Modified approach for the selective treatment of temporal lobe epilepsy: transsylvian—transcisternal mesial en bloc resection

Restricted access

Object. The authors propose a novel surgical approach for amygdalohippocampectomy (AH) in patients with temporal lobe epilepsy. Via a transsylvian—transcisternal route, the parahippocampal gyrus is directly exposed from its medial aspect, thus allowing a standardized en bloc resection of the temporomesial epileptogenic structures—the amygdala, anterior hippocampus, parahippocampal gyrus, and subiculum. Additional anatomical studies have been performed for standardization of this approach.

Methods. From 1990 to 1996, 32 patients presenting with medically intractable mesial temporal lobe epilepsy underwent AH via the transsylvian—transcisternal approach. Preoperative computerized tomography and magnetic resonance imaging revealed temporomesial lesions in 16 patients. Histopathological examination revealed cavernous malformations in seven patients, low-grade astrocytomas in four, hamartomas in three, and gangliogliomas in two patients. Specimens obtained in patients with no lesions were diagnosed as hippocampal sclerosis in all cases. No patient experienced permanent morbidity. Nine percent of the patients developed a temporary partial oculomotor nerve palsy. Only one patient developed a postoperative visual field deficit with a contralateral quadrantanopsia. With respect to seizure outcome, all patients benefited from surgery. At follow-up evaluation (mean 26.4 months), 80% of the patients were free from seizures (Engel Class I). Eight patients in this group were no longer receiving medication. Seventeen percent had experienced only one to several seizures since surgery (Engel Class II) and 3% reported a worthwhile improvement (Engel Class III).

Conclusions. In contrast to previously described standard techniques for AH, the transsylvian—transcisternal approach presented in this study offers improved anatomical orientation and intraoperative control over the mesial temporal lobe and preserves the lateral as well as the laterobasal temporal lobe.

Article Information

Address reprint requests to: Peter Vajkoczy, M.D., Department of Neurosurgery, Klinikum Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1–3, 68167 Mannheim, Germany.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Intraoperative photographs and artist's illustrations showing the surgical procedure used for the transsylvian—transcisternal approach. A and B: After opening the basal cisterns, the A1 segment of the anterior cerebral artery (A1), the ipsilateral optic nerve (N. II), the internal carotid artery (ICA), and the oculomotor nerve (N. III) can be identified during gentle retraction of the temporal pole. C and D: The sphenoidal compartment of the sylvian fissure is opened, thus exposing the M1 segment (M1) with its early dorsolateral branches (asterisk) and the proximal M2 segment of the middle cerebral artery. E and F: After careful dissection of the arachnoid tunnel, which repesents the lateral duplicate extension of Liliequist's membrane (LM), N. III is exposed from its interpeduncular origin to its dural exit into the cavernous sinus. After opening the ambient cistern and mobilizing the mesial temporal lobe, excellent exposure of the parahippocampal gyrus (PHG) is obtained. PCA = posterior cerebral artery. G and H: Posteroinferior view over the mesial temporal lobe with the temporal pole retracted, showing the sulcal (rhinal sulcus [RS]) and gyral topographic anatomy, the projection of the distinct architectonic areas (perirhinal cortex (filled circles), entorhinal cortex (asterisks), uncus (plus signs, in part covered by branches of the middle cerebral artery), and posterior parahippocampal cortex (open circles) of the parahippocampal gyrus, as well as the amygdala (green area), hippocampus (red area), and temporal horn (blue area). In this intraoperative view, N. III is covered by a rubber dam to protect it from mechanical irritation. The interrupted line illustrates the extent of the en bloc resection (limited laterally by the temporal horn and posteriorly by the midmesencephalic level). The “midmesencephalon,” that is, the posterior limit of the resection, is identified by arrows. I and J: View over the floor of the middle fossa after temporomesial en bloc resection and hemostasis. The midmesencephalon is identified by arrows.

