How I do it – selective amygdalohippocampectomy via subtemporal approach
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Surgery is superior over medicamentous treatment of pharmacoresistant mesial temporal lobe epilepsy caused by hippocampal sclerosis. The armamentarium of surgical procedures comprises standard temporal lobectomy and more selective procedures. Selective amygdalohippocampectomy can be performed via transcortical, transsylvian or subtemporal approach.
Describe the selective amygdalohippocampectomy through the subtemporal approach
After the detailed preoperative epilepsy evaluation, surgery can be offered to pharmacoresistant epilepsy patient with hippocampal sclerosis. Selective amygdalohippocampectomy can be safely performed through the subtemporal approach. The good knowledge of the mesial temporal lobe anatomy is necessary when performing this procedure.
• Perform the subtemporal craniotomy with additional bone removal up to temporal petrous part to minimize retraction of the brain.
• Release the CSF from the subarachnoid sulcal space in order to relax the temporal lobe. Dissect the arachnoid around basal temporal veins and protect them with hemostatic material in order to avoid vein rupture.
• After gyrus fusiformis corticotomy, always follow the white matter in order to enter the temporal horn.
• Place the self-retraining retractor gently to secure an unobstructed view of the intraventricular mesial temporal lobe structures.
• Visualize the choroid plexus and the inferior choroidal point. They represent the two most important landmarks.
• While performing the anterior disconnection the goal is to reach the arachnoid of the interpeduncular and crural cistern medially and the tentorial edge laterally.
• Follow the tentorial edge and the arachnoid of the temporal base to securely perform the lateral disconnection.
• Perform the posterior disconnection at the level of the mesencephalon superior colliculi.
• During the medial disconnection the dissection of the arachnoid of the hippocampal sulcus must be done as close to the hippocampus as possible in order to avoid damage to the brain stem perforators or the loop of the anterior choroidal artery.
• Knowledge of mesial temporal lobe anatomy is crucial.
KeywordsPharmacoresistant epilepsy Hippocampal sclerosis Selective amygdalohippocampectomy Subtemporal approach
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