Partial Klüver-Bucy syndrome in a Paediatric patient: A post-neurosurgical and neuropsychological cases.

A variety of cognitive, behavioural, and emotional impairments have been reported in the literature that are associated with the resection of the temporal cortex. Klüver-Bucy syndrome is one infrequently reported disorder in the paediatric population. This paper describes the neuropsychological findings of a female paediatric patient at 7 and 10 years of age with a diagnosis of partial Klüver-Bucy syndrome (pKBS) following total resection of the amygdala and right hippocampus to resect a glioma. The patient presented emotional problems, aggressiveness, hypermetamorphosis, social indifference, and behavioural dysexecutive syndrome, which was found at both 7 and 10 years, but with a decrease in the severity of alterations in attention, impulsivity, hyperactivity, and aggressive behaviour in a second evaluation after she had a neuropsychological intervention. These findings describe the neuropsychological profile of paediatric case with resection of the amygdala and right temporal lobe.

Transsylvian amygdalohippocampectomy for mesial temporal lobe epilepsy: Comparison of three different approaches.

OBJECTIVE: This study's objective was to compare the transinsular (TI-AH), transuncus (TU-AH), and temporopolar (TP-AH) amygdalohippocampectomy approaches regarding seizure control, temporal stem (TS) damage, and neurocognitive decline. METHODS: We included 114 consecutive patients with unilateral hippocampal sclerosis (HS) who underwent TI-AH, TU-AH, or TP-AH between 2002 and 2017. We evaluated seizure control using Engel classification. We used diffusion tensor imaging and postoperative Humphrey perimetry to assess the damage of the TS. We also performed pre- and postoperative memory performance and intelligence quotient (IQ). RESULTS: There were no significant differences in the proportion of patients free of disabling seizures (Engel IA+IB) among the three surgical approaches in the survival analysis. However, more patients were free of disabling seizures (Engel IA+IB) at 2 years of postsurgical follow-up with TP-AH (69.5%) and TI-AH (76.7%) as compared to the TU-AH (43.5%) approach (p = .03). The number of fibers of the inferior fronto-occipital fasciculus postoperatively was reduced in the TI-AH group compared with the TU-AH and TP-AH groups (p = .001). The rate of visual field defects was significantly higher with TI-AH (14/19, 74%) in comparison to the TU-AH (5/15, 33%) and TP-AH (13/40, 32.5%) approaches (p = .008). Finally, there was a significant postoperative decline in verbal memory in left-sided surgeries (p = .019) and delayed recall for both sides (p < .001) regardless of the surgical approach. However, TP-AH was the only group that showed a significant improvement in visual memory (p < .001) and IQ (p < .001) for both right- and left-sided surgeries. SIGNIFICANCE: The TP-AH group had better short-term seizure control than TU-AH, a lower rate of visual field defects than TI-AH, and improved visual memory and IQ compared to the other groups. Our findings suggest that TP-AH is a better surgical approach for temporal lobe epilepsy with HS than TI-AH and TU-AH.

Longitudinal Changes After Amygdala Surgery for Intractable Aggressive Behavior: Clinical, Imaging Genetics, and Deformation-Based Morphometry Study-A Case Series.

BACKGROUND: Intractable aggressive behavior (iAB) is a devastating behavioral disorder that may affect psychiatric patients. These patients have reduced quality of life, are more challenging to treat as they impose a high caregiver burden and require specialized care. Neuromodulatory interventions targeting the amygdala, a key hub in the circuitry of aggressive behavior (AB), may provide symptom alleviation. OBJECTIVE: To Report clinical and imaging findings from a case series of iAB patients treated with bilateral amygdala ablation. METHODS: This series included 4 cases (3 males, 19-32 years old) who underwent bilateral amygdala radiofrequency ablation for iAB hallmarked by life-threatening self-injury and social aggression. Pre- and postassessments involved full clinical, psychiatric, and neurosurgical evaluations, including scales quantifying AB, general agitation, quality of life, and magnetic resonance imaging (MRI). RESULTS: Postsurgery assessments revealed decreased aggression and agitation and improved quality of life. AB was correlated with testosterone levels and testosterone/cortisol ratio in males. No clinically significant side effects were observed. Imaging analyses showed preoperative amygdala volumes within normal populational range and confirmed lesion locations. The reductions in aggressive symptoms were accompanied by significant postsurgical volumetric reductions in brain areas classically associated with AB and increases in regions related to somatosensation. The local volumetric reductions are found in areas that in a normal brain show high expression levels of genes related to AB (eg, aminergic transmission) using gene expression data provided by the Allen brain atlas. CONCLUSION: These findings provide new insight into the whole brain neurocircuitry of aggression and suggest a role of altered somatosensation and possible novel neuromodulation targets.

