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Results for “Temporal Lobe Resection”

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PubMed2004

A combined subtemporal and transventricular/transchoroidal fissure approach to medial temporal lesions.

OBJECTIVE: To minimize therapeutic morbidity such as cognitive function disturbance and vascular injury to perforating arteries, preoperative functional mapping of the basal temporal lobe functions was performed and the medial temporal lesions were resected via a combined subtemporal and transventricular/transchoroidal fissure approach. METHODS: Twenty-one patients with medial temporal lesions including tumors, arteriovenous malformations, and medial temporal lobe epilepsy underwent operation. The neurovascular structures in the ambient cistern were first dissected free from the medial temporal lobe with a conventional subtemporal approach. Then, the temporal horn was opened through the basal surface of the temporal lobe. Finally, the ambient cistern was accessed from the temporal horn through the choroidal fissure. In five patients whose lesions were revealed to be located on the dominant side by preoperative intracarotid amytal administration test (Wada test), functional mapping of the basal temporal lobe language cortex was monitored for 1 week by use of a subdural electrocorticogram grid before the extirpation surgery. The entrance point from the temporal base to the temporal horn was determined by the result of the functional mapping. RESULTS: The lesions were resected safely and completely in all cases. Language and cognitive functions were preserved even in patients with the basal language area on the dominant side. CONCLUSION: Surgeons can confirm the important neurovascular structures from the subtemporal route and from the transtemporal horn route by a combined subtemporal and transventricular/transchoroidal fissure approach. This approach is especially effective for avoiding ischemic complications by allowing direct confirmation of the anterior choroidal and thalamoperforating arteries.

Adult↗

PubMed2005

Temporal lobe intraparenchymal retained foreign body from remote orbital trauma.

We present the case of a 35-year-old man with a new onset of seizure disorder who was found to harbor an intraparenchymal retained foreign body related to remote orbital trauma. Imaging revealed a rim-enhancing anterior medial temporal lobe mass. Histologic evaluation of the resected mass showed evidence of acute and chronic inflammation with associated foreign material. The patient described a "bar fight" 16 years previously in which he received a blow to the orbit with a pool cue stick. The diagnosis of a foreign body reaction should be considered when an intraparenchymal mass is identified in this location.

Adult↗

PubMed2005

Role of uncal resection in optimizing transsylvian access to the basilar apex: cadaveric investigation and preliminary clinical experience in eight patients.

OBJECTIVE: The pretemporal approach has gained popularity for the treatment of basilar apex aneurysms. However, it requires the sacrifice of anterior temporal bridging veins to allow posterior temporal lobe retraction and, for patients with dominant pretemporal venous drainage, has the attendant risk of venous hypertension, hemorrhagic venous infarction, or seizures postoperatively. Alternatively, we have found that splitting the sylvian fissure, resecting the uncus, and applying posterolateral retraction to the medial temporal lobe provides a similar exposure to the basilar apex while preserving the anterior temporal bridging veins. To evaluate the transsylvian, trans-uncal approach to the basilar apex, we report our initial clinical results using this exposure in eight consecutive patients. A morphometric cadaveric analysis comparing this approach with the pretemporal approach was also performed. METHODS: For the clinical study, all hospital charts and imaging studies were retrospectively reviewed for patients undergoing the transsylvian, trans-uncal approach for the treatment of an upper basilar trunk aneurysm between July 2000 and July 2002. In the anatomic study, six formalin-fixed cadaver specimens were used. Two sequential exposures of the basilar apex were performed on each specimen side. First, the pretemporal exposure was performed with anteroposterior temporal lobe retraction. Next, after the temporal lobe had been allowed to return to normal anatomic position, the retractor was repositioned on the medial aspect of the temporal lobe superficial to the uncus, and a 10 x 10 x 15-mm volume of uncus was removed. Morphometric measurements were performed for each exposure. RESULTS: Four basilar bifurcation and four superior cerebellar segment aneurysms in eight consecutive patients were successfully clip-ligated by use of the transsylvian, trans-uncal approach. All patients had temporal bridging veins that were preserved, as documented by angiography and operative reports. No patient developed a venous infarction or new postoperative seizures, with a mean follow-up of 9.75 months (range, 0.5-28 mo). The cadaveric analysis revealed that in addition to providing a similar exposure of the upper basilar complex, the transsylvian, trans-uncal approach provided additional exposure of the ipsilateral posterior cerebral and superior cerebellar arteries compared with the pretemporal approach. CONCLUSION: When approaching the basilar bifurcation, the transsylvian, trans-uncal approach provides superior exposure of the ipsilateral superior cerebellar and posterior cerebral arteries compared with the pretemporal approach, while preserving the anterior temporal bridging veins. This approach is most valuable in patients with dominant temporal venous drainage or when additional exposure of the ipsilateral posterior cerebral or superior cerebellar arteries is required.

