Mesial temporal lobe lesion approaches

Mesial temporal lobe lesion approaches

There are several ways to safely access mesial temporal structures. The transsylvian-transcisternal approach is a good way to access the mesial structures while preserving the lateral and basal temporal structures. Actual lesions associated with epileptogenesis in focal cortical dysplasia (FCD) may be larger than they appear on magnetic resonance imaging. For this reason, evaluations to locate sufficient epileptogenic foci, including invasive studies, should be completed for FCD, and epilepsy surgery should be performed according to these results. Regardless, the ultimate goal of all epilepsy surgeries is to maximize seizure control while maintaining neurological function. Therefore, a tailored approach based on the properties of the lesion is needed1).

For Campero et al., dividing the mesial temporal region (MTR) into 3 regions allows us to adapt the approach to lesion location. Thus, the anterior sector can be approached via the sylvian fissure, the middle sector can be approached transtemporally, and the posterior sector can be approached via the supracerebellar approach 2).

There are limited reports on the transcortical approach for the resection of tumors within this region.

Morshed et al., from the UCSF Medical Center, described the technical considerations and functional outcomes in patients undergoing transcortical resection of gliomas of the mesial temporal lobe (MTL).

Patients with a glioma (WHO grades I-IV) located within the MTL who had undergone the transcortical approach in the period between 1998 and 2016 were identified through the University of California, San Francisco (UCSF) tumor registry and were classified according to tumor location: preuncus, uncus, hippocampus/parahippocampus, and various combinations of the former groups. Patient and tumor characteristics and outcomes were determined from operative, radiology, pathology, and other clinical reports that were available through the UCSF electronic medical record.

Fifty patients with low- or high grade glioma were identified. The mean patient age was 46.8 years, and the mean follow-up was 3 years. Seizures were the presenting symptom in 82% of cases. Schramm classification types A, C, and D represented 34%, 28%, and 38% of the tumors, and the majority of lesions were located at least in part within the hippocampus/parahippocampus. For preuncus and preuncus/uncus tumors, a transcortical approach through the temporal pole allowed for resection. For most tumors of the uncus and those extending into the hippocampus/parahippocampus, a corticectomy was performed within the middle and/or inferior temporal gyri to approach the lesion. To locate the safest corridor for the corticectomy, language mapping was performed in 96.9% of the left-sided tumor cases, and subcortical motor mapping was performed in 52% of all cases. The mean volumetric extent of resection of low- and high-grade tumors was 89.5% and 96.0%, respectively, and did not differ by tumor location or Schramm type. By 3 months’ follow-up, 12 patients (24%) had residual deficits, most of which were visual field deficits. Three patients with left-sided tumors (9.4% of dominant-cortex lesions) experienced word-finding difficulty at 3 months after resection, but 2 of these patients demonstrated complete resolution of symptoms by 1 year.

Mesial temporal lobe gliomas, including larger Schramm type C and D tumors, can be safely and aggressively resected via a transcortical equatorial approach when used in conjunction with cortical and subcortical mapping 3).


Microsurgery was performed via transsylviantranstemporal, or subtemporal approaches on 62 patients with mesial temporal lobe gliomas, 33 with localized tumors within the mesial temporal structures (type A), 19 in anterior portion (type A1), and 14 extending to posterior portion (type A2); 19 patients with multicompartmental tumors involving the mesial temporal lobe, insular lobe, and posterior frontorbital gurus (type B); 14 patients with tumors involving the temporal pole and lateral areas of the temporal horn (type C); and 6 patients with tumors infiltrating the brain stem, basal nuclei and thalamus (type D).

