Anterior temporal lobectomy

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Anterior temporal lobectomy is the complete removal of the anterior portion of the
temporal lobe of the brain. It is a treatment option in temporal lobe epilepsy for those in
whom anticonvulsant medications do not control epileptic seizures.

The techniques for removing temporal lobe tissue vary from resection of large amounts
of tissue, including lateral temporal cortex along with medial structures, to more
restricted anterior temporal lobectomy (ATL) to more restricted removal of only the
medial structures (selective amygdalohippocampectomy, SAH).

Nearly all reports of seizure outcome following these procedures indicate that the best
outcome group includes patients with MRI evidence of mesial temporal sclerosis
(hippocampal atrophy with increased T-2 signal.) The range of seizure-free outcomes for
these patients is reported to be between 80 and 90%, which is typically reported as a sub-
set of data within a larger surgical series.[1][2]

Open surgical procedures such as ATL have inherent risks including damage to the brain
(either directly or indirectly by injury to important blood vessels), bleeding (which can
require re-operation), blood loss (which can require transfusion), and infection.
Furthermore, open procedures require several days of care in the hospital including at
least one night in an intensive care unit. Although such treatment can be costly, multiple
studies have demonstrated that ATL in patients who have failed at least two
anticonvulsant drug trials (thereby meeting the criteria for medically intractable temporal
lobe epilepsy) has lower mortality, lower morbidity and lower long-term cost in
comparison with continued medical therapy without surgical intervention.

The strongest evidence supporting ATL over continued medical therapy for medically
refractory temporal lobe epilepsy is a prospective, randomized trial of ATL compared to
best medical therapy (anticonvulsants), which convincingly demonstrated that the
seizure-free rate after surgery was ~ 60% as compared to only 8% for the medicine only
group.[3] Furthermore, there was no mortality in the surgery group, while there was
seizure-related mortality in the medical therapy group. Therefore, ATL is considered the
standard of care for patients with medically-intractable mesial temporal lobe epilepsy.

By Thomas C. Weiss
Published: 2010-01-20
Last Modified: 2010-09-14

The number of people who take medications to control seizures in the world is large,
with many people benefiting from the medications available for seizure control. There
are times when anti-seizure medications either do not work as well as they should, or at
all where control over seizures related to epilepsy are concerned.

***

The effects on a person's life because of uncontrolled gran mal or other forms of seizures
can be immense. When medications fail to assist in controlling seizures, one potential
option is a surgery known as a, 'temporal lobectomy.'

A temporal lobectomy involves the removal of a portion of the person's temporal lobe of
their brain. The surgery is the most common type of epilepsy surgery; it is also the most
successful type of epilepsy surgery. There are a number of highly-skilled and qualified
neurosurgeons who perform this type of surgery in America. Among people with
epilepsy who have undergone this surgery. Sixty to seventy-percent become free of the
seizures they experienced that caused abnormal movements, or impaired their
consciousness. Some of these people still may experience things such as auras, or
sensations like odors without an outside source.

Once the person who is having the surgery has both in position and asleep, the surgery
starts. A patch of hair over the person's temple is shaved; fortunately it is not necessary to
shave the person's entire head. Their skin is cut in a, 'C,' shaped partial circle above their
ear. A number of nickel-sized holes are created in a circular pattern. The surgeon uses a
saw to cut between the holes, removing a circle of bone approximately the size of the rim
of a small coffee cup. Once the procedure is over, the person's bone is hard-wired back
into place and eventually heals back into place in their skull. The wires that are used are
non-magnetic and MRI compatible; they hold the person's bone in place and do not need
to be removed.

The surgeon makes an incision in the person's membrane covering their brain, known as,
'dura matter,' exposing their temporal lobe. Portions of the person's temporal lobe are
removed by suction; a person's brain has a more or less, 'firm pudding,' consistency.
Different surgeons use various techniques and approaches depending upon their
preferences and the ways they were trained. No one particular technique has been proven
to be superior than another. The amount of matter removed commonly ranges from about
the size of a golf ball to the size of a small lemon, representing less than half of the
volume of the person's temporal lobe.

