Temporopolar amygdalohippocampectomy: seizure control and postoperative outcomes

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  • 1 Neuroimaging Laboratory (LNI), Department of Neurology,
  • 2 Divisions of Neurosurgery and
  • 3 Clinical Neurology,
  • 4 Department of Ophthalmology, and
  • 5 Department of Anatomical Pathology, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
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OBJECTIVE

The objective of this study was to evaluate the efficacy and safety of a modified surgical approach for the treatment of temporal lobe epilepsy secondary to hippocampal sclerosis (HS). This modified approach, called temporopolar amygdalohippocampectomy (TP-AH), includes a transsylvian resection of the temporal pole and subsequent amygdalohippocampectomy utilizing the limen insula as an anatomical landmark.

METHODS

A total of 61 patients who were diagnosed with HS and underwent TP-AH between 2013 and 2017 were enrolled. Patients performed pre- and postoperative diffusion tensor imaging and were classified according to Engel’s scale for seizure control. To evaluate the functional preservation of the temporal stem white-matter fiber tracts, the authors analyzed postoperative Humphrey perimetries and pre- and postoperative neurocognitive performance (Rey Auditory Verbal Learning Test [RAVLT], Weschler Memory Scale–Revised [WMS-R], intelligence quotient [IQ], Boston Naming Test [BNT], and semantic and phonemic fluency). Demographic data and surgical complications were also recorded and described.

RESULTS

After a median follow-up of 36 ± 16 months, 46 patients (75.4%) achieved Engel class I, of whom 37 (60.6%) were Engel class IA. No significant changes in either the inferior frontooccipital fasciculus and optic radiation tractography were observed postoperatively for both left- and right-side surgeries. Reliable perimetry was obtained in 40 patients (65.6%), of whom 27 (67.5%) did not present any visual field defects (VFDs) attributable to surgery, while 12 patients (30%) presented with quadrant VFD, and 1 patient (2.5%) presented with hemifield VFD. Despite a significant decline in verbal memory (p = 0.007 for WMS-R, p = 0.02 for RAVLT recognition), there were significant improvements in both IQ (p < 0.001) and visual memory (p = 0.007). Semantic and phonemic fluency, and scores on the BNT, did not change postoperatively.

CONCLUSIONS

TP-AH provided seizure control similar to historical temporal lobe approaches, with a tendency to preserve the temporal stem and a satisfactory incidence of VFD. Despite a significant decline in verbal memory, there were significant improvements in both IQ and visual memory, along with preservation of executive function. This approach can be considered a natural evolution of the selective transsylvian approach.

ABBREVIATIONS AD = axial diffusivity; ATL = anterior temporal lobectomy; BNT = Boston Naming Test; DTI = diffusion tensor imaging; EZ = epileptogenic zone; FA = fractional anisotropy; HS = hippocampal sclerosis; IFOF = inferior frontooccipital fasciculus; IQ = intelligence quotient; MCA = middle cerebral artery; MD = mean diffusivity; MTLE = mesial TLE; OR = optic radiation; RAVLT = Rey Auditory Verbal Learning Test; RD = radial diffusivity; TLE = temporal lobe epilepsy; TP-AH = temporopolar amygdalohippocampectomy; TS = temporal stem; UF = uncinate fasciculus; VFD = visual field defect; WAIS-R = Weschler Adult Intelligence Scale–Revised; WMS-R = Weschler Memory Scale–Revised.

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Contributor Notes

Correspondence João Paulo Sant Ana Santos de Souza: University of Campinas, São Paulo, Brazil. souza.medicine@gmail.com.

INCLUDE WHEN CITING Published online May 15, 2020; DOI: 10.3171/2020.3.JNS192624.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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