1. Surgical Management Of Medically Intractable Temporal Lobe EpilepsyBy
Amr Farid
Lecturer Of Neurosurgery
Mansoura University

3. Why we should help? Quality of life Physical injury
Neuropsychological functions impairment
Psychiatric problems
Sudden unexpected death in epilepsy
Complications of AEDs (Inexperienced prescriptions)

4. Introduction

5. Seizure classification:
Introduction
Seizure classification:
1. Partial seizures
A) Simple partial seizure
Motor
Sensory
Autonomic
Psychic
B) Complex partial
With simple partial onset
Without simple partial onset, altered awareness / memory from the onset
C) Partial seizures (simple or complex) evolving to secondary generalization

6. 2. Primary generalized (convulsive or nonconvulsive)
Introduction
2. Primary generalized (convulsive or nonconvulsive)
Absence seizures.
Myoclonic seizure
Clonic , tonic and tonic-clonic seizures
Atonic seizures
3. Unclassified seizures
4. Prolonged or repetitive seizures (status epilepticus)

7. Mesial and Neocortical Temporal Epilepsy Clinical Features
Introduction
Introduction
Mesial and Neocortical Temporal Epilepsy Clinical Features
NTLE
MTLE
Warning symptoms localized to the epigastrium ,throught, or chest with or without fear.
Initial motionless staring
oro-alimentary masticatory or swallowing automatisms with or without repetitive manual automatism
Seizures are significantly longer in duration (> 1 minute).
Ipsilateral automatisms followed by contralateral dystonic posturing.
A phenomenon of dreamy state with memory of past scenes (déjà vu )
Auditory hallucinations
Early contralateral dystonic posturing.
Rapid spread to suprasylvian area produce versive and colonic motor movement of head ,eye and face.

8. Localization of Partial Seizure Focus
Introduction
Localization of Partial Seizure Focus
20%
10%
70%
This is the most common type of adult-onset epilepsy.
Causes such as hippocampal sclerosis, low- grade tumors and cortical dysplasias , vascular malformation

9. Pre-operative Assessment Electro physiologically
Introduction
Pre-operative Assessment
Electro physiologically
Electroencephalography (EEG)
Continuous Video EEG
Value OF EEG
Diagnostic tool
Spikes , poly spike
Sharp wave
Sharp and slow waves
complexes.

10. Limitations of EEG: Introduction
Normal EEG findings do not exclude epilepsy.
The initial EEG may show normal results in 50% of cases.
Increasing the duration of recording.
Deep focus.
Artifact

11. (A) Non invasive electrodes
Introduction
Electrode Placement
(A) Non invasive electrodes
1- Scalp Electrodes:
Standard system.
2- Zygomatic and Periorbital Electrodes: (Anterior temporal foci)

12. The international 10-20 electrode system
Introduction
The international electrode system

13. (B) Semi-invasive Electrodes
Introduction
(B) Semi-invasive Electrodes
Nasopharyngeal Electrodes: mesial temporal and orbitofrontal foci.
Sphenoidal Electrodes: for long term ,with less artifacts.
Foramen Ovale Electrodes: mesio­basal temporal lobe epilepsy.
Tympanic Electrodes: middle or posterior basal temporal regions

14. (C) Invasive Electrodes
Introduction
(C) Invasive Electrodes
Epidural Electrodes
Subdural Strip and Grid Electrodes
Implanted Intracerebral Electrodes (Depth Electrodes)
Seizures are lateralized but not localized (eg, a left-sided).
Seizures are localized but not lateralized (eg, both temporal lobes).
Seizures are neither localized nor lateralized (eg. diffuse ictal).
Seizure localization is discordant with other data
Intraoperative , ECoG

15. Partial Onset Seizure – Left TLE
Introduction
Partial Onset Seizure – Left TLE
Generalized Onset Seizure

16. Origin Of EEG abnormality
Introduction
Generalized
Focal to generalized
Focal
Origin Of EEG abnormality

17. Neuroradiology Functional Magnetic Resonance Imaging (fMRI):
Introduction
Neuroradiology
Functional Magnetic Resonance Imaging (fMRI):
PET and SPECT imaging especially has shown both increased glucose metabolism and blood flow respectively in the epileptic cortex, which is depressed in the post-ictal and interictal states.
MRS is a newer tool that demonstrates regional metabolic alteration in epileptogenic tissue.
Magnetoencephalography:
Measurement of extracranial magnetic fields

18. Imaging issues: strategies for successful interpretation
Introduction
Cutting planes
Imaging issues: strategies for successful interpretation
(HIPPO SAGE)

19. MRI features of HS Introduction Secondary signs Primary signs
Unilateral atrophy of the mamillary body, fornix ,amygdala.
Increased T2 W signal in ant. temporal
white matter with loss of grey-white demarcation in the ipsilateral anterior temporal lobe.
Unilateral dilatation of the temp. horn.
Primary signs
Atrophic unilateral hippocampus .
Hyperintensity on both T2 W and FLAIR images
Loss of the hippocampal internal architecture and that of normal digitations of the head.

