van Rijckevorsel should be used with caution because of the risk of worsening the status or precipitating tonic SE. EEG monitoring is recommended, especially if the patient does not recover consciousness. Non-convulsive SE may require special management, such as corticoids or a ketogenic diet (Dan and Boyd 2005). Surgical treatment Generalized symptomatic epilepsies with bilateral EEG abnormalities may be secondary to a focal lesion and be improved by surgery (Wyllie et al 2007). Because of refractoriness to medical treatment and severity of seizures, various surgical procedures, even in cryptogenic cases, have been developed to treat epileptic drop attacks, the most devastating seizures, including callosotomy, (multi)lobar disconnection, multiple subpial transections (Patil et al 2004) or protocols of vagus nerve or deep brain stimulation. Furthermore, early surgery may improve the global prognosis of these children (Liu et al 2007). Callosotomy First described in 1940 by Van Wagenen and Herren, and previously recommended for epileptic drop attacks (tonic, atonic seizures) (Purves et al 1988; Nordgren et al 1991) callosotomy shows a lower efﬁcacy for tonic-clonic seizures and is still considered as a palliative treatment. Early cases encountered severe complications, including hemispheric edema, mesial hemisphere infarcts, even death. Progress in new microsurgical techniques dramatically improved the safety of callosotomy. Complete callosotomy is recommended for children with severe mental handicap (Rathore et al 2007) while a two-third or three-fourth anterior disconnection is preferred in later onset LGS or in crypto- genic cases with moderate mental handicap. Nevertheless, acute disconnection syndrome (reduction in verbal output, urinary incontinence, apathy, hemineglect) or callosal split syndrome (intermanual conﬂict) may occur, temporarily for a few weeks or for more prolonged periods. Worsening of focal seizures may occur postoperatively. Determinants of seizure outcome vary from one study to another. A better outcome has been related to the absence of focal abnormalities (Cukiert et al 2006), and a worse outcome to drop attacks associated with focal cerebral abnormality, to a greater mean duration of drop attacks, and to the presence of SW on EEG (Reutens et al 1993). Atypical absences have been noted to be dramatically improved in some reports (Machara et al 1996) but poorly inﬂuenced in other reports. 1012 The degree of signiﬁcant improvement reported after callosotomy is highly variable, depending on the time of publication, the extent of disconnection, the selection of patients, the seizure type analyzed and so on. About two-thirds of patients have been signiﬁcantly improved after callosotomy (Purves et al 1988; Rougier et al 1997; Kwam et al 2006; Cukiert et al 2006), but this improvement can be lost over time. Taken together, typical results consist of a (signiﬁcant) seizure reduction in 40% to 80% of patients, but speciﬁc effects on patients with LGS are rarely detailed. More recently, new surgical techniques, such as gamma knife (Pendl et al 1999; Eder et al 2006; Feichtinger et al 2006), have been developed for callosotomy (see below). Vagus nerve stimulation (VNS) VNS therapy was studied and approved in 1997 as add-on therapy in patients aged 12 years or older with refractory focal seizures. However, VNS should only be considered for patients who have been rejected for surgery or after surgery failure. There is however one exception to this general rule: VNS is now recommended before callosotomy. This recommendation is essentially based on subjective data but above all because VNS is fully reversible with fewer surgical risks compared to callosotomy. Nonetheless, failure in one option can be improved by the second option, whatever the order. Both techniques are considered as palliative treatments and seem to have equal efﬁcacy (Karceski 2001; You et al 2007b) even if results are difﬁcult to analyze because of the multitude of different parameters. Only a few adverse events related to surgery or to the device and stimulation have been reported, including infection, transient pain, voice alteration, and increased coughing as for other implanted patients. However, special care should be taken with patients who have swallowing difﬁculties, as stimulation may cause dysphagia and/or excessive salivation. In LGS, VNS shows a 24%–42% global seizure reduction (Horning et al 1997; Lundgren et al 1998; Ben-Menachem et al 1999; Parker et al 1999; Hosain et al 2000; Frost et al 2001; Aldemkamp et al 2002; Rychlicki et al 2006) with rare patients becoming seizure free (Parker et al 1999; Majoie et al 2001; Alexopoulos et al 2006). Some studies analyzed results from refractory childhood epilepsy including LGS, and it is not always possible to isolate data speciﬁc for LGS (Lundgren et al 1998; Parker et al 1999; Rychlicki et al 2006). Results seem better in the group with less mental Neuropsychiatric Disease and Treatment 2008:4(6)