Effect of unilateral amygdalotomy and hypothalamotomy in patients with refractory aggressiveness.

BACKGROUND: Neurosurgical treatment, although controversial, is considered a useful resource in the treatment of chronic psychiatric diseases such as refractory aggressiveness. OBJECTIVE: To evaluate the clinical results and side effects of posteromedial hypothalamotomy associated with amygdalotomy in patients with refractory aggressiveness. METHOD: A clinical trial was conducted in patients with chronic aggressiveness and refractory to pharmacological treatment. A central amygdalotomy associated with posteromedial hypothalamotomy was performed using thermo-coagulation by radiofrequency. The degree of aggressiveness was quantified by the Yudofsky's global scale of aggression. Postoperative changes in aggressive behavior continued to be evaluated every 6 months for at least 36 months. RESULTS: A statistically significant change in aggressive behavior was observed during 36 months of follow-up. The collateral effects of the association of both procedures are described, the most frequent being drowsiness and some cases of reduction in sexual behavior. CONCLUSION: Symmetric and simultaneous unilateral lesions of the central nucleus of the amygdala and the posteromedial hypothalamus contralateral to motor dominance give the same clinical effect in the reduction of the pathological aggression that the bilateral lesions.

[Efecto de la amigdalotomía e hipotalamotomía unilateral en pacientes con agresividad refractaria].

BACKGROUND: Neurosurgical treatment, although controversial, is considered a useful resource in the treatment of chronic psychiatric diseases such as refractory aggressiveness. OBJECTIVE: To evaluate the clinical results and side effects of posteromedial hypothalamotomy associated with amygdalotomy in patients with refractory aggressiveness. METHOD: A clinical trial was conducted in patients with chronic aggressiveness and refractory to pharmacological treatment. A central amygdalotomy associated with posteromedial hypothalamotomy was performed using thermo-coagulation by radiofrequency. The degree of aggressiveness was quantified by the Yudofsky's global scale of aggression. Postoperative changes in aggressive behavior continued to be evaluated every 6 months for at least 36 months. RESULTS: A statistically significant change in aggressive behavior was observed during 36 months of follow-up. The collateral effects of the association of both procedures are described, the most frequent being drowsiness and some cases of reduction in sexual behavior. CONCLUSION: Symmetric and simultaneous unilateral lesions of the central nucleus of the amygdala and the posteromedial hypothalamus contralateral to motor dominance give the same clinical effect in the reduction of the pathological aggression that the bilateral lesions.

ANTECEDENTES: El tratamiento neuroquirúrgico, aunque polémico, se considera un recurso útil en el tratamiento de enfermedades psiquiátricas crónicas como la agresividad refractaria. OBJETIVO: Evaluar los resultados clínicos y los efectos colaterales de la hipotalamotomía posteromedial (HPM) asociada a amigdalotomía en pacientes con agresividad refractaria. MÉTODO: Se realizó un ensayo clínico en pacientes con agresividad crónica y refractaria a tratamiento farmacológico. Se les realizó amigdalotomía central asociada a HPM mediante termocoagulación por radiofrecuencia. El grado de agresividad se cuantificó mediante la escala global de agresividad de Yudofsky. Los cambios postoperatorios en la conducta agresiva continuaron siendo evaluados cada 6 meses durante al menos 36 meses. RESULTADOS: Se observó un cambio estadísticamente significativo de la conducta agresiva, a lo largo de 36 meses de seguimiento. Se describen los efectos colaterales de la asociación de ambos procedimientos, siendo el de mayor frecuencia la somnolencia y algunos casos de reducción en la conducta sexual. CONCLUSIÓN: Las lesiones unilaterales simétricas y simultáneas del núcleo central de la amígdala y del hipotálamo posteromedial contralaterales a la dominancia motora dan el mismo efecto clínico en la reducción de la agresividad patológica que las lesiones bilaterales.

