British Journal of Neurosurgery, June 2014; 28(3): 374–377

© 2014 The Neurosurgical Foundation

ISSN: 0268-8697 print / ISSN 1360-046X online
DOI: 10.3109/02688697.2013.841854

ORIGINAL ARTICLE

Comparison of therapeutic effects between selective

amygdalohippocampectomy and anterior temporal lobectomy
for the treatment of temporal lobe epilepsy: A meta-analysis
Yongqin Kuang1, Tao Yang1,2, Jianwen Gu1, Bin Kong1,2 & Lin Cheng1
1Department of Neurosurgery, Chengdu Military General Hospital, Chengdu, P. R. China, and 2Third Military Medical University,

Chongqing, P. R. China

medicine. However, more than 20% of the epilepsy patients

Abstract
Background. Temporal lobe epilepsy (TLE) is a recurrent
chronic nervous system disease. The conventional treatment
is medicine. So far, anterior temporal lobectomy (ATL) and
selective amygdalohippocampectomy (SAH) are becoming the
two main approaches. Methods.To compare the therapeutic
effects between SAH and ATL in the treatment of temporal
lobe epilepsy, we conducted a meta-analysis of published
randomized controlled trials. The review applied the search
strategy developed by the Cochrane Epilepsy Group and the
Rev. Man 5.0 software to analyze. We also drew the forest plots
with Risk Ratio (RR) as effect size. Six studies were eligible,
with a total of 626 patients (337 patients with SAH and 289
patients with ATL). Results. There was no statistical significance
of postoperative seizure control rate after 1 year, as well as
the increase rate and decrease rate of verbal memory function
between SAH and ATL. There is no statistical difference of
therapeutic effects between SAH and ATL in the treatment
of temporal lobe epilepsy. Conclusion. It is advised that
clinically, physicians should choose the appropriate approach
according to operation indications to improve the results of
postoperative recovery.
Keywords: anterior temporal lobectomy; meta-analysis; selective
amygdalohippocampectomy; temporal lobe epilepsy
Introduction
Temporal lobe epilepsy (TLE) is a recurrent chronic ner-
vous system disease, originating from the epilepsy foci
localized in basolateral temporal lobe including fusiform
gyrus, parahippocampal gyrus, hippocampus and amygda-
las.1 The feature of TLE is simple partial seizure, generally
manifesting itself as partial seizure, secondary generalized
seizure or mixed seizure. The conventional treatment is
with intractable drug resistance ultimately develop differ-
ent levels of neurological dysfunction and psychological
changes.2 For such patients, surgical treatment is particu-
larly important as it can not only control epileptic fit, but
also facilitate the effectiveness of drugs in order to bring
down the morbidity and mortality.3–5
Patients have to undergo rigorous preoperative evalua-
tion and diagnosis before the surgical treatment of epilepsy
to ascertain operation indication and surgical technique and
locate epileptic foci. So far, anterior temporal lobectomy
(ATL)6 and selective amygdalohippocampectomy (SAH)7
have been the two main approaches to treat TLE and ATL
has been the most widely applied standard resection for
TLE with over 70% patients being cured postoperatively.8,9
ATL can ensure a wide operative field and reduce stress on
the surgeon. Nevertheless, ATL often damages the anterior
bundle fibers of the optic radiation and the language areas
located at the temporal tip and temporal base.10–12
SAH was first described by Niemeyer in 1895 when
he applied a transcortical approach via middle temporal
gyrus.13 In 1985, Yasargil et al. reported that they con-
ducted SAH by a trans-sylvian approach.14 Recently, a
transcortical approach via superior temporal sulcus and
a subtemporal approach have been widely applied.15–17
During SAH, only mesial temporal structures (hippocam-
pus, parahippocampal gyrus and amygdalas) are resected
with lateral temporal cortex preserved so as to conserve
functional temporal lobe as much as possible and minimize
the occurrence of complications such as aphasia caused
by the damaged cortex associated with verbal function in
lateral temporal lobe.
To investigate the usefulness of the two types of surgical
techniques and provide reliable foundation for their clinical
application, we compared the efficacy of SAH versus ATL for
the treatment of TLE with meta-analysis.

