Temporal lobe epilepsy (TLE) is the most common form of adult epilepsy that is amenable to surgical treatment. In the carefully selected patient, excellent seizure outcome can be achieved with minimal or no side effects from surgery. This may result in improved psychosocial functioning, achieving higher education, and maintaining or gaining employment. The objective of this paper is to discuss the surgical selection process of a patient with TLE. We define what constitutes a patient that has medically refractory TLE, describe the typical history and physical examination, and distinguish between mesial TLE and neocortical TLE. We then review the role of routine (ambulatory/sleep-deprived electroencephalography (EEG), video EEG, magnetic resonance imaging (MRI), neuropsychological testing, and Wada testing) and ancillary preoperative testing (positron emission tomography, single-photon emission computed tomography (SPECT), subtraction ictal SPECT correlated to MRI (SISCOM), magnetoencephalography, magnetic resonance spectroscopy, and functional MRI) in selecting surgical candidates. We describe the surgical options for resective epilepsy surgery in TLE and its commonly associated risks while highlighting some of the controversies. Lastly, we present teaching cases to illustrate the presurgical workup of patients with medically refractory TLE. 1. Introduction 1.1. History of Temporal Lobe Epilepsy Surgery Cerebral localization and electroencephalography (EEG) have together been two fundamental advances that have been paramount in the diagnosis and management of epilepsy. The clinical observations of Broca [1] and Jackson and Colman [2], along with the landmark observations of Fritsch and Hitzig [3], the electrical excitability of the human brain, and discrete localization of brain functions, began to be established. Through experiments of electrical stimulation on narcotized dogs, Fritsch and Hitzig were able to differentiate the motor from the nonmotor cortex [3]. Drawn to these findings, Sir Horsley was likely the first to attempt amelioration of epilepsy in a patient with posttraumatic seizures via a craniotomy [4]. Not long after this, in 1875, Caton was able to measure electrical activity from the cat brain [5], and this was followed by EEG recordings in humans by Berger in 1929 [6]. Thereafter, Bailey and Gibbs proceeded to operate on individuals with psychomotor epilepsy solely based on anterior temporal spikes on EEG [7]. Penfield later observed that patients failing neocortical resection could benefit from resection of the mesial temporal lobe
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