[Treatment of refractory aggressiveness by amygdalotomy and posteromedial hypothalamotomy by radiofrequency]. / Tratamiento de la agresividad refractaria mediante amigdalotomia e hipotalamotomia posteromedial por radiofrecuencia.

INTRODUCTION: Since, under certain circumstances, defensive or attacking behaviours display a pattern of motor dominance, as observed in subjects who participate in contact or fighting sports, aggressive behaviour was considered to have a dominant motor pattern. With the aim of preventing the functional problems reported with bilateral lesion procedures involving both the central nucleus of the amygdala and the posteromedial hypothalamus, the decision was made to combine them; thus, an amygdalotomy of the central nucleus of the amygdala and a posteromedial hypothalamotomy were to be performed simultaneously and unilaterally, on the basis of the motor dominance of the patient determined by means of the Edinburgh test. PATIENTS AND METHODS: This study describes the surgical experience in a series of nine patients diagnosed with refractory neuroaggressive syndrome. As part of the study protocol, a magnetic resonance brain scan was performed to rule out the presence of neoplasms, vascular diseases, infections and degenerative disorders. The degree of aggressiveness was quantified using Yudofsky's Overt Aggression Scale. Additionally, manual dominance was determined by means of the Edinburgh test. RESULTS AND CONCLUSIONS: Good control of aggressiveness was seen immediately. In some cases it was necessary to reduce the antipsychotic or benzodiazepine medication, as it was seen to increase aggressiveness. Only one case required a second surgical intervention. Follow-up was achieved in 100% of the cases at 24 months and 78% at 36 months.

TITLE: Tratamiento de la agresividad refractaria mediante amigdalotomia e hipotalamotomia posteromedial por radiofrecuencia.Introduccion. Dado que, en algunas circunstancias, las conductas defensivas o de ataque muestran un patron de dominancia motora, tal como se observa en los sujetos dedicados a los deportes de contacto o de lucha, se considero que la conducta agresiva tiene un patron motor dominante. Con el fin de evitar los problemas funcionales descritos con los procedimientos de lesion bilateral tanto del nucleo central de la amigdala como del hipotalamo posteromedial, se decidio combinarlos; es decir, realizar amigdalotomia del nucleo central de la amigdala e hipotalamotomia posteromedial de manera unilateral y simultanea, basandose en la dominancia motora del paciente mediante la prueba de Edimburgo. Pacientes y metodos. Este estudio muestra la experiencia quirurgica en una serie de nueve pacientes con el diagnostico de sindrome neuroagresivo resistente al tratamiento farmacologico. Dentro del protocolo de estudio, se les realizo resonancia magnetica cerebral para descartar la presencia de neoplasias, enfermedades vasculares, infecciones y trastornos degenerativos. El grado de agresividad se cuantifico mediante la escala global de agresividad de Yudofsky. Adicionalmente, se determino la dominancia manual a traves de la prueba de Edimburgo. Resultados y conclusiones. El buen control de la agresividad se observo de modo inmediato. En algunos casos fue necesario reducir la medicacion de antipsicoticos o benzodiacepinas, ya que aumentaban la agresividad. Solo un caso requirio una segunda cirugia. Se logro seguimiento del 100% de los casos en 24 meses y del 78% en 36 meses.

Amygdala and Hypothalamus: Historical Overview With Focus on Aggression.

Aggressiveness has a high prevalence in psychiatric patients and is a major health problem. Two brain areas involved in the neural network of aggressive behavior are the amygdala and the hypothalamus. While pharmacological treatments are effective in most patients, some do not properly respond to conventional therapies and are considered medically refractory. In this population, surgical procedures (ie, stereotactic lesions and deep brain stimulation) have been performed in an attempt to improve symptomatology and quality of life. Clinical results obtained after surgery are difficult to interpret, and the mechanisms responsible for postoperative reductions in aggressive behavior are unknown. We review the rationale and neurobiological characteristics that may help to explain why functional neurosurgery has been proposed to control aggressive behavior.