Adult↗

PubMed2000

Gamma knife radiosurgery as a primary treatment for prolactinomas.

OBJECT: The purpose of this study was to estimate the efficacy of gamma knife radiosurgery (GKS) in controlling tumor growth and endocrinopathy associated with prolactinomas. METHODS: Between 1993 and 1997, 164 of 469 patients with pituitary adenomas treated by GKS harbored prolactinomas. The dose to the tumor margin ranged from 9 to 35 Gy (mean 31.2 Gy), and the visual pathways were exposed to a dose of less than 10 Gy. The mean tumor diameter was 13.4 mm. The mean follow-up time for 128 cases was 33.2 months (range 6-72 months). Tumor control was observed in all but two patients who underwent surgery 18 and 36 months, respectively, after GKS. Clinical cure was achieved in 67 cases. Clinical improvement was noted with a decrease in the hyperprolactinemia after GKS. Nonetheless, in 31 (29%) of 108 patients who were followed for more than 2 years no improvement in serum prolactin levels was demonstrated, although this could be normalized by bromocriptine administration after treatment. Nine infertile women became pregnant 2 to 13 months after GKS and all gave birth to normal children. There was no visual deterioration related to GKS. Five women experienced premature menopause. In these patients there was subtotal disappearance of the tumor and an empty sella developed. CONCLUSIONS: Gamma knife radiosurgery as a primary treatment for prolactinomas can be safe and effective both for controlling tumor growth and for normalization of prolactin hypersecretion. A higher margin dose (> or = 30 Gy) seemed to be associated with a better clinical outcome. Gamma knife radiosurgery may make prolactinomas more sensitive to the bromocriptine.

Humans↗

PubMed1999

Middle ear adenocarcinoma with intracranial extension. Case report.

Middle ear adenocarcinoma is a very rare, locally invasive neoplasm assumed to arise from the middle ear mucosa. Although endolymphatic sac tumor (aggressive papillary middle ear tumor) and jugulotympanic paraganglioma may show brain invasion, intracranial extension of histologically confirmed middle ear adenocarcinoma has not been previously reported. The authors describe a 53-year-old man who suffered from otalgia and tinnitus for more than 10 years and from neurological deficits for 1 year due to a large temporal bone tumor that invaded the temporal lobe. A combined neurosurgical and otolaryngological resection was performed. Pathological analysis revealed a low-grade adenocarcinoma of a mixed epithelial-neuroendocrine phenotype, which showed a close histological similarity to, and topographical relationship with, middle ear epithelium. The authors conclude that middle ear adenocarcinoma belongs to the spectrum of extracranial tumors that have possible local extension to the brain.

Adenocarcinoma↗

PubMed1993

[The surgical treatment of epilepsy].

Twenty percent of the approximately 800,000 epileptic patients in Germany cannot be treated adequately by pharmacotherapy alone. According to conservative estimates, epilepsy surgery could be of fundamental therapeutic benefit to at least 10-25% of these patients. A complex presurgical diagnostic program is the basis for any epilepsy surgery. Numerous methods are used to create a hypothesis about the location and size of the epileptogenic area. In addition, before surgery is performed, it must be established that no additional serious neurological or neuropsychological deficits will result from the planned resection. For this purpose, electrostimulation of the cortex and temporary anaesthesia of brain areas by amobarbital tests are performed. In intractable epilepsy originating in the temporal lobe about 60% of patients become seizure free after surgery. Another 15-20% benefit from surgery by a significant improvement in their seizure situation. Resections of the dominant temporal lobe result in further impairment of memory functions in about 20-30% of patients.

