Seizure: European Journal of Epilepsy 81 (2020) 228–235

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Seizure: European Journal of Epilepsy

journal homepage: www.elsevier.com/locate/seizure

Review

Comparisons of the seizure-free outcome and visual field deficits between T

anterior temporal lobectomy and selective amygdalohippocampectomy: A
systematic review and meta-analysis
Ke Xua, Xiongfei Wanga,c, Yuguang Guana, Meng Zhaoa, Jian Zhoua, Feng Zhaia,
Mengyang Wangb, Tianfu Lib,c, Guoming Luana,c,*
a
Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
b
Department of Neurology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
c
Beijing Key Laboratory of Epilepsy, China

ARTICLE INFO ABSTRACT

Keywords: Purpose: The purpose of our study is to compare seizure-free outcome and the incidence of visual field deficits
Temporal lobe epilepsy (VFD) between anterior temporal lobectomy (ATL) and selective amygdalohippocampectomy (SAH) among
Different surgical methods patients with intractable temporal lobe epilepsy (TLE).
Seizure freedom Methods: We searched MEDLINE, Embase and Cochrane databases using keywords related to ATL, SAH and VFD.
Postoperative complications
Previous studies that compared ATL and SAH with seizure-free outcome and the incidence of VFD were included.
Individualized treatment
A fixed-effect model was used to conduct meta-analysis. Risk ratio with 95% confidence intervals were pooled
and used to elucidate each outcome.
Results: Twenty-three retrospective and three prospective studies were recruited with a total of 2930 cases (1390
cases for SAH and 1540 cases for ATL). The meta-analysis showed no significant difference in seizure freedom
(SAH 63.5% vs ATL 63.8%) of these two procedures (RR 0.95, 95%CI 0.90-1.01, P = 0.102), but the odds of
seizure freedom in ATL was higher than transsylvian SAH approach (RR 0.89 95% CI 0.82-0.96, P = 0.004).
Comparing with ATL for TLE, SAH for TLE caused lower frequency of postoperative VFD. (RR 0.87, 95%CI 0.76-
0.99, P = 0.034).
Conclusions: There was no significant difference on seizure freedom between ATL and SAH procedures, while
subgroup analysis demonstrated that ATL was associated with higher opportunity to achieve seizure-free than
transsylvian SAH approach. Furthermore, the incidence of postoperative VFD was significantly lower in SAH
than ATL. Individualized treatment achieving balance between seizure free and collateral damage should be
considered in clinical practice. Well-designed randomized controlled clinical trials would be necessary to vali-
date our findings.

1. Introduction Selective amygdalohippocampectomy (SAH) through transsylvian

Temporal lobe epilepsy (TLE) is a well-known constellation of epi-
lepsy frequently causing drug-resistant focal seizure. Surgical therapy is
regarded as an effective and well-established treatment for intractable
TLE [1]. Over the years, anterior temporal lobectomy (ATL), including
extensive resection of the lateral cortex as well as the amygdala and
hippocampal formation, has been the most widely used surgical pro-
cedure with a seizure freedom rate of 62% to 83%, which is mainly
influenced by the duration of follow-up [2]. However, with the aim of
preserving neurofunction and improving quality of life, minimal sur-
gical approaches are still being sought.
and transcortical approaches has been applied to conserve the func-
tional temporal neocortex and minimize the occurrence of post-
operative complications. In terms of seizure control, no significant
difference was found in most comparisons of SAH and ATL [3–7]. On
the other hand, some studies suggested that SAH achieved better neu-
ropsychological outcomes [8,9] and had lower risk of visual field def-
icits [10–12] (VFD) than ATL.
Previous meta-analyses drew discordant conclusions of the seizure-
free outcome and did not find any significant difference between these
two procedures [13,14]. Two other studies [9,15] reported that ATL
could achieve better seizure freedom than SAH. The main reason for the

⁎
Corresponding author at: Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, 50 Yikesong Road, Haidian District, Beijing, China.
E-mail address: sbnklgm@163.com (G. Luan).

