Amygdalohippocampotomy: surgical technique and clinical results

Clinical article

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Object

The removal of mesial temporal structures, namely amygdalohippocampectomy, is the most efficient surgical procedure for the treatment of epilepsy. However, disconnection of the epileptogenic zones, as in temporal lobotomy or, for different purposes, hemispherotomy, have shown equivalent results with less morbidity. Thus, authors of the present study began performing selective amygdalohippocampotomy in cases of refractory mesial temporal lobe epilepsy (TLE) to treat mesial temporal lobe sclerosis (MTLS).

Method

The authors conducted a retrospective analysis of all cases of amygdalohippocampotomy collected in a database between November 2007 and March 2011.

Results

Since 2007, 21 patients (14 males and 7 females), ages 20–58 years (mean 41 years), all with TLE due to MTLS, were treated with selective ablation of the lateral amygdala plus perihippocampal disconnection (anterior one-half to two-thirds in dominant hemisphere), the left side in 11 cases and the right in 10. In 20 patients the follow-up was 2 or more years (range 24–44 months, average 32 months). Clinical outcome for epilepsy 2 years after surgery (20 patients) was good/very good in 19 patients (95%) with an Engel Class I (15 patients [75%]) or II outcome (4 patients [20%]) and bad in 1 patient (5%) with an Engel Class IV outcome (extratemporal focus and later reoperation).

Surgical morbidity included hemiparesis (capsular hypertensive hemorrhage 24 hours after surgery, 1 patient), verbal memory worsening (2 patients), and quadrantanopia (permanent in 2 patients, transient in 1). Late psychiatric depression developed in 3 cases. Operative time was reduced by about 30 minutes (15%) on average with this technique.

Conclusions

Amygdalohippocampotomy is as effective as amygdalohippocampectomy to treat MTLS and is a potentially safer, time-saving procedure.

Abbreviations used in this paper:AHC = amygdalohippocampectomy; AHCo = amygdalohippocampotomy; EEG = electroencephalography; MTLS = mesial temporal lobe sclerosis; TLE = temporal lobe epilepsy.

Article Information

Address correspondence to: A. Gonçalves-Ferreira, M.D., Ph.D., Department of Neurosurgery P6, University Hospital Santa Maria, Av. Egas Moniz, 1649-035 Lisbon, Portugal. email: ajgonfer@fm.ul.pt.

Please include this information when citing this paper: published online February 22, 2013; DOI: 10.3171/2013.1.JNS12727.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Microdissection photographs showing transventricular features of the mesial temporal region. a: View with hippocampus in situ. 1, fimbria; 2, hippocampus head; 3, hippocampus body; 4, choroidal plexus; 5, choroidal fissure. b: View after hippocampus removal. 4, choroidal plexus; 6, optic tract; 7, basal vein; 8, posterior cerebral artery; 9, basilar artery; 10, oculomotor nerve. c:Black line indicates perihippocampal disconnection. 1, fimbria; 2, hippocampus head; 3, hippocampus body; 4, choroidal plexus; 5, choroidal fissure.

  • View in gallery

    Illustration of the hippocampus and its main vessels. The zone spared from dissection via AHCo is lined in black and indicated by thick arrows; the dotted lines with arrows represent the hippocampal disconnection; and the gray shaded area corresponds to the amygdala superimposition. 1, hippocampus head; 2, hippocampus body; 3, hippocampus tail; 4, fimbria; 5, parahippocampus; 6, posterior cerebral artery; 7, basal vein of Rosenthal. Printed with the permission of Antonio Gonçalves-Ferreira, 2013.

  • View in gallery

    Postoperative sagittal (left) and coronal (right) MR images showing the disconnection cleft (arrows) created by the perihippocampal dissection.

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