Trans-sylvian approach was performed in 25 cases of which total tumor removal was achieved in 14 cases, subtotal removal in 6 cases, and gross removal in 5 cases. Primary visual deficits worsened after surgery in 5 cases. Trans-temporal approach was used in 23 cases of which total tumor resection was achieved in 15 cases, subtotal resection in 5 cases, and gross resection in 3 cases. Primary visual deficits worsened after surgery in 5 cases. Four patients in which preoperative vision were good presented with visual deficits postoperatively. Subtemporal approach was used in 14 cases of which total tumor removal was achieved in 10 cases, and subtotal removal in 4 cases. All 14 patients did not develop worsened vision after surgery.

Trans-sylvian and subtemporal approaches can reduce possible harm to parenchyma and optic radiation, whereas approaches to the temporal horn through the superior and middle temporal gyri will induce damage to parenchyma and optic radiation 4).


The aim of Faust et al., was to categorize temporal lobe tumors based on anatomical, functional, and vascular considerations and to devise a systematic field manual of surgical approaches.

Tumors were classified into four main types with assigned approaches: Type I-lateral: transcortical; type II-polar: pterional/transcortical; type III-central: transsylvian/transopercular; type IV-mesial: transsylvian/trans-cisternal if more anterior (=Type IV A), and supratentorial/infraoccipital if more posterior (=type IV B). 105 patients have been operated on prospectively using the advocated guidelines. Outcomes were evaluated.

Systematic application of the proposed classification facilitated a tailored approach, with gross total tumor resection of 88 %. Neurological and surgical morbidity were less than 10 %. The proposed classification may prove a valuable tool for surgical planning 5).


Twenty formalin-fixed, adult cadaveric specimens were studied. Ten brains provided measurements to compare different surgical strategies. Approaches were demonstrated using 10 silicon-injected cadaveric heads. Surgical cases were used to illustrate the results by the different approaches. Transverse lines at the level of the inferior choroidal point and quadrigeminal plate were used to divide the medial temporal region into anterior, middle, and posterior portions. Surgical approaches to the medial temporal region were classified into four groups: superior, lateral, basal, and medial, based on the surface of the lobe through which the approach was directed. The approaches through the medial group were subdivided further into an anterior approach, the transsylvian transcisternal approach, and two posterior approaches, the occipital interhemispheric and supracerebellar transtentorial approaches.

The anterior portion of the medial temporal region can be reached through the superior, lateral, and basal surfaces of the lobe and the anterior variant of the approach through the medial surface. The posterior group of approaches directed through the medial surface are useful for lesions located in the posterior portion. The middle part of the medial temporal region is the most challenging area to expose, where the approach must be tailored according to the nature of the lesion and its extension to other medial temporal areas.

Each approach to medial temporal lesions has technical or functional drawbacks that should be considered when selecting a surgical treatment for a given patient. Dividing the medial temporal region into smaller areas allows for a more precise analysis, not only of the expected anatomic relationships, but also of the possible choices for the safe resection of the lesion. The systematization used here also provides the basis for selection of a combination of approaches 6).


Germano described a transsulcal temporal approach to mesiotemporal lesions and its application in three patients. Gross-total resection of the lesion was accomplished in all cases. An anatomical cadaveric study was also performed to delineate the microsurgical anatomy of this approach. Precise knowledge of temporal intraventricular landmarks allows navigation to the lesion without the need for a navigational system. This approach is helpful for neurologically intact patients with mesiotemporal lesions 7).

References

1)

Chong S, Phi JH, Lee JY, Kim SK. Surgical Treatment of Lesional Mesial Temporal Lobe Epilepsy. J Epilepsy Res. 2018 Jun 30;8(1):6-11. doi: 10.14581/jer.18002. eCollection 2018 Jun. Review. PubMed PMID: 30090756; PubMed Central PMCID: PMC6066696.
2)

Campero A, Ajler P, Rica C, Rhoton A Jr. Cavernomas and Arteriovenous Malformations in the Mesial Temporal Region: Microsurgical Anatomy and Approaches. Oper Neurosurg (Hagerstown). 2017 Feb 1;13(1):113-123. doi: 10.1227/NEU.0000000000001239. PubMed PMID: 28931254.
3)