https://doi.org/10.1016/j.seizure.2020.07.024
Received 31 May 2020; Received in revised form 21 July 2020; Accepted 23 July 2020
1059-1311/ © 2020 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.
K. Xu, et al.
different conclusions of these analyses was that the number of included
studies was varied. Moreover, no significant differences between these
two procedures were observed in a previous meta-analysis regarding
VFD differences. Therefore, we performed this systematic review and
meta-analysis, and included as many relevant studies as possible to
evaluate the difference between SAH and ATL in both seizure freedom
and VFD.
2. Methods
2.1. Search strategy
A literature research of PubMed, EMBASE, and Cochrane
Collaboration Database was conducted to identify relevant studies. The
following search terms were used for this research: i) Temporal lobe
epilepsy, ii) Selective amygdalohippocampectomy, iii) Anterior tem-
poral lobectomy, and iv) Visual field deficits. Results were restricted to
English-language articles published up to 2019. We also reviewed the
references of included articles to identify potential studies.
2.2. Inclusion and exclusion criteria
The following inclusion criteria were applied in this meta-analysis:
(1) For seizure outcomes: (a) Observational studies aiming at temporal
lobe epilepsy; (b) original clinical research articles comparing sei-
zure outcomes after SAH or ATL procedures; and (c) studies with at
least a 12 months follow-up period.
(2) For VFDs: (a) Visual field examined by kinetic Goldmann perimetry
or Humphrey static perimetry; (b) articles comparing number of
VFD patients after SAH or ATL procedure; and (c) patients tested
more than 30 days after surgery to avoid temporary VFD caused by
transient brain oedema.
Studies were excluded under following criteria: (a) If the number of
patients was less than 20; (b) non-human studies, reviews and meta-
analyses, case reports and letters, and conference abstracts; and (c)
studies providing insufficient information. We also excluded multiple
articles with overlapping patient populations from the same centre.
2.3. Data extraction
Two investigators independently extracted the first author’s name,
year of publication, country of origin, institution of investigation, study
design, sample size, types of surgery, presurgical evaluation, age of
patients at the time of surgery, gender ratio, duration of epilepsy,
duration of follow-up, Engel classification of seizure outcome, pa-
thology, and the number of VFD patients after surgery. Any discrepancy
was resolved through discussion. We contacted the corresponding au-
thor for further details when the relevant data were missing.
2.4. Outcome evaluation
The Engel classification system [16] was used for seizure outcome
assessment, and Engel class I was considered when the patient was
seizure-free after the surgery. Seizure outcome at 5 years after the
surgery was used for meta-analysis if the seizure outcome was recorded
at multiple prespecified time points. The final numbers of the SAH and
ATL patients incorporated into the research did not contain the patients
lost to follow-up.
2.5. Quality assessment
The methodological quality of these non-randomized studies was
evaluated by the modified Newcastle-Ottawa Scale (NOS) [17]. Studies
that achieved 6 or more points were considered to be of high quality
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Seizure: European Journal of Epilepsy 81 (2020) 228–235
and were included in our meta-analysis.
2.6. Data analysis
Stata/SE V15.1 for Windows (Stata, College Station, TX, USA) was
used for meta-analysis. Two meta-analyses were conducted to sepa-
rately compare seizure freedom and the incidence of VFD after the
surgery for SAH versus ATL. Risk ratio with 95% confidence intervals
were pooled and used to express each outcome, and P value < 0.05 was
considered statistically significant. Q statistic and I2 were used to test
for between-study heterogeneity. If statistically significant hetero-
geneity was present (Q statistic P < 0.05 or I2 ≥ 50%) between stu-
dies, the random-effect model was applied; otherwise fixed-effect model
was applied. Prespecified sensitivity analyses were performed to eval-
uate the stability of the results as following: using the random-effects
model, excluding each article in turn, and analysing studies that solely
focused on adults. Publication bias was examined with the application
of Begg's correlation and Egger's regression (Begg & Mazumdar, 1994;
Egger, Davey, Schneider, & Minder, 1997).
In subgroup analyses, the seizure-free outcome of ATL was com-
pared with that of transsylvian and transcortical SAH. Furthermore, we
compared the seizure-free outcome of SAH and ATL for studies which
exclusively focused on hippocampal sclerosis and studies reporting on
seizure-free outcome at 1-year, 2-year, and 5-year follow-ups.
3. Results
A total of 535 articles were identified according to our searching