20. MRI-PET fusion image (Lt TLE)
Introduction
Functional and Morphologic Data Fusion for Epileptogenic Foci Localisation
MRI +SPECT (Lt TLE)
MRI-PET fusion image (Lt TLE)

21. Scheme for preoperative evaluation in TLE
Introduction
Scheme for preoperative evaluation in TLE

22. Surgical Treatment of TLE
Introduction
Surgical Treatment of TLE
General Surgical procedures:
Resection techniques is simple excision of the structural lesion
Disconnection techniques (hippocampal transection )
Augmentation techniques ( vagal stimulation).
Gamma knife radiosurgery
Stereotactic radiofrequency ablation techniques .

23. Introduction
Epileptic Zones

24. Introduction
Temporal Lobectomy:
Temporal lobe resection produces a seizure-free state in 60% to 80 % of patients:
Anterior temporal lobectomy (ATL) is the most common surgical procedure performed in adolescents and adults.
Selective Amygdalohippocampectomy for patients with MTLE

25. Introduction
Temporal Lobectomy: A) Anterior temporal lobectomy with amygdalo-hippocampectomy

26. B) Selective Approaches to The Mesial Temporal Area
Introduction
B) Selective Approaches to The Mesial Temporal Area

27. Trans-sylvian approach
Introduction
Trans-sylvian approach

28. Meyer’s loop Introduction Risk for superior quadrant hemianopsia
50 –100% after standard temporal lobectomy
up to 50% after trans-sylvian selective amygdalohippocampectomy

29. Introduction

30. Aim Of
The Work

31. This study is to compare:
seizure and neuropsychological outcomes after:
Anterior temporal lobe resection plus amygdalo-hippocampectomy (AH)
versus selective amygdalo-hippocampectomy (AH) through trans sylvian approach
In the treatment of medically intractable temporal lobe epilepsy

32. Patients
&
Methods

33. Patients & Methods
This study was conducted on 24 patients with medically intractable Temporal Lobe Epilepsy at Tohoku University Hospital.

34. Inclusion criteria Exclusion criteria Patients & Methods
Medically intractable epilepsy due to identified temporal lobe focus.
Lesions may be intra or extra axial within the anatomical confines of the temporal lobe.
Both of neocortical and mesial temporal lobe.
Exclusion criteria
Patients unfit for surgery.
Presence of multiple brain lesions.
Pure extratemporal epileptogenic zone.

35. Presurgical evaluation
Patients & Methods
Presurgical evaluation
Drug resistant epilepsy : failure of two tolerated, appropriately chosen (whether as monotherapies or in combination) to achieve sustained seizure freedom over period of two years.
Detailed history :patients and close contact.
Clinical assessment
Electrophysiological assessment via ( VEEG).
Neuroimaging via routine MRI brain ,(FDG-PET), Interictal SPECT and magneto-encephalography (MEG) were done to confirm diagnosis.

36. Neuropsychological Test Battery
Patients & Methods
Neuropsychological Test Battery
Wechsler Adult Intelligence scale (WAIS-R: VIQ, PIQ, FIQ) and Wechsler Memory Scale (WMS-R: verbal , non verbal ,full memory) pre-operative and one year post operatively.
Changes or discrepancy of the score greater than 10 was defined as significant improvement ,changes within 10 defined as no significant changes and if lower than 10 will be considered impairment .
Also difference between Verbal and non verbal memory scores pre-operatively greater than ten was defined as verbal dominant memory impairment and vice verse or less than ten difference shows non significant laterality.

