Cerebral Commissurotomy - A Second Case Report

Cerebral Commissurotomy: A Second Case Report

J. E. Bogen, MD, E. D. Fisher, MD, and P. J. Vogel, MD
From the Department of Neurosurgery, School of Medicine, Loma Linda University. Los Angeles 33, California.

Reprinted From the Journal of the American Medical Association December 20, 1965, Vol. 194, pp. 1328 and 1329

THE SIZE and the location of the corpus callosum and anterior commissure suggest an important role in propagation of seizures from one side of the brain to the other. In 1940, Van Wagenen and Herren cut the corpus callosum to various extent in two dozen patients; only one had complete section of both corpus callosum and anterior commissure. The subsequent report by Akelaitisz on these patients indicates that a number of them were improved. Complete section of corpus callosum and anterior commissure was therefore offered to an apparently hopeless epileptic having one to three generalized convulsions per week, with best medical control." He has not had a generalized convulsion since that operation (Feb 6, 1962). Furthermore, although deficits in interhemispheric integration could be demonstrated under specialized testing conditions," the patient's well-being and general behavior were improved. Because of his excellent response, five more patients underwent this same operation. Four of them have been operated upon too recently for firm conclusions. However, the second patient to undergo the operation has had an excellent result for two years. Her case is presented here in detail.
Report of a Case
Preoperative Case History.--The patient, a 30-year-old woman, was born June 29, 1933. Her mother was then 22 years of age and had a daughter 3 years old. The patient was born during the sixth month, was in an incubator for some weeks, and on leaving the hospital weighed 5 lb (2,300 gm). She was first seen at the White Memorial Clinic at the age of 3 months. There was no abnormality except size: she weighed 7 lb 8 oz (3,405 gm) and was 19 inches (48.3 cm) tall. Her subsequent development was considered normal, including walking at 1 year and talking by the age of 2.
Both the patient and her mother agreed that she had always been right-handed and right-footed. Both of the patient's children, her sister, and both of her parents were known to be right-handed, as were all four grandparents. Her first convulsion was in June 1951, when she was four months pregnant. At that time she had a miscarriage. Her blood pressure was then 170/110 mm Hg. Her blood pressure returned to normal, but she continued to have seizures.
She was first admitted to the White Memorial Hospital on April 6, 1952, having had a total of eight known convulsions. Each of these was observed by her husband, who was awakened at night by a strange sound to find his wife "stiffened out" for two or three minutes. Examination was unrevealing. Chest x-rays showed calcifications near the right hiIum. The electroencephalogram showed left temporal slowing. The skull x-ray showed a mulberry calcification, measuring 1 cm, beneath the right central cortex. A right carotid angiogram was therefore done and the findings were normal.
From the Roes-Loos Medical Group (Dr. Bogen), the Department of Neurology, Loma Linda University School of Medicine (Dr. Fisher), and the Department of Neurosurgery, California College of Medicine (Dr. Vogel), Los Angeles.
In 1959, the patient had her first daytime seizure. She was given a mixture of diphenylhydantoin, phenobarbital, and methamphetamine hydrochloride (Phelantin Kapseals), 2.5 mg, twice daily, but continued to have episodes of "blank staring," as well as generalized convulsions with incontinence of urine and feces and sometimes tongue biting. Sometimes she manifested peculiar behavior, such as running around the house in a seemingly aimless fashion. By 1963 the seizures were worse, although she was taking the mixture of diphenylhydantoin, phenobarbital, and methamphetamine hydrochloride, 2.5 mg, twice daily; ethosuximide (Zarontin), 250 mg, twice daily; and phensuximide (Milontin), 500 mg, twice daily. She was hospitalized several times during this period for status epilepticus.
The patient was admitted to the White Memorial Hospital on Aug 19, 1963, having had about 50 spells in the three days preceding admission, while taking primidone (Mysoline), 250 mg, twice daily; ethosuximide, 250 mg, twice daily; and phenobarbital, 1 grain, four times each day. When recovered from her postidal stupor, she recalled having had "strange feelings" in the left side of the body preceding her convulsions. It was learned that the patient's grandmother and daughter also had convulsions. Examination showed some hypesthesia to pinprick on the left side. There was a slight hyperactivity of the left biceps reflex, but no abnormal toe or thumb sign. An EEG showed mild, diffuse slowing. Skull x-rays showed the same calcification as before. A pneunoencephalogram showed minimal ventricular dilatation.
Operation, Sept 5, 1963.-After a scalp flap was turned to the right, two bone plates were removed, leaving a bridge over the rolandic area. The brain looked and felt normal. It was necessary to divide a fairly large vein draining the right parietal area into the sagittal sinus. The corpus callosum and hippocampal commissure were divided separately. The right fornix was divided, as was the large massa intermedia, to obtain an adequate view of the third ventricle. The anterior commissure was severed with minimal lateral trauma There was no significant bleeding, and the closure was uneventful.
Postoperative Course.-Four hours after operation, the patient manifested a good grip on the right; Babinski's toe sign was positive on the right, and the entire left side was flaccid. Through the night, the left side remained flaccid to request, but the patient used both hands together to pull the covers over her breasts. Hyperreflexia and abnormality of the planter reflex on the right subsided in three days: a tonic grasp and proximal traction response (PTR) could be elicited as late as a week after operation. Apraxia, tonic grasp, and PTR remained on the left side for two weeks. By the end of the third week, left grasping subsided; no verbal instructions were followed with the left hand, but poses and gestures were copied excellently. By the fourth week the patient was walking well, although still apraxic with the left hand. By the eighth month she had good voluntary use of the left hand.