Kuang Yongqin and Yang Tao should be regarded as co-first authors.

Correspondence: Jianwen Gu, Department of Neurosurgery, Chengdu Military General Hospital, Chengdu 610083, P. R. China. Tel: ⫹ 86-28-86570361.
E-mail: gujianwengjwgu@hotmail.com.
Received for publication 8 April 2013; accepted 31 August 2013

374
 Comparison of therapeutic effects of TLE 375

Table I. The principal characteristics of eligible studies.

Number
Study Year Journal Start (Year) End (Year) ATL SAH
Arruda 199618 Ann Neurol NA NA 37 37
Clusmann 200219 J Neurosurg 1989 1997 98 138
Morino 200620 Epilepsy and Behavior 1999 2003 17 32
Paglioli 200621 J Neurosurg 1992 2002 80 81
Sagher 201222 Neurosurg Focus 2001 2007 51 45
Tahir 201223 Epilepsy Research 2006 2008 6 4
and Treatment
NA: not available.

Materials and methods Statistical analysis

Meta-analysis was conducted by Review Manager 5.0. Stan-
Literature search strategy
dardized mean difference with 95% confidence interval was
Published studies in SAH versus ATL for the treatment of
used for continuous data and relative risk ratio (RR) with
TLE were collected using PubMed, MEDLINE, EMBASE,
95% confidence interval was used for dichotomous data. A
Cochrane Controlled Trials Register and recursive literature
probability of P ⬍ 0.05 was considered significant. Statistical
searching up to October 2012 and Google scholar was used
heterogeneity was assessed before pooled analysis. A fixed
to search relevant studies. Key words of search were Tempo-
effect was applied for calculations in the absence of evidence
ral Lobe Epilepsy AND Anterior Temporal Lobectomy AND
of heterogeneity; otherwise, a random effects model was
Selective Amygdalohippocampectomy.
applied.
Study selection
Inclusion criteria: 1) The studies were original research Results
articles. 2) Experiment design was a randomized clinical
trial. 3) The studies had time limit on research duration
Description of studies
The initial search yielded 86 studies related to SAH versus
or publication. 4) The studies had explicit indication on
ATL as the treatment intervention for TLE, of which 25 were
sample size. 5) Patients were diagnosed with TLE. 6) Treat-
reviews or commentary literatures, 30 not randomized
ment intervention was SAH or ATL. 7) Outcome measures
controlled trials and 27 other types of literatures. Of these,
were seizure control rate, memory and IQ. 8) The method
four articles of randomized clinical trials met inclusion
of collecting materials was scientific. 9) The method of data
criteria. The second search yielded two articles. Finally, by
analysis was correct.
October 2012, we included six eligible studies of randomized
Exclusion criteria: 1) The studies did not provide the
clinical trials.18–23
source and exact number of case and control patients and the
studies were non-medical clinical research, animal experi-
ments and non-primary literature. 2) There were no clear Principal characteristics of studies
diagnostic criteria for the cases. 3) Patients had other types The principal characteristics (author, publishing year,
of epilepsy. 4) Treatment intervention was non-surgical such journal and the number of patients) are reported in
as medicine. 5) The studies were not randomized controlled Table I. These studies were published from 1989 to 2008. A
trials. 6) The method of data analysis was incorrect or not total of 626 patients are included (337 SAH and 289 ATL).
provided. 7) The studies were reviews. 8) The studies were dupli- Demographic data involving patients’ gender, age of onset
cate publications. 9) The studies were retrospective analysis. and mean duration are listed in Table II.

Quality assessment and data extraction
Two independent reviewers performed quality assessment
with respect to 1) general data: the first author, publishing
year, source and publishing date, 2) protocol of each study,
3) sample size, features and therapeutic outcomes of each
study and 4) conclusions.
Seizure control rate after 1 year
All the six studies18–23 involved seizure control rate after
1 year. No evidence of statistical heterogeneity was found and
therefore, we used a fixed effect model. The pooled estimate
of combined RR (95% CI) was 1.01 (0.94, 1.09), suggesting no
statistical significance (Z ⫽ 0.24, P ⫽ 0.81). It is evident that

Table II. The demographic data.