The portion of the person's brain that is removed during the surgery does not grow back.
Instead, the space that it once occupied fills with the fluid which surrounds the person's
brain. People sometimes wonder why replacement of seizure-producing scar with a
surgical scar is beneficial. The reason why is because not every scar is alike. The scar left
by neurosurgery is, 'clean,' meaning that it rarely leads to seizure activity. As surgeons
end the surgery, they close the field of surgery in reverse order to that which they opened.

The person who has gone through a temporal lobectomy is usually in the operating room
and recovery room for approximately four to eight hours, although sometimes they may
be there longer. The majority of delays in returning from this form of surgery are due to
administrative issues related to getting the operation started. Family members should not
make the assumption that the surgery is the cause of a long wait. The operation itself
commonly takes between two and three hours.

The person who has experienced this form of surgery might be disoriented for a day
afterwards; family members need to be prepared for this eventuality. A headache is one
of the clear issues associated with the surgery, but over-medicating the person is avoided
because the person needs to be allowed to wake up. The person is commonly nauseated
due to the anesthesia after the surgery, can have a sore throat because of the breathing
tube, and will experience swelling and bruising on their forehead and eye on the side the
surgery was performed. The swelling the person experiences peaks between two and four
days after the surgery. The person who has had the surgery usually stays overnight in the
hospital, or for two days in intensive care.

Commonly, by the third day after the surgery the person is able to sit up in a chair, walk
unassisted, and eat. The person is given seizure medications intravenously until they can
eat and drink. Not every anti-seizure medication has an intravenous form, so the person's
medication may be temporarily switched. The person is usually discharged from the
hospital within three to seven days after the surgery, and needs to plan on staying at home
with assistance for approximately a week after that. They may need to stay off of work or
refrain from heavy activity for a month. Some people who have a temporal lobectomy
experience fatigue or a persistent headache and need two or three months of
postoperative rest.

Complications can arise in approximately two-percent, or about one in every fifty people,
who have a temporal lobectomy. The complications may be serious and can include:

* Psychosis
* Death (0.1 - 0.5%)
* Reading difficulties
* Personality change
* Severe depression
* Partial loss of vision
* Psychiatric deterioration
* Severe speech problems
* Deterioration of memory ability
* Stroke, partial paralysis or numbness

There are some less serious complications that happen more frequently, to include
deterioration of word-finding abilities, for a few months after surgery. People can
experience pain and itching around the skin scar, particularly as it heals, infection of the
surgical site, skull indentations or additional cosmetic defects, minor loss of upper
peripheral vision on the side opposite the surgery, persistent headaches, transient
depression, drooping of an eyelid or forehead on the surgical side, or a variety of other
issues.
Seizure activity may flare up for a month or two after the person has surgery and their
brain heals. The seizure activity during the postoperative months does not mean the
operation was a failure; seizures may settle down as the person heals. It is important for
people considering a temporal lobectomy to discuss both the potential benefits and the
risks or the surgery with their surgeon.

Epilepsy surgery is successful approximately seventy-five percent of the time. People

may be able to discontinue all of their medications, commonly about a year after surgery.
Some people choose to continue taking anti-seizure medications. Others become free of
seizure activity, yet still require medications. The benefits of surgery for epilepsy might
fall short of a complete cure. People can still experience occasional auras or,
breakthrough,' seizures during times of stress. Twenty-five percent of people do not
respond favorably to surgery for epilepsy, commonly because not all of the focus could
be removed, or because the seizures we multi-focal.

Twenty-to-twenty-five percent of people still experience some complex partial or tonic-

clonic seizures, yet the number of seizures they experience is reduced by greater than
eighty-five percent. Ten-to-fifteen-percent of people experience no worthwhile
improvement whatsoever. What this means is that greater than eight-five-percent of
people who have undergone a temporal lobectomy experience a great improvement in
seizure control. Many people still need to continue taking anti-seizure medication, but
usually have to take less of it. Approximately twenty-five percent of the people who have
this form of surgery eventually are able to stop taking anti-seizure medications entirely.

