Temporal lobe epilepsy surgery Doc. MUDr. Eva Brichtová, Ph.D. Dpt. of Neurosurgery St. Anne University Hospital Brno and Masaryk University Brno Epilepsy Center Brno Temporal lobe anatomy C. Destrieux, Surgical anatomy of the hippocampus, Neurochirurgie 59 (2013) 149–158 • Objective: • •complete removal of functionally altered brain tissue causing clinical epileptic manifestation • •no seizures after surgery, without any neurological deficit, i.e. without reducing the quality of life Temporal lobe epilepsy surgery Lesionectomy Types of epilepsy surgery Cortical resection Non- lesional epilepsy (mostly extratemporal localisation) - - Standard temporal resections MTLE mesial temporal lobe epilepsy MTS mesiotemporal sclerosis Structural pathology removing - tumor (LGG, DNET, ganglioglioma), vascular malformation (cavernoma, AVM), gliosis (post-traumatic, post-inflammatory, post-stroke), cortical dysplasia Cavernoma Glioblastoma multiforme FCD Type Ib cortical dysplasia with abnormal tangential cortical lamination affecting 6-layered horizontal composition of the neocortex - abnormal layering of L2, L4, or both; L2 either missing or significantly depleted - blurred demarcation between L1 and L2, and between L2 and 3; L4 can be also missing - less sharply demarcated border toward white matter, immature small diameter neurons, hypertrophic neurons outside L5 control FCD Ib Control, normal cortex FCD type 1b FCD Type IIa 5258-08-IIa-100x - severe cortical dyslamination - dysmorphic neurons: neuronal cell diameter enlarged, cell nucleus diameter enlarged, aggregation of Nissl substance and its margination, accumulation of NFs (both phosphorylated and nonphosphorylated) - junction at gray/white matter blurred with heterotopic neurons in white matter 8389-08-02 sel 4979-08-NF NF-01 cortical dysplasia with dysmorphic neurons Hippocampal sclerosis Imaging the Temporal Lobe, Pratik Mukherjee, http://www.medscape.org/viewarticle/468200_3 AMTR Anteromedial temporal resection M.Brázdil a kol., Farmakorezistentní epilepsie, Triton, 2004 Temporal pole approx 3.5 cm removal (without the superior temporal gyrus), the amygdala, part of the hippocampus and part of theparahippocampal gyrus. Removal of the amygdala, part of the hippocampus and the parahippocampal gyrus Temporal neocortex saved. 1958 Niermeyer - transcortical approach via gyrus temporalis medius 1985 Yasargil a Wieser - via fissura Sylvii AHE Selective amygdalohippocampectomy M.Brázdil a kol., Farmakorezistentní epilepsie, Triton, 2004 Types of temporal resection C. Destrieux, Surgical anatomy of the hippocampus, Neurochirurgie 59 (2013) 149–158 C:\Users\Pokdak\AppData\Local\Temp\Rar$DI60.696\DSC07502.JPG Hošťacký 004.jpg DSC07528a.jpg DSC07517a.jpg Hippocampus normalni hippocampus CA4 CA3 CA2 CA1 Hippocampal sclerosis, ILAE typ 1 6173 11 40x CA2-4 20x CA4 CA3 CA2 CA1 15935-15-40x okraj amygdaly.jpg Amygdala Postoperative CT and MRI scan Effect of surgery: Engel I - no seizures Engel II - nearly seizure-free, sporadic seizure Engel III - a significant improvement Engel IV - insignificant improvement, unchanged, worsening Engel's classification Temporal lobe epilepsy surgery- outcome Epilepsy Center Brno 1995-2009 Engel classification Total: 161 patients 19 temporal resections 2cortical resections 5lesionectomy (4x cavernoma, 1x glioma) 12AMTR 13 Temporal lobe epilepsy surgery Epilepsy Center Brno 2015 AMTR 5 men, 7 women, average age 32 yrs 7x l.dx., 5x l.sin. Epilepsy surgery in Czech republic 2002 - 2014 Teamwork Neurologist Neurosurgeon Neuroradiologist Neuropsychologist EEG technician Histopathologist Geneticist EPILEPSY CENTER BRNO Kontakt: eva.brichtova@fnusa.cz Fakultní nemocnice u sv. Anny v Brně Pekařská 53, Brno 656 91 Česká republika Tel: + 420 543 181 111 www.fnusa.cz