ABSTRACT
To highlight the technical details involved and their impact on seizure control and accordingly the quality of life in patients with complex partial seizures caused by various pathologies during surgical resection of the amygdala and the hippocampus using a simple transcortical transventricular sub-pial approach to the region. Eleven patients presenting with complex partial seizures not responding to medical treatment caused by various pathologies including mesial temporal lobe sclerosis, benign and malignant temporal lobe tumors were operated upon by trans-cortical sub-pial amygdalo-hippocampectomy either alone or combined with other approaches in the period between January 2005 to November 2007. Pre-operatively all patients' symptoms and signs along with medications used for seizure control were documented. Patients were not taken into surgery unless an adequate level of anti-epileptics was documented in serum. An MRI with and without contrast was performed in all patients before surgery. All patients were operated through a standard trans-cortical approach to the temporal horn of the lateral ventricle. Following identification of hippocampus and choroidal fissure and plexus a subpial disconnection of the hippocampus was done from anterior to posterior followed by a subpial amygdalectomy and then the surgical specimen was removed either alone or combined with the tumor. No cortical mapping was used. An awake craniotomy was used in 3 patients with dominant hemisphere lesions. Post operatively all patients were clinically assessed; all neurological deficits were noted and documented. The need for anti-epileptic therapy as well as seizure control was documented. A follow-up MRI was performed 2 months after surgery in all patients to document the extent of resection of amygdala and hippocampus. Functional and radiological outcome were then correlated with surgical technique by analyzing the operative details for each individual case. Patients were followed-up for periods ranging from 6 months to 2 years. Seizure control was classified into four classes according to Engel. Class I were patients no longer having seizures whether or not on treatment. Class II were patients who experienced only one or several seizures, class III patients who were still having seizures but with a less frequency than before and class IV were patients who showed no seizure control following surgery. 11 patients with complex partial seizures caused by various pathologies have been operated using a standard trans-cortical trans-ventricular completely sub-pial approach to the amygdala and the hippocampus for various pathological lesions of the temporal lobe. There were no mortalities or major neurological deficits. One patient developed meningitis, one developed ventriculitis, one developed a temporary partial third nerve palsy. Two patients exhibited a short term memory deficit. Eight patients showed an Engel class I seizure control, two patients showed an Engel class II seizure control and one patient showed an Engel class III seizure control. The trans-cortical trans-ventricular completely sub-pial approach to the amygdala and the hippocampus offers a simple and reliable as well as safe technique for the surgical resection of the amygdala and the hippocampus with results comparable to those of other reported series using more complex approaches to the region