Read more: http://www.disabled-world.com/health/neurology/epilepsy-temporal-

lobectomy.php#ixzz0zhJ5OAPd

Temporal Lobectomy Surgical Procedure

After the patient is positioned and asleep, the surgery begins. A patch of hair over
the temple is shaved, but it is not necessary to shave the entire head. Skin is cut in
a "C"ﾝ-shaped partial circle above the ear. Several nickel-sized holes are drilled
in a circular pattern. A bone-saw cuts between the holes to remove a circle of bone
about the circumference of a small coffee cup rim. At the end of the procedure,
this bone will be hard-wired back in place and eventually will calcify to seal to the
skull. The wires are non-magnetic (MRI compatible), hold the bone firmly in
place, and never need to be removed.

The membrane over the brain, the dura mater, then is cut open, exposing the
temporal lobe. Portions of the temporal lobe are removed by suction, since the
brain has a "firm pudding"ﾝ consistency. Different surgeons use different
techniques and approaches, depending upon preference and training, but no one
technique is proven superior to the others. The amount usually removed ranges
between the size of a golf ball and a small lemon, representing well less than half
the volume of the temporal lobe.

The portion of brain removed never grows back. The space that it occupied fills
with the fluid surrounding the brain. Patients sometimes wonder why replacing a
seizure-producing scar with a surgical scar is beneficial. The reason is that not all
scars are alike. The "clean"ﾝ scar left by neurosurgery rarely leads to seizures.
Closure of the surgical field occurs in reverse order to the opening.

Patients typically are in the operating room and recovery room for 4 - 8 hours,
sometimes longer. Most delays in returning from surgery are administrative
problems in getting the operation started, so family should not assume that that the
surgery is the cause of the long wait. The operation itself usually takes about 2 - 3
hours.

The family should be prepared for the patient to be disoriented for a day
postoperatively. Headache is a clear issue, but over-medication is avoided to
allow the patient to wake up. The patient will be nauseated from the anesthesia,
have a sore throat from the breathing tube, and will have swelling and bruising of
the forehead and eye on the side of surgery. The swelling increases to a peak 2 - 4
days after surgery. An overnight or two-day stay in intensive care is common.

By day three after surgery, most patients are able to sit in a chair, walk with
assistance, and eat. Until post-operative patients can eat and drink, seizure
medications are given intravenously. Since not every medicine has an intravenous
form, a temporary switch to one that does may be required. Hospital discharge
happens 3 - 7 days after surgery. Patients should plan on staying at home with
assistance for a week, and staying off work or heavy activities for a month. A few
patients have persistent headache or fatigue, and require 2 - 3 months post-
operative rest.

Complications of Temporal Lobectomy

Complications occur in about two percent of patients (one-in-fifty) who have this
surgery. Complications can be serious, including as a partial list:

• Severe speech problems

• Reading difficulties
• Stroke, partial paralysis or numbness
• Personality change
• Deterioration of memory ability
• Partial loss of vision
• Psychiatric deterioration
• Severe depression
 • Psychosis
• Death (0.1 - 0.5%)
• Others

Less serious complications occur more often, such as deterioration of word-

finding ability for a few months after surgery, (pain-itching around the skin scar
(especially as it heals), infection of the surgical site, skull indentations or other
cosmetic defects, persistent headaches, minor loss of upper peripheral vision on
the side opposite the surgery, drooping of eyelid or forehead on the surgical side,
transient depression, and a variety of other problems.

Seizures occasionally flare up for 1 - 2 months after seizure surgery, as the brain
heals. Seizures during the postoperative months do not mean that the operation
was a failure, seizures may settle down with healing. You should discuss the
potential benefits and risks of surgery with your surgeon, and give what is known
as "informed consent"ﾝ for the procedure if you agreed to have surgery.

Epilepsy surgery is successful about 75 percent of the time. Patients may be able
to go off all medications, typically about a year after the surgery. Some patients
choose to stay on their medications; others become free from seizures, but still
require medication. Benefit of surgery may fall short of a complete cure. Patients
may still have occasional auras (simple partial warnings) or rare breakthrough
seizures at times of great stress. Twenty-five percent of patients do not respond
favorably to seizure surgery, usually because not all of the focus could be
removed or because the seizures were in fact multi-focal.