Efecto de la amigdalotomía e hipotalamotomía unilateral en pacientes con agresividad refractaria / Effect of tonsillotomy and unilateral hypothalamotomy in patients with refractory aggressiveness

Resumen Antecedentes: El tratamiento neuroquirúrgico, aunque polémico, se considera un recurso útil en el tratamiento de enfermedades psiquiátricas crónicas como la agresividad refractaria. Objetivo: Evaluar los resultados clínicos y los efectos colaterales de la hipotalamotomía posteromedial (HPM) asociada a amigdalotomía en pacientes con agresividad refractaria. Método: Se realizó un ensayo clínico en pacientes con agresividad crónica y refractaria a tratamiento farmacológico. Se les realizó amigdalotomía central asociada a HPM mediante termocoagulación por radiofrecuencia. El grado de agresividad se cuantificó mediante la escala global de agresividad de Yudofsky. Los cambios postoperatorios en la conducta agresiva continuaron siendo evaluados cada 6 meses durante al menos 36 meses. Resultados: Se observó un cambio estadísticamente significativo de la conducta agresiva, a lo largo de 36 meses de seguimiento. Se describen los efectos colaterales de la asociación de ambos procedimientos, siendo el de mayor frecuencia la somnolencia y algunos casos de reducción en la conducta sexual. Conclusión: Las lesiones unilaterales simétricas y simultáneas del núcleo central de la amígdala y del hipotálamo posteromedial contralaterales a la dominancia motora dan el mismo efecto clínico en la reducción de la agresividad patológica que las lesiones bilaterales.

Abstract Background: Neurosurgical treatment, although controversial, is considered a useful resource in the treatment of chronic psychiatric diseases such as refractory aggressiveness. Objective: To evaluate the clinical results and side effects of posteromedial hypothalamotomy associated with amygdalotomy in patients with refractory aggressiveness. Method: A clinical trial was conducted in patients with chronic aggressiveness and refractory to pharmacological treatment. A central amygdalotomy associated with posteromedial hypothalamotomy was performed using thermo-coagulation by radiofrequency. The degree of aggressiveness was quantified by the Yudofsky's global scale of aggression. Postoperative changes in aggressive behavior continued to be evaluated every 6 months for at least 36 months. Results: A statistically significant change in aggressive behavior was observed during 36 months of follow-up. The collateral effects of the association of both procedures are described, the most frequent being drowsiness and some cases of reduction in sexual behavior. Conclusion: Symmetric and simultaneous unilateral lesions of the central nucleus of the amygdala and the posteromedial hypothalamus contralateral to motor dominance give the same clinical effect in the reduction of the pathological aggression that the bilateral lesions.

Anatomic Investigation of the Trajectory for Stereotactic Laser Amygdalohippocampectomy.

BACKGROUND: Magnetic resonance imaging-guided laser interstitial thermal therapy (LITT) has emerged as a promising treatment for mesial temporal lobe epilepsy. Surgeons must understand the relevant anatomy that is traversed by the catheter and affected by ablation. OBJECTIVE: To study the anatomic structures crossed by the LITT catheter until it reaches the amygdala. METHODS: Three human cadaveric heads were implanted with catheters using a frameless stereotactic technique. The Visualase® system (Medtronic, Dublin, Ireland) was utilized to ablate along the trajectory. Coronal and oblique axial slices were created. Fiber tract dissections were performed in a lateral-medial and inferior-superior scheme. Magnetic resonance tractography was acquired to illustrate the tracts dissected. RESULTS: Entry points occurred within 4 cm of the transverse and sagittal sinus, inferior to the lambdoid suture. The cortex of the inferior occipital gyrus was crossed in the region of the transverse occipital sulcus. The vertical occipital fasciculus was crossed en route to passing through the optic radiations. The catheter crossed through or inferior to the optic radiations before piercing the parahippocampal gyrus at about 4 cm from the skull. The catheter entered the hippocampus as it pierced the superior margin of the parahippocampus at 6 cm. The catheter entered the head of the hippocampus to lie inferolateral to the amygdala in the last centimeter of the trajectory. CONCLUSION: Understanding the anatomic principles of LITT catheter trajectories will improve the ability to perform this procedure. The current study is the first to examine the anatomy of this trajectory and will serve as the basis for future studies.