strategy. After screening duplicates, we identified 317 eligible studies.
Forty-four studies remained after reviewing the title and abstract
(Fig. 1). Six studies were excluded for the following reasons: non-blind
randomized trial [18], number of patients less than 20 [19,20], follow-
up for less than 1 year [21,22], and overlapping patient population
[23]. Twenty-six articles which included 2930 cases (1390 cases under
SAH and 1540 cases under ATL) met the inclusion criteria for meta-
analysis.
3.1. Study characteristics
The characteristics of included studies are presented in Table 1.
These studies were from Canada (6), Germany (6), USA (4), UK (3),
Australia (2), Japan (1), China (1), Brazil (1), and France (2). Of these
26 observational studies, three were prospective studies [24–26], and
the remaining ones were retrospective study designs. Among these 26
articles, 22 compared seizure outcomes between SAH and ATL [3,5,7,
[24–42], 4 compared the incidence of VFD between SAH and ATL
[11,43–45], and the other 2 included both the comparisons [27,32].
The average follow-up period of seizure outcomes was 12 to 104.4
months, and the testing time of visual field ranged from 1 to 9 months.
In these studies, SAH was performed through transcortical (trans-su-
perior temporal gyrus [2 studies] [30,43], trans-middle temporal gyrus
[11 studies]7,12,26,28,31,33–36],42,45]), subtemporal (2 studies
[11,29]), transsylvian (13 studies [3,5,[11,[24,25,[27,29,
[30,32,38,39,42,43]), and unmentioned (2 studies [40,41]) ap-
proaches. The type of procedure to be performed (ATL or SAH) was
determined on the basis of the surgery timing, experience and tech-
nique of the surgeon, and results of presurgical evaluation. The char-
acteristics of the patients in studies included in the meta-analysis are
presented in Table 2. There were 6 studies5,7,26,32,35,42]covering the
pathology of hippocampal sclerosis (HS) exclusively; the rest of the
studies included HS and other pathologies, such as tumour, dysplasia,
and gliosis.
Most of the included articles achieved 6 or more points on the
modified NOS; five retrospective articles [3,11,38,40,45] achieved 5
points because of low scores in the comparability category, and two of
them11,45] were included in VFD meta-analysis. All of the studies
K. Xu, et al.
Fig. 1. PRISMA flow chart of study selection and reasons for exclusion. PRISMA: preferred Reporting Items for systematic Reviews and Meta-analyses.
showed complete follow-up time for seizure outcome and provided
sufficient reasons for the patients lost to follow-up.
3.2. Seizure freedom
Twenty-two studies [3,5,7,24–42] comparing 2621 patients (1236
cases under SAH and 1385 cases under ATL) were included in the meta-
analysis for seizure freedom. There was no significant difference be-
tween seizure freedom (SAH 63.5% vs ATL 63.8%) of the two proce-
dures (RR 0.95, 95%CI 0.90-1.01, P = 0.102) (Fig. 2). The random-
effect model was used for meta-analysis because moderate hetero-
geneity existed between the included studies (Q statistic P = 0.025 and
I2 = 40.7%).
3.3. Subgroup analysis
There were 11 studies [3,5,24,25,27,29,30,32,38,39,42] comparing
ATL and transsylvian SAH. The odds of seizure freedom were sig-
nificantly higher in ATL than in the transsylvian SAH approach (RR
0.89, 95% CI 0.82-0.96, P = 0.004) (Fig. 3). There was no hetero-
geneity between the studies (Q statistic P = 0.242 and I2 = 21.1%).
Twelve studies [7,26,28–31]], [33–37]],42] compared ATL with the
transcortical SAH approach. There was no significant difference be-
tween these two approaches (RR 1.02, 95% CI 0.93-1.12, P = 0.601);
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no significant heterogeneity between these studies was observed (Q
statistic P = 0.321 and I2 = 12.7%). The subgroup analysis which
compared transsylvian SAH and transcortical SAH was not performed
because there were only three studies29,30,42] comparing these two
approaches concurrently.
Six studies [5,7,26,32,35,42] which exclusively focused on hippo-
campal sclerosis compared seizure freedom of SAH and ATL. The
probability of achieving seizure freedom revealed no difference in these
two procedures (RR 1.13, 95%CI 0.92-1.17, P = 0.528). There was no
heterogeneity between studies in this subgroup meta-analysis (Q sta-
tistic P = 0.446 and I2 =0.0%). Significant difference between these
two procedures was not observed with respect to seizure freedom at the
1-year, 2-year, and 5-year follow-up.
3.4. VFD
Six studies [11,12,27,32,43,45] were included in VFD meta-ana-
lysis, and the odds of VFD were significantly lower in SAH as compared
to that in ATL (RR 0.87, 95%CI 0.76-0.99, P = 0.034) (Fig. 4). The
subgroup analysis was not performed because of limited studies, and
there was no heterogeneity between the included studies (Q statistic P
= 0.694 and I2 = 0.0%).
K. Xu, et al. Seizure: European Journal of Epilepsy 81 (2020) 228–235