On the first postoperative day there was mumbling; on the second day there was intelligible speech; and on the third day the patient was oriented for place but did not recognize her husband. Disorientation for time persisted for two weeks. Difficulty in the recall of recent events continued for many weeks.
A seizure occurred on the sixth day after operation, with clonic spasms of the right side of the face and the right arm and leg, which lasted for 30 seconds. At this time the patient was receiving diphenylhydantoin (Dilantin), 100 mg, and phenobarbital, 30 mg, every six hours. Episodes of right-sided clonic spasms became more frequent as anticonvulsants were withdrawn between the 20th, and 26th days. There were occasional dreamy states lasting several minutes. Thirty-three days after operation, the patient had a generalized convulsion. Anticonvulsants were reinstituted after a second generalized convulsion occurred on the 40th day, and there has been no convulsion since. The patient has continued taking diphenylhydantoin, 100 mg, as well as mephobarbital (Mebaral), 100 mg, both three times daily. During the first year, she often complained of numbness of the left side lasting a few minutes, but in the second year only once.
Comment
The patient's spells often began in the fashion of an "essential" grand mal with sudden emergence of a bilateral convulsion. However, temporal-lobe epilepsy is suggested by the occasional occurrence of "blank staring," occasional fugue states, and the 1952 EEG showing a left temporal focus. A third diagnosis is suggested by the presence of calcification beneath the right central cortex, combined with the "strange feelings" in the left side of the body. In conclusion, there is a suspicion of a seizure diathesis as well as evidence of multiple foci. Since convulsions occurred when medicines were withdrawn in the hospital, the operation has 'evidently potentiated the effect of the medicines, rather than abolished the neural basis for generalized convulsions.
Like the patient of the previous study,8 the patient described herein has cooperated in an extensive program of special testing aimed at delineating the functional syndrome of hemispheric disconnection. These tests have been conducted mainly by Gazzaniga and Sperry in the Laboratories of Psychobiology at the California Institute of Technology and reported in detail elsewhere.'-" Generally the results in this case, even more than in the earlier case,3 show a remarkable absence of functional impairment in nearly all ordinary behavior. Overall intelligence was minimally affected. However, under special conditions in which the activity of the two hemispheres can be separately tested, it is possible to demonstrate a variety of hemispheric disconnection deficits basically similar to those seen in animal studies,''" with certain additional features associated with speech and other lateral Specialization. Geschwind has published a survey of clinical literature from a perspective similar to ours (both stemming from the animal experiments of Sperry and his coworkers' '').
Like the patient of the earlier report," the patient described herein can do any activity with the right hand upon verbal request. If an object is placed in her left hand while she is blindfolded, although she cannot name the object, she can use it in an appropriate fashion. She is now able to carry out verbal commands with her left hand or left leg, while this still presents difficulties for the patient of the previous report.8 Inability to write with the left hand persisted only six months, whereas it is still characteristic of the other patient. Whereas he has been unable to localize any stimulus on the left side, except perhaps that of deep pressure,' she can localize even a light stimulus on the left torso and proximal limb parts, 'but she is unable to identify individual fingertips.
This patient, like the other one, also shows failure to notice stimuli on the left side of the body if her attention is occupied with some task involving the right hand." When the patient (her left hemisphere dominant) is asked about activities that have just been carried out successfully by the left hand, she sometimes cannot recall them.
The most striking difference between the present case and the case reported earlier with visualized cortical damage, is the degree of control which each hemisphere has acquired over the ipsilateral hand." Furthermore, there has been a gradual improvement in ipsilateral control that may be to some extent attributed to the frequent testing and reeducation. The patient now regularly uses the left hand at will, and this degree of control perhaps also accounts for her not having the difficulty with antagonistic movements between the two sides that was so characteristic of the earlier patient.
Summary
Amelioration of a convulsive disorder in a 30year-old woman was achieved by division of the cerebral commissures. Her personality and ordinary behavior were unaffected, but special tests showed the presence of deficits in interhemispheric integration.
Harry Edwards, PhD, administered the preoperative and postoperative intelligence tests.
Generic and Trade Names of Drug Ethosuximide-Zarontin.
References
1. Van Wagenen, W.P., and Herren, R.Y.: Surgical Division of Commissural Pathways in the Corpus Callosum, Arch Neurol Psychist 44r740-7ss (Oct) 1940.
2. Akelaitis, A.J.: A Study of Gnosis, Praxis, and Language Following Section of the Corpus Callosun and Anterior Commissure, J Neurosurg 1:94-102 (March) 1944.
3. Bogen, J.E., and Vogel, P.J.: Cerebral Commissurotomy in Man: Preliminary Case Report, Bull Los Angeles Neurol Soc 21:169-172 (Dec) 19M.
4.Gazzaniga, MS; Bogen, J.E.; and Sperry, R.W.: Some Functional gtfects of Sectioning the Cerebral Commissures in Man, Proc Not Acod Sci USA 48:1765-1769 (Oct) 1962.
5. Gazzaniga, M.S.; Bogen, JE.; and Sperry, R.W.: Laterality Effects in Somesthesis Following Cerebral Commissurotomy in Man, Neuropsychologio 1:209-216 (Dec) 1963.
6. Gazumip, M.S.; Bogen, J.E.; and Sperry, R.W.: Observations on Visual Perception After Diacornexion of the Cerebral Hemispheres in Man, Brain s8(pt a): 221-236, 1965.
7. Sperry, R.W.: Some Developments in Brain Lesion Studies of Learning, Fed Proc 20:609-616 (July, pt 1) 1961.
8. Sperry, R.W.: The Great Cerebral Commissure, Sci Amer 210:42-52 (Jan) 1964.
9. Geschwind, N.: Disconne·ion Syndromes in Animals and Man, Brain 8s(pt 2): 237-294, 1985.