Transtemporal amygdalohippocampectomy: a novel minimally-invasive technique with optimal clinical results and low cost.

Mesial temporal sclerosis creates a focal epileptic syndrome that usually requires surgical resection of mesial temporal structures. OBJECTIVE: To describe a novel operative technique for treatment of temporal lobe epilepsy and its clinical results. METHODS: Prospective case-series at a single institution, performed by a single surgeon, from 2006 to 2012. A total of 120 patients were submitted to minimally-invasive keyhole transtemporal amygdalohippocampectomy. RESULTS: Of the patients, 55% were male, and 85% had a right-sided disease. The first 70 surgeries had a mean surgical time of 2.51 hours, and the last 50 surgeries had a mean surgical time of 1.62 hours. There was 3.3% morbidity, and 5% mild temporal muscle atrophy. There was no visual field impairment. On the Engel Outcome Scale at the two-year follow-up, 71% of the patients were Class I, 21% were Class II, and 6% were Class III. CONCLUSION: This novel technique is feasible and reproducible, with optimal clinical results.

Transtemporal amygdalohippocampectomy: a novel minimally-invasive technique with optimal clinical results and low cost / Amigdalo-hipocampectomia transtemporal: técnica minimamente invasiva com ótimos resultados clínicos e baixo custo

ABSTRACT Mesial temporal sclerosis creates a focal epileptic syndrome that usually requires surgical resection of mesial temporal structures. Objective: To describe a novel operative technique for treatment of temporal lobe epilepsy and its clinical results. Methods: Prospective case-series at a single institution, performed by a single surgeon, from 2006 to 2012. A total of 120 patients were submitted to minimally-invasive keyhole transtemporal amygdalohippocampectomy. Results: Of the patients, 55% were male, and 85% had a right-sided disease. The first 70 surgeries had a mean surgical time of 2.51 hours, and the last 50 surgeries had a mean surgical time of 1.62 hours. There was 3.3% morbidity, and 5% mild temporal muscle atrophy. There was no visual field impairment. On the Engel Outcome Scale at the two-year follow-up, 71% of the patients were Class I, 21% were Class II, and 6% were Class III. Conclusion: This novel technique is feasible and reproducible, with optimal clinical results.

RESUMO A esclerose mesial temporal é uma síndrome epiléptica focal que requer ablação de estruturas mesiais temporais. Objetivo: Descrever e padronizar a técnica operatória e resultados clínicos. Métodos: Série prospectiva de casos de uma única instituição, realizadas por um único cirurgião, de 2006 a 2012. 120 doentes foram submetidos a amigdalo-hipocampectomia transtemporal por acesso mínimo (keyhole). Resultados: 55% eram do sexo masculino, 85% apresentavam doença do lado direito. As primeiras 70 cirurgias tiveram um tempo cirúrgico médio de 2,51 horas, e as últimas 50 cirurgias tiveram um tempo cirúrgico médio de 1,62 horas. Houve morbidade de 3,3%. 5% dos doentes apresentaram atrofia leve de músculo temporal. O controle das convulsões foi avaliado com a Escala de Engel no segundo ano de pós operatorio, 71% eram Classe I, 21% Classe II, 6% Classe III. Conclusão: Esta nova técnica é viável, reprodutível e com resultados clínicos adequados.

Minimally Invasive Transpalpebral Endoscopic-Assisted Amygdalohippocampectomy.

BACKGROUND: Although anterior temporal lobectomy may be a definitive surgical treatment for epileptic patients with mesial temporal sclerosis, it often results in verbal, visual, and cognitive dysfunction. Studies have consistently reported the advantages of selective procedures compared with a standard anterior temporal lobectomy, mainly in terms of neuropsychological outcomes. OBJECTIVE: To describe a new technique to perform a selective amygdalohippocampectomy (SAH) through a transpalpebral approach with endoscopic assistance. METHODS: A mini fronto-orbitozygomatic craniotomy through an eyelid incision was performed in 8 patients. Both a microscope and neuroendoscope were used in the surgeries. An anterior SAH was performed in 5 patients who had the diagnosis of temporal lobe epilepsy with mesial temporal sclerosis. One patient had a mesial temporal lesion suggesting a ganglioglioma. Two patients presented mesial temporal cavernomas with seizures originating from the temporal lobe. RESULTS: The anterior approach allowed removal of the amygdala and hippocampus. The image-guided system and postoperative evaluation confirmed that the amygdala may be accessed and completely removed through this route. The hippocampus was partially resected. All patients have discontinued medication with no more epileptic seizures. The patients with cavernomas and ganglioglioma also had their lesions completely removed. One-year follow-up has shown no visible scars. CONCLUSION: The anterior route for SAH is a rational and direct approach to the mesial temporal lobe. Anterior SAH is a safe, less invasive procedure that provides early identification of critical vascular and neural structures in the basal cisterns. The transpalpebral approach provides a satisfactory cosmetic outcome.

