Selective

Amygdalohippocampectomy
Alastair T. Hoyt, MD, Kris A. Smith, MD*

KEYWORDS
 Amygdalohippocampectomy  Epilepsy  Mesial temporal sclerosis  Subtemporal
 Temporal lobectomy  Transcortical  Transsylvian

KEY POINTS
 Selective amygdalohippocampectomy effectively reduces seizure severity and frequency in pa-
tients with mesial temporal epilepsy.
 Selective procedures seem to be as effective as anterior temporal lobectomy in patients whose dis-
ease is limited to the mesial temporal structures.
 Although the evidence is inconclusive, it suggests that selective amygdalohippocampectomy may
preserve neurocognitive function better than anterior temporal lobectomy.
 Multiple approaches are available to access the mesial temporal structures.
 There is no definitive evidence for the superiority of a particular approach in terms of seizure control
or neurocognitive outcome.

INTRODUCTION However, anteromedial temporal lobe resection

entails resection of the anterior portion of the tem-
Eliminating seizures while preserving a patient’s poral lobe, which may not be implicated in seizure
neurologic function is the defining goal of all epi- production in isolated mesial temporal disease.
lepsy surgery. Epilepsy of the temporal lobe, and Driven by a desire to preserve structures outside
specifically epilepsy localized to the mesial tempo- of the epileptogenic zone, investigators have devel-
ral structures, is by far the most common focal ep- oped so-called selective procedures. Specifically,
ilepsy in adults and is among the most common selective amygdalohippocampectomy (SAHC)
focal epilepsies afflicting children.1 Mesial tempo- has been described as an alternative to target
ral lobe epilepsy (MTLE) is also among the least only the mesial temporal structures while preserv-
likely type of epilepsy to be adequately controlled ing the lateral neocortex, temporal pole, and tem-
with medical treatment alone.2 A prospective poral white matter tracts.9–11 No incontrovertible
randomized controlled trial published by Wiebe evidence exists, but selective procedures should
and colleagues3 demonstrated that anterior tem- theoretically reduce the morbidity of epilepsy
poral lobectomy (ATL) with resection of the mesial surgery.12
temporal structures is superior to medical man- Although the terms ATL and SAHC are com-
agement for drug-resistant MTLE. Engel and monly used for this procedure, both terms are
colleagues4 confirmed their findings in 2012 in a somewhat misleading. As described by most in-
similarly methodologically sound study. Such vestigators, ATL involves resection of not only
resection offers increased quality of life to pa- the anterior portion of the temporal lobe but also
tients5 and has been found to be cost-effective in most of the hippocampus, amygdala, and parahip-
neurosurgery.theclinics.com

both children and adults.6–8 pocampal structures. Similarly, SAHC involves

Disclosures: The authors have no financial disclosures.

Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center,
350 West Thomas Road, Phoenix, AZ 85013, USA
* Corresponding author.
E-mail address: [email protected]

Neurosurg Clin N Am 27 (2016) 1–17

http://dx.doi.org/10.1016/j.nec.2015.08.009
1042-3680/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
2 Hoyt & Smith

resection of the bulk of the hippocampus, amyg- Box 2

dala, and parahippocampal structures. Presurgical epilepsy evaluation

Mandatory studies
PATIENT EVALUATION OVERVIEW
Indications  Review of seizure history, semiology, and
symptoms
SAHC is reserved for patients with disabling,
 Neuropsychological evaluation
medically intractable seizures that originate unilat-
erally in mesial temporal structures (Box 1).4,13–15  Video scalp EEG monitoring
The American Academy of Neurology recom-  High-resolution MRI with coronal projections
mends that patients with drug-resistant MTLE re-
Complementary studies
sulting in disabling complex partial seizures be
referred for surgery5 because of a single random-  PET with fludeoxyglucose F 18
ized controlled trial and a further 24 observational  Ictal single-photon emission computed
studies.16 The International League Against Epi- tomography
lepsy (ILAE) defined drug resistance as failure of  Magnetoencephalography
2 tolerated, appropriately chosen, and used anti-
 Intracarotid amobarbital testing (Wada test)
epileptic drug schedules.15
 Selective posterior cerebral artery amobar-
bital testing (selective Wada test)
Preoperative Evaluation
 Intracranial EEG electrode monitoring
There are 2 key factors in selecting a patient for
 Functional MRI
SAHC. First, localization of the epileptogenic zone
to the mesial temporal structures is paramount.  Diffusion tensor imaging
Second, assessment of the risk for function decline Abbreviations: EEG, electroencephalography; MRI,
due to surgery is no less important. A full discussion magnetic resonance imaging; PET, positron emission
of seizure localization and risk assessment is tomography.
beyond the scope of this article, but most inves-
tigators2,16–20 agree that a thorough neurologic
examination, clear understanding of the seizure Complementary evaluation techniques can also
semiology, interictal electroencephalographic be of great value. However, a well-designed sys-
(EEG) evaluation, high-resolution magnetic reso- tematic review by Burch and colleagues21 of
nance imaging (MRI) of the brain, and neuropsycho- noninvasive presurgical evaluation other than
logical evaluation represent a minimum presurgical EEG and MRI identified no randomized trials or
investigation (Box 2). Indeed, the ILAE Subcommis- cohort studies, and minimal high-quality evidence
sion for Pediatric Epilepsy Surgery concluded that of effectiveness in any individual complementary
interictal EEG, neuropsychological assessment, study. The investigators opined that each of the
and high-resolution MRI were mandatory.19 complementary techniques may be useful in the
context of a comprehensive evaluation and rec-
Box 1 ommended thorough discussion of individual
Patient selection for SAHC cases in a multidisciplinary conference to provide
an optimal surgical plan. As elegantly described
Indications by Spencer and Burchiel,20 the selection of pa-
 Disabling, drug-resistant, mesial temporal tients should depend on converging lines of
lobe epilepsy evidence.
Some investigators advocate reserving SAHC for
Contraindications
cases when imaging abnormalities are present on
 Evidence that patients will have neurocogni- MRI.13 Other surgeons argue that if there is reason-
tive decline with surgery, which would able confidence of a mesial temporal seizure origin,
outweigh the benefit of seizure control
SAHC may be offered with the option of completing
 Multifocal onset of seizures or bilateral inde- resection of the neocortical structures at a later
pendent mesial temporal lobe onset date if necessary. ATL with resection of the medial
 Patients’ general medical inability to tolerate structures may be more appropriate if there are
surgery findings consistent with neocortical sources.22
Abbreviations: SAHC, selective amygdalohippocam-
The senior author’s current practice is to stereotac-
pectomy. tically implant depth electrodes into the hippocam-
pus and amygdala bilaterally in MRI-negative
 Selective Amygdalohippocampectomy 3