ATL surgery has been recognized as an efficient treatment option for certain types of
seizures in patients diagnosed with temporal lobe epilepsy (TLE). Characterized by
transient disturbances of brain function and seizures, TLE is the most common form of
epilepsy. ATL is optimal for patients with seizures that do not respond to medications,
patients who are unable to tolerate medication side effects, or patients with seizures
caused by structural abnormalities in the brain.

Demographics

Epilepsy is the most common serious neurological condition in the United States. Its
incidence is greatest in young chidren and in the elderly, with five to 10 cases diagnosed
per 1,000. The lifetime prevalence amounts to 2–5% of the population. Epilepsy is
slightly more common in males than females. The frequency of seizure activity in the
epileptic population is as follows.

• 33% have less than one seizure per year

• 33% have one to 12 seizures per year
• 33% have more than one seizure per month
• 60% also have other neuropsychiatric problems

Description

ATL surgical procedures:

• Anesthesia. The patient is anesthetized with a combination of drugs that achieves

a state of unconsciousness.
• Preparation of the surgical field. An antiseptic solution is applied to the patient's
scalp, face, and neck. Surgical drapes are placed around the surgical region to
maintain a sterile surgical field.
• Temporal incision. Using a scalpel blade, the neurosurgeon makes an incision in
the skin and muscle of the temporal region of the head located on the side of the
head above the ear, and pulls away the flap of scalp.
• Control of bleeding. Blood obstructing the surgeon's view of the surgical field is
irrigated and suctioned away as surgery proceeds.
• Craniotomy. Using a high-speed drill, the neurosurgeon removes a section of
bone (bone flap) from the skull and makes an incision through the protective
membranes of the brain (dura) in order to expose the temporal lobe.
• Removal of the anterior lobe. Using an operating microscope to enlarge the
features of the surgical area, the neurosurgeon removes the temporal anterior lobe.
• Closure. Once bleeding is under control, every layer of tissue cut or divided to
reach the surgical site is closed. The cavity is irrigated completely and the dura is
closed in a watertight manner using tack-up sutures. The bone flap is returned into
place. Muscle and tissues are closed with sutures, while the skin is closed with
staples. No drain is needed.

Diagnosis/Preparation

An ATL pre-surgical diagnosis requires reliable diagnostic levels classified as (1) seizure,
(2) epilepsy, and (3) syndrome. The epilepsy and syndromic diagnoses are usually
combined. The seizure diagnosis is determined from the physical and neurological
manifestations of the condition recorded in the patient's history and from
electroencephalogram (EEG) evaluations. Because seizures commonly result from
cortical damage, neuroimaging techniques are used to identify and localize the damaged
area. They include:

• Magnetic resonance imaging (MRI). Brain MRI is the best structural imaging
technique available. Every ATL surgical evaluation usually includes a complete
MRI study.
 • Positron emission tomography (PET) . Unlike MRI, PET provides information
on brain metabolism rather than on structure. Typically, the epileptic region's
metabolism is lowered unless the scan is obtained during a seizure.
• Single photon emission tomography (SPECT). SPECT scans visualize blood flow
through the brain and are used as another method for localizing the epileptic site.

Routinely, all ATL candidates also undergo neuropsychological testing.

To prepare for ATL, the patient discontinues any medication being taken and that has
been associated with bleeding disorders at least three weeks prior to ATL surgery.
Antibiotics may be administered intravenously one hour before surgery. Minimal hair is
shaved over the temporal area of the head.

Aftercare

After ATL surgery, the neurosurgeon provides instructions for the nurses, pharmacists,
therapists, and other physicians caring for the patient postoperatively. Once the
anesthesiologist determines that the patient is stable, the surgeon authorizes transport to
the postoperative care area. Most patients go to the recovery area, but some critical
patients may be taken to an intensive care unit (ICU) for close monitoring. As is the
case for almost all types of brain surgery, the patient is initially nursed with the head of
the bed elevated to 30 degrees.