Microsurgical techniques in temporal lobe epilepsy.

Temporal lobe resection is the most prevalent epilepsy surgery procedure. However, there is no consensus on the best surgical approach to treat temporal lobe epilepsy. Complication rates are low and efficacy is very high regarding seizures after such procedures. However, there is still ample controversy regarding the best surgical approach to warrant maximum seizure control with minimal functional deficits. We describe the most frequently used microsurgical techniques for removal of both the lateral and mesial temporal lobe structures in the treatment of medically intractable temporal lobe epilepsy (TLE) due to mesial temporal sclerosis (corticoamygdalohippocampectomy and selective amygdalohippocampectomy). The choice of surgical technique appears to remain a surgeon's preference for the near future. Meticulous surgical technique and thorough three-dimensional microsurgical knowledge are essentials for obtaining the best results.

Anterior temporal lobectomy versus selective amygdalohippocampectomy in patients with mesial temporal lobe epilepsy / Lobectomia temporal anterior versus amigdalohipocampectomia seletiva para epilepsia de lobo temporal mesial

ABSTRACT Objective To contribute our experience with surgical treatment of patients with mesial temporal lobe epilepsy (mTLE) undergoing anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SelAH). Method This is a retrospective observational study. The sample included patients with medically refractory mTLE due to unilateral mesial temporal sclerosis who underwent either ATL or SelAH, at Hospital de Clinicas – UFPR, from 2005 to 2012. We report seizure outcomes, using Engel classification, cognitive outcomes, using measurements of verbal and visuospatial memories, as well as operative complications. Result Sixty-seven patients (33 ATL, 34 SelAH) were studied; median follow-up was 64 months. There was no statistically significant difference in seizure or neuropsychological outcomes, although verbal memory was more negatively affected in ATL operations on patients’ dominant hemispheres. Higher number of major complications was observed in the ATL group (p = 0.004). Conclusion Seizure and neuropsychological outcomes did not differ. ATL appeared to be associated with higher risk of complications.

RESUMO Objetivo Contribuir com nossa experiência para o tratamento cirúrgico de pacientes com epilepsia do lobo temporal mesial submetidos a lobectomia temporal anterior (LTA) ou amigdalohipocampectomia seletiva (AHS). Método Estudo retrospectivo observacional. Foram incluídos pacientes com epilepsia refratária devido a esclerose mesial temporal unilateral, submetidos a LTA ou AHS no Hospital de Clínicas – UFPR, entre 2005-2012. Foram comparados os resultados cognitivos (análises de memórias verbal e visuoespacial), controle de crises (Engel) e complicações cirúrgicas. Resultados Sessenta e sete pacientes (33 LTA, 34 AHS) foram estudados; o período de acompanhamento médio foi de 64 meses. Não houve diferença no controle das crises ou resultado neuropsicológico, mas a memória verbal foi mais negativamente afetada nos pacientes submetidos à LTA no hemisfério dominante. Maior número de complicações graves ocorreu no grupo de LTA (p = 0.004). Conclusão Controle de crises e resultados neuropsicológicos não diferiram. LTA pareceu estar associada a um maior risco cirúrgico.

Anterior temporal lobectomy versus selective amygdalohippocampectomy in patients with mesial temporal lobe epilepsy.