patients in order to ensure unilateral, medial-onset SURGICAL TREATMENT OPTIONS

seizures before offering SAHC. Preponderant uni-
lateral magnetoencephalograph spikes may be an Many approaches to the mesial temporal struc-
alternative noninvasive confirmatory test; however, tures have been described.9,13,28–43 The 3 best
there are currently only limited data to support this described methods among these approaches are
practice.23 the transcortical, transsylvian, and subtemporal
approaches. A brief history, surgical details, and
Timing of Surgery special considerations of each approach are dis-
cussed in the order in which they were first
The Early Randomized Surgical Epilepsy Trial re- described in the literature.
sults suggest that patients with MTLE benefit
from early intervention.4 In that study, patients Transcortical Approach
with MTLE, hippocampal sclerosis, and disabling
drug-resistant seizures for less than 2 years were Overview
randomized to surgery or medical treatment. Niemeyer43 first described the transventricular
None of the 23 patients in the medical group and amygdalohippocampectomy in 1958. The ap-
11 of 15 patients in the surgical group were seizure proach he described has subsequently been
free at the 2-year follow-up. Unpublished data termed the transcortical SAHC (TC SAHC). In
from the authors’ center (KA Smith, 2012) sug- 1969, Niemeyer and Bello35 described the same
gests that surgical treatment (lesionectomy approach using microsurgical techniques. In the
without SAHC) of patients who are discovered to original description, the temporal lobe was entered
have cavernous malformations of the mesial tem- in the middle temporal gyrus. Other investigators
poral structures within 6 months of the onset of have described modifications of this technique
seizures results in superior seizure control out- with access through the superior temporal gyrus,20
comes relative to patients who have been treated superior temporal sulcus,44 middle temporal gy-
medically for more than 1 year before surgery. rus,13,37 and inferior temporal sulcus.38 Regardless
Despite these findings, studies suggest that of the exact site of access to the temporal lobe, this
many patients present for surgical evaluation approach traverses the lateral temporal structures
only after many years of symptoms. At Columbia to provide access to the temporal horn of the lateral
University in New York, the mean duration from ventricle and, thus, the amygdala, hippocampus,
the onset of symptoms to referral to a comprehen- and parahippocampal gyrus. Variations have also
sive epilepsy program was 22.6 years from 1996 to been developed using multiple cranial exposures,
1999 and 21.1 years from 2004 to 2007.24 At the including a limited temporal craniotomy38 and a
University of California, Los Angeles, the mean small keyhole craniotomy centered over the middle
duration was 17.1 years from 1995 to 1998 and temporal gyrus.45
18.6 years from 2005 to 2008.25
Operative procedure
Patients are positioned either in a lateral decubitus
Patient Age
position or supine with the shoulder ipsilateral to
There is some evidence to suggest that pediatric the surgical site elevated. The head is fixated
patients respond differently than adult patients to and rotated contralateral such that the axis of the
SAHC.13 Clusmann and colleagues26 compared temporal lobe lies horizontally. A pretragal linear
ATL and SAHC in a pediatric cohort and found incision37,46 or a curvilinear frontotemporal inci-
that 94% of patients obtained a good outcome sion13 based just above the zygoma is opened
(Engel classes I and II) with ATL compared with and the temporalis is divided. Stereotactic naviga-
74% with SAHC. Datta and colleagues27 tion can be very helpful in planning a craniotomy,
compared the outcome after SAHC in an adult particularly if a small craniotomy is planned that
and pediatric cohort and found superior outcomes does not provide complete visualization of the
in the adult patient population, with 100% of the lateral temporal anatomy.13,38,45,46 A corticotomy
treated adults and only 55% of the treated children is performed and extended to a length of 2 to
achieving Engel class I and II outcomes. The path- 3 cm parallel to the superior temporal sulcus.
ophysiological basis for these observations re- Dissection is carried medially under microscopic
mains unclear.13 The authors speculate that the magnification, splitting the white matter fibers in
pediatric population of patients with refractory ep- a slitlike fashion in the anteroposterior direction,
ilepsy includes a higher percentage of patients with until the temporal horn of the lateral ventricle is
congenital abnormalities in the temporal lobe or encountered. Self-retaining retractors are then
genetically based primary epilepsies as compared frequently placed to maintain the working corridor.
with the typically acquired MTLE seen in adults. The hippocampus, choroid plexus, choroidal
4 Hoyt & Smith

fissure, and amygdala can be visualized on the described variations on the approach.2,49,50 This
medial inferior walls of the ventricle. approach takes advantage of the sylvian fissure
An opening is made in the ependyma at the ven- to access the mesial temporal region without
tricular sulcus at the junction of the hippocampus disruption of the lateral and anterior neocortex of
and the collateral eminence, and dissection is car- the white matter tracts surrounding the lateral
ried into the parahippocampal gyrus. With a com- ventricle. Yas‚argil and colleagues’ stated goal
bination of microdissection and ultrasonic was to perform a “pure lesionectomy.”11
aspiration, a subpial dissection of the parahippo-
campal gyrus in performed. The tentorial edge, Operative procedure
oculomotor nerve, posterior communicating ar- Patients are positioned in the supine position with
tery, posterior cerebral artery, and optic tract are the shoulder ipsilateral to the operative site sup-
typically visible through the pia; care should be ported. The head is fixated and rotated such that
taken to not violate the pia to preserve these the malar eminence is the highest point of the sur-
structures. Subpial dissection is carried forward gical field to bring the sylvian fissure into a roughly
into the tissue of the uncus. With traction from mi- vertical orientation. A semilunar incision is opened
crodissectors, the choroidal fissure can be similar to other pterional approaches. The tempo-
opened and the thin attachment of the fimbria ralis may be divided or dissected via an interfascial
hippocampi can be divided, allowing the hippo- technique. A craniotomy is fashioned overlying the
campus to be mobilized laterally and inferiorly. sylvian fissure. The craniotomy should extend su-
The vessels of the hippocampal arcade are coag- perior to the fissure by approximately 1.5 cm. A
ulated and divided as close as possible to the hip- drill is used to flatten the greater and lesser wings
pocampus to avoid injury to the parent vessels. of the sphenoid to the level of the superior orbital
The hippocampus is transected in the coronal fissure to facilitate exposure. The dura is opened
plane at the junction of the body and tail, providing and reflected over the remolded sphenoid and
an en bloc resection of the body and head of the orbit. Under microscopic magnification, the syl-
hippocampus. vian fissure is opened from the region of the ca-
Attention is turned to the residual parahippo- rotid bifurcation to about 2 cm distal to the MCA
campal gyrus and amygdala, which is resected bifurcation. The limen insulae, ascending M1
within the bounds of the medial and inferior pial branch, and anterior third of the insular cortex
margins. The amygdala may be as high as the hor- with its associated M2 branches can be visualized.
izontal segment of the middle cerebral artery The inferior circular sulcus, which separates the
(MCA). Additional subpial ultrasonic aspiration temporal operculum from the insula, is identified.
and microdissection of the tail of the hippocampus A 1- to 2-cm corticotomy is created in the tem-
is carried posteriorly from the site of the coronal poral stem at the level of the limen insulae, and
transection to at least the plane of the colliculi. dissection is carried down to the uncus parallel
The wound is irrigated and closed. to the M1 segment until the temporal horn of the
lateral ventricle is encountered. The tissue within
Special surgical considerations the uncus is resected by subpial dissection, taking
The location of the lateral temporal corticotomy care that the pia-arachnoid boundary is left intact.
can be varied, depending on the required angle The amygdala can be identified at the anterior
to approach the mesial structures on navigation.13 border of a line between the choroidal fissure
Some investigators37 advocate placing the inci- and the limen insulae. The amygdala and associ-
sion in a more posterior position (just anterior to ated entorhinal cortex in the anterior portion of
the plane of the central sulcus) in the nondominant the parahippocampal gyrus are resected. The
hemisphere and in a more anterior position (just opening into the ventricle is extended posteriorly
anterior to the plane of the precentral sulcus) in to better visualize the choroid emerging from the
the dominant hemisphere. The use of intraopera- choroidal fissure, which will mark the mesial
tive image-guided navigation can also be used to boundary of hippocampal dissection. An incision
tailor an entry site.45,47 is created in the floor of the lateral ventricle, lateral
to the hippocampus in the region of the collateral
Transsylvian Approach
eminence, and carried down to the collateral sul-
Overview cus. This incision defines the lateral boundary of
The transsylvian approach for SAHC (TS SAHC) the resection. Microdissectors and gentle traction
was introduced by Yas‚argil and colleagues in are used to define the superior medial border of
1973 and was first described by Wieser and Ya- the hippocampus along the choroidal fissure.
s‚argil48 in 1982, with several subsequent descrip- This incision provides access to the hippocampal
tions.10,11,39 Various investigators have now vessels entering the hippocampal fissure, which
 Selective Amygdalohippocampectomy 5

are divided as closely as possible to the hippo-

campus to avoid injury to the parent vessels. Sub-
pial dissection is carried along the pial boarder of
the subiculum and the inferior parahippocampal
gyrus until it meets with the lateral portion of the
dissection near the collateral sulcus. The body of
the hippocampus and the associated parahippo-
campal gyrus are then transected in the coronal
plane as posteriorly in the exposure as possible,
resulting in an en bloc resection of the hippocam-
pus and parahippocampal gyrus. Additional resec-
tion of the tail of the hippocampus may be pursed
with ultrasonic aspiration to ensure that the poste-
rior extent of resection reaches the tectal plate.
The wound is irrigated and closed in a typical
fashion.

