An assured way to kindle a lively debate among epilepsy specialists is to ask, "What is the best surgery for medically refractory mesial temporal lobe epilepsy (mTLE)—anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SAH)?" Usually, patients with mTLE have seizures arising from epileptogenic lesions such as hippocampal sclerosis or low-grade gliomas involving the lesion and surrounding hippocampus, amygdala, and parahippocampal cortex, although some mTLE cases do not have detectable lesions on imaging. ATL removes the temporal pole to allow access to the lesion and mesial temporal structures (figure, A and B),1 whereas SAH uses a small temporal neocortical resection to approach and remove mesial structures (figure, C and D).2 The rationale for SAH has been that it should provide equivalent seizure control because the mesial structures, the presumed source of the seizures, are removed with limited damage of the lateral temporal neocortex and underlying white matter, possibly reducing cognitive functions. Other recent approaches being developed to treat mTLE using the SAH concept include radiosurgery3 and MRI-guided laser ablation.
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