Callosotomy might be preferred as the primary treatment in children with Lennox-Gastaut syndrome, and no specific findings on MRI if atonic seizures prevail in the patient's clinical picture; when myoclonic seizures prevail, the same might hold true in favour of VNS. When atypical absence or generalised tonic-clonic seizures are the main concern, although both procedures carry similar effectiveness, VNS might be considered a good option as an initial approach, taking into account the adverse event profile. Patients should be advised that both procedures are not very effective in the treatment of tonic seizures.

All patients benefit from the procedure. The CM seems to play a role in modulating the epileptic discharges and attention in these patients. On the other hand, it is not the generator of the epileptic abnormality and appeared not to be involved in non-REM sleep-related interictal spiking modulation.

Macrostimulation might be used to confirm that the hardware was working properly. There was no typical RR derived from each studied thalamic nuclei after LF stimulation. On the other hand, absence of such RRs was highly suggestive of hardware malfunction or inadequate targeting. Thalamic-DBS (Th-DBS) RR was always bilateral after unilateral stimulation, although they somehow prevailed over the stimulated hemisphere. Contrary to Th-DBS, Hip-DBS gave rise to localized RR over the ipsolateral temporal neocortex, and absence of this response might very likely be related to inadequate targeting or hardware failure. Increased spiking was seen over temporal neocortex during hippocampal electrode insertion; this might point to the more epileptogenic hippocampal region in each individual patient. We did not notice any intraoperative response difference among patients with temporal lobe epilepsy with or without MTS. The relationship between these intraoperative findings and seizure outcome is not yet clear and should be further evaluated.

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SUMMARYWe studied the effects of vagus nerve stimulation (VNS) on eating seizures, which theoretically would be triggered by neural activity and signaling from organs innervated by the vagus nerve. Three adult patients with daily nonreflex and reflex eating seizures were studied; one patient also had hot-water seizures. One patient had bilateral polymicrogyria and two had normal magnetic resonance imaging (MRI) findings. All patients were submitted to VNS implantation and had at least 2 years of postimplantation follow-up. Final stimulation parameters were 2.0-2.5 mA, 500 ls, and 30 Hz. Eating seizures decreased 70-95% and nonreflex seizures decreased 0-40% after VNS. There was no improvement in hot-water seizures. VNS seems to be an especially useful treatment modality in patients with reflex eating seizures not amenable to resective surgery.

SUMMARYPurpose: We report the outcome of patients with refractory idiopathic generalized epilepsy (IGE) who were submitted to extended one-stage callosal section. Methods: Eleven patients with IGE who were submitted to extended one-stage callosal section were studied. Preoperative workup included history and neurologic examination, interictal, and ictal electroencephalography (EEG) recording, high resolution 1.5T magnetic resonance imaging (MRI) and intelligence quotient (IQ) testing. All patients were submitted to extended one-stage microsurgical callosal section, leaving only the splenium intact. Results: Preoperative ictal patterns included repetitive spike and wave or polyspike and wave discharges or fast epileptic recruiting rhythm. MRI showed no focal lesions. Preoperatively, mean general IQ was 85. Postoperatively, at least a 75% reduction in the frequency of generalized tonicclonic seizures was noted in all patients. In three patients absences disappeared completely, and the others had at least 90% reduction in seizure frequency. Only one patient had myoclonic seizures preoperatively, and these seizures disappeared after callosal section. After surgery, mean general IQ was 89. A very clear increase in attention level was noted in all patients. Postoperative interictal EEG recordings showed rupture of bilateral synchrony in all patients. Discussion: This article reports on a large and homogeneous series of patients with refractory IGE submitted for callosal section. There was a marked decrease in generalized seizure frequency and increase in the attention level in this patient population. Our results suggest that corticocortical interaction might have a role in IGE pathogenesis. Callosotomy is a safe, effective, and underused palliative procedure in these wellselected patients with refractory IGE.

SUMMARYWe describe a child with epilepsy associated with double-cortex syndrome in whom vagus nerve stimulation (VNS) generated parkinsonian symptoms. A 13-year-old girl presented with refractory secondary generalized epilepsy from the age of 6 years and mental retardation. Her electroencephalography (EEG) showed diffuse polyspike and wave discharges. Magnetic resonance imaging (MRI) showed double-cortex syndrome. She was submitted to extended callosal section at the age of 10 years, which yielded 50% seizure frequency reduction. She was submitted to VNS by the age of 12 years. As stimulation intensity was increased, there was appearance of extrapyramidal symptoms: She developed bilateral tremor and rigidity, and gait and postural disturbance. All symptoms disappeared 7-10 days after VNS was turned off. Several attempts to reactivate VNS led to the same results. During the periods when VNS was on she presented with marked seizure frequency reduction. This is the first report of a clinically evident direct effect of VNS on the basal ganglia. KEY WORDS: Outcome, Callosotomy, Generalized epilepsy.Vagus nerve stimulation (VNS) has been used increasingly in the treatment of refractory epilepsy. It has been shown to be an effective palliative procedure in focal and generalized epileptic syndromes, in both adults and children (Benifla et al., 2006;Ardesch et al., 2007;Amar et al., 2008).Although its effectiveness has been confirmed by various studies, the exact pathway through which the antiepileptic effect of VNS is obtained is not yet clear. The nucleus of the tractus solitarius is considered an early relay, but the progression of the up-going information in the cortical direction is not known. Single-photon emission computed tomography (SPECT) and positron emission tomography (PET) have been employed to study patients undergoing VNS but have so far yielded inconsistent results (Chae et al., 2003). The effect of VNS on basal ganglia physiology is extremely poorly studied. Handforth et al. (2003) published a pilot study, including nine patients, on the effects of VNS on essential tremor, and showed a small improvement in some patients, but no worsening in any patient. More recently, Marrosu et al. (2007) published a very small series (three patients) reporting on the effects of VNS on cerebellar tremor and dysphagia in patients with multiple sclerosis, showing some degree of improvement, but no worsening of the symptoms. Although thousands of patients have already been submitted to VNS as a treatment for refractory epilepsy, these last two studies remain the only ones to discuss the effects of VNS on basal ganglia and movement disorders. No previous report has pointed out any clinically significant effect of VNS on basal ganglia in persons with epilepsy.We describe a child with refractory generalized epilepsy (Lennox-like pattern) associated with double-cortex syndrome as seen on MRI in whom VNS generated severe, stimulation-related, parkinsonian syndrome.

OBJETIVES: Studies have shown that people with epilepsy have a low degree of participation in physical activities. The purpose of this study was to assess the physical exercise habits in patients after epilepsy surgery using a standardized questionnaire. MMETHODOLOGY: The study population consisted of 102 patients submitted to cortico-amigdalo-hippocampectomy. A questionnaire was designed to assess physical activities participation before and after surgery. Patients were classified as physically active, inadequately active or sedentary. The questionnaire was applied pre-operatively and after a mean of 47 months post-operatively. RESULTS: Forty eight per cent of the patients participated in physical activities before surgery and 56% of them did so post-operatively. No considerable changes in physical activity participation were observed after surgery. Additionally, the frequency they needed supervision during exercise, were advised by a physician not to practice exercise or cautioned by a relative or friend against participation in sports did not change significantly after successful epilepsy surgery. Less exercise-related seizures occurred postoperatively. CONCLUSION: Difficulties adapting to seizure freedom and psychosocial and psychiatric co-morbidity might be important factors interfering in these physical activity habits. A multidisciplinary approach might be the only way to try to alter some aspects of these patients' postoperative life style.