Dilemmas in Temporal Lobe

Epilepsy Surgery

Dr Dilip S Kiyawat
Epilepsy Guidance Clinic
Jehangir Hospital
Pune
 Is he a surgical candidate
• Intractability
• szrs not controlled after adequate trial with 3
first line AEDs including polytherapy.
• Determine how the szrs affect the pts QOL

• Concordance
• EEG, MRI, Neuropsycology and seizure
semiology
 What age to select
• Effects of repeated seizures on the brain
• It takes about 20 years to recognize
• Surgery as the last resort
• Addition of 4th AED helps only 5% of
patients
Seizures Affect Other Areas of Brain

Surgical resection of these areas have not only abolished recurrent fits
but also reverse the developmental delay and improve memory
function and intelligence
Hippocampal Atrophy
Left Hippocampal Hyperintensity
Ganglioglioma
Gangliogioma
DNET
Nodular Neuronal Heteropia
 What should be resected
• Temporal neocortex: Recording with depth and surface
electrodes show szrs of strict neocortical origin were
rare.
• The percentage of szrs is only 10% in the lesions
confined to the surface of temporal lobe - AVM,
dysplasias and tumours
• Crucial role is played by A&H in TLE
• Szr discharge start either in hippocampus > amygdala
• Habitual szrs and aura can be reproduced by stimulation
of A&H but rarely from the neocortical contacts
How to and How much to resect
• Initial failures of temporal surgery was attributed
to a too little resection of temporal lobe
• Among the factors which influence the outcome
in epilepsy surgery, the extent and modalities of
resection are the most neglected and poorly
studied ones.
• In a series of 40 patients considered failures, a
secondary hippocampectomy lead to szr free
status in 63% of patients.
 Extent and modality of resection
Cortico-amygdalectomy (CA)

• Resection of anterior 4.5 cm of temporal

neocortex
• Amygdala, together with parahippocampus
adjacent to it
• Results with this modality show higher failure
rate
• This operation is a safe compromise in dominant
temporal lobe pathology who have failed the
amytal test
 Extent and modality of resection
Cortico-amygdalohippocampectomy (CAH)

Anterior temporal lobectomy anterior 4.5 cm of

neocortex
Amygdala
Hippocampus
Parahippocampal gyrus, fusiform gyrus and uncus
Extent and modality of resection
Selective amygdalohippocampectomy
(SAH)

• Trans sulcal - Approached through

superior or inferior temporal sulcus
• Trans sylvian fissure approach
Extent and modality of resection
Lesionactomy and cortico-amygdalohippocampectomy

Well circumscibed obvious lesions are excised together

with gliotic area around it
These are: benign tumours, cortical dysplasias or vascular
malformations
In vast majority of cases these lesions affect both
neocortex and limbic structures and are treated by CAH
and lesion excision
 Extent and modality of resection
Secondary
Cortico- Amygdalohippocampectomy
(SECAH)
Recurrence of szrs has been noted where
resection at the first operation was limited to
neocortex or the hippocampus was not removed
completely Recurrence of szrs 40 cases
First operation Recurrence of szrs
Only cortex 6
CA 13
CAH 21
Extent and modality of resection
Post operative szr outcome TLE
Engle (1987)
• Class l: Seizure free
• Class ll: Rare szrs (3/yr)
• Class lll: Worthwhile improvement (>90%
improvement)
• Class lV: No worthwhile improvement(<90%
improvement)
– lV a: significant improvement(60 to 90% reduction)
– lV b: no change (less than 60% reduction)
– lV c: worse
 Outcome from various modalities (523)
Outcome CAH CA SAH SECAH
(348)% (100)% (43)% (56)%
l 67 44 72 55
ll & lll 20 12 17 31
Total (87) (56) (89) (86)

lV A 10 16 4 7
lV B 3 28 7 7
Total (13) (44) (11) (14)
 Outcome and extent of
hippocampal resection (523)
Extent of Outcome l-ll-lll Outcome lV A –
resection % lV B %
No removal 56 44

1 – 1.5 cm 77 23

2 – 2.5 cm 86 14

3 – 3.5 cm 94 6
 Dominant hemisphere pathology

• Dominant hemisphere contains memory

and speech
• Dominant temporal lobe mainly contains
memory
• Non dominant temporal lobe contains
constructional and structural capability
 Poor Lateralization
• Bilateral spikes/slow waves on EEG
• Multiple video EEGs
• Cortical recording from subdural grid or
strip - interictal or ictal
 case
• Male 19 yrs
• Fits since the first day of life
• Forceps delivery
• Eye deviation to Rt and lifting of Lt UL
• Opening the zip of his pant and passing
urine in public and in the class
• Frequency 7-8 /30
• Many trials of 2-3 AEDs failed
 EEG

• Bilateral spikes
• Video EEG: Also inconclusive
 Bilateral Subdural Strip
Recordings From Temporal
Lobe