  • View in gallery

    Schematic drawing showing temporomesial region distances measured on axial sections through 10 adult human cadaver hemispheres. S–V = rhinal sulcus to tip of temporal horn; P–V = temporal pole to tip of temporal horn; P–M = temporal pole to midlevel of brainstem; V–M = tip of temporal horn to midlevel of brainstem. Shaded area represents extent of temporomesial en bloc resection.

  • View in gallery

    Preoperative and postoperative MR images obtained in a 27-year-old patient with intractable complex partial epilepsy and a temporomesial low-grade astrocytoma on the left side. A: Preoperative axial T2-weighted image showing small lesion within the left mesial temporal lobe. B–D: Postoperative T1-weighted images of axial (B), coronal (C), and sagittal (D) sections. E: Postoperative axial T2-weighted image. Note radiographically documented preservation of the lateral and laterobasal temporal cortices as well as of the temporal stem.

References

1.

Andermann F: Identification of candidates for surgical treatment of epilepsy in Engel J Jr (ed): Surgical Treatment of the Epilepsies. New York: Raven Press1987 pp 5170Andermann F: Identification of candidates for surgical treatment of epilepsy in Engel J Jr (ed): Surgical Treatment of the Epilepsies. New York: Raven Press 1987 pp 51–70

2.

Awad IARosenfeld JAhl Jet al: Intractable epilepsy and structural lesions of the brain: mapping, resection strategies, and seizure outcome. Epilepsia 32:1791861991Awad IA Rosenfeld J Ahl J et al: Intractable epilepsy and structural lesions of the brain: mapping resection strategies and seizure outcome. Epilepsia 32:179–186 1991

3.

Bear JLothmann EW: An in vitro study of focal epileptogenesis in combined hippocampal-parahippocampal slices. Epilepsy Res 14:1831931993Bear J Lothmann EW: An in vitro study of focal epileptogenesis in combined hippocampal-parahippocampal slices. Epilepsy Res 14:183–193 1993

4.

Berkovic SFAndermann FOlivier Aet al: Hippocampal sclerosis in temporal lobe epilepsy demonstrated by magneteic resonance imaging. Ann Neurol 29:1751821991Berkovic SF Andermann F Olivier A et al: Hippocampal sclerosis in temporal lobe epilepsy demonstrated by magneteic resonance imaging. Ann Neurol 29:175–182 1991

5.

Cascino GD: How has neuroimaging improved patient care? Epilepsia 35 (Suppl 6):S103S1071994Cascino GD: How has neuroimaging improved patient care? Epilepsia 35 (Suppl 6):S103–S107 1994

6.

Cascino GDKelly PJSharbrough FWet al: Long-term follow-up of stereotactic lesionectomy in partial epilepsy: predictive factors and electroencephalographic results. Epilepsia 33:6396441992Cascino GD Kelly PJ Sharbrough FW et al: Long-term follow-up of stereotactic lesionectomy in partial epilepsy: predictive factors and electroencephalographic results. Epilepsia 33:639–644 1992

7.

Dasheiff RM: Epilepsy surgery: is it an effective treatment? Ann Neurol 25:5065101989Dasheiff RM: Epilepsy surgery: is it an effective treatment? Ann Neurol 25:506–510 1989

8.

Ebeling UReulen HJ: Neurosurgical topography of the optic radiation in the temporal lobe. Acta Neurochir 92:29361988Ebeling U Reulen HJ: Neurosurgical topography of the optic radiation in the temporal lobe. Acta Neurochir 92:29–36 1988

9.

Engel J JrShewmon DA: Who should be considered a surgical candidate? in Engel J Jr (ed): Surgical Treatment of the Epilepsiesed 2. New York: Raven Press1993 pp 2334Engel J Jr Shewmon DA: Who should be considered a surgical candidate? in Engel J Jr (ed): Surgical Treatment of the Epilepsies ed 2. New York: Raven Press 1993 pp 23–34

10.

Engel J JrVan Ness PCRassmussen TBet al: Outcome with respect to epileptic seizures in Engel J Jr (ed): Surgical Treatment of the Epilepsiesed 2. New York: Raven Press1993 pp 609621Engel J Jr Van Ness PC Rassmussen TB et al: Outcome with respect to epileptic seizures in Engel J Jr (ed): Surgical Treatment of the Epilepsies ed 2. New York: Raven Press 1993 pp 609–621

11.