Morshed RA, Young JS, Han SJ, Hervey-Jumper SL, Berger MS. The transcortical equatorial approach for gliomas of the mesial temporal lobe: techniques and functional outcomes. J Neurosurg. 2018 Apr 20:1-9. doi: 10.3171/2017.10.JNS172055. [Epub ahead of print] PubMed PMID: 29676697.
4)

Jiang ZL, Wang ZC, Jiang T. [Surgical outcomes of different approaches for mesial temporal lobe gliomas]. Zhonghua Yi Xue Za Zhi. 2005 Sep 7;85(34):2428-32. Chinese. PubMed PMID: 16321253.
5)

Faust K, Schmiedek P, Vajkoczy P. Approaches to temporal lobe lesions: a proposal for classification. Acta Neurochir (Wien). 2014 Feb;156(2):409-13. doi: 10.1007/s00701-013-1917-4. Epub 2013 Nov 8. Review. PubMed PMID: 24201756.
6)

Campero A, Tróccoli G, Martins C, Fernandez-Miranda JC, Yasuda A, Rhoton AL Jr. Microsurgical approaches to the medial temporal region: an anatomical study. Neurosurgery. 2006 Oct;59(4 Suppl 2):ONS279-307; discussion ONS307-8. PubMed PMID: 17041498.
7)

Germano IM. Transsulcal approach to mesiotemporal lesions. Anatomy, technique, and report of three cases. Neurosurg Focus. 1996 Nov 15;1(5):e4. PubMed PMID: 15099055.

Anterior temporal lobectomy (ATL)

Anterior temporal lobectomy for mesial temporal sclerosis is a very effective measure to control seizures, and the probability of being seizure-free is approximately 70-90%. However, 30% of patients still experience seizures after surgery.

In neurosurgery there are several situations that require transgression of the temporal cortex. For example, a subset of patients with temporal lobe epilepsy require surgical resection (most typically, en-bloc anterior temporal lobectomy). This procedure is the gold standard to alleviate seizures but is associated with chronic cognitive deficits. In recent years there have been multiple attempts to find the optimum balance between minimising the size of resection in order to preserve cognitive function, while still ensuring seizure freedom. Some attempts involve reducing the distance that the resection stretches back from the temporal pole, whilst others try to preserve one or more of the temporal gyri. More recent advanced surgical techniques (selective amygdalohippocampectomy) try to remove the least amount of tissue by going under (sub-temporal), over (trans-Sylvian) or through the temporal lobe (middle-temporal), which have been related to better cognitive outcomes. Previous comparisons of these surgical techniques focus on comparing seizure freedom or behaviour post-surgery, however there have been no systematic studies showing the effect of surgery on white matter connectivity. The main aim of this study, therefore, was to perform systematic ‘pseudo-neurosurgery’ based on existing resection methods on healthy neuroimaging data and measuring the effect on long-range connectivity. We use anatomical connectivity maps (ACM) to determine long-range disconnection, which is complementary to existing measures of local integrity such as fractional anisotropy or mean diffusivity. ACMs were generated for each diffusion scan in order to compare whole-brain connectivity with an ‘ideal resection’, nine anterior temporal lobectomy and three selective approaches. For en-bloc resections, as distance from the temporal pole increased, reduction in connectivity was evident within the arcuate fasciculusinferior longitudinal fasciculusinferior frontooccipital fascicle, and the uncinate fasciculus. Increasing the height of resections dorsally reduced connectivity within the uncinate fasciculus. Sub-temporal amygdalohippocampectomy resections were associated with connectivity patterns most similar to the ‘ideal’ baseline resection, compared to trans-Sylvian and middle-temporal approaches. In conclusion, we showed the utility of ACM in assessing long-range disconnections/disruptions during temporal lobe resections, where we identified the subtemporal resection as the least disruptive to long-range connectivity which may explain its better cognitive outcome. These results have a direct impact on understanding the amount and/or type of cognitive deficit post-surgery, which may not be obtainable using local measures of white matter integrity 1).

