Stereotactic Radiofrequency Amygdalohippocampotomy (SRAH) Using a Combined Approach: a New Technique for the Treatment of Refractory Temporal Lobe Epilepsy (TLE) Secondary to Mesial Sclerosis (MS)

Introduction: Compared to the more classical procedures (temporal lobectomy and selective amygdalohippocampectomy) used to treat refractory TLE secondary to MS, SRAH, by sparing more temporal lobe isocortex and white matter tracts, has the potential to induce less cognitive decline; seizure control, however, is inferior with this technique. SAH has been performed with either posterior or lateral approaches. Complete ablation of the amygdala is improbable with the former, while multiple tracks, and thus, greater transgression of the neocortex and white matter tracts, are necessary with the latter. To circumvent these shortcomings and to improve seizure control, we devised a new technique, the SRAH using a combined (posterior and superior) approach.

Methods: Two right-handed male patients, ages 41 and 42, disease duration of 28 and 25 years, presenting with MS (right side, 1; left side, 1) and intractable TLE underwent SRAH. Preoperative assessment included MR, EEG, and neuropsychological evaluation. The long axis of the hippocampus was approached via an occipital burr-hole; two tracks, 3.0 mm apart, were made and after uneventful electrical stimulation (3.5V/100 Hz), 10 radiofrequency lesions (75°C/60”), 3.0 mm apart, were performed in each track. The amygdala, on the other hand, was approached from above (Kocher point) and ablated with seven radiofrequency lesions (same parameters). Postoperatively, MR and EEG were performed; neuropsychological evaluation will be repeated 6 months after surgery.

Results: Both patients are seizure-free since surgery (Engel 1A). Postop EEG was normal in one patient (follow-up = 5 months) and revealed sporadic spikes in the other (follow-up = 3 months). Early postop MR confirmed appropriate lesion placement, encompassing the whole hippocampus and amygdala, and absence of surgical complications in both.

Conclusions: In spite of the minuteness of our sample and the shortness of the follow-up, SRAH, using a combined approach, seems to be a safe and effective means for the treatment of TLE secondary to MS.

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