Table 1
Characteristics of studies included in the meta-analysis.
No. Ref. Country Design No. (SAH/ATL) Approach of SAH Follow-up (mos) Analysis NOS scale

For seizure-free outcome:

Wang et al. 2018 CN retro 72(39/33) TS 46 1,2,3 6
Elliott et al. 2018 CAN retro 79(18/61) TC (MTG) 63.6 1 7
Mathon et al. 2017 FR retro 389(180/209) TS + TC (STG) 104.4 1 6
Schmeiser et al. 2017 GER retro 432(200/147) TS + ST 60 1 6
Nascimento et al. 2016 CAN retro 67(34/33) TC (MTG) 60 1 5
Bujarski et al. 2013 US retro 69(39/30) TC (MTG) 116.4 1,3 6
Wendling et al. 2013 GER retro 95(46/49) TS 84 1,2,3 7
Sagher et al. 2012 US retro 96(45/51) TC (MTG) 44 1,3 6
Schramm et al. 2011 GER pro 199(125/74) TS 12 1 7
Schijns et al. 2011 GER pro 134(58/58) TS 33 1 7
Tanriverdi et al. 2010 CAN retro 256(133/123) TC (MTG) 12 1,3 7
Tanriverdi et al. 2008 CAN retro 100(50/50) TC (MTG) 60 1 6
Paglioli et al. 2006 BR pro 161(81/80) TC (MTG) 60 1 6
Morino et al. 2006 JPN retro 49(32/17) TS 60 1,3 6
Bate et al. 2006 UK retro 114(32/82) TC (MTG) 12 1 7
Mittal et al. 2005 CAN retro 109(13/57) TC (NA) 60 1 7
Clusmann et al. 2002 GER retro 321(138/98) TS 36 1 5
Mackenzie et al. 1997 AUS retro 100(28/72) TS 12 1 5
Lee et al. 1997 AUS retro 38(13/25) TS 12 1 6
Kellett et al. 1997 UK retro 29(24/45) NA 12 1 5
Arruda et al. 1995 CAN retro 74(37/37) NA 33.4 1 6
Renowden et al. 1995 UK retro 67(17/50) TS + TC (MTG) 24 1 6
For visual field deficits: Testing time (mos)
Schmeiser et al. 2017 GER retro 366(179/134) TS + ST 3-6 2 5
Mathon et al. 2017 FR retro 389(180/209) TS + TC (STG) 6-9 2 6
Mengesha et al. 2009 US retro 51(18/33) TC (MTG) 1-3 2 7
Egan et al. 2000 US retro 29(14/15) TC (MTG) 3 2 5

Abbreviations: retroretrospective; proprospective; TCtranscortical; TStranssylvian; 1sizure free outcomes; 2visual field deficits; 3neurophysiology; STGsuperior
temporal gyrus; MTGmiddle temporal gyrus; STsubtemporal; NAnot available; NOSNewcastle-Ottawa Scale.

