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Subash Lohani, Joseph R. Madsen, Ann M. Bergin, and Edward R. Smith

The combination of moyamoya syndrome and symptomatic mesial temporal sclerosis (MTS) has not previously been reported. The authors present the case of a 5-year-old boy with symptomatic MTS who developed progressive moyamoya syndrome. This combination of progressive moyamoya and a structural seizure focus presented a unique clinical problem, with the natural history of MTS predicting a high likelihood of needing resection in the future, which could be challenging following any type of moyamoya-related revascularization surgery. In anticipation of this problem, the patient underwent resection of the right inferior and mesial temporal lobe followed by right pial synangiosis as a 1-day combined operation. Postoperatively he recovered well without any neurological deficits and had an uneventful hospital stay. This case of moyamoya is unique in its association with MTS, and for the simultaneous operations for pial synangiosis and temporal lobectomy, highlighting the importance of surgical planning in patients with dual pathological processes.

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Kostas N. Fountas, Ioannis Tsougos, Efstathios D. Gotsis, Stylianos Giannakodimos, Joseph R. Smith, and Eftychia Z. Kapsalaki

I t is widely accepted that MTLE constitutes the most common form of partial epilepsy in adults. 18 , 23 It has been estimated that approximately 20% of patients suffering from MTLE eventually develop medically refractory epilepsy. 6 Mesial temporal sclerosis represents one of the most common pathological entities responsible for MTLE. 19 , 24 , 26 The imaging and histopathological features of MTS regarding the hippocampus and the mesial temporal structures are well documented and have been extensively described in the literature. However, there is a

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Gloria J. Guzmán Pérez-Carrillo, Christopher Owen, Katherine E. Schwetye, Spencer McFarlane, Ananth K. Vellimana, Soe Mar, Michelle M. Miller-Thomas, Joshua S. Shimony, Matthew D. Smyth, and Tammie L. S. Benzinger

. Discussion Mesial temporal sclerosis is a known cause of intractable epilepsy in the pediatric population. It is a condition that affects the hippocampus, although it is not uniformly affected, with the dentate gyrus and the CA1, CA4, and CA3 (to a lesser degree) sections of the hippocampus being primarily involved. 4 Histologically, there is neuronal cell loss, gliosis, and sclerosis in the hippocampus ( Fig. 3 ). The sclerotic hippocampus is distinguished from the normal hippocampus by neuronal loss and gliosis, particularly in the CA1 subfield and the end folium of the

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Edwin Ramos, Selim Benbadis, and Fernando L. Vale

15 Gonzalez-Martinez JA , Srikijvilaikul T , Nair D , Bingaman WE : Long-term seizure outcome in reoperation after failure of epilepsy surgery . Neurosurgery 60 : 873 – 880 , 2007 16 Hardy SG , Miller JW , Holmes MD , Born DE , Ojemann GA , Dodrill CB , : Factors predicting outcome of surgery for intractable epilepsy with pathologically verified mesial temporal sclerosis . Epilepsia 44 : 565 – 568 , 2003 17 Hennessy MJ , Elwes RD , Binnie CD , Polkey CE : Failed surgery for epilepsy. A study of persistence and

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Matthew D. Smyth, David D. Limbrick Jr., Jeffrey G. Ojemann, John Zempel, Shenandoah Robinson, Donncha F. O'Brien, Russell P. Saneto, Monisha Goyal, Richard E. Appleton, Francesco T. Mangano, and Tae Sung Park

– 1649 , 2001 12 Ng YT , McGregor AL , Wheless JW : Magnetic resonance imaging detection of mesial temporal sclerosis in children . Pediatr Neurol 30 : 81 – 85 , 2004 13 Park TS , Bourgeois BF , Silbergeld DL , Dodson WE : Subtemporal transparahippocampal amygdalohippocampectomy for surgical treatment of mesial temporal lobe epilepsy. Technical note . J Neurosurg 85 : 1172 – 1176 , 1996 14 Porter BE , Judkins AR , Clancy RR , Duhaime A , Dlugos DJ , Golden JA : Dysplasia: a common finding in intractable pediatric

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Aimen Kasasbeh, Edward C. Hwang, Karen Steger-May, S. Kathleen Bandt, Amy Oberhelman, David Limbrick, Michelle M. Miller-Thomas, Joshua S. Shimony, and Matthew D. Smyth

