Calosotomia nas epilepsias generalizadas refratarias

Orientador: Carlos A. M. GuerreiroTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: Foram estudados 51 pacientes com epilepsias generalizadas refratárias, submetidos a calosotomia parcial ou total. As idades variaram de 1 ano a 28 anos, com média de 9,4 anos. Vinte e oito pacientes eram do sexo masculino, e 23 do sexo feminino. Todos os pacientes foram acompanhados por no mínimo 6 meses prévios à cirurgia. Todos eles apresentaram refratariedade comprovada ao tratamento medicamentoso, e não apresentaram características de focalidade que permitissem uma abordagem cirúrgica com ressecção cortical. Foram estudadas crises atônicas, tônicas, tônico-clônicas generalizadas, ausências, mioclônicas, parciais e espasmos em salva. Todos os pacientes apresentavam mais de um tipo de crise, 86% deles apresentando três ou mais formas diferentes de crises. Todos apresentavam déficit cognitivo moderado ou grave. Dezoito pacientes foram submetidos a calosotomia total, e 33 à secção parcial (mínimo de 2/3) do corpo caloso. Houve uma diferença estatisticamente significante no controle de todas as formas de crise estudadas. Houve uma diferença significante no controle das crises de ausência atípica, mioclônicas e espasmos em salva, para a calosotomia total, e para as crises tônico-clônicas generalizadas, nos pacientes com SW, em relação à calosotomia parcial. Vinte e seis entre os 51 pacientes apresentaram um controle igualou >75% para duas entre três, três entre quatro, ou quatro entre cinco de suas formas de crise. As crises atônicas (79,6%) seguidas das ausências atípicas (64%) foram as que apresentaram melhores índices de controle igualou >75%. Os resultados, aliados a outros relatos de literatura, sugerem que a calosotomia é um procedimento efetivo para reduzir a frequência de algumas formas de crise, predominantemente atônicas, ausências atípicas e tônicas, e que a calosotomia total parece mais efetiva para o controle de crises mioclônicas e espasmos em salva, particularmente nos pacientes com encefalopatias graves. Os dados sugerem que mecanismos comissurais e subcorticais estejam operantes nas epilepsias generalizadas refratárias, explicando a limitação da calosotomia no controle de crises nesses pacientesAbstract: We studied 51 patients with refractory generalized epilepsies, submitted to partial or complete callosotomy. The ages varied from 1 yr to 28 years, mean of 9,4 years. Twenty eight patients were male and 23 female. Ali patients were treated for a minimum of 6 months before surgical indication. Ali were proved refractory to medical treatment, and had no signs of a focal resectable cortical lesion. Types of seizures studied were atonic, tonic, tonic-clonic, absences, myoclonic, partia I and serial spasms. Ali patients presented more than one seizure type, 86% of them presenting with three or more types of seizures. There was a significant decrease in the number of ali types of seizures, after surgery. There was a significant difference between the two procedures, with better results for the group submitted to complete section, for the following seizure types: absences, myoclonic and serial spasms. This was als9 true of tonic-clonic seizures, for the patients with West syndrome. Twenty six of the 51 patients had a more than 75% control for two of three, three of four or four of five of their seizure types. Atonic (79,6%), followed by absence (64%) seizures, were the seizure types which showed the highest improvement. Our results, together with data from the review of the literature, suggest that callosotomy is an effective procedure to decrease the frequency of some types of seizures, specially atonic, absences and tonic. Complete callosotomy seems to be more effective to decrease myoclonic, absences and spasms, specially in patients with severe encephalopathies. The data point to mfxed commissural and subcortical mechanisms, active in the refractory symptomatic generalized epilepsies, helping to explain the limitations of callosotomy in allaying the seizures of these patientsDoutoradoDoutor em Neurociencia

Vagus nerve stimulator in patients with epilepsy: indications and recommendations for use

Epilepsy comprises a set of neurologic and systemic disorders characterized by recurrent spontaneous seizures, and is the most frequent chronic neurologic disorder. In patients with medically refractory epilepsy, therapeutic options are limited to ablative brain surgery, trials of experimental antiepileptic drugs, or palliative surgery. Vagal nerve stimulation is an available palliative procedure of which the mechanism of action is not understood, but with established efficacy for medically refractory epilepsy and low incidence of side-effects. In this paper we discuss the recommendations for VNS use as suggested by the Brazilian League of Epilepsy and the Scientific Department of Epilepsy of the Brazilian Academy of Neurology Committee of Neuromodulation

Effects of unilateral stereotactic posterior striatotomy on harmaline-induced tremor in rats

Although long known and the most prevalent movement disorder, pathophysiology of essential tremor (ET) remains controversial. the most accepted hypothesis is that it is caused by a dysfunction of the olivocerebellar system. Vilela Filho et al. [2001; Stereotact Funct Neurosurg 77:149-150], however, reported a patient with unilateral hand ET that was completely relieved after a stroke restricted to the contralateral posterior putamen and suggested that ET could be the clinical manifestation of posterior putamen hyperactivity. the present study was designed to evaluate this hypothesis in the most often used model of ET, harmaline-induced tremor in rats. Fifty-four male Wistar rats were randomly distributed into three groups: experimental (EG), surgical control (SCG), and pharmacological control (PCG) groups. EG animals underwent stereotactic unilateral posterior striatotomy. SCG rats underwent sham lesion at the same target. PCG served exclusively as controls for harmaline effects. All animals received, postoperatively, intraperitoneal harmaline, and the induced tremor was video-recorded for later evaluation by a blind observer. Thirteen animals were excluded from the study. Limb tremor was reduced ipsilaterally to the operation in 20 of 21 rats of EG and in two of nine of SCG, being asymmetric in one of 10 of PCG rats. Comparisons between EG x SCG and EG x PCG were statistically significant, but not between SCG x PCG. Limb tremor reduction was greater in anterior than in posterior paws. Lateral lesions yielded better results than medial lesions. These results suggest that the posterior striatum is involved with harmaline-induced tremor in rats and support the hypothesis presented. (c) 2013 Wiley Periodicals, Inc.Univ Fed Goias, Sch Med, Div Neurosurg, Goiania, Go, BrazilUniversidade Federal de São Paulo, Sch Med, Dept Neurosurg, São Paulo, BrazilPontifical Catholic Univ Goias, Sch Med, Dept Neurosci, Goiania, Go, BrazilGoiania Neurol Inst, Goiania, Go, BrazilUniversidade Federal de São Paulo, Sch Med, Dept Neurosurg, São Paulo, BrazilWeb of Scienc