3.5. Sensitivity analysis and publication bias
In the sensitivity analysis for seizure-free outcome, the result re-
mained stable after we excluded each article in turn. Nineteen studies
achieving 6 or more points on the NOS were included to perform meta-
analysis, and the result of seizure outcomes was not different with the
exclusion of low-quality studies (RR 0.96, 95%CI 0.90-1.02, P =
0.220).
No significant publication bias was found in the meta-analysis ac-
cording to the reflection of P values from Begg’s correlation (SAH vs

Table 2
Characteristics of patients in studies included in the meta-analysis.
No. Ref. Gender male% Surgery side (left%) Age at surgery (yr, Mean) Duration of seizure (yr, Mean) Pathology

For seizure-free outcome:

Wang et al. 2018 56.9 48.6 SAH: 23.6; ATL: 23.5 SAH: 7.9; ATL: 7.8 HS and others
Elliott et al. 2018 57.0 45.6 Total: 10.6 Total: 5.7 HS and others
Mathon et al. 2017 47.5 53 Total: 36.8 Total: 24.9 97.1% HS and DP
Schmeiser et al. 2017 47.4 50.7 Total: 34.0 Total: 21.0 HS and others
Nascimento et al. 2016 55.2 50.7 SAH: 33.4; ATL: 37.6 SAH: 25.4; ATL: 27.4 HS and others
Bujarski et al. 2013 NA 43.4 SAH: 35.1; ATL: 34.7 SAH: 26.5; ATL: 25.1 94% HS and others
Wendling et al. 2013 44.2 53.7 SAH: 38.5; ATL: 38.9 SAH: 27.0; ATL:25.3 100%HS
Sagher et al. 2012 47.9 14.6 SAH: 38.3; ATL: 36.0 SAH: 21.2; ATL: 21.0 47% HS and others
Schramm et al. 2011 46.6 50.2 SAH: 40.7; ATL: 38.5 SAH: 24.0; ATL: 22.0 HS and others
Schijns et al. 2011 52.6 58.6 Total: 33.1 Total: 23.6 HS and GWMA
Tanriverdi et al. 2010 48.0 51.6 Total: 30.3 SAH: 24.0; ATL: 17.0 100%HS
Tanriverdi et al. 2008 37.0 43.0 SAH: 37.2; ATL: 34.9 SAH: 22.6; ATL: 22.5 100%HS
Paglioli et al. 2006 54.7 57.8 SAH: 30.7; ATL: 31.9 SAH: 25.1; ATL: 22.8 100%HS
Morino et al. 2006 44.9 53.0 SAH: 37.5; ATL: 32.2 SAH: 25.6; ATL: 20.2 100%HS
Bate et al. 2006 54.4 NA SAH: 35.0; ATL: 33.0 SAH: 25.0; ATL: 21.0 HS and gliosis
Mittal et al. 2005 52.3 61.5 Total: 13.2 Total: 7.7 HS and others
Clusmann et al. 2002 48.9 48.0 Total: 29.7 Total: 17.9 HS and others
Mackenzie et al. 1997 NA NA NA NA HS and others
Lee et al. 1997 55.2 100 SAH: 26.9; ATL: 27.0 NA 47.3% MTS and others
Kellett et al. 1997 NA NA NA NA NA
Arruda et al. 1995 59.5 NA Total: 32.1 Total: 19.5 100% MTS
Renowden et al. 1995 47.8 44.8 SAH: 23.6; ATL: 21.3 SAH: 12.0; ATL: 12.0 100%HS
For visual field deficits:
Schmeiser et al. 2017 49.0 54.0 SAH: 39.0; ATL: 33.0 SAH: 21.0; ATL: 23.0 HS and others
Mathon et al. 2017 47.5 53.0 Total: 36.8 Total: 24.9 97.1% HS and DP
Mengesha et al. 2009 41.2 45.1 SAH: 37.4; ATL: 36.4 NA HS and others
Egan et al. 2000 27.6 55.2 SAH: 36.0; ATL: 37.0 NA 77% MTS