Anterior temporal lobectomy (ATL) with amygdalohippocampectomy (ATLAH) has been shown to be more efficacious than continued medical therapy in a randomized, controlled trial 2).

Minimally invasive approaches to treating MTLE might achieve seizure freedom while minimizing adverse effects.

Anterior temporal lobectomy as described by Penfield and Baldwin 3). is the most established neurosurgical procedure for temporal lobe epilepsy, for those in whom anticonvulsant medications do not control epileptic seizures.

It consists in the complete removal of the anterior portion of the temporal lobe of the brain.

Knowledge of the temporomesial region, including neurovascular structures around the brainstem, is essential to keep this procedure safe and effective 4).

The techniques for removing temporal lobe tissue vary from resection of large amounts of tissue, including lateral temporal cortex along with medial structures, to more restricted anterior temporal lobectomy (ATL) to more restricted removal of only the medial structures (selective amygdalohippocampectomy, SAH).

Limits of resection

The measurements are made along the middle temporal gyrus.

Dominant temporal lobe: Up to 4-5 cm may be removed

Non Dominant: 6- 7 cm.


Nearly all reports of seizure outcome following these procedures indicate that the best outcome group includes patients with MRI evidence of mesial temporal sclerosis (hippocampal atrophy with increased T-2 signal.) The range of seizure-free outcomes for these patients is reported to be between 80 and 90%, which is typically reported as a sub-set of data within a larger surgical series.

Open surgical procedures such as ATL have inherent risks including damage to the brain (either directly or indirectly by injury to important blood vessels), bleeding (which can require re-operation), blood loss (which can require transfusion), and infection. Furthermore, open procedures require several days of care in the hospital including at least one night in an intensive care unit. Although such treatment can be costly, multiple studies have demonstrated that ATL in patients who have failed at least two anticonvulsant drug trials (thereby meeting the criteria for medically intractable temporal lobe epilepsy) has lower mortality, lower morbidity and lower long-term cost in comparison with continued medical therapy without surgical intervention.

The strongest evidence supporting ATL over continued medical therapy for medically refractory temporal lobe epilepsy is a prospective, randomized trial of ATL compared to best medical therapy (anticonvulsants), which convincingly demonstrated that the seizure-free rate after surgery was ~ 60% as compared to only 8% for the medicine only group.

Furthermore, there was no mortality in the surgery group, while there was seizure-related mortality in the medical therapy group. Therefore, ATL is considered the standard of care for patients with medically intractable mesial temporal lobe epilepsy.

Surgical resection is the gold standard treatment for drug-resistant focal epilepsy, including mesial temporal lobe epilepsy (MTLE) and other focal cortical lesions with correlated electrophysiological features. Anterior temporal lobectomy with amygdalohippocampectomy (ATLAH) has been shown to be more efficacious than continued medical therapy in a randomized, controlled trial 5).

The most common surgical procedure for the mesial temporal lobe is the standard anterior temporal resection or what is commonly called the anterior temporal lobectomy. There are, however, a number of other more selective procedures for removal of the mesial temporal lobe structures (amygdala, hippocampus, and parahippocampal gyrus) that spare much of the lateral temporal neocortex. Included in these procedures collectively referred to as selective amygdalohippocampectomy are the transsylvian, subtemporal, and transcortical (trans-middle temporal gyrus) selective amygdalohippocampectomy 6).

The ATL group scored significantly worse for recognition of fear compared with selective amygdalohippocampectomy (SAH) patients. Inversely, after SAH scores for disgust were significantly lower than after ATL, independently of the side of resection. Unilateral temporal damage impairs facial emotion recognition (FER). Different neurosurgical procedures may affect FER differently 7).

