They allow a more precise and extended resection of mesial temporal structures and apparently lead to a better seizure control. CONCLUSIONS: These vascular and neural structures are landmarks that "guide" surgeons through the temporal lobe. To date 32 patients were operated on, with mean follow up of 23,1 months 29 (90%) are in Engel I (26 IA, 3 IB), and 3 (10%)are in Engel II. The amygdala is removed intra or subpially following the carotid artery anteriorly, choroidal fissure posteriorly, optic tract and the inferior choroidal point superiorly. Finally the tail of the hippocampus is sectioned at the atrium (posterior disconnection) and the tegmentum mesencephalon comes to the view. The medial wall of the temporal horn is then removed "freeing" the head of the hippocampus (anterior disconnection), and the contents of the crural cistern come to the view (peduncle, anterior choroidal artery, basal vein). The shape deformation of the hippocampus from the nonepileptic group to the epileptic group was evaluated using TPS analysis, which was derived from a mathematical model used in computer graphics and applied to morphometrics by Bookstein (1989, 1991). The neocortical removal is done following the gray matter of the collateral sulcus that points toward the floor of the temporal horn once the ventricle is opened, the medial disconnection of the hippocampectomy starts with the opening of the choroidal fissure, which separates the fornix from the thalamus, up to the inferior choroidal point, the beginning of the choroidal plexus in the temporal horn,and the contents of the ambient cistern are seen (posterior cerebral artery, basal vein). The landmarks were marked on the digital images using TPSDIG 2.04 software. RESULTS: The surgery consists of neocortical removal, hippocampectomy and amygdalectomy. The clinical outcome was based on the follow up of 32 patients with mesial temporal sclerosis who underwent temporal lobectomy and amygdalohippocampectomy. METHODS:The surgical anatomy and the operative technique were studied in 52 adult cadaveric hemispheres and 12 adult cadaveric heads, after perfusion of the arteries and veins with colored latex. CONCLUSIONS: Additional landmarks for localizing the underlying hippocampus may be helpful in temporal lobe surgery.
To prove its efficacy, we present the preliminary clinical outcome of 32 patients who have been operated on using this technique. The hippocampus tended to be more superiorly located and shorter in females and left sides, but this was not statistically significant. Based on this study, there are relatively constant anatomical landmarks between the hippocampus and overlying temporal cortex.RATIONALE: We present the surgical anatomy and the operative technique of the temporal lobectomy and amygdalohippocampectomy, based on anatomical landmarks. The mean distance from the anterior temporal tip to the hippocampal head was identical in the cadavers and MRIs of patients with medial temporal lobe sclerosis.Īdditional landmarks for localizing the underlying hippocampus may be helpful in temporal lobe surgery. The length of the hippocampus tended to be shorter in females, but this too failed to reach statistical significance. Although the hippocampus tended to be more superiorly located in female specimens and on the left side, this did not reach statistical significance. In general, the length of the hippocampus was along the inferior temporal sulcus and inferior aspect of the middle temporal gyrus. The authors also validated their study using magnetic resonance imaging (MRI) scans of 10 patients suffering from medial temporal lobe sclerosis where the distance from the hippocampal head to the anterior temporal tip was measured. They then measured the distance between the hippocampus and superficial landmarks. (b) Averaged event-related responses in the hippocampus from 11 subjects. The right hippocampus was selected using the same anatomical landmarks in the right hemi-sphere. The authors removed 10 human cadaveric brains from the cranium and observed the relationships between the lateral temporal neocortex and the underlying hippocampus. (a) Sections from the anatomical template with the left hip-pocampal region of interest outlined in red. Accessing the hippocampus for amygdalohippocampectomy and minimally invasive procedures, such as depth electrode placement, require an accurate knowledge regarding the location of the hippocampus.
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