anterior temporal lobectomy

Anterior temporal lobectomy is a classic procedure for the treatment of temporal lobe epilepsy with the best therapeutic effect. After long-term follow-up, 2/3 of the patients were excellent. The curative effect can reach more than 90%. Treatment of diseases: temporal lobe epilepsy Indication Anterior temporal lobectomy is applicable to: 1. Unilateral temporal lobe epilepsy, manifested as psychomotor epilepsy or (and) large seizure type of epilepsy, anti-epileptic drug treatment is ineffective. Those with a disease duration of 3 to 4 years or more. 2. Multiple EEG examinations and sleep EEG and sphenoidal electrodes, nasopharyngeal electrode records confirmed that the epileptogenic focus was located in the anterior temporal lobes. 3. CT or MRI has a limited positive finding and is consistent with clinical findings and EEG results. Contraindications Chronic, active psychiatric patients, mental retardation, and personality disorder patients are contraindications for surgery. Patients with independent epileptic foci on both sides of the temporal lobe were contraindicated for bilateral temporal lobe resection. Preoperative preparation 1. Reduce or completely stop anti-epileptic drugs 1 to 2 days before surgery. However, seizures are frequent and severe, and anti-epileptic drugs may not be stopped. Intramuscular injection of 100 mg of phenobarbital sodium 30 min before surgery. 2. Disable morphine and diazepam sedatives before surgery to avoid affecting the observation of intraoperative EEG. Surgical procedure 1. Make a question mark incision. The skull hole should be drilled behind the humeral forehead and above the zygomatic arch. Bite the sphenoid bones deep into the ground. And bite off the lower edge of the sacral scale directly to the bottom of the cranial fossa, fully exposed the lateral fissure, frontal forehead, bungee, middle part, part of the central area. The dura mater is "U" shaped to cut. A radial incision was added, and the dura mater was suspended and sutured on the periosteum of the bone window. 2. Visually observe the presence or absence of abnormal lesions on the surface of the temporal lobe, such as subarachnoid enlargement, arachnoid cyst, and small brain regurgitation. Look at the side-cracking blood vessels, recognize the Labbé vein, and identify the central anterior and posterior gyrus. 3. Cortical electrode and deep electrode tracing, to find and verify the epileptogenic focus and its range. The cortical electrodes were placed in the lower part of the frontal lobe, the upper iliac crest, the middle iliac crest and the inferior temporal gyrus, and were digitally marked and recorded on the drawings. The deep aurometer was used to trace the amygdala and hippocampus with or without a spike discharge. The bungee was retrogradely 3 cm and 5 cm back, and each was inserted vertically 3.5 cm. The tip of the front electrode was located in the amygdala, and the tip of the posterior electrode was located in the hippocampus. In recent years, there is a thin strip of silica gel and a "T"-shaped electrode that cuts the middle cortex of the iliac crest 2 to 3 cm deep to the lower corner of the lateral ventricle, exposes the hippocampus, and directly places the electrode on the sea horse to detect whether the epileptogenic foci are located in the hippocampus. 4. Determine the extent of resection of the temporal lobe. The left temporal lobe is allowed to be removed 5 cm after the bungee is removed. The right temporal lobe is allowed to remove the anterior temporal lobe range 6 cm after the bungee. Generally, the posterior resection should not exceed the Labbé vein. However, some people now advocate that the scope of resection is smaller, from the bungee to the lateral side of the brain, 4.5 cm backward, not exceeding the central anterior groove. The back of the cranial fossa is usually 5 cm posteriorly. If the non-main hemisphere can be extended by 0.5cm each, to expand the scope of resection, to avoid postoperative aphasia and hemianopia. 5. When removing the temporal lobe, the arachnoid membrane of the lateral cerebral palpebral sulcus is usually firstly cut, and the frontal lobe and the temporal lobe are separated, forward to the sphenoid ridge, down to the bottom of the cranial fossa, and back to the front end of the hook. When the cerebral artery is separated, it needs to be protected. The first and second segments of the artery are divided into 3 to 4 branches, which should be electrocoagulated and cut off. Then, before the Labbé vein, 6 cm backwards from the iliac crest, the dominant hemisphere is a 4.5 cm plane, and the temporal lobe cortex is cut transversely from the lower edge of the iliac crest to about 45° obliquely forward. Cut off the upper, middle and lower back of the temporal lobe. The brain was retracted with two brain plates, and the white matter of the temporal lobe was cut inward and into the lower corner of the lateral ventricle. At this time, the choroid plexus is visible, and cerebrospinal fluid is poured out. Continue to cut the shuttle back to the side sub-ditch. Separate the eucalyptus island cover reveals the island leaf, which is shaped like a conical hillock with its top pointing to the front and the bottom to form an island threshold. The temporal lobe is retracted to the outside, and the hippocampus of the whitish white hair in the lower corner is fully exposed, and the brain tissue is cut by the bipolar electrocoagulation to reach the cerebral ventricle wall, and reaches the lower corner. The inner upper part of