Special surgical considerations

The narrow working corridor of the transsylvian
route requires the surgeon to be familiar with the
surgical anatomy and handling of the vascular
structures. Meticulous handling of the sylvian
veins is essential, and medial mobilization of the
Fig. 1. Stereotactic keyhole temporal approach
MCA’s temporal trunk may provide additional showing curved incision (dashed line) and approxi-
space for cortical incision. A generous opening mate position of the small craniotomy allowing access
of the fissure is thought to be key to avoiding to the floor of the middle fossa for subtemporal
vascular complications.2 amygdalohippocampectomy. (Courtesy of Barrow
Neurological Institute, Phoenix, AZ; with permission.)
Subtemporal Approach
Overview temporal floor, where a small burr hole is made in
Several investigators, including Hori and col- the inferior aspect of the exposure. An ovoid crani-
leagues,42 Park and colleagues,40 and Takaya otomy measuring approximately 2.5 cm in diam-
and colleagues,41 have described SAHC via a sub- eter is fashioned based on the temporal floor. It is
temporal corridor (ST SAHC). The subtemporal often helpful to widen and flatten the inferior aspect
approach avoids disruption of the neocortical tis- of the cranial opening with a high-speed drill to
sue of the lateral temporal lobe and the white mat- bring the inferior margin of the craniotomy flush
ter pathways, which traverse the periventricular with the temporal floor and provide a slightly wider
white matter and temporal stem. The authors favor working corridor. Reverse Trendelenburg posi-
a minimal access approach, which carries the tioning is used initially to aid in brain relaxation.
additional advantages of a small craniotomy and The operating microscope is introduced. The
small wound (Figs. 1 and 2).9 dura mater is opened revealing the inferior tempo-
ral gyrus. A wide nonstick Cottonoid is introduced
Operative procedure beneath the inferior temporal gyrus, and cerebro-
Patients are positioned supine with a large shoul- spinal fluid is aspirated from the extra-axial space
der roll placed under the ipsilateral shoulder. The to aid in relaxation. Working along the inferior
head is secured in a head holder, rotated contralat- aspect of the temporal lobe, the collateral sulcus
eral to the operative side, and placed in lateral is identified. Stereotactic guidance is used to
extension such that the zygoma is the highest point establish a trajectory to the tip of the temporal
of the surgical field. The surgeon remains posi- horn of the lateral ventricle. A small corticotomy
tioned at the vertex throughout the procedure. is opened in the lateral inferior aspect of the para-
Mannitol and modest hyperventilation are given to hippocampal gyrus after opening the collateral sul-
aid in brain relaxation. A 4- to 5-cm pretragal inci- cus; dissection is carried into the uncus, gradually
sion is opened based at the zygoma and extending aiming progressively cephalad. The floor of the
curving posteriorly just above the pinna. The tem- lateral temporal horn of the lateral ventricle is
poralis is divided, and fishhooks are placed to opened near its tip and extended posteriorly.
retract soft tissue and maintain a low profile in the This position provides visualization of the land-
field. Stereotactic guidance is used to identify the marks on the medial wall of the ventricle important
6 Hoyt & Smith

aspiration extending to the inferior medial pial

margin. Working anteriorly from the transection
of the hippocampus, the surgeon elevates the
parahippocampal gyrus from the pia. The parahip-
pocampal tissue at the head of the hippocampus
is likewise elevated from the medial and inferior
pial boundaries. At this juncture, the hippocampus
is tethered only by the arcade of vessels entering
the hippocampal fissure. These vessels are coag-
ulated and divided as closely to the hippocampus
as possible. The head and body of the hippocam-
pus may be removed en bloc.
Attention is turned to the tail of the hippocampus
posterior to the site of the coronal transection. The
tail is aspirated ultrasonically beyond the level of
the tectal plate into the atrium. The remaining
parahippocampal gyrus is likewise resected to
the pial reflection at the medial temporal-
occipital junction. The wound is irrigated until
complete hemostasis is ensured and then is
closed. Postoperative MRI is routinely performed
to assess for any retraction injury and to document
Fig. 2. Keyhole craniotomy concept for subtemporal the extent of hippocampal resection back to the
amygdalohippocampectomy. The craniotomy is based
level of the tectal plate (Fig. 3).
on the temporal floor (middle arrow). To reach the
amygdala, patients are rotated and the operating mi- Special surgical considerations
croscope is angled anteriorly (top arrow). To reach the Care should be taken to preserve the basal surface
tail of the hippocampus, patients are rotated in the
of the temporal lobe and to minimize retraction,
opposite direction and the microscope is angled pos-
teriorly (bottom arrow). (From Little AS, Smith KA, Kir-
particularly in the lateral aspect of the exposure tra-
lin K, et al. Modifications to the subtemporal selective versed by large anastomotic veins. These veins, if
amygdalohippocampectomy using a minimal-access present, are not retracted to prevent avulsion.
technique: seizure and neuropsychological outcomes. Although self-retaining retractors can be placed to
J Neurosurg 2009;111(6):1272; with permission.) aid in elevation of the temporal lobe, this is typically
not necessary and is avoided to prevent retraction
to guiding the remainder of the resection, which injury. Initially placing patients in the reverse Tren-
are familiar from the TC SAHC or ATL. delenburg position with continued cerebrospinal
The posterior inferior surface of the amygdala is fluid aspiration allows development of the subtem-
identified just anterior and superior to the choroid poral space, and gradual progression to a slight
plexus arising from the choroidal fissure. The Trendelenburg position allows for the upward angle
amygdala is resected with ultrasonic aspiration un- necessary for access to the mesial structures.
til the pial surface adjacent to the sylvian fissure is Working instruments may be used for dynamic
identified, thereby defining the superior and ante- retraction during the procedure as needed.
rior limits of amygdala resection. Subpial dissection Frequent repositioning of the head and microscope
with microdissectors is carried along this boundary with the aid of intraoperative image guidance allows
until the remaining uncal tissue is resected. The access with minimal retraction, and patients should
tentorial edge, oculomotor nerve, posterior be firmly secured to the operating table to prevent
communicating artery, posterior cerebral artery, intraoperative movement.
and optic tract are typically visible through the pia.
Other Approaches
After completion of the amygdalectomy, atten-
tion is turned to the hippocampus. A Cottonoid is A variety of other approaches for SAHC have been
placed along the superior margin of the choroid described (Table 1). Vajkoczy and colleagues28
plexus at the body of the hippocampus. Counter- described a transsylvian-transcisternal approach,
traction is placed against the Cottonoid as micro- which involved opening of the chiasmatic, carotid,
dissectors are used to peel the hippocampus interpeduncular, and ambient cisterns via a trans-
inferiorly from the choroidal fissure. This plane is sylvian exposure to mobilize the medial surface of
developed posteriorly, and the hippocampus is the temporal lobe. Figueiredo and colleagues29
transected in the coronal plane with ultrasonic described a mini-modified orbitozygomatic
 Selective Amygdalohippocampectomy 7

Fig. 3. (A) Postoperative coronal T2-weighted magnetic resonance imaging (MRI) showing that the hippocampus
was resected with preservation of all lateral temporal lobe structures. The approach does not disrupt the tempo-
ral stem (arrow). (B) Postoperative axial T2-weighted MRI obtained at different levels showing selective resection
of the mesial temporal structures. The hippocampus was resected posteriorly just beyond the level of the collic-
ular plate. (From Little AS, Smith KA, Kirlin K, et al. Modifications to the subtemporal selective amygdalohippo-
campectomy using a minimal-access technique: seizure and neuropsychological outcomes. J Neurosurg
2009;111(6):1269; with permission.)

approach to the mesial temporal structures SURGICAL COMPLICATIONS

through a small supraorbital craniotomy in a
cadaveric study, proposing that an anterior Avoidance of complications during and after
approach would theoretically preserve the lateral SAHC is of the utmost importance because
temporal cortex, lateral basal cortex, temporal many patients are neurologically intact.1 The sur-
stem, and optic tract. Similarly, Chen and col- geon and patients should undertake a detailed dis-
leagues30 described a transorbital endoscopic cussion of risks, benefits, and alternatives before
approach in cadaveric specimens. Türe and col- surgery. Clear estimation of risks is difficult,
leagues31 described approaching the mesial tem- partially because some ill effects of surgery, such
poral structures from the posterior aspect via a as visual field defects, have at times been consid-
supracerebellar-transtentorial approach.32 Shi- ered expected, inevitable, or acceptable.1,51
mizu and colleagues33 outlined a subtemporal In a structured review of the literature in 2013,
zygomatic approach, and Miyamoto and colle- Georgiadis and colleagues1 identified reported
agues34 described a subtemporal and transven- complications in adult and pediatric patients un-
tricular/transchoroidal approach. Fig. 4 illustrates dergoing resective temporal lobe surgeries. Only
the general differences between the various ap- 2 studies in the group focused exclusively on
proaches to the mesial temporal structures. SAHC. In addition, individual reports of surgical

Table 1
Theoretical advantages of various approaches to SAHC

Approach Transcortical Transsylvian Subtemporal

Advantages  Can be performed with a  Avoids injury to lateral  Avoids injury to lateral
minimal access craniotomy temporal neocortex temporal neocortex
and small wound  Avoids injury to white  Avoids injury to temporal
 Provides good matter tracts lateral to white matter tracts and
visualization of ventricular the temporal horn the temporal stem
and medial temporal  Provides good  Can be performed with a
anatomy visualization of minimal-access
ventricular and medial craniotomy and small
temporal anatomy wound
Disadvantages  Requires incision of lateral  Requires a substantial  Small working corridor
temporal neocortex craniotomy  Visualization of anatomy
 Disrupts white matter  Entails the incumbent can be challenging
tracts lateral to the risks of transsylvian  Requires some retraction
ventricle dissection of the basal temporal lobe
 Requires incision of the and possible traction on
temporal stem the vein of Labbé
8 Hoyt & Smith

