Temporopolar Amygdalohippocampectomy for Mesial Temporal Lobe Epilepsy: A Two-Dimensional Anatomical Operative Video

Mesial temporal lobe epilepsy is the most frequent type of focal epilepsy in young adults and the most commonly reported in surgical series worldwide.(1,2) When seizures become refractory to drug therapy, they are unlikely to remit spontaneously, and for the 30% of patients with epilepsy that is refractory to antiepileptic drugs, resection of the mesial temporal lobe structures provides seizure control rates of 70%e80%.(3,4) The transsylvian route for amygdalohippocampectomy has been used at our institution for many years, evolving from the first description of Yasargil through the inferior circular sulcus of insula to the most recent one through the amygdala trying to preserve the temporal stem.(5,6) Despite good outcomes according to the Engel classification, analysis of late postoperative magnetic resonance imaging scans of our patients showed a high incidence of temporal pole atrophy and potential gliosis.(7,8) Therefore, we decided to keep the transsylvian route, but we removed a portion of the temporal pole anterior to the limen insula, resulting in a temporopolar amygdalohippocampectomy.(4,9) Temporopolar amygdalohippocampectomy demonstrated good temporal stem preservation, good visual outcomes, and good memory results.4 We also advocate that the transsylvian route has the potential to provide a superior view and resection of the piriform cortex, that is associated with seizure outcome after surgery.(10) We present a case of a 42-year-old woman who had refractory seizures secondary to mesial temporal lobe epilepsy and underwent temporopolar amygdalohippocampectomy with a good outcome, remaining seizure-free (Engel IA) (Video 1). The patient provided consent for surgery and video publication.