Epilepsy: Mesial Temporal

Mesial temporal lobe epilepsy (MTLE) is one of the most common focal epilepsy syndromes. Roughly one third of patients with MTLE continue to have disabling seizures despite multiple trials of antiepileptic medications. Surgical resection of the mesial temporal lobe in patients with drug-resistant mesial temporal epilepsy can lead to freedom from disabling seizures in 60-90% of patients. However proper patient selection is essential in order to achieve high rates of seizure freedom. In this chapter, we first discuss the pathophysiology and semiology of mesial temporal lobe epilepsy. After reviewing the diagnosis, we detail the preoperative workup necessary to determining if a patient is appropriate for surgery. Surgical intervention for mesial temporal epilepsy has evolved significantly over the past two decades. We discuss in detail the classical surgical approaches including anterior temporal lobectomy and selective amygdalohippocampectomy in addition to outcomes and complications of surgery. We then discuss newer surgical approaches to MTLE, including stereotactic laser amygdalohippocampotomy, stereotactic radiosurgery, and neuromodulation, emphasizing how these new techniques supplement traditional approaches in order to provide surgical options to a greater population of patients with MTLE.