Fig. 4. The different approaches to the hippocampus. Note that the transsylvian approach involves some transec-
tion of the temporal stem in order to gain access to the temporal horn and visualize the hippocampus. The trans-
sulcal and trans-T2–gyral approaches are technically easiest to perform; however, they result in injury and some
disconnection of the lateral temporal white matter in order to access the mesial structures. The subtemporal
approach, by entering into the collateral sulcus between the fusiform and parahippocampal gyrus, spares all
of the lateral temporal structures and the frontotemporal connections of the temporal stem and, therefore,
should theoretically have potentially the best chance of preserving cognitive functions related to the lateral tem-
poral lobe. (Courtesy of Barrow Neurological Institute, Phoenix, AZ; with permission.)

complications after SAHC can be identified in the Ischemic Events

literature (Table 2). No deaths as a result of sur-
Engel and colleagues4 reported that 21.4% of pa-
gery were noted.
tients demonstrated ischemic changes following
Jobst and Cascino52 systematically reviewed 55
SAHC on postoperative MRI imaging, but only
publications from 1993 to 2014. When temporal
7.1% were symptomatic because of these
lobe operations including ALT were included, a
changes. There is evidence of increased blood
mortality rate of 0.4% was reported. Transient
flow velocities after TS SAHC,54,55 but it is unclear
neurologic complications occurred in approxi-
if this represents symptomatic vasospasm. Martens
mately 10% of patients, and permanent neurologic
and colleagues56 reported a 47.9% rate of temporal
complications were noted in about 5%. One-half of
lobe infarcts and a 10.4% rate of frontal lobe infarcts
the permanent deficits were visual field defects.
after TS SAHC. Interestingly, none of the infarcts led
Major complications, such as infarction and hydro-
to clinical symptoms, and patients with infarcts
cephalus, occurred in 1.5%, whereas minor com-
were more often seizure free following surgery. Neu-
plications occurred in 5%. The most frequently
ropsychological study of those patients showed
reported minor complications were cerebrospinal
that in language-dominant hemisphere temporal
fluid leak (8.5%), aseptic meningitis (3.6%), wound
lobe infarcts, verbal memory performance suffered
infections (3%), and hemorrhage (2.5%). Sepa-
but verbal fluency and speech comprehension were
rately, an inpatient database of complication rates
not significantly affected.
for ATL showed an 8% overall incidence.53
 Selective Amygdalohippocampectomy 9

Table 2
Select publications detailing surgical complications after SAHC

Author, Number of Complications

Year Approach Study Design Patients Reported Notes
Vajkoczy Modified Retrospective 32 Epidural/subdural Perimetry was performed
et al,28 TS SAHC hematoma 6% on 93% of patients.
1998 CN III palsy 9% CN palsy was transient
VFD 3% in all cases.
Oertel TC SAHC Prospective 60 Hemiparesis 5% The use of intraoperative
et al,106 CN palsy 5% navigation on
2004 Aphasia 1.7% complications was
Infection 1.7% compared: 7.9% with
navigation and 21.7%
without.
Hori ST SAHC Retrospective 26 VFD 7% Visual field testing was
et al,101 performed in only 10
2007 patients.
Acar TC SAHC Retrospective 39 VFD 10.3% Hemiparesis, CN palsy,
et al,107 Aphasia 2.6% and aphasia were all
2008 Hemiparesis 2.6% transient.
CN palsy 2.6%
Hemotympanum 2.6%
Frontal branch of facial
nerve palsy 2.6%
Tanriverdi TC SAHC Retrospective 50 VFD 2% Visual field testing was
et al,62 not performed.
2008
Little ST SAHC Retrospective 36 Frontal branch of Visual field testing was
et al,9 facial nerve palsy 3% done by confrontation.
2009 VFD 3%
Yaşargil TS SAHC Retrospective 73 Aphasia 11% Speech disturbance and
et al,11 Subdural hematoma 1.3% CN III palsy were
2010 VFD 1.3% transient in all patients.
CN III palsy 4%
Bandt TC SAHC Retrospective 76 Transient aphasia 2.7% Visual field testing was
et al,108 not performed.
2013

Abbreviations: CN, cranial nerve; SAHC, selective amygdalohippocampectomy; ST SAHC, subtemporal SAHC; TC SAHC,
transcortical SAHC; TS SAHC, transsylvian SAHC; VFD, visual field defect.
Data from Refs.9,11,28,62,101,106–108

Visual Field Deficits between middle temporal gyrus TC SAHC and

modified ATL sparing the superior temporal gyrus.
The anterior bundle of the geniculocalcarine tract
Mengesha and colleagues59 found a similar fre-
makes a prominent anterior curve, known as the
quency of visual field defects, but those in SAHC
Meyer loop, and traverses the temporal lobe in
were less severe. Renowden and colleagues60
the roof and lateral wall of the temporal horn of
demonstrated MRI evidence of damage to tempo-
the lateral ventricle.57 It extends to the anterior
ral white matter after both TS SAHC and TC SAHC,
margin of the ventricle, bringing it into the surgical
with an accompanying 53% incidence of incom-
field of many temporal epilepsy surgeries. Reports
plete quadrantanopia. Yeni and colleagues61
place the incidence of visual field defects up to
found field defects on perimetric measurement in
100% in ATL.58 Selective procedures should theo-
36% of patients after TS SAHC, which was
retically limit damage to these structures and
thought to be related to disruption of the Meyer
reduce the incidence of postoperative distur-
loop during incision of the temporal stem. Lower
bances, but Egan and colleagues58 found no dif-
incidence has been reported after subtemporal
ference in the incidence of visual field defects
approaches.9,47
10 Hoyt & Smith

EVALUATION OF OUTCOME AND LONG- suggest that selective procedures have a superior
TERM RECOMMENDATIONS functional outcome.75,76
Seizure Control A single controlled trial77 comparing the memory
outcomes of surgically and medically treated pa-
Control of seizures is the primary measure of suc-
tients with temporal lobe epilepsy revealed that
cess after SAHC. Two prospective randomized
both groups had cognitive decline after 10 years,
clinical trials have demonstrated the superiority
although seizure-free patients showed significant
of surgical treatment of MTLE over medical man-
recovery of nonmemory function after surgery. Ev-
agement, with 58% to 73% of surgical patients
idence from structured reviews and meta-ana-
achieving seizure freedom versus 0% to 8% in
lyses78–82 suggests that intelligence is not
the medical group.3,4 An analysis by Jobst and
affected by temporal lobe surgery. Verbal decline
Cascino52 of 9 systematic reviews and 2 large
is the most common adverse event following tem-
case studies identified rates of seizure freedom
poral lobe resection, with 44% of patients with left-
following temporal lobe surgery of 34% to 73%
sided surgery and 20% with right-sided surgery
(median 62.4%). However, no randomized clinical
showing a decline in verbal memory.80 Nondomi-
trials comparing SAHC with medical management
nant resections do not seem to be associated
alone have been performed to date. Therefore,
with substantial nonverbal memory decline.79,82
rates of seizure control after SAHC are frequently
Naming deficits were present in 34% of dominant
compared with those following ATL.
temporal lobe resections.78,80 Evidence is accu-
Reported outcomes vary considerably, with
mulating that postoperative memory preservation
most large series reporting that 50% to 90% of pa-
after ATL depends on reorganization within the
tients with MTLE are seizure free 1 year after
ipsilateral temporal lobe, including the posterior
SAHC.11,16,26,52,62–70 For example, Mackenzie
hippocampus, anterior cingulum, orbitofrontal cor-
and colleagues64 reported only 21% seizure
tex, and insula.83
freedom at 1 year after SAHC, whereas Tanriverdi
and Olivier68 reported 100% seizure freedom at
the same interval. Several factors contribute to Comparison of Anterior Temporal Lobectomy
the variability of reported outcomes. First, and Selective Amygdalohippocampectomy
although outcomes are frequently reported using
Although selective procedures were developed in
the scale proposed by Engel and colleagues,71
an effort to preserve function, no prospective, ran-
there is no clear consensus of what constitutes a
domized controlled trials demonstrate superiority
satisfactory outcome. Second, MTLE is the com-
of SAHC or ATL. Two meta-analyses have sup-
mon pathologic expression of a highly heteroge-
ported a moderate advantage to seizure control
neous group of patients. Third, the technique,
with ATL for a 5% to 8% greater likelihood of
approach, and experience of the surgeon vary.
seizure freedom.84,85 A comparison study at 2
Most importantly, accuracy of seizure localization
separate centers also suggested that ATL was
and patient selection can vary independently
slightly more effective in seizure control than
from the technical success of surgery and exerts
SAHC, but the difference did not reach statistical
perhaps the highest influence on outcome.
significance.86 However, SAHC led to significantly
There is evidence that seizures recur in patients
better results in visual encoding, verbal and short-
who are initially seizure free.16,62,72,73 Conversely,
term memory, and visual working memory. Many
some studies suggest the effect of surgery is
retrospective studies are available (see Table 3).
more durable. Wasade and colleagues74 reported
Most studies suggest that, in appropriately
long-term outcomes of 253 patients up to 15 years
selected patients, seizure control after surgery is
after surgery, with a mean just more than 10 years.
similar for SAHC or ATL,51,68,86–90 whereas others
Among patients who had undergone temporal
suggest ATL provides superior seizure control.26,66
resection, 78% reported favorable (Engel class I
There is evidence to suggest that neuropsycho-
and II) outcomes after more than 15 years.
logical outcomes are improved after selective pro-
cedures,49,88,91–93 although some investigators
found no significant differences.94,95 Helmstaedter
Neuropsychological Outcomes
and colleagues91 performed a detailed prospec-
Although seizure control following surgery is of tive study suggesting that, in surgery on the domi-
utmost concern, preservation of function is equally nant side, ATL was less impactful on measures of
important. There is a paucity of high-quality data verbal learning than SAHC, whereas on the
specific to SAHC,52 and comparison is often nondominant side, selective surgery was less
made to the better-characterized risks following impactful. Interestingly, a study of category-
ATL (Table 3). Converging lines of evidence related naming and object recognition found no
 Table 3
Select publications comparing temporal lobe resection surgeries

