Reconsidering the Role of Sequelae in Posterior Callosotomy

Dear Editor,We read with interest the recent review by Mithani et al. [1] on contemporary disconnection and neuromodulation treatments for generalized drug-resistant epilepsy. The synthesis is both timely and comprehensive. The authors should be commended for their synthesis of current surgical strategies. However, we wish to contest the implication that posterior callosotomy is intrinsically associated with a higher risk of sequelae compared to anterior or total sectioning.Historically, concerns over disconnection syndromes – particularly those affecting motor and perceptual interhemispheric integration – have led many groups to favor anterior callosotomy while reserving posterior sectioning for salvage cases [2, 3]. While this rationale is understandable, recent evidence does not support the view that posterior callosotomy necessarily entails a greater burden of neurocognitive or behavioral sequelae. On the contrary, more recent data challenge the assumption that posterior callosotomy entails greater neurocognitive morbidity.Selective posterior callosotomy has demonstrated substantial efficacy in controlling drop attacks while sparing prefrontal connectivity and higher-order cognitive domains. Paglioli et al. [4] showed that posterior sectioning effectively abolished drop attacks with preservation of neuropsychological function. Subsequent work by Frigeri et al. [5] reinforced these findings, reporting significant seizure reduction with negligible persistent disconnection syndromes. Taken together, these series suggest that when anatomically tailored, posterior callosotomy achieves seizure control without introducing the classical deficits historically attributed to commissural disconnection.We, therefore, caution against perpetuating the assumption that posterior sectioning is inherently riskier than anterior approaches. Rather, contemporary evidence supports posterior callosotomy as a rational first-line strategy in carefully selected patients with generalized epilepsies characterized by drop attacks. Comparative prospective studies are warranted to better delineate efficacy and neurocognitive safety across anterior, complete, and posterior approaches.There was no funding source.E.P. and A.P. conceptualized this work. T.M.F., R.P., and E.C.-L. screened the literature for publications. W.A.M., V.Z., and F.S.M. drafted the initial version of the manuscript. E.P. and A.P. critically revised the manuscript.