A lthough its pathogenesis remains controversial, mesial temporal sclerosis is recognized as a significant underlying cause of childhood epilepsy of temporal lobe origin. 4 , 11 , 18 , 30 , 34 , 37–39 , 41 , 43 , 44 , 48 The prevalence of MTS in children is uncertain, although its reported prevalence among all brain MRI studies in children has been as high as 3.1%. 35 , 38 The proportion is considerably higher in pediatric patients with epilepsy, which has been reported to be as high as 57% in those who have undergone epilepsy surgery. 3 , 4 , 10 , 25

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Robert E. Elliott, Robert J. Bollo, Jonathan L. Berliner, Alyson Silverberg, Chad Carlson, Eric B. Geller, William B. Barr, Orrin Devinsky, and Werner K. Doyle

T emporal lobe epilepsy is the most frequent type of treatment-resistant epilepsy. 21 , 23 , 24 A randomized, controlled trial demonstrated the superior efficacy of surgery over prolonged medical therapy for TLE. 71 Mesial temporal sclerosis is the most common recognized cause of TLE, and rates of seizure freedom after surgery range from 60% to 90% in most studies. 7 , 14 , 19 , 56 , 71 However, there remains significant variation among centers in patient selection criteria 15 , 25 , 26 and surgical technique for the management of MTS. 7 , 20 , 55

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Arthur Cukiert, Jose Augusto Buratini, Elcio Machado, Alcione Sousa, Joaquim Vieira, Cassio Forster, Meire Argentoni, and Cristine Baldauf


The authors conducted a study to assess the efficacy of surgery in patients who underwent magnetic resonance (MR) imaging alone for localization of foci in temporal lobe epilepsy (TLE).


One hundred patients (43 men, 57 women) with a clinical diagnosis of TLE were prospectively studied (mean age 28 ± 9 years [± standard deviation {SD}]). All patients underwent high-resolution MR imaging, and in all unilateral mesial temporal sclerosis (MTS) was diagnosed by visual inspection. All patients underwent interictal pre-operative electroencephalography (EEG) and in 87 patients pre- and 1-year postoperative neuropsychological testing was performed. Both EEG and neuropsychological examinations were conducted in a blinded fashion, and these data were not taken into account during the surgery-related decision-making process. All patients underwent a corti-coamygdalohippocampectomy at the side of the MTS. Surgery-related outcome was rated as Class I (seizure free or simple partial seizures only) or Class II (⩾ 90% improvement). The follow-up period ranged from 18 to 48 months (mean 24 ± 5 months [±SD]). No patient underwent prolonged video-EEG monitoring, Wada testing, positron emission tomography, or single-photon emission computerized tomography.

In eighty-nine patients Class I results were achieved, and 11 Class II results were achieved postoperatively. There was no mortality in this series. Except for in two patients who underwent surgery in the dominant temporal lobe, there was no postoperatively cognitive decline. In these two patients verbal memory decline occurred, which was associated with posterior temporal cortical damage, demonstrated postoperatively on MR imaging. Twenty-five percent of the patients experienced improved memory function related to the nonoperated side, and 54% experienced a 10% gain in general intelligence quotient status.


In patients with clinically suspected TLE, MR imaging alone is able to localize temporal lobe foci correctly. Ruling out pseudoseizures remains the only indication for prolonged video-EEG recordings in this group of patients.

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Fernando L. Vale, Glen Pollock, and Selim R. Benbadis

epilepsy surgery . Neurosurgery 60 : 873 – 880 , 2007 16 Hardy SG , Miller JW , Holmes MD , Born DE , Ojemann GA , Dodrill CB , : Factors predicting outcome of surgery for intractable epilepsy with pathologically verified mesial temporal sclerosis . Epilepsia 44 : 565 – 568 , 2003 17 Hennessy MJ , Elwes RD , Binnie CD , Polkey CE : Failed surgery for epilepsy. A study of persistence and recurrence of seizures following temporal resection . Brain 123 : 2445 – 2466 , 2000 18 Hennessy MJ , Elwes RD , Rabe-Hesketh S

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Gary W. Mathern, James K. Pretorius, Thomas L. Babb, and Bruce Quinn

fiber sprouting typical of mesial temporal sclerosis (MTS). There was significant neuron loss in CA1, relative sparing of CA2, and an average overall neuron loss of 56%. The autopsy showed that the right hippocampus ( Fig. 4B ) had neuron loss that averaged 30%. However, the pattern was not typical for MTS in that the greatest neuron loss was in CA2, an unusual feature for this disease, and there was less loss in CA1 and prosubiculum than expected ( Fig. 4C ). Furthermore, only the surgically removed left hippocampus showed aberrant mossy fiber sprouting into the