Duration of
Study Number of Follow- Classification of
Author, Year Comparing Design Patients up (mo) Favorable Outcome Seizure Outcome Cognitive Outcome
Helmstaedter et al,65 ATL vs TS SAHC vs Retro 59 3 Seizure free No difference Favors ALT
1996 lesionectomy
Mackenzie et al,64 ATL vs SAHC Retro 100 12 Engel III or better Favors ATL No difference
1997
Clusmann et al,87 2002 ATL vs TS SAHC vs Retro 321 38 Engel II or better No difference Favors SAHC
lesionectomy
Clusmann et al,26 2004 ATL vs TS SAHC Retro 89 (peds) 46 Engel II or better Favors ATL No difference on
right, favors ATL on
left
Hader et al,109 2005 ATL vs TC SAHC Retro 72 Not specified Engel II or better No difference No difference
Paglioli et al,88 2006 ATL vs TC SAHC Pro 161 70 Engel I No difference Favors SAHC
Morino et al,49 2006 ATL vs TS SAHC Retro 49 12 Seizure free No difference Favors SAHC
Bate et al,66 2007 CAH vs SAHC Retro 114 12 Engel II or better Favors ATL Not reported
Tanriverdi and CAH vs TC SAHC Retro 72 12 Engel II or better No difference No difference

Selective Amygdalohippocampectomy
Olivier68 2007
Helmstaedter et al,91 Modified ATL vs Pro 97 12 Only Engel I included Only Engel I included ATL better verbal
2008 TS SAHC learning, SAHC
better figural
learning
Tanriverdi et al,62 2008 CAH vs TC SAHC Retro 100 60 Engel II or better No difference Not examined
Tanriverdi et al,89 2010 CAH vs TC SAHC Retro 256 12 Engel II or better No difference No difference
Sagher et al,86 2012 ATL vs TC SAHC Retro 96 44 Engel I No difference No difference
Bujarski et al,72 2013 ATL vs TC SAHC Retro 69 81 Engel II or better No difference No difference
Wendling et al,90 2013 ATL vs TS SAHC Retro 95 102 Seizure free No difference Favors SAHC
Mansouri et al,110 ATL vs TC SAHC Retro 54 40 Seizure free No difference No difference
2014
Abbreviations: ATL, anterior temporal lobectomy; CAH, corticoamygdalohippocampectomy; peds, pediatric patients; Pro, prospective; Retro, retrospective; SAHC, selective amygda-
lohippocampectomy; TC SAHC, transcortical SAHC; TS SAHC, transsylvian SAHC.
Data from Refs.26,49,62,64–66,72,86–91,109,110

11
12 Hoyt & Smith

differences in patients undergoing ATL or selective neuropsychological outcomes among the 80 pa-
procedures but superior outcomes following tients studied. Other investigators have reported
SAHC using laser interstitial thermal ablation.96 similar equality of seizure control between the
Although psychiatric outcomes are infrequently two methods.70,99 Inconsistency in testing tech-
reported, Bujarski and colleagues72 found no dif- niques between studies, particularly in regard to
ference in depression or anxiety between ATL neuropsychological function, make high-quality
and SAHC. However, measures of paranoia in- comparisons difficult, if not impossible (Table 4).
creased overall with ATL and decreased overall Von Rhein and colleagues100 evaluated neuro-
with selective surgery. Taking this evidence to- psychological outcomes in matched cohorts of
gether, SAHC seems to be as effective as ALT in patients who underwent transsylvian and subtem-
patients with disease limited to the mesial tempo- poral approaches. Although the study design did
ral structures. Although not conclusive, the not allow a comparison of seizure control, the in-
converging evidence suggests that selective vestigators found more decline in verbal recogni-
resection likely offers better neurocognitive out- tion memory in left TS SAHC and more decline in
comes. More esoteric functions attributed to the figural memory and verbal fluency with ST SAHC.
anterolateral temporal lobe, such as semantic Very positive outcomes were reported in several
memory and relating conceptual understanding studies of subtemporal approaches.9,41,101–103 Ta-
to social norms, are difficult to assess with stan- kaya and colleagues41 demonstrated postopera-
dard neuropsychiatric paradigms but would theo- tive improvement in glucose metabolism, verbal
retically be preserved by SAHC and be impaired memory, attention, and delayed recall following a
after ATL.97 subtemporal approach in a limited number of
patients without a control group. In a detailed anal-
ysis of 47 patients, Hill and colleagues104 demon-
Comparison of Approaches to Selective
strated decline in memory, verbal intellect, and
Amygdalohippocampectomy
naming in 29% to 38% of patients undergoing
Data supporting the use of a particular surgical dominant hemisphere surgery, and declines in
approach for SAHC are even more limited than memory in 36% of patients undergoing nondomi-
data comparing SAHC with ATL. Lutz and col- nant hemisphere surgery using the minimal access
leagues98 published a rare, prospective random- approach described by the senior author. Current
ized trial comparing transsylvian and transcortical investigations are under way to determine if
approaches. With the exception of phonemic preoperative factors, such as hippocampal vol-
fluency, which improved after transcortical proce- ume on MRI, can identify patients at higher risk
dures, there was no difference in seizure or for developing deficits after ST SAHC. Some

Table 4
Select publications comparing approaches to SAHC

Duration of
Number of Follow-up Seizure Cognitive
Author, Year Comparing Study Design Patients (mo) Outcome Outcome
Renowden TC SAHC vs Retrospective 17 24 No No difference
et al,60 TS SAHC difference
1995
Lutz et al,98 TC SAHC vs Randomized 80 7 No Slightly better
2004 TS SAHC prospective difference phonemic
fluency
in TC SAHC
von Rhein ST SAHC vs Prospective 26 12 Could not No difference
et al,100 TS SAHC cohort report
2011
Drane et al,96 TC SAHC vs Nonrandomized 58 6 No Favored SLAHC in
2015 ATL vs prospective difference naming and
SLAHC recognition of
famous faces

Abbreviation: SAHC, selective amygdalohippocampectomy; SLAHC, stereotactic laser amygdalohippocampectomy; ST