37. Case example Patients & Methods Pre-op Post-op
Post-op gains or declines
WMS-R
Verbal memory → 75
Non-verbal memory → 83
Significant gain
No change
Pattern of memory impairment
Verbal dominant
VDMI
No dominancy

38. (b) Procedures Patients & Methods Operative Techniques:
Two groups of patients enrolled into the study:
Group (A): Anterior temporal Iobectomy and amygdalo-hippocampectomy (14 patients).
Group (B): Selective amygdalohippocampectomy (AH) through trans-sylvian approach (10 patients).
Post operative Histopathological Studies

39. Patients & Methods
(c) Patients' follow up
All patients will be followed up for 1-2 Years after the procedure via:
Seizure frequency every 1 month (Engel class.)
Neurological examination
Neuropsychological (WMS ,WAIS)R.
Radiologically by MRI
Electro-physiologically by inter-ictal EEG.
All the patients will be kept on anti epileptic drug regimen throughout the follow up period.
Statistical methods
Data were analyzed using JMP software, version 11

40. Results

41. Results
Preoperative status:
Age: ranged from 19 to 53yrs with mean of 34.8yrs and standard deviation of 10.9yrs

42. Demographic data and febrile seizure history in both groups
Results
Demographic data and febrile seizure history in both groups
Type of surgery
ATL/AH
SAH 14 10
No.
32.8
37.7
Age (Y)
Mean
9.7
12.3
Std. Dev
Sex 9 8 F 5 2 M
10.3
17.8
Epilepsy onset (Y)
7.1
Handedness 1 L 13 R
Associated conditions 7
Febrile Seizure
Meningitis, Febrile seizure 3
No associated conditions

43. Seizure semiology Results N % of Total Seizure semiology 5 20.83%
Abdominal aura >Automotor seizure
Abdominal aura >Automotor seizure >GTC 1
4.17%
Abdominal aura >Dialeptic seizure >Rt face clonic seizure
Automotor >GTC
Automotor seizure 2
8.33%
Complex motor seizure
Complex motor seizure >Lt body clonic seizure
Dialeptic >GTC
Dialeptic >Rt oro-facial/arm clonic >GTC
Dialeptic seizure

44. Preoperative pattern of memory impairment and side of the Temp. focus
Results
Preoperative pattern of memory impairment and side of the Temp. focus

45. The pre operative WMS-R scores
Results
The pre operative WMS-R scores
The left TLE group performed worse than right TLE group on verbal memory. But for demonstration of the pre operative non verbal memory scores were not so confirmatory

46. Results
Seizure Outcome
Engel classification

47. Results
Seizure outcome in Engel classification according to the type of surgery
Majority of patients shows better seizure outcome after Temporal lobe epilepsy surgery.
Engel class IA (79% ATL/AH, 70% SAH), Engel II A (14% ATL/AH &10% SAH) Engle IIB (7% ATL/AH and 10% SAH) and (10%Engle IID with SAH group).

48. Seizure outcome and the duration of epilepsy
Results
Seizure outcome and the duration of epilepsy
Better Engel class with patients who have shorter duration while worse control in patients with longer period (25% Engel class I, 30-36yrs),(75% Engel Class I, 8-13yrs).

49. Results
Age of patients and seizure outcome
Young age group (19-23Y) shows 83% Engel class lA while older group (46-53Y)shows lower outcome (67% Engel class. lA)

50. Neuropsychological outcome
Results
Neuropsychological outcome
Intelligence Quotient (IQ)
Significant improvement in full IQ after surgery (43% ATL/AH and 30% SAH) groups with minimal impairment percent (7% ATL/AH) but the majority of patients shows no significant difference in pre-post operative Full IQ scores (50% ATL/AH and 70% SAH).

51. Postoperative memory changes
Results
Postoperative memory changes
WMS-R / Verbal Memory

52. WMS-R / Non Verbal Memory
Results
WMS-R / Non Verbal Memory

53. Matched Pairs Results P Neuropsychological Evaluation Preoperative
Postoperative P
Mean SD
WAIS-R: FIQ 78
21.04 86
22.74
< *
WMS-R: verbal
74.8
22.95
82.2
22.8
0.0027*
WMS-R: visual 89
17.2
93.7
18.5
0.0586
WMS-R: full
75.9
22.06
83.5
22.47
0.0029*

54. Results P Neuropsychological Evaluation Preoperative Postoperative
Mean SD
WAIS-R: FIQ
77.71
19.73
85.85
20.46 *
WMS-R: verbal
74.07
20.73
77.29
19.79
0.18
WMS-R: visual
90.86
15.43
91.36
18.68
0.45
WMS-R: full
75.14
20.04
78.36
19.53

55. Results P Neuropsychological Evaluation Preoperative Postoperative
Mean SD
WAIS-R: FIQ
78.5
23.87
86.1
26.76
0.0103*
WMS-R: verbal
75.7
26.90 89
25.95 *
WMS-R: visual
86.5
20.01
96.9
18.66
0.0071*
WMS-R:full
76.9
25.73
90.6.5
25.5 *

56. Pathological findings
Results
Pathological findings N
% of Total
Pathology 1
4.17%
Cavernous malformation 2
8.33%
Ganglioglioma 17
70.83% HS 4
16.67%
HS, CD
Pathological findings and surgical approaches
Type of surgery
Pathology
Cavernous malformation
Ganglioglioma HS
HS, CD N
Lesionectomy + ATL/AH 1
ATL/AH 10 3 13
Lesionectomy+SAH 2
SAH 7 8

