J Neurol Surg A Cent Eur Neurosurg 2015; 76(05): 407-414
DOI: 10.1055/s-0035-1549303
Surgical Technique Article
Georg Thieme Verlag KG Stuttgart · New York

Modified Anterior Temporal Lobectomy: Anatomical Landmarks and Operative Technique

Enrico Ghizoni
1   Division of Neurosurgery, Department of Neurology, University of Campinas, Campinas, São Paulo, Brazil
J. P. Almeida
1   Division of Neurosurgery, Department of Neurology, University of Campinas, Campinas, São Paulo, Brazil
Andrei F. Joaquim
1   Division of Neurosurgery, Department of Neurology, University of Campinas, Campinas, São Paulo, Brazil
Clarissa L. Yasuda
2   Department of Neurology, University of Campinas, Campinas, São Paulo, Brazil
Brunno M. de Campos
2   Department of Neurology, University of Campinas, Campinas, São Paulo, Brazil
Helder Tedeschi
1   Division of Neurosurgery, Department of Neurology, University of Campinas, Campinas, São Paulo, Brazil
Fernando Cendes
2   Department of Neurology, University of Campinas, Campinas, São Paulo, Brazil
› Author Affiliations
Further Information

Publication History

17 June 2014

19 January 2015

Publication Date:
22 May 2015 (online)


There is great controversy about which surgical approach is the most selective and efficient for resection of mesial structures of the temporal lobe for treatment of mesial temporal lobe epilepsy. Selective approaches have been described in an attempt to preserve the neocortex and the temporal stem. Nonselective approaches, such as anterior temporal lobectomy (ATL), result in injuries in these structures. We describe a modified selective technique for resection of the amygdala and hippocampus with resection of the temporal pole performed through the Sylvian fissure based on anatomical landmarks and diligent microsurgical techniques. Briefly, after opening the Sylvian fissure, the temporal pole is resected and the temporal horn is directly accessed through the uncus, in an anteroposterior direction, preserving the temporal stem and the neocortex of the temporal lobe. The surgical technique used by our group is described in detail with illustrations. Precise microsurgical techniques associated with knowledge of microsurgical anatomy are of paramount importance for temporal lobe epilepsy surgery. According to our analysis, the modified ATL approach to the temporal mesial structures is a feasible selective technique that can be used as an alternative to traditional surgical procedures.