SAHC, subtemporal SAHC; TC SAHC, transcortical SAHC; TS SAHC, transsylvian SAHC.
Data from Refs.60,96,98,100
 Selective Amygdalohippocampectomy 13

surgeons,98,105 in an effort to preserve cognitive results in the partial disconnection or injury to the
function, have begun to explore other ablation spared lateral cortex. ST SAHC is the authors’
techniques, such as laser thermal ablation. Early favored approach because of the minimal access
reports of these techniques suggest positive re- needed and because of the theoretical lack of
sults with respect to preservation of function but disconnection or damage from the approach itself,
with likely diminished long-term seizure control although admittedly ventral visual pathway injury
compared with complete mesial resections. Clin- may contribute to memory decline beyond what
ical trials comparing laser ablation with SAHC would occur from hippocampectomy alone. Expe-
have been initiated to accurately quantify the po- rience and skill on the part of the treating surgeon
tential disparity. are necessities for the safe and efficacious execu-
tion of all the discussed approaches. Specialized
Long-term Follow-up training in a high-volume center is strongly recom-
mended before attempting these techniques
The authors advocate follow-up of patients who
independently.
have undergone SAHC for at least 1 year after sur-
gery. Because neuropsychological outcomes are
central to evaluating the success of surgery, formal REFERENCES
neuropsychological testing should be performed
1. Georgiadis I, Kapsalaki EZ, Fountas KN. Temporal
between 6 months and 1 year after surgery.
lobe resective surgery for medically intractable ep-
ilepsy: a review of complications and side effects.
Discontinuation of Medical Treatment Epilepsy Res Treat 2013;2013:752195.
If patients are seizure free after surgery, reducing 2. Kovanda TJ, Tubbs RS, Cohen-Gadol AA. Transsyl-
or eliminating the use of antiepileptic drugs is vian selective amygdalohippocampectomy for
possible. Reported rates of recurrent seizures treatment of medial temporal lobe epilepsy: surgi-
with discontinuation of medical therapy vary, and cal technique and operative nuances to avoid com-
little information is available for selective proce- plications. Surg Neurol Int 2014;5:133.
dures alone. In reviews including ATL, 25% of 3. Wiebe S, Blume WT, Girvin JP, et al. A randomized,
MTLE surgery had seizures after stopping medical controlled trial of surgery for temporal-lobe epi-
management, as opposed to 46% in neocortical lepsy. N Engl J Med 2001;345(5):311–8.
epilepsy. Approximately 88% of those individuals 4. Engel J Jr, McDermott MP, Wiebe S, et al. Early
who underwent temporal lobe procedures re- surgical therapy for drug-resistant temporal lobe
gained seizure freedom after reinitiating medica- epilepsy: a randomized trial. JAMA 2012;307(9):
tions.16 The authors’ practice is to continue 922–30.
antiepileptic drugs at presurgical doses for 5. Engel J Jr, Wiebe S, French J, et al. Practice
1 year after surgery, at which time a taper of med- parameter: temporal lobe and localized neocortical
ications may be initiated. resections for epilepsy: report of the Quality Stan-
dards Subcommittee of the American Academy of
SUMMARY Neurology, in association with the American Epi-
lepsy Society and the American Association of
SAHC has been developed in an attempt to treat Neurological Surgeons. Neurology 2003;60(4):
MTLE while sparing temporal lobe structures 538–47.
sacrificed during ATL. The preponderance of the 6. Widjaja E, Li B, Schinkel CD, et al. Cost-effective-
data suggests that SAHC is as effective in seizure ness of pediatric epilepsy surgery compared to
control as ATL in appropriately selected patients. medical treatment in children with intractable epi-
Although not conclusive, evidence suggests better lepsy. Epilepsy Res 2011;94(1–2):61–8.
preservation of neuropsychological function with 7. Silfvenius H. Cost and cost-effectiveness of epi-
SAHC. lepsy surgery. Epilepsia 1999;40(Suppl 8):32–9.
A variety of approaches exist, each with theoret- 8. Langfitt JT, Holloway RG, McDermott MP, et al.
ical advantages and disadvantages; but a review Health care costs decline after successful epilepsy
of the published data does not establish the supe- surgery. Neurology 2007;68(16):1290–8.
riority of a particular surgery. Each approach can 9. Little AS, Smith KA, Kirlin K, et al. Modifications to
be technically challenging. Certainly, the risk of the subtemporal selective amygdalohippocampec-
deficits not related to resection of mesial temporal tomy using a minimal-access technique: seizure
structures is present for all approaches. TS SAHC and neuropsychological outcomes. J Neurosurg
has a higher risk of vascular injury and stroke. TC 2009;111(6):1263–74.
SAHC is likely the easiest approach technically 10. Yas‚argil MG, Türe U, Boop FA. Selective amygdalo-
but does not spare the optic radiations, and it hippocampectomy. In: Kaye AH, Black PM, editors.
14 Hoyt & Smith

Operative neurosurgery, vol. 2. London: Harcourt 25. Haneef Z, Stern J, Dewar S, et al. Referral pattern
Publishers Limited; 2000. p. 1275–83. for epilepsy surgery after evidence-based recom-
11. Yas‚argil MG, Krayenbuhl N, Roth P, et al. The se- mendations: a retrospective study. Neurology
lective amygdalohippocampectomy for intractable 2010;75(8):699–704.
temporal limbic seizures. J Neurosurg 2010; 26. Clusmann H, Kral T, Gleissner U, et al. Analysis of
112(1):168–85. different types of resection for pediatric patients
12. Devinsky O. The myth of silent cortex and the with temporal lobe epilepsy. Neurosurgery 2004;
morbidity of epileptogenic tissue: implications for 54(4):847–59 [discussion: 859–60].
temporal lobectomy. Epilepsy Behav 2005;7(3): 27. Datta A, Sinclair DB, Wheatley M, et al. Selective
383–9. amygdalohippocampectomy: surgical outcome in
13. Wheatley BM. Selective amygdalohippocampec- children versus adults. Can J Neurol Sci 2009;
tomy: the trans-middle temporal gyrus approach. 36(2):187–91.
Neurosurg Focus 2008;25(3):E4. 28. Vajkoczy P, Krakow K, Stodieck S, et al. Modi-
14. Berg AT, Langfitt J, Shinnar S, et al. How long does fied approach for the selective treatment of tem-
it take for partial epilepsy to become intractable? poral lobe epilepsy: transsylvian-transcisternal
Neurology 2003;60(2):186–90. mesial en bloc resection. J Neurosurg 1998;
15. Kwan P, Arzimanoglou A, Berg AT, et al. Definition 88(5):855–62.
of drug resistant epilepsy: consensus proposal by 29. Figueiredo EG, Deshmukh P, Nakaji P, et al. Ante-
the ad hoc Task Force of the ILAE Commission rior selective amygdalohippocampectomy: tech-
on Therapeutic Strategies. Epilepsia 2010;51(6): nical description and microsurgical anatomy.
1069–77. Neurosurgery 2010;66(3 Suppl Operative):45–53.
16. Ryvlin P, Cross JH, Rheims S. Epilepsy surgery in 30. Chen HI, Bohman LE, Loevner LA, et al. Transorbital
children and adults. Lancet Neurol 2014;13(11): endoscopic amygdalohippocampectomy: a fea-
1114–26. sibility investigation. J Neurosurg 2014;120(6):
17. French JA, Williamson PD, Thadani VM, et al. Char- 1428–36.
acteristics of medial temporal lobe epilepsy: I. Re- 31. Türe U, Harput MV, Kaya AH, et al. The paramedian
sults of history and physical examination. Ann supracerebellar-transtentorial approach to the
Neurol 1993;34(6):774–80. entire length of the mediobasal temporal region:
18. Radhakrishnan K, So EL, Silbert PL, et al. Predic- an anatomical and clinical study. Laboratory inves-
tors of outcome of anterior temporal lobectomy tigation. J Neurosurg 2012;116(4):773–91.
for intractable epilepsy: a multivariate study. 32. Lafazanos S, Türe U, Harput MV, et al. Evaluating
Neurology 1998;51(2):465–71. the importance of the tentorial angle in the parame-
19. Cross JH, Jayakar P, Nordli D, et al. Proposed dian supracerebellar-transtentorial approach for
criteria for referral and evaluation of children for ep- selective amygdalohippocampectomy. World Neu-
ilepsy surgery: recommendations of the Subcom- rosurg 2015;83(5):836–41.
mission for Pediatric Epilepsy Surgery. Epilepsia 33. Shimizu H, Kawai K, Sunaga S, et al. Hippocampal
2006;47(6):952–9. transection for treatment of left temporal lobe epi-
20. Spencer D, Burchiel K. Selective amygdalohippo- lepsy with preservation of verbal memory. J Clin
campectomy. Epilepsy Res Treat 2012;2012: Neurosci 2006;13(3):322–8.
382095 [Epub June 20, 2011]. 34. Miyamoto S, Kataoka H, Ikeda A, et al. A combined
21. Burch J, Hinde S, Palmer S. The clinical effective- subtemporal and transventricular/transchoroidal
ness and cost-effectiveness of technologies used fissure approach to medial temporal lesions. Neuro-
to visualise the seizure focus in people with refrac- surgery 2004;54(5):1162–7 [discussion: 1167–9].
tory epilepsy being considered for surgery: a sys- 35. Niemeyer P, Bello H. Amygdalohippocampectomy
tematic review and decision-analytical model. in temporal lobe epilepsy: microsurgical technique.
Health Technol Assess 2012;16:1–157. Excerpta Med 1973;293:20.
22. Gil-Nagel A, Risinger MW. Ictal semiology in hippo- 36. Olivier A. Temporal resections in the surgical treat-
campal versus extrahippocampal temporal lobe ment of epilepsy. Epilepsy Res Suppl 1992;5:175–88.
epilepsy. Brain 1997;120(Pt 1):183–92. 37. Olivier A. Transcortical selective amygdalohippo-
23. Kaiboriboon K, Nagarajan S, Mantle M, et al. Inter- campectomy in temporal lobe epilepsy. Can J
ictal MEG/MSI in intractable mesial temporal lobe Neurol Sci 2000;27(Suppl 1):S68–76 [discussion:
epilepsy: spike yield and characterization. Clin S92–6].
Neurophysiol 2010;121(3):325–31. 38. Miyagi Y, Shima F, Ishido K, et al. Inferior temporal
24. Choi H, Carlino R, Heiman G, et al. Evaluation of sulcus approach for amygdalohippocampectomy
duration of epilepsy prior to temporal lobe epilepsy guided by a laser beam of stereotactic navigator.
surgery during the past two decades. Epilepsy Res Neurosurgery 2003;52(5):1117–23 [discussion:
2009;86(2–3):224–7. 1123–4].
 Selective Amygdalohippocampectomy 15