Abbreviations: DP: dual pathology; GWMA: gray-white matter abnormalities; HS: hippocampal sclerosis; MTS: mesial temporal sclerosis; NA: not available.

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Fig. 2. Forest plot and meta-analysis comparing selective amygdalohippocampectomy (SAH) and anterior temporal lobectomy (ATL) for seizure-free outcome. M-H,
Mantel-Haenszel.
ATL: P = 0.176; transsylvian SAH vs ATL: P = 0.876; transcortical SAH
vs ATL: P = 0.150) and Egger’s regression (SAH vs. ATL: P = 0.057;
transsylvian SAH vs ATL: P = 0.413; transcortical SAH vs ATL: P =
0.101). The shapes of the funnel plots did not show any strong evidence
of asymmetry.
4. Discussion
After precise analysis of sufficient data, this systematic review has
drawn the reliable conclusion that no significant difference exists be-
tween SAH and ATL procedures considering the odds of seizure
freedom, while the subgroup analysis demonstrated that ATL has higher
odds of seizure freedom than the transsylvian SAH approach. Moreover,
the results remained stable after sensitivity analysis with exclusion of
each study. In addition, SAH has lower risk of VFD than ATL, which is
concordant with the results of several previous articles [10–12].
Previous meta-analyses drew discordant conclusions after com-
paring seizure-free outcome in ATL and SAH. The reasons for these
inconsistent conclusions can be summarized as following: different in-
clusion criteria (especially, how strict were the exclusion criteria ap-
plied for temporal-plus epilepsy), and the different time points selected
for analysis. A randomized comparative trial [18] also found no dif-
ference between SAH and ATL procedures on seizure-free outcome. The
studies by Hu et al. [9] and Josephson et al. [15] found that ATL can
achieve better seizure freedom than SAH, which seems to be logically
accepted because of broader resection in ATL. Kuang et al. [13] did not
find significant difference regarding seizure control between the two
approaches. More than 10 recently published studies were
[24,27–31,33,34,39,40], included in our meta-analysis compared to
theirs. Three of the studies 24,29,30 with large sample size could influ-
ence the weight distribution of the result. The study by Jain et al. did
not identify any difference in seizure-free outcome of ATL versus that of
SAH [14], which is concordant with our finding. However, comparison
between different approaches of ATL and SAH was not performed in
their study.
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Within the subgroup analysis, it was observed that the seizure-free
outcome of ATL was higher than that of the transsylvian SAH approach,
while no difference was found for the transcortical SAH approach. In
many cases, the actual epileptogenic zone may not merely be defined as
the lesions identified on MRI. Besides, focal cortical dysplasia (FCD) is
the most common lesion accompanying hippocampal sclerosis, and
many FCD lesions cannot be detected clearly in MRI. In addition, some
seizures that originated in the temporal pole and quickly spread to the
hippocampus can also mislead our diagnosis. Thus, all the situations
mentioned above may cause poor seizure-free outcome after the
transsylvian SAH approach.
The reported rate of VFD following anterior temporal resection
varies widely from 0% to 100%, predominantly occurring in the su-
perior quadrantanopia. Studies recruited in this analysis describe con-
troversial views on the results while comparing the VFD rate of SAH
and ATL. Schmeiser et al. [11] found fewer VFD in subtemporal SAH,
whereas, Mengesha et al. [44] reported that the incidence of VFD after
SAH was lower than that after ATL. On the other hand, Egan et al. [45],
Mathon et al. [43], and Wang et al. [27] found no difference in the
incidence of VFD between SAH and ATL. This meta-analysis shows that
SAH has a lower risk of VFD. ATL may cause contralateral superior
homonymous quadrantanopia by disruption of the Meyer’s loop and
anterior bundle of the optic radiations that traverse through the tem-
poral lobe. Subtemporal SAH was reported with a lower incidence of
VFD than other approaches since it involves approaching the temporal
horn through its floor [46]. Another rare randomized study also de-
monstrated that subtemporal SAH shows significantly fewer VFDs than
transsylvian SAH. Additionally, the occurrence of VFD in the sub-
temporal group was associated with closer distance of the optic radia-
tion to the temporal base [47]. However, comparison between sub-
temporal SAH and other approaches was not performed in our meta-
analysis because of the limited number of recruited articles [11,29].
Preoperative visualization of the optic radiation and sparing tissue
posterosuperior to the temporal horn [48] are recommended to help in
reducing the opportunity of optic radiation injury.
K. Xu, et al. Seizure: European Journal of Epilepsy 81 (2020) 228–235

