electrical activity. EEG is used to attempt to locate the focal point(s) of the seizure activity.
Several neuroimaging procedures are used to obtain images of the brain. These may reveal structural abnormalities that the neurosurgeon must be aware of. These procedures may include magnetic resonance imaging (MRI), x rays, computed tomography (CT) scans, or positron emission tomography (PET) imaging.
Neuropsychological tests may be done to provide a baseline against which the results of the surgery are measured. A Wada test may also be performed. In this test, a drug is injected into the artery leading to one half of the brain, putting it to sleep, allowing the neurologist to determine where language and other functions in the brain are localized, which may be useful for predicting the result of the surgery.
Aftercare
The patient remains in the hospital for about a week, possibly more depending on any complications that have occurred during surgery and on the health of the patient. There may be some discomfort afterwards. Tylenol with codeine may be prescribed for pain. Bending over should be avoided if possible, as it may lead to headache in the week or so after the procedure. Ice packs may be useful for pain and itchiness of the sutures on the head. Another several weeks of convalescence at home are required before the patient can resume normal activities. Heavy lifting or straining may continue to cause headaches or nausea, and should be avoided until the doctor approves. A diet rich in fiber can help avoid constipation, which may occur following surgery. Patients remain on anti-seizure medication at least for the short term, and may continue to require medication.
Risks
There is a slight risk of infection or hemorrhage from the surgery, usually less than 1%. Disconnection of the two hemispheres of the brain can cause some neuropsychological impairments such as decreased spontaneity of speech (it may be difficult to bring the right words into one's mind) and decreased use of the non-dominant hand. These problems usually improve over time. Complete cutting of the corpus callosotomy produces more long-lasting, but very subtle deficits in connecting words with images. These are usually not significant, or even noticed, by the patient.
Normal Results
Patients typically experience a marked reduction in number and severity of seizures, with a small percentage of people becoming seizure free. Drop attacks may be eliminated completely in approximately 70% of patients. Other types of seizure are also reduced by 50% or more from corpus callosotomy surgery.
Morbidity and Mortality Rates
Serious morbidity or mortality occurs in 1% or less of patients. Combined major and minor complication rates are approximately 20%.
Alternatives
Newer anti-seizure medications have partially replaced corpus callosotomy. Focal epilepsy is treated with focal surgery such as temporal lobectomy or hemispherectomy. Vagus nerve stimulation is an alternative for some patients.
See also Hemispherectomy; Vagal nerve stimulation.
Resources
Books
Devinsky, O. A Guide to Understanding and Living withEpilepsy. Philadelphia: EA Davis, 1994.
Organizations
Epilepsy Foundation.www.epilepsyfoundation.org.
— Richard Robinson