  • References

  • 1 Arruda F, Cendes F, Andermann F , et al. Mesial atrophy and outcome after amygdalohippocampectomy or temporal lobe removal. Ann Neurol 1996; 40 (3) 446-450
  • 2 Yasuda CL, Tedeschi H, Oliveira EL , et al. Comparison of short-term outcome between surgical and clinical treatment in temporal lobe epilepsy: a prospective study. Seizure 2006; 15 (1) 35-40
  • 3 Wiebe S, Blume WT, Girvin JP, Eliasziw M ; Effectiveness and Efficiency of Surgery for Temporal Lobe Epilepsy Study Group. A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med 2001; 345 (5) 311-318
  • 4 Falconer MA, Taylor DC. Surgical treatment of drug-resistant epilepsy due to mesial temporal sclerosis. Etiology and significance. Arch Neurol 1968; 19 (4) 353-361
  • 5 Niemeyer P. The transventricular amygdala-hippocampectomy in temporal lobe epilepsy. In: Baldwin M, Bailey P, , eds. The Temporal Lobe Epilepsy. Springfield, IL: Charles C Thomas; 1958: 461-482
  • 6 Yaşargil MG, Teddy PJ, Roth P. Selective amygdalo-hippocampectomy. Operative anatomy and surgical technique. Adv Tech Stand Neurosurg 1985; 12: 93-123
  • 7 Bate H, Eldridge P, Varma T, Wieshmann UC. The seizure outcome after amygdalohippocampectomy and temporal lobectomy. Eur J Neurol 2007; 14 (1) 90-94
  • 8 Clusmann H, Schramm J, Kral T , et al. Prognostic factors and outcome after different types of resection for temporal lobe epilepsy. J Neurosurg 2002; 97 (5) 1131-1141
  • 9 Lutz MT, Clusmann H, Elger CE, Schramm J, Helmstaedter C. Neuropsychological outcome after selective amygdalohippocampectomy with transsylvian versus transcortical approach: a randomized prospective clinical trial of surgery for temporal lobe epilepsy. Epilepsia 2004; 45 (7) 809-816
  • 10 Wen HT, Rhoton Jr AL, de Oliveira E , et al. Microsurgical anatomy of the temporal lobe: part 1: mesial temporal lobe anatomy and its vascular relationships as applied to amygdalohippocampectomy. Neurosurgery 1999; 45 (3) 549-591 ; discussion 591–592
  • 11 Fernández-Miranda JC, de Oliveira E, Rubino PA, Wen HT, Rhoton Jr. AL. Microvascular anatomy of the medial temporal region: part 1: its application to arteriovenous malformation surgery. Neurosurgery 2010; 67 (3 Suppl Operative) ons237-ons276 ; discussion ons276
  • 12 Wen HT, Rhoton Jr AL, De Oliveira E, Castro LHM, Figueiredo EG, Teixeira MJ. Microsurgical anatomy of the temporal lobe: part 2—sylvian fissure region and its clinical application. Neurosurgery 2009; 65 (6 Suppl): 1-35 ; discussion 36
  • 13 Duvernoy H. The Human Hippocampus: Functional Anatomy, Vascularization and Serial Sections with MRI. Vienna, Austria: Springer; 2005
  • 14 Ebeling U, von Cramon D. Topography of the uncinate fascicle and adjacent temporal fiber tracts. Acta Neurochir (Wien) 1992; 115 (3-4) 143-148
  • 15 Kier EL, Staib LH, Davis LM, Bronen RA. MR imaging of the temporal stem: anatomic dissection tractography of the uncinate fasciculus, inferior occipitofrontal fasciculus, and Meyer's loop of the optic radiation. AJNR Am J Neuroradiol 2004; 25 (5) 677-691
  • 16 Peltier J, Travers N, Destrieux C, Velut S. Optic radiations: a microsurgical anatomical study. J Neurosurg 2006; 105 (2) 294-300
  • 17 Türe U, Yaşargil MG, Friedman AH, Al-Mefty O. Fiber dissection technique: lateral aspect of the brain. Neurosurgery 2000; 47 (2) 417-426 ; discussion 426–427
  • 18 Rubino PA, Rhoton Jr AL, Tong X, Oliveira Ed. Three-dimensional relationships of the optic radiation. Neurosurgery 2005; 57 (4, Suppl): 219-227 ; discussion 219–227
  • 19 Choi C, Rubino PA, Fernandez-Miranda JC, Abe H, Rhoton Jr AL. Meyer's loop and the optic radiations in the transsylvian approach to the mediobasal temporal lobe. Neurosurgery 2006; 59 (4) (Suppl. 02) ONS228-ONS235 ; discussion ONS235–ONS236
  • 20 Yaşargil MG. Microneurosurgery. Vol 4B. New York, NY: Thieme; 1996: 252-290
  • 21 Foldvary N, Nashold B, Mascha E , et al. Seizure outcome after temporal lobectomy for temporal lobe epilepsy: a Kaplan-Meier survival analysis. Neurology 2000; 54 (3) 630-634
  • 22 Elsharkawy AE, Alabbasi AH, Pannek H , et al. Long-term outcome after temporal lobe epilepsy surgery in 434 consecutive adult patients. J Neurosurg 2009; 110 (6) 1135-1146
  • 23 Yeni SN, Tanriover N, Uyanik O , et al. Visual field defects in selective amygdalohippocampectomy for hippocampal sclerosis: the fate of Meyer's loop during the transsylvian approach to the temporal horn. Neurosurgery 2008; 63 (3) 507-513 ; discussion 513–515
  • 24 Isolan GR, Azambuja N, Paglioli Neto E, Paglioli E. Hippocampal microsurgical anatomy regarding the selective amygdalohippocampectomy in the Niemeyer's technique perspective and preoperative method to maximize the corticotomy. Arq Neuropsiquiatr 2007; 65 (4A): 1062-1069
  • 25 Coppens JR, Mahaney KB, Abdulrauf SI. An anteromedial approach to the temporal horn to avoid injury to the optic radiation fibers and uncinate fasciculus: anatomical and technical note. Neurosurg Focus 2005; 18 (6B): E3
  • 26 Paglioli E, Palmini A, Portuguez M , et al. Seizure and memory outcome following temporal lobe surgery: selective compared with nonselective approaches for hippocampal sclerosis. J Neurosurg 2006; 104 (1) 70-78
  • 27 Helmstaedter C, Richter S, Röske S, Oltmanns F, Schramm J, Lehmann TN. Differential effects of temporal pole resection with amygdalohippocampectomy versus selective amygdalohippocampectomy on material-specific memory in patients with mesial temporal lobe epilepsy. Epilepsia 2008; 49 (1) 88-97
  • 28 Fountas KN, Tsougos I, Gotsis ED, Giannakodimos S, Smith JR, Kapsalaki EZ. Temporal pole proton preoperative magnetic resonance spectroscopy in patients undergoing surgery for mesial temporal sclerosis. Neurosurg Focus 2012; 32 (3) E3
  • 29 Tsapkini K, Frangakis CE, Hillis AE. The function of the left anterior temporal pole: evidence from acute stroke and infarct volume. Brain 2011; 134 (Pt 10) 3094-3105