Surgical techniques for the treatment of temporal lobe epilepsy

Abstract

Temporal lobe epilepsy (TLE) is the most common form of medically intractable epilepsy. Advances in electrophysiology and neuroimaging have led to a more precise localization of the epileptogenic zone within the temporal lobe. Resective surgery is the most effective treatment for TLE. Despite the variability in surgical techniques and in the extent of resection, the overall outcomes of different TLE surgeries are similar. Here, we review different surgical interventions for the management of TLE.

Figure 1

((a) and (b)) Coronal T2 and FLAIR magnetic resonance image (MRI) respectively depicting a left mesial temporal sclerosis. (c) Coronal T2 MRI depicting hippocampectomy site after selective amygdalohippocampectomy on left and temporal gyri (superior (T1), middle (T2), and inferior (T3) gyri, the fusiform gyrus (T4), and the parahippocampal gyrus (T5)) on right side.

Figure 2

MRI coronal inversion recovery image (right) at the level of optic tract ((a), blue line) depicting the anatomical relationship of the amygdala to the optic tract (b).

Figure 3

Surgical specimen photographs of the hippocampus and amygdala. The brownish color of the amygdala tissue is noted.

Figure 4

Intraoperative photographs showing (a) the dissection of the fimbria to expose the choroidal point. (b) Postresection of the uncus and amygdala showing the third cranial nerve, brainstem, PCA (posterior cerebral artery), and the tentorial edge.

Figure 5

Intraoperative photographs demonstrating pre and post resection for right anterior temporal lobectomy.

Figure 6

Snapshot from neuronavigation showing the entry point through the middle temporal gyrus and the trajectory toward the temporal horn ((a) and (b)). ((c) and (d)) showed the posterior extent of mesial temporal structures resection at the level of quadrigeminal plate.

Figure 7

(a) Intraoperative photograph showing site of skin incision for selective amygdalohippocampectomy. (b) Minicraniotomy and dura exposure. (c) Corticectomy at middle temporal gyrus (T2). (d) Transcortical access to temporal horn. (e) Hippocampus exposure. (f) Postoperative sagittal T2 MRI depicting the transcortical access through middle temporal gyrus.

Figure 8

Diagram representing transcortical selective amygdalohippocampectomy approach.