the lower corner is a round amygdala, which is cut into the lateral part of the basement and the inner part of the cortex which is adjacent to the hook through the center of the amygdala. And then pull back the lower corner to reveal the choroid plexus, do not oppress at this time, because the choroid plexus is attached to the brain stem and the visual bundle. The hippocampus was cut from the posterior aspect of the choroid plexus, and the upper surface of the hippocampus was exposed. In the posterior part of the hippocampus and hippocampus, the hippocampus of 3.0 to 3.5 cm was cut transversely in the coronal orientation. Lift the hippocampus and cut it to the cerebellum, remove the anterior temporal lobe and its hippocampus, hippocampus, hook back, and the amygdala on the lateral side. At this time, care should be taken to protect the inner pial membrane intact and not to damage the structure in the brain bottom pool. The 1/3 of the anterior choroidal artery of the hippocampus and the hooked back should be electrocoagulated, and several Ammon's angle arteries can be electrocoagulated. 6. EcoG tracing should be performed after surgery. If there is still abnormal discharge, it should be resected, but the cortex and iliac crest of the insular and lateral fissures do not need to be removed. The surgery field completely stopped bleeding, repeated washing with normal saline, and the dura mater was tightly sutured, and the cavity was filled with physiological saline. The muscle flap was repositioned and the scalp was sutured in two layers. The drainage of the drainage tube was performed for 24 hours. 7. Anterior medial temporal lobe resection In addition to the above-mentioned standard temporal lobe resection, there is an Anteridiomedia temporal lobectomy. This is proposed by Spencer. According to the epileptogenic focus, most of the medial temporal lobe structure, radical resection of the medial temporal lobe structure can control seizures in 85% of patients without neuropsychological or neurological dysfunction. The anterior medial temporal lobe resection included most of the hippocampal formation, and the lateral cortex of the temporal lobe only resected the iliac crest with a margin of about 3.5 cm posteriorly. Spencer pointed out that this procedure has two advantages: 1 because there is no need for ECoG and language function positioning examination, so there is no need to perform surgery under local anesthesia; 2 is the only surgical method that can preserve the visual field without damage. The steps of the procedure are briefly described as follows: First, the sacral tip is extended back to the iliac crest to 3 to 3.5 cm, and then bent downward, across the iliac crest and the iliac crest, and then terminated in the occipital condyle until the majority of the resection is removed. When cutting, the arachnoid of the upper iliac crest is cut open first, but it does not affect the upper back of the iliac crest, and cuts 3 cm deep into the sac. The wedge-shaped temporal lobe tissue was excised and was about 3 cm3 large. The posterior resection margin of the inner surface of the temporal lobe is located in the upper level of the upper sulcus, and the amygdala and hippocampus are removed as much as possible 8. Experience of the Nanjing Military Region General Hospital The Nanjing Military Region General Hospital has accumulated more than 100 experiences of anterior temporal lobectomy for many years. It is believed that as long as you can pay attention to the following points in surgical techniques, you can successfully complete the operation and reduce the damage. 1 Looking for the lateral ventricle angle: First, we must determine the posterior resection line of the temporal lobe resection, usually in the standard temporal lobe resection, no more than 5cm behind the dominant hemisphere, and cut the cortex vertically and deep in the middle of the iliac crest. And white matter, about 3 ~ 4cm into the lateral ventricle horn, at this time there is cerebrospinal fluid outflow, visible ventricular wall whitish ependymal, or visible choroid plexus. However, sometimes because of the narrow angle of the sacral angle, when the cerebrospinal fluid outflow is not obvious, the depth should be properly controlled, and the choroid plexus can help locate. 2 resection of the temporal lobe neocortex: on the posterior resection line, from the posterior and posterior anterior resection of the cortex and white matter, until the bungee, how much remains in the upper retinal cortex, can also be replenished with a suction device until the remaining Back to the pia mater and arachnoid. Then, on the posterior incision line, the lateral (outer side) until the base of the skull directly reaches the temporal lobes and the lateral temporal cortex is removed. 3 removal of the medial structure of the medial temporal lobe (hippocampus, amygdala and hippocampus, hook back): after the removal of the lateral temporal lobe, good anatomical exposure, can make the amygdala, hippocampus structure exposed in the field. According to the need to remove most of the amygdala, hippocampus front and hippocampus side and hook back. According to the three major steps of surgery, the anatomical hierarchy is clear, and beginners are easy to understand and master. complication The mortality of the anterior temporal lobe resection was <0.5%, the permanent hemiplegia was 2.4%, the temporary hemiplegia was 4.2%, and the same hemianopia was 8.3%. Can be complicated by aseptic meningitis, subdural hematoma, memory loss and mental symptoms.