Risks

All surgical procedures are associated with risks and complications that vary depending
on the location of the procedure (the approach and dissection required), the pathology
(what has to be done to accomplish the surgical objective), and patient factors (such as
age, general medical condition, etc.).

A specific risk associated with ATL is possible injury to the cerebral cortex, the outer
portion of the brain that consists of layers of nerve cells and their connections, during the
lobectomy procedure.

Normal results

ATL offers a high chance of seizure-free outcome in patients suffering from drug-
resistant seizures originating in the temporal lobe of the brain. The procedure is
considered to be the most common and rewarding of all the surgeries for epilepsy.
Morbidity and mortality rates

ATL is the most common surgery performed to treat medically refractory epilepsy and, in
most cases, will diminish or abolish seizures.

In 1997, Sperling et al. reported in the Epilepsy Quarterly the five-year outcomes of 89
patients with uncontrolled seizures who underwent ATL at the Graduate Hospital in
Philadelphia, Pennsylvania. The patients in this study underwent ATL as a result of no
response (or allergy) to at least three medications. Five years postoperatively, 80 of 89
patients (90%) no longer had seizures or experienced more than 80% seizure reduction.
Only five patients (6%) exhibited no worthwhile improvement, although a modest
reduction in seizure frequency may have been noted. Among the seizure-free patients, 49
were cured of their epilepsy (i.e., they had no seizures after temporal lobectomy).

Alternatives
Anti-convulsant drug development programs

Once the diagnosis of epilepsy is established, a course of medication is usually prescribed

for the control of seizures. ATL only becomes the preferred approach when a patient does
not respond to medication. As an alternative to surgery, a patient may elect to become an
active participant in an anti-convulsant drug development program that may offer an
opportunity to participate in studies of experimental medications.

Other surgical techniques

Other surgical techniques such as corpus callosotomy can be performed in selected

patients who are ineligible for ATL. In this procedure, the white matter tract connecting
the two halves of the brain is cut to halt the spread of seizures and to limit their severity.

Read more: Anterior Temporal Lobectomy - procedure, recovery, blood, removal,

complications, medication, cells, types, risk, children, Definition, Purpose,
Demographics, Description, Diagnosis/Preparation, Aftercare, Risks
http://www.surgeryencyclopedia.com/A-Ce/Anterior-Temporal-
Lobectomy.html#ixzz0zhKY7ydZ
Temporal Lobectomy-Epilepsy Surgery

Temporal lobectomy is most commonly done to remove scarring in the deep portion of
the temporal lobe. A standard anterolateral temporal lobectomy involves removing 4-5
cm of lateral cortex (superior, middle, and inferior temporal gyri) and the
parahippocampal formation (parahippocampal gyrus and hippocampus). This is done
through an incision that resembles a question mark just in front of the ear on the correct
side (picture). The temporalis muscle (used for chewing) is incised and stripped off the
underlying skull. A hole in the skull (craniotomy) is made with an air drill and the
covering of the brain is encountered (dura mater) (picture). This covering is opened with
a small scalpel and the underlying temporal lobe is visualized. The posterior aspect of the
resection is measured from the anterior aspect of the middle compartment (the tip of the
temporal lobe) and resection starts by coagulating and cutting the blood vessels and
transparent membrane covering the portion of the temporal lobe to be removed. This
continues until the ventricle (brain fluid space) in the deep portion of the lobe is
encountered. Once this is found the lateral lobe is removed. Next, the operating
microscope is utilized to peel the hippocampus, amygdala, and parahippocampal gyrus
off the deeper structures (picture). These deeper structures include the brainstem, the
third and fourth cranial nerves, the posterior cerebral artery, the posterior communicating
artery, and the anterior choroidal artery. Once the scar is removed, the brain is irrigated
and signs of bleeding looked for. Once the operative site is clean, the dura is sutured
closed and the skull bone replaced and held in place with small titanium plates and
screws (picture). The temporalis muscle is then repaired and the skin closed. The head is
sterilely wrapped and the patient taken to the recovery room.