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Introduction: Mesial temporal lobe epilepsy (MTLE) is one of the most prevalent forms of focal epilepsy in surgical series, particularly among adults. Over the decades, different surgical strategies have been developed to address drug-resistant epilepsy while safeguarding neurological and cognitive functions. Among these strategies, anterior temporal lobectomy (ATL), involving the removal of the temporal pole and mesial temporal structures, has emerged as a widely employed technique. Numerous modifications have been proposed to mitigate the risks associated with aphasia, cognitive issues, and visual field defects. Methods: Our approach is elucidated through intraoperative and cadaveric dissections, complemented by neuroradiological and cadaveric measurements of key anatomical landmarks. A retrospective analysis of patients with drug-resistant MTLE who were treated using our ATL technique at IRCCS Neuromed (Pozzilli) is presented. Results: A total of 385 patients were treated with our ATL subpial technique anatomically focused on the anterior Sylvian point (ASyP). The mean FU was 9.9 ± 5.4 years (range 1-24). In total, 84%of patients were free of seizures during the last follow-up, with no permanent neurological deficits. Transient defects were as follows: aphasia in 3% of patients, visual field defects in 2% of patients, hemiparesis in 2% of patients, and cognitive/memory impairments in 0.8% of patients. In cadaveric dissections, the ASyP was found at a mean distance from the temporal pole of 3.4 ± 0.2 cm (range 3-3.8) at the right side and 3.5 ± 0.2 cm (3.2-3.9) at the left side. In neuroimaging, the ASyP resulted anterior to the temporal horn tip in all cases at a mean distance of 3.2 ± 0.3 mm (range 2.7-3.6) at the right side and 3.5 ± 0.4 mm (range 2.8-3.8) at the left side. Discussion: To the best of our knowledge, this study first introduces the ASyP as a reliable and reproducible cortical landmark to perform the ATL to overcome the patients' variabilities, the risk of Meyer's loop injury, and the bias of intraoperative measurements. Our findings demonstrate that ASyP can be a safe cortical landmark that is useful in MTLE surgery because it is constantly present and is anterior to risky temporal regions such as temporal horn and language networks.
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BACKGROUND AND OBJECTIVES: The combined petrosal intertentorial approach (CPIA) has been proposed as an alternative to standard combined petrosal approach (SCPA). CPIA has been designed to maintain integrity of the temporal dura with a view to reduce temporal lobe morbidity and venous complications. This study has been designed to perform a quantitative comparison between these approaches. METHODS: Five human specimens were used for this study. CPIA was performed on one side and SCPA on the opposite side. The area of exposure (petroclival and brainstem), surgical freedom, and angles of attack to a predefined target were measured and compared. RESULTS: SCPA provided a significantly larger petroclival area of exposure (6.81 ± 0.60 cm2) over the CPIA (5.59 ± 0.59 cm2), P = .012. The area of brainstem exposed with SCPA was greater than with CPIA (7.17 ± 0.84 vs 5.63 ± 0.72, P = .014). The area of surgical freedom was greater in SCPA rather than in CPIA (8.59 ± 0.55 and 7.13 ± 0.96 cm2, respectively, P = .019). There was no significative difference between CPIA and SCPA in the vertical angles of attack for the Meckel cave, Dorello canal, and root entry zone of cranial nerve VII. Conversely, the horizontal angles of attack permitted by the CPIA were significantly smaller for the Meckel cave (52.36° ± 5.01° vs 64.4° ± 5.3°, P = .006) and root entry zone of cranial nerve VII (30.7° ± 4.4° vs 40.1° ± 6.2°, P = .025). CONCLUSION: CPIA is associated with a reduction in terms of the area of surgical freedom (22%), skull base (18%), brainstem exposure (17%), and horizontal angles of attack (18%-23%) when compared with SCPA. This loss in terms of exposure is counterbalanced by the advantage of keeping the temporal lobe covered by an extra layer of meningeal tissue, thus possibly reducing the risk of temporal lobe injury and venous infarction. These results need to be validated with adequate clinical experience.
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BACKGROUND: Surgical management of parasagittal meningiomas (PMs) remains controversial in the literature. The need to pursue a resection as radical as possible and the high risk of venous injuries contribute to making the sinus opening a widely argued choice. This study aimed to analyze factors affecting the risk of recurrence and to assess clinical outcomes of patients who underwent surgical resection of PMs with conservative or aggressive management of the intrasinusal portion. METHODS: A single-institution retrospective review of all patients with PM surgically treated between January 2013 and March 2021 was conducted. RESULTS: Among 56 patients, the sinus was opened in 32 patients (57%), and a conservative approach was used in 24 patients (43%). The sinus opening was found to be a predictive factor of radical resection (Simpson grade [SG] I-II) (P = 0.007). SG was the only predictive factor of recurrence (P < 0.001). The radical resection group (SG I-II) showed recurrence-free survival at 72 months of about 90% versus 30% in the non-radical resection group (SG III-IV) (log-rank test = 14.21, P < 0.001). Aggressive management of the sinus and radical resection were not found to be related to permanent deficit (P = 0.214 and P = 0.254) or worsening of Karnofsky performance scale score (P = 0.822 and P = 0.933). CONCLUSIONS: Removal of the intrasinusal portion of the tumor using standard procedures is not associated with a higher risk of permanent deficit or worsening of Karnofsky performance scale and reduces the risk of recurrence.