Management Approach for Mesial Temporal Sclerosis

Diagnostic Evaluation

MRI is the initial imaging investigation of choice for suspected MTS, with thin coronal slices through the area of suspected seizure origin, showing higher sensitivity (84%) compared to CT (62%) 1, 2
FDG-PET shows glucose hypometabolism in MTS cases and can provide additional information when MRI is normal or shows nonspecific findings, with sensitivity of 63-67% 1, 2
Ictal SPECT can demonstrate hyperperfusion of the epileptogenic region during seizures, while interictal SPECT typically shows hypoperfusion 2, 3
Subtraction ictal SPECT co-registered to MRI (SISCOM) improves sensitivity and specificity of seizure-related perfusion networks 3

The standard length of time given to medical management before considering surgery is typically 2 years, but earlier surgical intervention may be considered when multiple appropriate AEDs fail to establish control 4

Complete surgical resection of the epileptogenic region is the treatment of choice for medically refractory MTS 5, 4
Extended resection has shown higher success rates and low morbidity compared to lesionectomy alone 5, 4
Temporal lobectomy has demonstrated better seizure outcomes than lesionectomy alone in multiple studies 5

Duration of epilepsy prior to resection does not appear to affect epilepsy outcome 5
Concordance between multiple diagnostic modalities (MRI, EEG, PET, SPECT) is associated with better surgical outcomes 3
Complete removal of the epileptogenic zone is critical for optimal seizure control 5, 4

Incomplete resection significantly increases the risk of seizure recurrence and need for reoperation 5, 4
Functional neuroimaging (PET/SPECT) should be considered when MRI is normal or shows nonspecific findings 1, 6