Outcome

Functional MRIResting state fMRIdiffusion tensor imaging modalities can be used effectively, in an additive fashion, to predict functional reorganization and cognitive outcome following anterior temporal lobectomy 8).

Complications

Case series

Of 1214 patients evaluated for surgery in the epilepsy Center of Faculdade de Medicina de São Jose do Rio Preto (FAMERP), a tertiary Brazilian epilepsy center, 400 underwent ATL for MTS. Number and type of auras was analyzed and compared with Engel Epilepsy Surgery Outcome Scalefor outcome.

Analyzing the patients by the type of aura, those who had extratemporal auras had worst result in post-surgical in Engel classifcation. While mesial auras apparently is a good prognostic factor. Patients without aura also had worse prognosis. Simple and multiple aura had no difference. In order to identify the most appropriate candidates for ATL, is very important to consider the prognostic factors associated with favorable for counseling patients in daily practice 9).


Boucher et al. compared preoperative vs. postoperative memory performance in 13 patients with selective amygdalohippocampectomy (SAH) with 26 patients who underwent ATL matched on side of surgery, IQ, age at seizure onset, and age at surgery. Memory function was assessed using the Logical Memory subtest from the Wechsler Memory Scales – 3rd edition (LM-WMS), the Rey Auditory Verbal Learning Test (RAVLT), the Digit Span subtest from the Wechsler Adult Intelligence Scale, and the Rey-Osterrieth Complex Figure Test. Repeated measures analyses of variance revealed opposite effects of SAH and ATL on the two verbal learning memory tests. On the immediate recall trial of the LM-WMS, performance deteriorated after ATL in comparison with that after SAH. By contrast, on the delayed recognition trial of the RAVLT, performance deteriorated after SAH compared with that after ATL. However, additional analyses revealed that the latter finding was only observed when surgery was conducted in the right hemisphere. No interaction effects were found on other memory outcomes. The results are congruent with the view that tasks involving rich semantic content and syntactical structure are more sensitive to the effects of lateral temporal cortex resection as compared with mesiotemporal resection. The findings highlight the importance of task selection in the assessment of memory in patients undergoing TLE surgery10).

References

1)

Busby N, Halai AD, Parker GJM, Coope DJ, Lambon Ralph MA. Mapping whole brain connectivity changes: The potential impact of different surgical resection approaches for temporal lobe epilepsy. Cortex. 2018 Nov 17;113:1-14. doi: 10.1016/j.cortex.2018.11.003. [Epub ahead of print] PubMed PMID: 30557759.
2) , 5)

Wiebe S, Blume WT, Girvin JP, Eliasziw M. A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med. 2001;345(5):311–318.
3)

PENFIELD W, BALDWIN M. Temporal lobe seizures and the technic of subtotal temporal lobectomy. Ann Surg. 1952 Oct;136(4):625-34. PubMed PMID: 12986645; PubMed Central PMCID: PMC1803045.
4)

Schaller K, Cabrilo I. Anterior temporal lobectomy. Acta Neurochir (Wien). 2016 Jan;158(1):161-6. doi: 10.1007/s00701-015-2640-0. Epub 2015 Nov 23. PubMed PMID: 26596998.
6)

Wheatley BM. Selective amygdalohippocampectomy: the trans-middle temporal gyrus approach. Neurosurg Focus. 2008 Sep;25(3):E4. doi: 10.3171/FOC/2008/25/9/E4. Review. PubMed PMID: 18759628.
7)

Wendling AS, Steinhoff BJ, Bodin F, Staack AM, Zentner J, Scholly J, Valenti MP, Schulze-Bonhage A, Hirsch E. Selective amygdalohippocampectomy versus standard temporal lobectomy in patients with mesiotemporal lobe epilepsy and unilateral hippocampal sclerosis: post-operative facial emotion recognition abilities. Epilepsy Res. 2015 Mar;111:26-32. doi: 10.1016/j.eplepsyres.2015.01.002. Epub 2015 Jan 16. PubMed PMID: 25769370.
8)

