Temporal lobe epilepsy surgery

see also epilepsy surgery.

Temporal lobe epilepsy surgery complications.

Patients who had a keyhole approach for temporal lobe epilepsy with over 2 years follow-up were compared with all patients who had selective amygdalohippocampectomy performed in a non-keyhole fashion over the same time period. Rates of seizure freedom were comparable in the 17 patients with keyhole surgery and the 34 individuals who had a non-keyhole approach. However, patients treated with keyhole surgery were discharged from the hospital earlier than non-keyhole patients (p=0.04), and with a shorter operative time (p=0.0001). The restricted keyhole surgical exposure has not limited the ability to perform surgery for temporal lobe epilepsy with favorable results on reducing the seizure tendency, and patients may be benefited by a minimal access technique with a more rapid recovery from surgery 1).

Yang et al. described operations they were performed through a 6-cm vertical linear incision and a low 2.5-cm keyhole craniotomy at the anterior squamous temporal bone. Resection of the anterior-most portions of the middle and inferior temporal gyri provided a cylinder-like corridor to the mesial temporal lobe. Identification of the temporal horn through a basal approach was followed by resection of the amygdala, uncus, and hippocampus-parahippocampal gyrus.

A 9-year series included 683 patients with a minimum follow-up duration of 2 years. Surgery times were short (range, 1 h 35 min to 2 h 30 min). Only a small percentage of patients had complications (1.76 %), and the rate of Engel Class I seizure-free outcome was 87 %. No overt speech problems or visual field deficits were identified. Compared with the most popular conventional trans-middle temporal gyrus approach, this technique can make the operation easier, safer, and less traumatic to functional lateral neocortex 2).

Magnetic resonance (MR)-guided stereotactic laser ablation

see Magnetic resonance guided laser induced thermal therapy for epilepsy.

Separately, Laser interstitial thermotherapy (LITT) has found a role in the treatment of temporal lobe epilepsy because it allows the creation of a precise lesion along the amygdala and hippocampus. Although seizure control rates appear to be somewhat inferior to open temporal lobectomy and selective amygdalohippocampectomy, the procedure is generally well tolerated, and because of its minimally invasive nature, it has the potential to reach a large segment of epilepsy patients who would be good surgical candidates but have shied away from open surgery.

Temporal lobectomy has long been established as a safe and effective treatment for refractory temporal lobe epilepsy 3).

Anterior temporal lobectomy is curative for many patients with disabling medically refractory temporal lobe epilepsy, but carries an inherent risk of disabling verbal memory loss. Although accurate prediction of iatrogenic memory loss is becoming increasingly possible, it remains unclear how much weight such predictions should have in surgical decision making.

For patients with left temporal lobe epilepsy, quantitative assessment of risk and benefit should guide recommendation of therapy. In particular, risk for and potential impact of verbal memory decline should be carefully weighed against the degree of disability conferred by continued seizures on a patient-by-patient basis 4).

The advantage of selective amygdalohippocampectomy (SAH) over anterior temporal lobectomy (ATL) for the treatment of temporal lobe epilepsy (TLE) remains controversial. Because ATL is more extensive and involves the lateral and medial parts of the temporal lobe, it may be predicted that its impact on memory is more important than SAH, which involves resection of medial temporal structures only. However, several studies do not support this assumption. Possible explanations include task-specific factors such as the extent of semantic and syntactic information to be memorized and failure to control for main confounders 5).

see Temporal lobe epilepsy surgery case series.

Boling W. Minimal access keyhole surgery for mesial temporal lobe epilepsy. J Clin Neurosci. 2010 Sep;17(9):1180-4. doi: 10.1016/j.jocn.2010.01.030. Epub 2010 Jun 11. PubMed PMID: 20541416.
Yang PF, Zhang HJ, Pei JS, Lin Q, Mei Z, Chen ZQ, Jia YZ, Zhong ZH, Zheng ZY. Keyhole epilepsy surgery: corticoamygdalohippocampectomy for mesial temporal sclerosis. Neurosurg Rev. 2015 Aug 16. [Epub ahead of print] PubMed PMID: 26277790.
Wiebe S, Blume WT, Girvin JP, Eliasziw M: A randomized, controlled trial of surgery for temporal lobe epilepsy. N Engl J Med 345:311–318, 2001
Akama-Garren EH, Bianchi MT, Leveroni C, Cole AJ, Cash SS, Westover MB. Weighing the value of memory loss in the surgical evaluation of left temporal lobe epilepsy: A decision analysis. Epilepsia. 2014 Sep 19. doi: 10.1111/epi.12790. [Epub ahead of print] PubMed PMID: 25244498.
Boucher O, Dagenais E, Bouthillier A, Nguyen DK, Rouleau I. Different effects of anterior temporal lobectomy and selective amygdalohippocampectomy on verbal memory performance of patients with epilepsy. Epilepsy Behav. 2015 Nov;52(Pt A):230-5. doi: 10.1016/j.yebeh.2015.09.012. PubMed PMID: 26469799.
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