39. Yas‚argil MG, Teddy PJ, Roth P. Selective surgery for intractable temporal lobe epilepsy in
amygdalo-hippocampectomy. Operative anatomy the United States. Arch Neurol 2011;68(6):725–9.
and surgical technique. Adv Tech Stand Neurosurg 54. Schaller C, Zentner J. Vasospastic reactions in
1985;12:93–123. response to the transsylvian approach. Surg Neu-
40. Park TS, Bourgeois BF, Silbergeld DL, et al. Subtem- rol 1998;49(2):170–5.
poral transparahippocampal amygdalohippocam- 55. Schaller C, Jung A, Clusmann H, et al. Rate of
pectomy for surgical treatment of mesial temporal vasospasm following the transsylvian versus trans-
lobe epilepsy. Technical note. J Neurosurg 1996; cortical approach for selective amygdalohippo-
85(6):1172–6. campectomy. Neurol Res 2004;26(6):666–70.
41. Takaya S, Mikuni N, Mitsueda T, et al. Improved 56. Martens T, Merkel M, Holst B, et al. Vascular events
cerebral function in mesial temporal lobe epilepsy after transsylvian selective amygdalohippocam-
after subtemporal amygdalohippocampectomy. pectomy and impact on epilepsy outcome. Epilep-
Brain 2009;132(Pt 1):185–94. sia 2014;55(5):763–9.
42. Hori T, Tabuchi S, Kurosaki M, et al. Subtemporal 57. Kucukyuruk B, Richardson RM, Wen HT, et al.
amygdalohippocampectomy for treating medically Microsurgical anatomy of the temporal lobe and
intractable temporal lobe epilepsy. Neurosurgery its implications on temporal lobe epilepsy surgery.
1993;33(1):50–6 [discussion: 56–7]. Epilepsy Res Treat 2012;2012:769825.
43. Niemeyer P. The transventricular amygdala- 58. Egan RA, Shults WT, So N, et al. Visual field deficits
hippocampectomy in the temporal lobe epilepsy. in conventional anterior temporal lobectomy versus
Temporal lobe epilepsy. Springfield (IL): Charles amygdalohippocampectomy. Neurology 2000;
C. Thomas; 1958. p. 461–82. 55(12):1818–22.
44. Olivier A. Relevance of removal of limbic structures 59. Mengesha T, Abu-Ata M, Haas KF, et al. Visual
in surgery for temporal lobe epilepsy. Can J Neurol field defects after selective amygdalohippo-
Sci 1991;18(4 Suppl):628–35. campectomy and standard temporal lobectomy.
45. Boling W. Minimal access keyhole surgery for J Neuroophthalmol 2009;29(3):208–13.
mesial temporal lobe epilepsy. J Clin Neurosci 60. Renowden SA, Matkovic Z, Adams CB, et al. Selec-
2010;17(9):1180–4. tive amygdalohippocampectomy for hippocampal
46. Binder DK, Schramm J. Resective surgical tech- sclerosis: postoperative MR appearance. AJNR
niques: mesial temporal lobe epilepsy. In: Am J Neuroradiol 1995;16(9):1855–61.
Luders HO, editor. Textbook of epilepsy surgery. Lon- 61. Yeni SN, Tanriover N, Uyanik O, et al. Visual field
don: Informa; 2008. p. 1083–92. defects in selective amygdalohippocampectomy
47. Thudium MO, Campos AR, Urbach H, et al. The for hippocampal sclerosis: the fate of Meyer’s
basal temporal approach for mesial temporal sur- loop during the transsylvian approach to the tem-
gery: sparing the Meyer loop with navigated diffu- poral horn. Neurosurgery 2008;63(3):507–13 [dis-
sion tensor tractography. Neurosurgery 2010;67(2 cussion: 513–5].
Suppl Operative):385–90. 62. Tanriverdi T, Olivier A, Poulin N, et al. Long-term
48. Wieser HG, Yas‚argil MG. Selective amygdalohippo- seizure outcome after mesial temporal lobe epilepsy
campectomy as a surgical treatment of mesiobasal surgery: corticalamygdalohippocampectomy versus
limbic epilepsy. Surg Neurol 1982;17:445–57. selective amygdalohippocampectomy. J Neurosurg
49. Morino M, Uda T, Naito K, et al. Comparison of neu- 2008;108(3):517–24.
ropsychological outcomes after selective amygda- 63. Spencer S, Huh L. Outcomes of epilepsy surgery in
lohippocampectomy versus anterior temporal adults and children. Lancet Neurol 2008;7(6):525–37.
lobectomy. Epilepsy Behav 2006;9(1):95–100. 64. Mackenzie RA, Matheson J, Ellis M, et al. Selective
50. Bahuleyan B, Fisher W, Robinson S, et al. Endo- versus non-selective temporal lobe surgery for ep-
scopic transventricular selective amygdalohippo- ilepsy. J Clin Neurosci 1997;4(2):152–4.
campectomy: cadaveric demonstration of a new 65. Helmstaedter C, Elger CE, Hufnagel A, et al.
operative approach. World Neurosurg 2013;80(1– Different effects of left anterior temporal lobectomy,
2):178–82. selective amygdalohippocampectomy, temporal
51. Sindou M, Guenot M, Isnard J, et al. Temporo- cortical lesionectomy on verbal learning, memory,
mesial epilepsy surgery: outcome and compli- and recognition. J Epilepsy 1996;9:39–45.
cations in 100 consecutive adult patients. Acta 66. Bate H, Eldridge P, Varma T, et al. The seizure
Neurochir (Wien) 2006;148(1):39–45. outcome after amygdalohippocampectomy and
52. Jobst BC, Cascino GD. Resective epilepsy surgery temporal lobectomy. Eur J Neurol 2007;14(1):90–4.
for drug-resistant focal epilepsy: a review. JAMA 67. McIntosh AM, Wilson SJ, Berkovic SF. Seizure
2015;313(3):285–93. outcome after temporal lobectomy: current re-
53. McClelland S 3rd, Guo H, Okuyemi KS. Population- search practice and findings. Epilepsia 2001;
based analysis of morbidity and mortality following 42(10):1288–307.
16 Hoyt & Smith