Adult↗

PubMedDate not supplied

Differential effects of left and right anterior temporal lobectomy on verbal learning and memory performance.

The California Verbal Learning Test (CVLT) was utilized to identify the quantitative and qualitative alterations in verbal learning and memory performance that discriminated between patients following partial resection of the left (dominant) (n = 26) or right (nondominant) (n = 31) temporal lobe. Patients were administered the CVLT preoperatively and 6 months postoperatively, and the differential effects of laterality of resection on verbal learning and memory performance were determined. Following left temporal resection, patients showed significantly more serial clustering, a lower proportion of words recalled from the middle of the list, and more intrusion errors in free recall. Patients who underwent right temporal resection showed significantly greater recall of words from the middle and fewer words from the end of the list, more semantic clustering, and greater ability to recall verbal material after a short delay. These findings suggest that anterior temporal lobectomy (ATL) results in changes in the way verbal material is acquired, and affects the rate of forgetting. Patients who undergo left ATL become more dependent on less effective and efficient learning strategies, and forget the material that they have acquired at a faster rate. The opposite tendencies characterize patients who undergo right ATL.

Adult↗

PubMed2005

Rundown of GABA type A receptors is a dysfunction associated with human drug-resistant mesial temporal lobe epilepsy.

Pharmacotherapeutic strategies have been difficult to develop for several forms of temporal lobe epilepsy, which are consequently treated by surgical resection. To examine this problem, we have studied the properties of transmitter receptors of tissues removed during surgical treatment. We find that when cell membranes, isolated from the temporal neocortex of patients afflicted with drug-resistant mesial temporal lobe epilepsy (TLE), are injected into frog oocytes they acquire GABA type A receptors (GABA(A)-receptors) that display a marked rundown during repetitive applications of GABA. In contrast, GABA(A)-receptor function is stable in oocytes injected with cell membranes isolated from the temporal lobe of TLE patients afflicted with neoplastic, dysgenetic, traumatic, or ischemic temporal lesions (lesional TLE, LTLE). Use-dependent GABA(A)-receptor rundown is also found in the pyramidal neurons of TLE neocortical slices and is antagonized by BDNF. Pyramidal neurons in cortical slices of a traumatic LTLE patient did not show GABA(A)-receptor rundown. However, the apparent affinity of GABA(A)-receptor in oocytes microtransplanted with membranes from all of the epileptic patients studied was smaller than the affinity of receptors transplanted from the nonepileptic brain. We conclude that the use-dependent rundown of neocortical GABA(A)-receptor represents a TLE-specific dysfunction, whereas the reduced affinity may be a general feature of brains of both TLE and LTLE patients, and we speculate that our findings may help to develop new treatments for TLE and LTLE.

Adolescent↗

PubMed1988

Scalp-recorded P300 activity in patients following unilateral temporal lobectomy.

The bilateral distribution and overall amplitude of the P300 component of the event-related brain potential (ERP) was studied in epileptic patients in whom the amygdala, hippocampal, and anterior temporal lobe areas of the brain had been resected unilaterally. Previous reports have suggested that a neural generator of the P300 elicited in the commonly used target detection ('Oddball') paradigm lies in these medial temporal areas. In an Oddball paradigm, there was no evidence of any left-right hemisphere asymmetry in the scalp distribution of the P300 that varied as a function of the side of surgery in either the left or right temporal lobectomy patients. Moreover, there were no statistically significant differences in overall P300 amplitude or latency between the patients and controls. These data do not support the hypothesis that the primary generator of the scalp-recorded P300 in the Oddball paradigm lies in the hippocampus and amygdala.