Falconer MASerafetinides EACorsellis JAN: Etiology and pathogenesis of temporal lobe epilepsy. Arch Neurol 10:2332481964Falconer MA Serafetinides EA Corsellis JAN: Etiology and pathogenesis of temporal lobe epilepsy. Arch Neurol 10:233–248 1964

12.

Feindel WRasmussen T: Temporal lobectomy with amygdalectomy and minimal hippocampal resection: review of 100 cases. Can J Neurol Sci 18 (Suppl 4):6036051991Feindel W Rasmussen T: Temporal lobectomy with amygdalectomy and minimal hippocampal resection: review of 100 cases. Can J Neurol Sci 18 (Suppl 4):603–605 1991

13.

Fried IKim JHSpencer DD: Hippocampal pathology in patients with intractable seizures and temporal lobe masses. J Neurosurg 76:7357401992Fried I Kim JH Spencer DD: Hippocampal pathology in patients with intractable seizures and temporal lobe masses. J Neurosurg 76:735–740 1992

14.

Gibo HCarver CCRhoton ALet al: Microsurgical anatomy of the middle cerebral artery. J Neurosurg 54:1511691981Gibo H Carver CC Rhoton AL et al: Microsurgical anatomy of the middle cerebral artery. J Neurosurg 54:151–169 1981

15.

Goldring SEdwards IHarding GWet al: Results of anterior temporal lobectomy that spares the amygdala in patients with complex partial seizures. J Neurosurg 77:1851931992Goldring S Edwards I Harding GW et al: Results of anterior temporal lobectomy that spares the amygdala in patients with complex partial seizures. J Neurosurg 77:185–193 1992

16.

Goncalves-Ferreira AMiguens JFarias JPet al: Selective amygdalohippocampectomy: which route is the best? An experimental study in 80 cerebral hemispheres. Stereotact Funct Neurosurg 63:1821911994Goncalves-Ferreira A Miguens J Farias JP et al: Selective amygdalohippocampectomy: which route is the best? An experimental study in 80 cerebral hemispheres. Stereotact Funct Neurosurg 63:182–191 1994

17.

Hori TTabuchi SKurosaki Met al: Subtemporal amygdalohippocampectomy for treating medically intractable temporal lobe epilepsy. Neurosurgery 33:50571993Hori T Tabuchi S Kurosaki M et al: Subtemporal amygdalohippocampectomy for treating medically intractable temporal lobe epilepsy. Neurosurgery 33:50–57 1993

18.

Jack CRNichols DASharbrough FWet al: Selective posterior cerebral artery injection of amytal: new method of preoperative memory testing. Mayo Clin Proc 64:9659751989Jack CR Nichols DA Sharbrough FW et al: Selective posterior cerebral artery injection of amytal: new method of preoperative memory testing. Mayo Clin Proc 64:965–975 1989

19.

Jooma RYeh HSPrivitera MDet al: Lesionectomy versus electrophysiologically guided resection for temporal lobe tumors manifesting with complex partial seizures. J Neurosurg 83:2312361995Jooma R Yeh HS Privitera MD et al: Lesionectomy versus electrophysiologically guided resection for temporal lobe tumors manifesting with complex partial seizures. J Neurosurg 83:231–236 1995

20.

Kelly PJSharbrough FWKail BAet al: Magnetic resonance imaging-based computer-assisted stereotactic resection of the hippocampus and amygdala in patients with temporal lobe epilepsy. Mayo Clin Proc 62:1031081987Kelly PJ Sharbrough FW Kail BA et al: Magnetic resonance imaging-based computer-assisted stereotactic resection of the hippocampus and amygdala in patients with temporal lobe epilepsy. Mayo Clin Proc 62:103–108 1987

21.

