Plenary II: Surgical Controversies 9:00 a.m.‐10:30 a.m.

Robert E. Gross*, David W. Loring†, John T. Langfitt‡, George A. Ojemann§, André Olivier¶ and Christoph Helmstaedter∥
*Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA; †McKnight Brain Institute, University of Florida, Gainesville, FL; ‡Department of Neurology, University of Rochester, Rochester, NY; §Department of Neurosurgery, University of Washington, Seattle, WA; ¶Division of Neurosurgery, Montreal Neurological Hospital and Institute, Montreal, QC, Canada and ∥Bereich Neuropsychologie, Universitätsklinik für Epileptologie, Bonn, GermanySummary: The surgical treatment of mesial temporal lobe epilepsy (MTLE) by amygdalo‐hippocampectomy (AH) has a high likelihood of yielding a seizure‐free outcome and associated improvement in quality‐of‐life. Nevertheless, there are several important areas of controversy with regard to the surgical approach, differences of which may impact the rate of success and the incidence of adverse effects. Cognitive sequelae of temporal lobe surgery may result from (1) resection or transgression of the lateral (neocortical) temporal lobe or the temporal stem, which may lead to impairment in learning, and/or (2) resection of mesial structures, which may lead to decline in material‐specific memory. The recent multi‐center clinical trial analyzing the predictors of post‐surgical quality‐of‐life will be discussed, including the finding that improvement depends on seizure‐freedom irrespective of the occurrence of verbal memory decline. Nevertheless, it is incumbent on surgeons to minimize the occurrence of these cognitive sequelae while maximizing the possibility of seizure‐freedom. Several approaches to gain access to the mesial structures will be compared with regard to cognitive outcome, including anterior temporal lobectomy (standard vs. tailored), trans‐cortical selective AH and trans‐sylvian selective AH, which differ in terms of their disruption of the temporal neocortex and temporal stem. Alternative approaches to the mesial resection will be compared with regard to seizure‐free rates and the incidence of post‐surgical decline in memory, including tailoring the hippocampal resection to the presence of inter‐ictal epileptic spikes vs. performing a standardized resection, and the influence of the amount of hippocampal tissue resected. Open discussion of recent results addressing these important issues will hopefully either propel the field towards consensus, or highlight the need for further randomized clinical trials to improve patient outcome following amygdalo‐hippocampectomy for MTLE.