OBJECTIVE: To contribute our experience with surgical treatment of patients with mesial temporal lobe epilepsy (mTLE) undergoing anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SelAH). METHOD: This is a retrospective observational study. The sample included patients with medically refractory mTLE due to unilateral mesial temporal sclerosis who underwent either ATL or SelAH, at Hospital de Clinicas - UFPR, from 2005 to 2012. We report seizure outcomes, using Engel classification, cognitive outcomes, using measurements of verbal and visuospatial memories, as well as operative complications. RESULT: Sixty-seven patients (33 ATL, 34 SelAH) were studied; median follow-up was 64 months. There was no statistically significant difference in seizure or neuropsychological outcomes, although verbal memory was more negatively affected in ATL operations on patients' dominant hemispheres. Higher number of major complications was observed in the ATL group (p = 0.004). CONCLUSION: Seizure and neuropsychological outcomes did not differ. ATL appeared to be associated with higher risk of complications.

Modified Anterior Temporal Lobectomy: Anatomical Landmarks and Operative Technique.

There is great controversy about which surgical approach is the most selective and efficient for resection of mesial structures of the temporal lobe for treatment of mesial temporal lobe epilepsy. Selective approaches have been described in an attempt to preserve the neocortex and the temporal stem. Nonselective approaches, such as anterior temporal lobectomy (ATL), result in injuries in these structures. We describe a modified selective technique for resection of the amygdala and hippocampus with resection of the temporal pole performed through the Sylvian fissure based on anatomical landmarks and diligent microsurgical techniques. Briefly, after opening the Sylvian fissure, the temporal pole is resected and the temporal horn is directly accessed through the uncus, in an anteroposterior direction, preserving the temporal stem and the neocortex of the temporal lobe. The surgical technique used by our group is described in detail with illustrations. Precise microsurgical techniques associated with knowledge of microsurgical anatomy are of paramount importance for temporal lobe epilepsy surgery. According to our analysis, the modified ATL approach to the temporal mesial structures is a feasible selective technique that can be used as an alternative to traditional surgical procedures.

Patient satisfaction with temporal lobectomy/selective amygdalohippocampectomy for temporal lobe epilepsy and its relationship with Engel classification and the side of lobectomy.

PURPOSE: The aim of this study was to investigate not only the effectiveness of epilepsy surgery in improving seizure control but also patient satisfaction with the result of the procedure in a sample of patients operated on at a specialized epilepsy unit. METHODS: Patients with temporal lobe epilepsy who had undergone epilepsy surgery (temporal lobectomy/amygdalohippocampectomy) were interviewed in a standardized telephone survey about their satisfaction with the results of the surgery. The morbidity of the surgery was also analyzed retrospectively. The initial study population consisted of 6 amygdalohippocampectomy and 102 temporal lobectomy patients and was reduced to a final sample consisting of 4 amygdalohippocampectomy and 67 lobectomy patients, as the other patients were not available for interview. Surgical results were based on the Engel classification, and satisfaction with the surgery was assessed by asking patients to rate their result and state whether they would make the same decision (to be operated on) again. RESULTS: A significant number of patients classified as Engel I or II, who considered the surgical outcome good or excellent, said they would have the surgery again (p<0.001). Left temporal lobectomy patients whose results fell in the Engel III/IV bracket were less satisfied (p=0.001) than right temporal lobectomy patients with the same Engel classifications (0.048). Left temporal lobectomy patients who were classified as Engel class III and IV were less likely to have the surgery again if they had the choice (p=0.016). DISCUSSION: Patient satisfaction with the results of epilepsy surgery may depend not only on achieving seizure control but also on the temporal lobe resected. Since worse results were associated with lower satisfaction rates only for left temporal resection patients, it is possible that the cognitive consequences of this procedure compound the worse surgical result, leading to decreased satisfaction.

Hippocampal gene expression dysregulation of Klotho, nuclear factor kappa B and tumor necrosis factor in temporal lobe epilepsy patients.