Age Gender Age of onset Duration (Year)
Study ATL SAH ATL SAH ATL SAH ATL SAH
Arruda 199618 32.5 31.6 33/4 1/36 NA NA 20.8 18.1
Clusmann 200219 29.7* NA NA NA NA 17.9*
Morino 200620 32.2 37.5 9/8 13/19 12.0 11.9 NA NA
Paglioli 200621 31.9 30.7 43/37 45/36 NA NA 22.8 25.1
Sagher 201222 36.0 38.3 26/25 20/25 15.0 17.1 21.0 21.2
Tahir 201223 22.0* NA NA NA NA NA NA
*Combined average number of the two groups.
376 Y. Kuang et al.
Fig. 1. Comparison of seizure control rate after 1 year in patients who underwent ATL or SAH.
with respect to seizure control rate after 1 year, there was no
statistical difference between ATL and SAH (see Fig. 1).
Verbal memory gain and loss after 1 year
There were two studies19,21 indicating verbal memory gain
after 1 year and the data were not statistically heterogeneous.
Therefore, data were pooled under a fixed effect model with
combined RR (95% CI) at 1.08 (0.68, 1.72), suggesting no
statistical significance (Z ⫽ 0.33, P ⫽ 0.74) (see Fig. 2).
There were two studies19,21 containing verbal memory
loss after 1 year and no evidence of statistical heterogeneity
was found. Therefore, data were pooled under a fixed effect
model with combined RR (95% CI) at 1.34 (0.95, 1.90), sug-
gesting no detection of statistically significant association
(Z ⫽ 1.66, P ⫽ 0.10) (Fig. 3).
Discussion
After an exhaustive literature search and a second focused
search, six studies were included and underwent reading
in full and meta-analysis.18–23 The patients in each study
had more than 1 year of follow-up. This study assessed the
efficacy of SAH and ATL for the treatment of TLE with three
main outcome measures: postoperative seizure control rate
after 1 year, the increase rate and decrease rates of verbal
memory function. Among the three measures, seizure con-
trol rate was the important one to reflect the therapeutic
Fig. 2. Comparison of verbal memory gain after 1 year in patients who underwent ATL or SAH.
Fig. 3. Comparison of verbal memory loss after 1 year in patients who underwent ATL or SAH.
effects of surgical treatment of epilepsy. The results showed
that there is no statistical difference between SAH and ATL
for the treatment of TLE with regard to seizure control rate
after 1 year.
Previous studies24–26 compared cognitive outcome in
patients who underwent either SAH or ATL. Some claimed
that SAH offered cognitive advantages over ATL.24,25 Some
did not find any significant differences between the two types
of surgery.26 Others, however, provided equivocal conclu-
sion.27 In this study, the results showed no statistical varia-
tion in the increase rate and decrease rate of verbal memory
function between patients who underwent SAH or ATL 1 year
before. Instead of increase rate and decease rate, Morino
et al. averaged the measurement of verbal and behavioral
memory function changes in the report of SAH versus ATL
for the treatment of TLE.20 Therefore, this study was excluded
from our study. Besides, Morino et al. compared the changes
of IQ between the two groups, which is a rare measurement
in other literatures.20 As a consequence, we did not conduct
meta-analysis with respect to IQ.
Our study has several limitations which deserve notice.
1) Only six studies were included and some had small
sample sizes, let alone less data with the same measure-
ments, which might affect the pooled analysis. 2) Without
mentioning the issues such as blinding or random alloca-
tion in the eligible studies, Jadd score could not take place.
3) It is unlikely to exclude selection biases and uncertain

confounding factors. 4) Due to the small total number of
eligible studies, we did not carry out comparative analysis
on side of surgery, age and gender.
Conclusion
To sum up, there were no significant postoperative group
differences with regard to efficacy of SAH versus ATL for the
treatment of TLE, which indicates that more high-quality
randomized controlled trails are needed to provide evidence.
It is advised that clinically, physicians should choose the
appropriate technique according to operation indications
for postoperative improvement in recovery.
Declaration of interest: The authors report no declarations
of interest. The authors alone are responsible for the content
and writing of the paper.
This work was supported by a grant from the National
Natural Science Foundation of China (No. 81071037).
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