Osipowicz K, Sperling MR, Sharan AD, Tracy JI. Functional MRI, resting state fMRI, and DTI for predicting verbal fluency outcome following resective surgery for temporal lobe epilepsy. J Neurosurg. 2016 Apr;124(4):929-37. doi: 10.3171/2014.9.JNS131422. Epub 2015 Sep 25. PubMed PMID: 26406797.
9)

da Cruz Adry RAR, Meguins LC, Pereira CU, da Silva Júnior SC, de Araújo Filho GM, Marques LHN. Auras as a prognostic factor in anterior temporal lobe resections for mesial temporal sclerosis. Eur J Neurol. 2018 Jun 28. doi: 10.1111/ene.13740. [Epub ahead of print] PubMed PMID: 29953714.
10)

Boucher O, Dagenais E, Bouthillier A, Nguyen DK, Rouleau I. Different effects of anterior temporal lobectomy and selective amygdalohippocampectomy on verbal memory performance of patients with epilepsy. Epilepsy Behav. 2015 Oct 12;52(Pt A):230-235. doi: 10.1016/j.yebeh.2015.09.012. [Epub ahead of print] PubMed PMID: 26469799.

UpToDate: Temporal horn entrapment

Temporal horn entrapment

Entrapment of the temporal horn, known as isolated lateral ventricle (ILV).

Temporal horn entrapment is a very rare kind of isolated focal non communicating hydrocephalus caused by obstruction at the trigone of the lateral ventricle, which seals off the temporal horn from the rest of the ventricular system 1) 2) 3).

A very thoughtful review of the literature in 2013 reported only 24 cases 4)

In 2017 Guive Sharifi et al published a Review of Literature http://www.jneuro.com/neurology-neuroscience/an-idiopathic-huge-trapped-temporal-horn-surgical-strategy-and-review-of-literature.pdf

Etiology

Obstruction around the trigone of the lateral ventricle caused by inflammations, tumors, infections, or after surgical processes. Most reports are unilateral and acquired.

Treatment

Standard treatment has not yet been established for this condition, and only a few cases have been reported in the literature.

Entrapped temporal horn syndrome secondary to obstructive neoplastic lesions is most frequently treated by surgical excision of the offending lesion.

Golpayegani et al., from the Department of Neurosurgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Department of Neurosurgery, Children’s Hospital Medical Center, Tehran University of Medical Sciences, TehranIran, reported in 2018 the first congenital case of huge bilateral temporal horn entrapment. A six-month-old boy was admitted with progressive intracranial hypertension who was managed with bilateral ventricular catheters and Y tube connected to one peritoneal catheter 5).


Zhang et al., reviewed their database to report their experience with endoscopic fenestration for treating entrapped temporal horn caused by atrial adhesions. All endoscopic operations performed from February 2015 to December 2016 were reviewed.

Three patients developed temporal horn entrapment after tumor resection. Fenestration was successful in all patients, with a subsequent stomy of the septum pellucidum. Follow-up magnetic resonance imaging 1 year later showed a patent reduction of the entrapped horn.

Endoscopic fenestration is an option in the treatment of entrapped temporal horns. However, more experience is required to recommend it as the treatment of choice 6).


Entrapment of the temporal horn, known as isolated lateral ventricle (ILV), is a rare type of noncommunicating focal hydrocephalus, and its standard treatment has not been established.

Hasegawa et al. report two cases of endoscopic surgery for ILV, and highlight the anatomical surgical nuances to avoid associated surgical risks.

The authors present two surgical cases with ILV treated by endoscopic surgery. The first patient with recurrent ILV, due to shunt malfunction, following the initial shunt placement for ILV. In the second patient, the ILV recurred due to choroid plexus inflammation caused by cryptococcal infection. Endoscopic temporal ventriculocisternostomy was effective in both cases. However, in the second case, the choroidal fissure was fenestrated, which led to cerebral infarction in the territory of the choroidal artery zone, attributed to damaging the branches of the choroidal segment of the anterior choroidal artery.