BACKGROUND: Previous research in animal seizure models indicates that the pleiotropic cytokine TNF is an important effector/mediator of neuroinflammation and cell death. Recently, it has been demonstrated that TNF downregulates Klotho (KL) through the nuclear factor kappa B (NFkB) system in animal models of chronic kidney disease and colitis. KL function in the brain is unclear, although Klotho knockout (Kl-/-) mice exhibit neural degeneration and a reduction of hippocampal synapses. Our aim was to verify if the triad KL-NFKB1-TNF is also dysregulated in temporal lobe epilepsy associated with hippocampal sclerosis (TLE(HS)) patients. FINDINGS: We evaluated TNF, NFKB1 and KL relative mRNA expression levels by reverse transcription quantitative PCR (RT-qPCR) in resected hippocampal tissue samples from 14 TLE(HS) patients and compared them to five post mortem controls. Four reference genes were used: GAPDH, HPRT1, ENO2 and TBP. We found that TNF expression was dramatically upregulated in TLE(HS) patients (P <0.005). NFKB1 expression was also increased (P <0.03) while KL was significantly downregulated (P <0.03) in TLE(HS) patients. Hippocampal KL expression had an inverse correlation with NFKB1 and TNF. CONCLUSIONS: Our data suggest that, similar to other inflammatory diseases, TNF downregulates KL through NFkB in TLE(HS) patients. The remarkable TNF upregulation in patients is a strong indication of hippocampal chronic inflammation. Our finding of hippocampal KL downregulation has wide implications not only for TLE(HS) but also for other neuronal disorders related to neurodegeneration associated with inflammation.

Pre-surgical predictors for psychiatric disorders following epilepsy surgery in patients with refractory temporal lobe epilepsy and mesial temporal sclerosis.

Psychiatric outcomes of patients submitted to epilepsy surgery have gained particular interest given the high prevalence of pre-surgical psychiatric disorders (PD) in this population. The present study aimed to verify the possible pre-surgical predictors for psychiatric disorders following epilepsy surgery in a homogeneous series of patients with refractory temporal lobe epilepsy and mesial temporal sclerosis (TLE-MTS). Data from 115 TLE-MTS patients (65 females; 56.5%) who underwent cortico-amygdalohippocampectomy were included. Pre- and post-surgical psychiatric evaluations were performed using DSM-IV criteria. Pre-surgical PD - particularly mood, anxiety and psychotic disorders - were diagnosed in 47 patients (40.8%). Twenty-seven patients (54% of those with pre-surgical PD) demonstrated a remission of psychiatric symptoms on post-surgical psychiatric evaluation. Eleven patients (9.6%) developed de novo PD. The presence of pre-surgical depression (OR=3.32; p=0.008), pre-surgical interictal psychosis (OR=4.39; p=0.009) and epileptiform discharges contralateral to the epileptogenic zone (OR=2.73; p=0.01) were risk factors associated with post-surgical PD. Although epilepsy surgery is considered to be the best treatment option for patients with refractory TLE-MTS, the relatively high psychiatric comorbidities observed in surgical candidates and their possible negative impact on post-surgical outcomes require a careful pre-surgical evaluation of clinical, sociodemographic and psychiatric factors.

Speech preservation using a non-linear paradigm for determination of the extent of neocortical resection in patients with mesial temporal sclerosis submitted to cortico-amygdalo-hippocampectomy (CAH).

RATIONALE: The rationale for using a non-linear (proportional) paradigm for determining the extent of the neocortex to be removed in temporal lobe resection was based on anatomical and intra-operative cortical mapping findings. We present our results regarding speech preservation in patients submitted to CAH using the central artery as an anatomical landmark for determining the posterior border of neocortical resection. METHODS: Two hundred and fifty consecutive right-handed patients with left unilateral mesial sclerosis were studied. All patients were submitted to CAH under general anesthesia and without intraoperative electrocorticography. The posterior border of the lateral neocortical resection was defined by a line perpendicular to the temporal axis at the level of the central artery. RESULTS: Seven patients had transient (1-3 weeks; mean=9 days) receptive speech disturbance. There was no permanent speech deficit. Imaging documented edema or contusion at the posterior temporal cortical border in all patients who had transient speech deficits. The mean extent of cortical resection was 3.9 cm in adults and 3.1cm in kids. DISCUSSION: This is the first report in the literature discussing the use of a non-linear paradigm to determine the extent of lateral neocortical removal in this patient population. We found no permanent speech disturbances in this series. The non-linear approach used in this series proved to be safe and effective to avoid post-operative speech disorders. It was able to compensate for different brain and head sizes, and allowed smaller neocortical removal when compared to traditional linear approaches.