Electrophysiology↗

PubMed1997

H. M.'s medial temporal lobe lesion: findings from magnetic resonance imaging.

Although neuropsychological studies of the amnesic patient H. M. provide compelling evidence that normal memory function depends on the medial temporal lobe, the full extent of his surgical resection has not been elucidated. We conducted magnetic resonance imaging studies to specify precisely the extent of his bilateral resection and to document any other brain abnormalities. The MRI studies indicated that the lesion was bilaterally symmetrical and included the medial temporal polar cortex, most of the amygdaloid complex, most or all of the entorhinal cortex, and approximately half of the rostrocaudal extent of the intraventricular portion of the hippocampal formation (dentate gyrus, hippocampus, and subicular complex). The collateral sulcus was visible throughout much of the temporal lobe, indicating that portions of the ventral perirhinal cortex, located on the banks of the sulcus, were spared; the parahippocampal cortex (areas TF and TH) was largely intact. The rostrocaudal extent of the ablation was approximately 5.4 cm (left) and 5.1 cm (right). The caudal 2 cm, approximately, of the hippocampus body (normal length, approximately 4 cm) was intact, although atrophic. The temporal stem was intact. Outside the temporal lobes, the cerebellum demonstrated marked atrophy, and the mammillary nuclei were shrunken. The lateral temporal, frontal, parietal, and occipital lobe cortices appeared normal for age 66 years. The mediodorsal thalamic nuclei showed no obvious radiological changes. These findings reinforce the view that lesions of the hippocampal formation and adjacent cortical structures can produce global and enduring amnesia and can exacerbate amnesia beyond that seen after more selective hippocampal lesions.

Aged↗

PubMed2005

Electro-clinical characteristics and postoperative outcome of medically refractory tumoral temporal lobe epilepsy.

BACKGROUND: Very few studies have specifically addressed surgical treatment and outcome of patients with tumor-related temporal lobe epilepsy (TLE). AIM: To define the postoperative seizure outcome and the factors that influenced the outcome of patients with tumor-related TLE. MATERIALS AND METHODS: We selected patients whose surgical pathology revealed a temporal lobe neoplasm and who had completed > 1 year of postoperative follow-up. We reviewed the clinical, EEG, radiological and pathological data, and the seizure outcome of these patients and assessed the factors that influenced the outcome. RESULTS: Out of the 409 patients who underwent surgery for refractory TLE during the 8-year study period, there were 34 (8.3%) patients with temporal lobe neoplasms. The median age at surgery was 20 years and the median duration of epilepsy prior to surgery was 9.0 years. MRI revealed tumor in the mesial location in 21 (61.8%) patients. Interictal and ictal epileptiform EEG abnormalities were localized to the side of th lesion in the majority. Mesial temporal lobe structures were included in the resection, if they were involved by the tumor; otherwise, lesionectomy alone was performed. During a median follow-up of 4 years, 27 (79%) patients were completely seizure-free. The only factor that predicted long-term seizure-free outcome was being seizure-free during the first two postoperative years. CONCLUSIONS: Our results emphasize the fact that in patients with tumoral TLE, when the seizures are medically refractory, surgery offers potential for cure of epilepsy in the majority.

Adolescent↗

PubMed1995

Electrocorticography and temporal lobe epilepsy: relationship to quantitative MRI and operative outcome.

We investigated the relationship between electrocorticography (ECoG), quantitative magnetic resonance imaging (MRI), and surgical outcome in 165 patients with intractable nonlesional temporal lobe epilepsy (NLTLE). A standard mesial temporal resection was performed in all patients. Patients with an operative follow-up < 1 year were excluded from the study. The extent of the lateral temporal neocortex resection (LCR) was guided by ECoG and the side of surgery. The extent of the LCR was not predictive of seizure outcome in patients with or without hippocampal formation atrophy (p > 0.5). Patients undergoing a right anterior temporal lobectomy had a larger LCR (p < 0.0001), but the side of surgery was not of predictive value in determining seizure outcome (p > 0.1). The topography of the acute intracranial spikes did not correlate with operative outcome (p > 0.5) and was independent of hippocampal volumetric studies (p > 0.5). The postexcision ECoG was also shown not to be of prognostic importance (p > 0.5). Our results indicates that the extent of the lateral temporal cortical resection and the ECoG findings are not important determinants of surgical outcome in patients with NLTLE.

Adolescent↗

PubMed1996

A novel computer-assisted volumetric stereotactic approach for resecting tumors of the posterior parahippocampal gyrus.