Endoscopic temporal ventriculocisternostomy is considered as a safe and less invasive procedure for treatment of symptomatic ILV. However, the technique is still associated with risks. To avoid complications, it is necessary to be familiar with the anatomy of the choroidal arteries and the pertinent endoscopic intraventricular orientation. Addtitionally, sufficient experience is required before it can be recommended as the treatment of choice 7).


A 76-year-old male presented with altered mental status and left-sided weakness. Noncontrast computed tomography of the head showed a right ganglionic intraparenchymal hemorrhage with resultant entrapment of the temporal horn. Using Robotic Stereotactic Assistance (ROSA), intrahematomal and intraventricular catheters were placed. The temporal horn was immediately decompressed, and the hematoma almost completely resolved with scheduled administration of intrathecal alteplase in the ensuing 48 hours postoperatively.

Frameless image-guided placement of intraparenchymal hematoma catheter using Robotic Stereotactic Assistance is safe and efficient 8)


Paredes et al., reviewed their cases of temporal horn entrapment treated between May 2013 and December 2014 and report their experience with endoscopic temporal ventriculocisternostomy. Four patients were identified (3 adults and 1 child) who underwent this treatment. In 3 patients, the condition developed after tumor resection, and in 1 patient it developed after resection of an arteriovenous malformation. In 1 patient, a recurrent trapped temporal horn developed and a refenestration was successfully performed. No procedure-related complications were observed, and all of the patients remained shunt-free at last follow-up (range 4-24 months). Endoscopic temporal horn ventriculocisternostomy is a safe and effective procedure for the treatment of symptomatic temporal horn entrapment in selected cases. However, there is little experience with the procedure to recommend it as the treatment of choice 9).


In 2015 Spallone et al., reported a case of a 58-year-old man who presented with pure Wernicke aphasia (never described before in the albeit rare cases of isolated temporal horn dilatation) that regressed completely following successful ventriculoperitoneal shunting 10).

Chen et al described in 2013 an alternate approach involving temporal horn to prepontine cistern shunting followed by radiosurgery of the offending lesion. This 41-year-old woman with a history of meningiomatosis presented with progressive, incapacitating headache. Magnetic resonance imaging (MRI) showed growth of a right trigone meningioma, causing entrapment of the right temporal horn. A ventricular catheter was placed using frame-based stereotaxy and image fusion computed tomography/MRI to connect the entrapped lateral ventricle to the prepontine cistern. The patient reported complete resolution of her symptoms after the procedure.

Postoperative MRI revealed decompression of the temporal horn. The trigonal meningioma was treated with stereotactic radiosurgery. The patient remained asymptomatic at the 2-year follow-up 11).

In 1992 two cases of entrapment of the temporal horn, computed tomography demonstrated the typical appearance of a comma-shaped homogeneous area isodense with water surrounded by a periventricular low-density area. The cause was probably choroid plexitis resulting in obstruction of the cerebrospinal fluid pathway at the atrium. External drainage followed by shunt emplacement was indicated 12).

Maurice-Williams and Choksey reported in 1986 three cases of temporal horn entrapment: A recurrent glioma, a previous tuberculous meningitisand surgical excision of an intracranial arteriovenous malformation which extended into the trigone. Shunting of the trapped temporal horn provided satisfactory treatment 13)

References

1)

Berhouma M, Abderrazek K, Krichen W, Jemel H (2009) Apropos of an unusual and menacing presentation of neurosarcoidosis: The space-occupying trapped temporal horn. Clin Neurol Neurosurg 111: 196-199.

2)

Bohl MA, Almefty KK, Nakaji P (2015) Defining a standardized approach for the bedside insertion of temporal horn external ventricular drains: Procedure development and case series. Neurosurgery 79: 296-304.