Fig. 3. Forest plot and meta-analysis comparing seizure-free outcome of transsylvian or transcortical SAH and ATL. M-H, Mantel-Haenszel.

Our meta-analysis can help in better evaluation of operative risks in with the following factors: demographics, criteria for selection, ex-
clinical practice, thereby, providing individualized treatment. While perience and technique of the surgeon, aetiology, use of antiepileptic
selecting the type of surgical approach, a balance between seizure drugs after surgery, methodology, and follow-up duration. To provide
freedom and collateral damage should be considered. Patients with better evidence regarding the efficacy and complications of ATL and
severe epileptic symptomatology and long epilepsy duration could have SAH, RCTs comprehensively comparing the differences of SAH and ATL
a higher demand for postoperative seizure control, while in individuals, procedures are definitely necessary.
such as drivers, whose primary concern is visual field function, pre-
operative evaluation and intraoperative protection of relevant tissues
5. Conclusion
are particularly essential.
Several limitations reduce the scientific value of this meta-analysis;
Discordant results from previous studies may create confusion for
these need to be explored further. All the recruited studies were ob-
clinical physicians. According to this meta-analysis, no significant dif-
servational studies, which implies that the current absence of RCTs may
ference exists between SAH and ATL procedures considering the
have increased the influence of confounders on the research outcome,
probability of seizure freedom, while the subgroup analysis demon-
and the risk of selection bias. In this study, the neuropsychological
strated that ATL is associated with higher odds of seizure-free outcome
outcomes between SAH and ATL were compared. However, the mean
than transsylvian SAH. On the other hand, the probability of VFD is
changes in full-scale IQ, verbal IQ, and performance IQ scores before
significantly lower in SAH than ATL. Well-designed RCTs are needed to
and after surgery were not mentioned in the recruited articles.
validate our findings. In different disorders, like malignant tumours,
Moreover, the method of neuropsychological testing is not unified,
with definite surgical indication, treatment of epilepsy should be highly
making it impossible to be analysed in this meta-analysis.
individualized based on a balance between the disease characteristics
Heterogeneity and inconsistency in the meta-analysis was associated
and patient’s demands.

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K. Xu, et al.
Fig. 4. Forest plot and meta-analysis comparing VFD of SAH and ATL. M-H, Mantel-Haenszel.
Disclosure
We confirm that we have read the journal's position on issues in-
volved in ethical publication and affirm that this report is consistent
with the guidelines. This work was supported by the National Natural
Science Foundation of China (81790654, 81790650), Capital’s Funds
for Health Improvement and Research (2020-4-8012).
Declaration of Competing Interest
The authors report no declarations of interest.
Acknowledgment
The authors thank Dr Bertrand Mathon who provided important
information for this study.
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