57. Pathological findings seizure outcome
Results
Pathological findings seizure outcome

58. Complications of surgery
Results
Complications of surgery

59. Case
Presentation

60. Case No 1 45yrs old right-handed female Onset of epilepsy: 13y.o.
Semiology: Automotor seizures
MRI: Lt medial temporal non-enhanced lesion
EEG: (ictal) Lt temporal, (interictal)
FDG-PET: Lt medio-basal temporal hypometabolism
Neuropsychology: Impaired verbal memory (WMS-R verbal 55 vs visual 78)
One year post operative neuropsychology: significant improvement.
Epilepsy diagnosis:
Lt temporal lobe epilepsy
Lt medial temporal lesion
Procedures:
Lt fronto-temporal craniotomy
Selective :Lesionectomy Amygdalo-hippocampectomy
Intra-operative EEG

61. Case No 1
EEG examination consistent with left temporal epileptogenic dysfunction.

62. Preoperative MRI T1 (axial) cuts shows left temporal lesion.
Case No 1
Preoperative MRI T1 (axial) cuts shows left temporal lesion.

63. Case No 1
FDG-PET-MRI fusion

64. Hippocampal volumetry
Case No 1
Hippocampal volumetry

65. Postoperative T2 axial MRI
Case No 1
Postoperative T2 axial MRI

66. Case No 2
48 years old right-handed female.
Etiology: Hippocampal sclerosis
Onset of intractable seizures: 7 y.o.
Semiology: Aura > Loss of awareness
MRI: Lt hippocampal atrophy
EEG: (ictal) Lt temporal onset, (interictal) Lt temporal spikes .
FDG-PET: Lt mesio-basal temporal hypometabolism
Neuropsych: Impaired verbal memory (WMS-R verbal 82 vs visual 104)
Epilepsy diagnosis: Lt mesial temporal lobe epilepsy
Post operative Engel class. I , significant improvement of verbal memory
Procedures:
Left Anterior temporal lobectomy
Amygdalo-hippocampectomy

67. Case No 2
EEG examination consistent with left ant. temporal epileptogenic dysfunction.

68. Preoperative MRI (coronal) cuts
Case No 2
Preoperative MRI (coronal) cuts

69. Hippocampal volumetry
Case No 2
Rt hippocampus: 3.49 cm3
Lt hippocampus: 2.03 cm3
FDG-PET-MRI fusion
Hippocampal volumetry

70. ECoG confirmed epileptic spikes in the anterior temporal cortex
Case No 2
Maximum amplitude spikes
ECoG confirmed epileptic spikes in the anterior temporal cortex

71. Case No 2
Post operative MRI

72. Case No 3 21 year old, right-handed male
Onset of epilepsy: 13 years old
Seizure frequency: Monthly
Associated condition: Hx. of febrile seizures
MRI: Rt hippocampal atrophy
Seizure symptoms: Automotor , GTC
Ictal EEG: Rt anterior temporal onset
Interictal EEG: Rt anterior temporal spikes (BESA analysis)
FDG-PET: Rt medial temporal hypo-metabolism
IMZ-SPECT: Reduced uptake in Rt antero-mesial temporal
Neuropsych: Low IQs, impaired verbal and non verbal memory ( postoperative significant improvement)
Epilepsy diagnosis: Rt mesial temporal lobe epilepsy
Post operative Engel class. I
Procedures:
Right Trans-sylvian selective amygdalo -hippocampectomy
Intra-operative EEG

73. BESA Epilepsy Report analysis of EEG
Case No 3
BESA Epilepsy Report analysis of EEG
Rt temporal Epileptogenic dysfunction

74. Hippocampal volumetry
Case No 3
Preoperative MRI (STIR, FLAIR)
Hippocampal volumetry

75. FDG-PET-MRI coregistration
Case No 3
FDG-PET-MRI coregistration

76. Post operative MRI Case No 3 Hippocampus Head Fimbria
Parahippocampal gyrus
Post operative MRI

77. Conclusion

78. conclusion Temporal lobe epilepsy (TLE) is the most common focal.
Hippocampal sclerosis (HS) its major pathological substrate.
Risk factors for post operative cognitive decline after surgery
TLE surgery effective for intractable epilepsy with 70-80% favorable seizure outcome
Goals of surgery is to abolish the seizures and avoid any neurologic deficits .
A secondary goal, in cases of tumors and vascular malformations is to entirely remove