3)

Bruck W, Sander U, Blanckenberg P, Friede RL (1991) Symptomatic xanthogranuloma of choroid plexus with unilateral hydrocephalus. Case report. J Neurosurg 75: 324-327.

4)

Krähenbühl AK, Baldauf J, Gaab MR, Schroeder HW. Endoscopic temporal ventriculocisternostomy: an option for the treatment of trapped temporal horns. J Neurosurg Pediatr. 2013 May;11(5):568-74. doi: 10.3171/2013.2.PEDS12417. Epub 2013 Mar 22. PubMed PMID: 23521153.

5)

Golpayegani M, Salari F, Anbarlouei M, Habibi Z, Nejat F. Huge bilateral temporal horn entrapment: a congenital abnormality and management. Childs Nerv Syst. 2018 Jul 28. doi: 10.1007/s00381-018-3924-5. [Epub ahead of print] PubMed PMID: 30056473.

6)

Zhang B, Wang X, Li C, Li Z. Neuroendoscopic Fenestration for Entrapped Temporal Horn After Surgery: Report of 3 Cases. World Neurosurg. 2018 Apr;112:77-80. doi: 10.1016/j.wneu.2018.01.096. Epub 2018 Jan 31. PubMed PMID: 29371166.

7)

Hasegawa T, Ogiwara T, Nagm A, Goto T, Aoyama T, Hongo K. Risks of endoscopic temporal ventriculocisternostomy for isolated lateral ventricle: Anatomical surgical nuances. World Neurosurg. 2017 Nov 15. pii: S1878-8750(17)31959-9. doi: 10.1016/j.wneu.2017.11.036. [Epub ahead of print] PubMed PMID: 29155114.

8)

Alan N, Lee P, Ozpinar A, Gross BA, Jankowitz BT. Robotic Stereotactic Assistance (ROSA) Utilization for Minimally Invasive Placement of Intraparenchymal Hematoma and Intraventricular Catheters. World Neurosurg. 2017 Dec;108:996.e7-996.e10. doi: 10.1016/j.wneu.2017.09.027. Epub 2017 Sep 14. PubMed PMID: 28919568.

9)

Paredes I, Orduna J, Fustero D, Salgado JA, de Diego JM, de Mesa FG. Endoscopic temporal ventriculocisternostomy for the management of temporal horn entrapment: report of 4 cases. J Neurosurg. 2017 Jan;126(1):298-303. doi: 10.3171/2016.1.JNS152248. Epub 2016 Apr 15. PubMed PMID: 27081903.

10)

Spallone A, Belvisi D, Marsili L. Entrapment of the Temporal Horn as a Cause of Pure Wernicke Aphasia: Case Report. J Neurol Surg Rep. 2015 Jul;76(1):e109-12. doi: 10.1055/s-0035-1549225. Epub 2015 May 13. PubMed PMID: 26251784; PubMed Central PMCID: PMC4520970.

11)

Chen CC, Kasper EM, Zinn PO, Warnke PC. Management of entrapped temporal horn by temporal horn to prepontine cistern shunting. World Neurosurg. 2013 Feb;79(2):404.e7-10. doi: 10.1016/j.wneu.2011.02.025. Epub 2011 Nov 7. PubMed PMID: 22120406.

12)

Tsugane R, Shimoda M, Yamaguchi T, Yamamoto I, Sato O. Entrapment of the temporal horn: a form of focal non-communicating hydrocephalus caused by intraventricular block of cerebrospinal fluid flow–report of two cases. Neurol Med Chir (Tokyo). 1992 Apr;32(4):210-4. Review. PubMed PMID: 1378565.

13)

Maurice-Williams RS, Choksey M. Entrapment of the temporal horn: a form of focal obstructive hydrocephalus. J Neurol Neurosurg Psychiatry. 1986 Mar;49(3):238-42. PubMed PMID: 3958736; PubMed Central PMCID: PMC1028721.
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