The authors report their experience using a novel surgical approach for resecting tumors located in the posterior parahippocampal gyrus. Prior attempts to resect epileptogenic foci in this location have been limited by a significant risk of injury to lateral temporal lobe cortical and vascular structures. To avoid these potential complications, the authors have used a lateral occipitosubtemporal, computer-assisted stereotactic volumetric approach to resect radiographically defined tumors in seven patients with intraaxial neoplasms of the posteromedial temporal lobe. This series included one female and six male patients, ranging in age from 15 to 67 years, who presented with seizures, visual field loss, or headache. Gross-total resection of three high-grade gliomas, two gangliogliomas, and one mixed glioma was accomplished with no permanent morbidity or operative mortality. The authors conclude that this approach is advantageous for resecting tumors in this location because, by avoiding unnecessary brain resection or retraction, it significantly reduces the risk of injury to lateral temporal lobe structures, helps maintain precise spatial and anatomical orientation for the surgeon, and, like all computer-assisted volumetric approaches, delineates the margin between the tumor and surrounding neural tissue.

Adolescent↗

PubMed1997

Direct intraoperative measurement of human brain temperature.

OBJECTIVE: Because hypothermia enhances human tolerance for cerebral ischemia, profound hypothermia is induced in many centers so that the circulation can be arrested while clips are applied to high-risk giant cerebral aneurysms. Brain temperature is measured directly with an intracerebral probe that avoids the uncertainty of surrogate monitoring. However, when there is a large thermal gradient between brain temperature and that of the operating room, even direct measurements can sometimes be misleading. This study was undertaken to determine how deeply a thermal sensor must be embedded in the cerebral parenchyma to ensure that the ambient environment does not distort the measurement of brain temperature. METHODS: Each of 39 normothermic patients had a thermocouple sensor inserted into a temporal lobe seizure focus just before its resection. Brain temperature was measured as the sensor was withdrawn in stages. RESULTS: At both 3 and 2 cm beneath the cortical surface, the temperature of the brain was essentially the same. However, when the sensor was withdrawn to 1 cm, recorded temperature decreased from 35.7 +/- 0.9 to 34.3 +/- 1.4 degrees C (P < 0.001) and irrigation in the vicinity caused major thermal change. At shallower depths, even lower brain temperatures were recorded. No morbidity was attributable to the temperature measurements. CONCLUSION: Direct intraoperative measurement of human brain temperature is feasible and safe, but accuracy requires that the temperature sensor be inserted at least 2 cm into the cerebral cortex.

Body Temperature Regulation↗

PubMed2003

Potentially misleading extratemporal lobe lesions in patients with temporal lobe epilepsy.

From a series of 217 consecutive temporal resections for intractable epilepsy between 1993 and 2000, we identified all patients with large non-neoplastic extratemporal lesions. Only patients with known postsurgical outcomes with follow up for more than two years were included. Fifteen patients were identified. All patients had a history of medically refractory epilepsy with clinical and ictal evidence of mesial temporal seizure onset. Eleven patients had extratemporal lesions ipsilateral to the seizure focus, whereas four patients had the lesions contralateral to the seizure focus. Nine of the 15 patients had evidence of hippocampal atrophy on magnetic resonance imaging (MRI). Following temporal resection, nine of these patients (60%) became seizure free (Engel class 1A), two patients were free of disabling seizures only (Engel class 1B), and two patients had a few early seizures but then became seizure free for at least two years (Engel class 1C). Two patients had significant improvement (Engel class 2). Thus, the finding of large extratemporal lesions on MRI was potentially misleading. When clinical semiology and ictal EEG recordings provide evidence of temporal onset seizures, anterior temporal resection should be considered in patients with extratemporal lesions.

Adult↗

PubMed1995

Quantitative hippocampal MRI and intractable temporal lobe epilepsy.