68. Tanriverdi T, Olivier A. Cognitive changes after uni- 83. Duchowny M, Bhatia S. Epilepsy: preserving mem-
lateral cortico-amygdalohippocampectomy unilat- ory in temporal lobectomy-are networks the key?
eral selective-amygdalohippocampectomy mesial Nat Rev Neurol 2014;10(5):245–6.
temporal lobe epilepsy. Turk Neurosurg 2007; 84. Hu WH, Zhang C, Zhang K, et al. Selective amyg-
17(2):91–9. dalohippocampectomy versus anterior temporal lo-
69. Yas‚argil MG, Wieser HG, Valavanis A, et al. Surgery bectomy in the management of mesial temporal
and results of selective amygdala-hippocampectomy lobe epilepsy: a meta-analysis of comparative
in one hundred patients with nonlesional limbic epi- studies. J Neurosurg 2013;119(5):1089–97.
lepsy. Neurosurg Clin N Am 1993;4(2):243–61. 85. Josephson CB, Dykeman J, Fiest KM, et al. System-
70. Wieser HG, Ortega M, Friedman A, et al. Long-term atic review and meta-analysis of standard vs selec-
seizure outcomes following amygdalohippocam- tive temporal lobe epilepsy surgery. Neurology
pectomy. J Neurosurg 2003;98(4):751–63. 2013;80(18):1669–76.
71. Engel JJ, Van Ness P, Rasmussen TB, et al. Outcome 86. Sagher O, Thawani JP, Etame AB, et al. Seizure
with respect to epileptic seizures. In: Engel JJ, editor. outcomes and mesial resection volumes following
Surgical treatment of the epilepsies. New York: Ra- selective amygdalohippocampectomy and tempo-
ven Press; 1993. p. 609–21. ral lobectomy. Neurosurg Focus 2012;32(3):E8.
72. Bujarski KA, Hirashima F, Roberts DW, et al. Long- 87. Clusmann H, Schramm J, Kral T, et al. Prognostic
term seizure, cognitive, and psychiatric outcome factors and outcome after different types of resec-
following trans-middle temporal gyrus amygdalo- tion for temporal lobe epilepsy. J Neurosurg 2002;
hippocampectomy and standard temporal lobec- 97(5):1131–41.
tomy. J Neurosurg 2013;119(1):16–23. 88. Paglioli E, Palmini A, Portuguez M, et al. Seizure
73. de Tisi J, Bell GS, Peacock JL, et al. The long-term and memory outcome following temporal lobe sur-
outcome of adult epilepsy surgery, patterns of gery: selective compared with nonselective ap-
seizure remission, and relapse: a cohort study. proaches for hippocampal sclerosis. J Neurosurg
Lancet 2011;378(9800):1388–95. 2006;104(1):70–8.
74. Wasade VS, Elisevich K, Tahir R, et al. Long-term 89. Tanriverdi T, Dudley RW, Hasan A, et al. Memory
seizure and psychosocial outcomes after resective outcome after temporal lobe epilepsy surgery: cor-
surgery for intractable epilepsy. Epilepsy Behav ticoamygdalohippocampectomy versus selective
2015;43:122–7. amygdalohippocampectomy. J Neurosurg 2010;
75. Schramm J. Temporal lobe epilepsy surgery and 113(6):1164–75.
the quest for optimal extent of resection: a review. 90. Wendling AS, Hirsch E, Wisniewski I, et al. Selec-
Epilepsia 2008;49(8):1296–307. tive amygdalohippocampectomy versus standard
76. Helmstaedter C. Cognitive outcomes of different temporal lobectomy in patients with mesial tempo-
surgical approaches in temporal lobe epilepsy. ral lobe epilepsy and unilateral hippocampal scle-
Epileptic Disord 2013;15(3):221–39. rosis. Epilepsy Res 2013;104(1–2):94–104.
77. Helmstaedter C, Kurthen M, Lux S, et al. Chronic ep- 91. Helmstaedter C, Richter S, Roske S, et al. Differential
ilepsy and cognition: a longitudinal study in tempo- effects of temporal pole resection with amy-
ral lobe epilepsy. Ann Neurol 2003;54(4):425–32. gdalohippocampectomy versus selective amygda-
78. Ives-Deliperi VL, Butler JT. Naming outcomes of lohippocampectomy on material-specific memory
anterior temporal lobectomy in epilepsy patients: in patients with mesial temporal lobe epilepsy. Epi-
a systematic review of the literature. Epilepsy Be- lepsia 2008;49(1):88–97.
hav 2012;24(2):194–8. 92. Helmstaedter C, Grunwald T, Lehnertz K, et al. Dif-
79. Lee TM, Yip JT, Jones-Gotman M. Memory deficits ferential involvement of left temporolateral and tem-
after resection from left or right anterior temporal poromesial structures in verbal declarative learning
lobe in humans: a meta-analytic review. Epilepsia and memory: evidence from temporal lobe epi-
2002;43(3):283–91. lepsy. Brain Cogn 1997;35(1):110–31.
80. Sherman EM, Wiebe S, Fay-McClymont TB, et al. 93. Wendling AS, Steinhoff BJ, Bodin F, et al. Selective
Neuropsychological outcomes after epilepsy sur- amygdalohippocampectomy versus standard tem-
gery: systematic review and pooled estimates. Ep- poral lobectomy in patients with mesiotemporal
ilepsia 2011;52(5):857–69. lobe epilepsy and unilateral hippocampal scle-
81. Téllez-Zenteno JF, Dhar R, Hernandez-Ronquillo L, rosis: post-operative facial emotion recognition
et al. Long-term outcomes in epilepsy surgery: abilities. Epilepsy Res 2015;111:26–32.
antiepileptic drugs, mortality, cognitive and psy- 94. Jones-Gotman M, Zatorre RJ, Olivier A, et al.
chosocial aspects. Brain 2007;130(Pt 2):334–45. Learning and retention of words and designs
82. Vaz SA. Nonverbal memory functioning following following excision from medial or lateral temporal-
right anterior temporal lobectomy: a meta-analytic lobe structures. Neuropsychologia 1997;35(7):
review. Seizure 2004;13(7):446–52. 963–73.
 Selective Amygdalohippocampectomy 17

95. Wolf RL, Ivnik RJ, Hirschorn KA, et al. Neurocogni- 103. Mikuni N, Miyamoto S, Ikeda A, et al. Subtemporal
tive efficiency following left temporal lobectomy: hippocampectomy preserving the basal temporal
standard versus limited resection. J Neurosurg language area for intractable mesial temporal
1993;79(1):76–83. lobe epilepsy: preliminary results. Epilepsia 2006;
96. Drane DL, Loring DW, Voets NL, et al. Better object 47(8):1347–53.
recognition and naming outcome with MRI-guided 104. Hill SW, Gale SD, Pearson C, et al. Neuropsycho-
stereotactic laser amygdalohippocampotomy for logical outcome following minimal access sub-
temporal lobe epilepsy. Epilepsia 2015;56(1):101–13. temporal selective amygdalohippocampectomy.
97. Bonner MF, Price AR. Where is the anterior tempo- Seizure 2012;21(5):353–60.
ral lobe and what does it do? J Neurosci 2013; 105. Gross RE, Mahmoudi B, Riley JP. Less is more:
33(10):4213–5. novel less-invasive surgical techniques for mesial
98. Lutz MT, Clusmann H, Elger CE, et al. Neuropsy- temporal lobe epilepsy that minimize cognitive
chological outcome after selective amygdalohippo- impairment. Curr Opin Neurol 2015;28(2):182–91.
campectomy with transsylvian versus transcortical
106. Oertel J, Gaab MR, Runge U, et al. Neuronaviga-
approach: a randomized prospective clinical trial
tion and complication rate in epilepsy surgery.
of surgery for temporal lobe epilepsy. Epilepsia
Neurosurg Rev 2004;27(3):214–7.
2004;45(7):809–16.
107. Acar G, Acar F, Miller J, et al. Seizure outcome
99. Cendes F, Dubeau F, Olivier A, et al. Increased
following transcortical selective amygdalohippo-
neocortical spiking and surgical outcome after se-
campectomy in mesial temporal lobe epilepsy.
lective amygdalo-hippocampectomy. Epilepsy Res
Stereotact Funct Neurosurg 2008;86(5):314–9.
1993;16(3):195–206.
100. von Rhein B, Nelles M, Urbach H, et al. Neuropsy- 108. Bandt SK, Werner N, Dines J, et al. Trans-middle tem-
chological outcome after selective amygdalohip- poral gyrus selective amygdalohippocampectomy for
pocampectomy: subtemporal versus transsylvian medically intractable mesial temporal lobe epilepsy in
approach. J Neurol Neurosurg Psychiatry 2012; adults: seizure response rates, complications, and
83(9):887–93. neuropsychological outcomes. Epilepsy Behav
101. Hori T, Yamane F, Ochiai T, et al. Selective subtem- 2013;28(1):17–21.
poral amygdalohippocampectomy for refractory 109. Hader WJ, Pillay N, Myles ST, et al. The benefit of
temporal lobe epilepsy: operative and neuropsy- selective over standard surgical resections in the
chological outcomes. J Neurosurg 2007;106(1): treatment of intractable temporal lobe epilepsy. Ep-
134–41. ilepsia 2005;46:253–60.
102. Hori T, Yamane F, Ochiai T, et al. Subtemporal 110. Mansouri A, Fallah A, McAndrews MP, et al. Neuro-
amygdalohippocampectomy prevents verbal me- cognitive and seizure outcomes of selective amyg-
mory impairment in the language-dominant hemi- dalohippocampectomy versus anterior temporal
sphere. Stereotact Funct Neurosurg 2003;80(1–4): lobectomy for mesial temporal lobe epilepsy. Epi-
18–21. lepsy Res Treat 2014;2014:306382.