Trans orbital eyebrow approach for selective resections in mesial temporal lobe epilepsy: Technical aspects and preliminary case series

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Introduction: Selective amygdalo-hippocampectomy (SAH) is commonly performed in drug-resistant mesial temporal lobe epilepsy (MTLE) with seizure-free outcome in 70-80% of patients, however cognitive risks with respect to surgical approaches remain debated. Research question: The preliminary experience of a new surgical route through the orbit are evaluated with the aim to improve the benefits/risks of SAH. Methods: Patients were recruited among a cohort of 100 patients investigated in the Epilepsy Unit of the department of Neurosurgery, between 2022 and 2024. A SAH through a transorbital approach with an eyebrow incision was performed in 3 patients (2 males, 22-51 years) after investigation for pure MTLE (right side in 2, non-lesional in 1).Surgical outcome was assessed with respect to seizures according to the International League Against Epilepsy (ILAE) classification. Results: No local or general complications occurred postoperatively except a transient diplopia due to ocular oedema. Mean volume of resection was of 9.2 cc, and virtual dissection of tractograms demonstrated that the resection cavity spared the optic, uncinate and inferior longitudinal pathways in all cases.With a 12 to 31 month-follow-up (mean 22 months), seizure-free outcome (ILAE class 1) was obtained in all patients. Neuropsychological evaluation showed increased or stable cognitive and memory performances, with an improvement of quality of life (QOL) in all. Aesthetical results were excellent. Conclusion: Transorbital eyebrow approach is safe and effective for SAH, with a positive impact on cognitive functions and QOL. Although preliminary, these findings suggest that it may be an option in patients with pure MTLE.

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