OBJECTIVES: To evaluate and compare T2 relaxometry and volumetrics of hippocampus in the presurgical evaluation of patients with intractable temporal lobe epilepsy (TLE), and to correlate these quantitative MRI measures with the pathology of the resected hippocampus. PATIENTS: Forty patients with intractable TLE who underwent presurgical evaluation and subsequent temporal lobe surgery. MAIN OUTCOME MEASURES: Hippocampal T2 (HCT2), volumes of hippocampi and hippocampal volume ratio (HCVR) (volume of hippocampus with higher HCT2 divided by volume of hippocampus with lower HCT2), and qualitative pathology. RESULTS: Thirty-two patients had hippocampal sclerosis, three patients had end-folium sclerosis, one patient had amygdala sclerosis, and four patients had a foreign tissue lesion in the temporal lobe. HCT2 (R/L) correlated inversely with the ratio of hippocampal volumes (R/L) (r = -0.91; p < 0.0001). A high T2 signal in an atrophic hippocampus was characteristic of hippocampal sclerosis. All patients with hippocampal sclerosis had an HCVR below control values, and only one of these had an HCT2 in the normal range. HCVR produced one false-positive result. The patients with end-folium sclerosis had normal HCT2 and HCVR. The patient with amygdala sclerosis had a normal hippocampus on qualitative and quantitative assessment. Of the four patients with a lesion, one had a mildly increased HCT2 and one had mild volume asymmetry. Hippocampal volume asymmetry could be reliably detected on visual inspection of the MRI with an HCVR of 0.85 or less, and an increase of HCT2 with a T2 of 115 msec or higher. CONCLUSION: Quantitative MRI combining HCT2 and HCVR is a reliable method for diagnosing hippocampal sclerosis noninvasively. End-folium sclerosis and amygdala sclerosis should be considered in patients with intractable TLE and negative findings on MRI studies, including quantitative measures of the hippocampus.

Adolescent↗

PubMed1993

The surgery for epilepsy with speech arrest.

The problems confronting patients with epilepsy, their families, and the surgeons wishing to help such patients, are discussed. It is important for physicians in other specialties to realize that epilepsy surgery is not nowadays complex, difficult, painful or uncertain; furthermore such operations are based on finding and removing focal lesions rather than "epileptogenic cortex" and the result in terms of integration of the patient into society is much improved if such intervention is performed while the patient is young, with time to gain academic and social skills after the operation. The selection of patients suitable for operation is discussed as well as methods of determining which hemisphere is dominant for speech and whether or not the focal lesion involves language centres. The majority of patients with drug resistant epilepsy suitable for operation have abnormalities in one temporal lobe. The pathological lesion is described and the advantages and disadvantages of various operations for temporal lobe epilepsy discussed. Extra-temporal cortical resection in the dominant hemisphere is also considered, particularly with reference to the preservation of language function. It is important that neurosurgeons realise that MRI and CT scanning have transformed epilepsy surgery from being a rather nebulous, time consuming art, to being for the majority of patients, a clear cut, straight forward procedure firmly based on "Oslerian" pathological principles. Far too few patients are being offered an operation (which renders 60-70% seizure free); neurosurgeons should respond to this challenge.

Adolescent↗

PubMed1998

Hypothalamic hamartomas and gelastic epilepsy: a spectroscopic study.

BACKGROUND: Patients with hypothalamic hamartomas present with epileptic attacks of laughter and later experience multiple seizure types and cognitive decline, suggestive of secondary generalized epilepsy. It has been suggested in the past that gelastic seizures originate in the temporal lobes rather than in the hamartoma, but temporal resections have been ineffective. Recent electrophysiologic evidence suggests that the epileptogenic discharges may originate in the hamartoma itself. METHODS: We used proton magnetic resonance spectroscopic imaging to quantify the amount of neuronal damage in the temporal lobes and hamartomas of patients with hypothalamic hamartomas and gelastic seizures. Five patients were studied and the relative intensity of N-acetylaspartate to creatine (NAA/Cr) was determined for both temporal lobes as well as for the hamartoma. These values were compared with signals from the temporal lobes and hypothalami of normal control subjects. RESULTS: NAA/Cr was not significantly different from normal control subjects for either temporal lobe, nor was there a significant asymmetry between the two temporal lobes for any of the patients. NAA resonance signals were present in the hamartomas, and the ratio of NAA to Cr was decreased in the hamartomas compared with the hypothalami of normal control subjects (t = 4.5, p = 0.005). CONCLUSIONS: We found no detectable neuronal damage in the temporal lobes of patients with hypothalamic hamartomas and gelastic epilepsy. This is further evidence that gelastic seizures do not originate in the temporal lobes of these patients.

Adolescent↗