Kraemer DLAwad IA: Vascular malformations and epilepsy: clinical considerations and basic mechanisms. Epilepsia 35 (Suppl 6):S30S431994Kraemer DL Awad IA: Vascular malformations and epilepsy: clinical considerations and basic mechanisms. Epilepsia 35 (Suppl 6):S30–S43 1994

22.

Lévesque MFNakasato NVinter SHVet al: Surgical treatment of limbic epilepsy associated with extrahippocampal lesions: the problem of dual pathology. J Neurosurg 75:3643701991Lévesque MF Nakasato N Vinter SHV et al: Surgical treatment of limbic epilepsy associated with extrahippocampal lesions: the problem of dual pathology. J Neurosurg 75:364–370 1991

23.

Nayel MHAwad IALuders H: Extent of mesiobasal resection determines outcome after temporal lobectomy for intractable complex partial seizures. Neurosurgery 29:55611991Nayel MH Awad IA Luders H: Extent of mesiobasal resection determines outcome after temporal lobectomy for intractable complex partial seizures. Neurosurgery 29:55–61 1991

24.

Niemeyer P: The transventricular amygdalo-hippocampectomy in the temporal lobe epilepsy in Baldwin MBailey P (eds): Temporal Lobe Epilepsy. Springfield, Ill: Charles C Thomas1958 pp 461482Niemeyer P: The transventricular amygdalo-hippocampectomy in the temporal lobe epilepsy in Baldwin M Bailey P (eds): Temporal Lobe Epilepsy. Springfield Ill: Charles C Thomas 1958 pp 461–482

25.

Ojemann GADodrill CB: Verbal memory deficits after left temporal lobectomy for epilepsy. Mechanism and intraoperative prediction. J Neurosurg 62:1011071985Ojemann GA Dodrill CB: Verbal memory deficits after left temporal lobectomy for epilepsy. Mechanism and intraoperative prediction. J Neurosurg 62:101–107 1985

26.

Okuma TKumashiro H: Natural history and prognosis of epilepsy in Wada JAPenry JK (eds): The Xth Epilepsy International Symposium. Advances in Epileptology. New York: Raven Press1980 pp 135141Okuma T Kumashiro H: Natural history and prognosis of epilepsy in Wada JA Penry JK (eds): The Xth Epilepsy International Symposium. Advances in Epileptology. New York: Raven Press 1980 pp 135–141

27.

Olivier A: Temporal resections in the surgical treatment of epilepsy in Theodore WH (ed): Surgical Treatment of Epilepsy. Amsterdam: Elsevier1992 pp 175188Olivier A: Temporal resections in the surgical treatment of epilepsy in Theodore WH (ed): Surgical Treatment of Epilepsy. Amsterdam: Elsevier 1992 pp 175–188

28.

Olivier AAndermann FDubeau F: Transsulcal selective amygdalohippocampectomy for mesial temporal epilepsy: surgical technique and results. J Neurosurg 82:360A1995 (Abstract)Olivier A Andermann F Dubeau F: Transsulcal selective amygdalohippocampectomy for mesial temporal epilepsy: surgical technique and results. J Neurosurg 82:360A 1995 (Abstract)

29.

Park TSBourgeois BFDSilbergeld DLet al: Subtemporal transparahippocampal amygdalaohippocampectomy for surgical treatment of mesial temporal lobe epilepsy. J Neurosurg 85:117211761996Park TS Bourgeois BFD Silbergeld DL et al: Subtemporal transparahippocampal amygdalaohippocampectomy for surgical treatment of mesial temporal lobe epilepsy. J Neurosurg 85:1172–1176 1996

30.

Renowden SAMatkovic ZAdams CBTet al: Selective amygdalohippocampectomy for hippocampal sclerosis: postoperative MR appearance. AJNR 16:185518611995Renowden SA Matkovic Z Adams CBT et al: Selective amygdalohippocampectomy for hippocampal sclerosis: postoperative MR appearance. AJNR 16:1855–1861 1995

31.

Reynolds EH: Early treatment and prognosis of epilepsy. Epilepsia 28:971061987Reynolds EH: Early treatment and prognosis of epilepsy. Epilepsia 28:97–106 1987

32.

Ribak CEHarris ABVaughn JEet al: Inhibitory, GABAergic nerve terminals decrease at sites of focal epilepsy. Science 205:2112141979Ribak CE Harris AB Vaughn JE et al: Inhibitory GABAergic nerve terminals decrease at sites of focal epilepsy. Science 205:211–214 1979

33.

Rougier ASaint-Hilaire JMBouvier Get al: Evaluation and surgical treatment of the epilepsies. Neurochirurgie 38 (Suppl 1):31121992Rougier A Saint-Hilaire JM Bouvier G et al: Evaluation and surgical treatment of the epilepsies. Neurochirurgie 38 (Suppl 1):3–112 1992

34.

Schäffler LLüders HOMorris HH IIIet al: Anatomic distribution of cortical language sites in the basal temporal language area in patients with left temporal lobe epilepsy. Epilepsia 35:5255281994Schäffler L Lüders HO Morris HH III et al: Anatomic distribution of cortical language sites in the basal temporal language area in patients with left temporal lobe epilepsy. Epilepsia 35:525–528 1994

35.

Shimizu HSuzuki IIshijima B: Zygomatic approach for resection of mesial temporal epileptic focus. Neurosurgery 25:7988011989Shimizu H Suzuki I Ishijima B: Zygomatic approach for resection of mesial temporal epileptic focus. Neurosurgery 25:798–801 1989

36.

Siegel AMWieser HGWichmann Wet al: Relationships between MR-imaged total amount of tissue removed, resection scores of specific mediobasal limbic sub-compartments and clinical outcome following selective amygdalohippocampectomy. Epilepsy Res 6:56651990Siegel AM Wieser HG Wichmann W et al: Relationships between MR-imaged total amount of tissue removed resection scores of specific mediobasal limbic sub-compartments and clinical outcome following selective amygdalohippocampectomy. Epilepsy Res 6:56–65 1990

37.

Spencer DDSpencer SS: Surgery for epilepsy. Neurol Clin 3:3133301985Spencer DD Spencer SS: Surgery for epilepsy. Neurol Clin 3:313–330 1985

38.

Van Buren JMBaldwin M: The architecture of the optic radiation in the temporal lobe of man. Brain 81:15401958Van Buren JM Baldwin M: The architecture of the optic radiation in the temporal lobe of man. Brain 81:15–40 1958

39.

Yaşargil MGTeddy PJRoth P: Selective amygdalo-hippocampectomy. Operative anatomy and surgical technique. Adv Tech Stand Neurosurg 12:931231985Yaşargil MG Teddy PJ Roth P: Selective amygdalo-hippocampectomy. Operative anatomy and surgical technique. Adv Tech Stand Neurosurg 12:93–123 1985

40.

Yaşargil MGWieser HGValavanis Aet al: Surgery and results of selective amygdalo-hippocampectomy in one hundred patients with nonlesional limbic epilepsy. Neurosurg Clin North Am 4:2432611993Yaşargil MG Wieser HG Valavanis A et al: Surgery and results of selective amygdalo-hippocampectomy in one hundred patients with nonlesional limbic epilepsy. Neurosurg Clin North Am 4:243–261 1993

41.

Yeh HSTew JMGartner M: Seizure control after surgery on cerebral arteriovenous malformations. J Neurosurg 78:12181993Yeh HS Tew JM Gartner M: Seizure control after surgery on cerebral arteriovenous malformations. J Neurosurg 78:12–18 1993

42.

Zeintl WRTompkins KMessmer Ket al: Static and dynamic microcirculatory video image analysis applied to clinical investigations. Progr Appl Microcirc 11:1101986Zeintl WR Tompkins K Messmer K et al: Static and dynamic microcirculatory video image analysis applied to clinical investigations. Progr Appl Microcirc 11:1–10 1986

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 7 7 6
Full Text Views 98 98 29
PDF Downloads 71 71 20
EPUB Downloads 0 0 0

PubMed

Google Scholar