Abstracts

Anterior temporal lobectomy (ATL) and amygdalohippocampectomy (AH) are effective treatment alternatives in patients with temporal lobe epilepsy refractory to medical treatment. Neuropsychological deficits (language and memory) are the most common post-operatory complications. Surgical complications per se are rarely expected, both locally or at remote sites. Recent papers have shed some light on the frequency of cerebellar hemorrhage in patients submitted to ATL. We report on three of such cases and present a literature review.
Eighty-one patients were subjected to ATL/AH at our institution between 1997 and 2002. Among those we sought for patients presenting with cerebellar hemorrhage following the surgical procedures. Their charts were reviewed for seizure history, clinical, laboratorial and antiepileptic drugs profile, surgical technique and outcome in terms of neurological sequelae and seizure control.
We identified 3/81(3,7%) patients (2 male, 1 female, ages 31-38 years) presenting with cerebellar hemorrhage following ATL/AH. They all had mesiotemporal lobe epilepsy, related to mesial temporal sclerosis (2 left/dominant, 1 right/non-dominant hemispheres). Pre-surgical protocols were unremarkable in all cases, with unilateral interictal epileptiform discharges and ictal onsets, ipsilateral to the hippocampal atrophy. They were all in a multiple drug regime, including valproic acid, phenytoin and carbamazepine in 2 cases and carbamazepine and phenobarbital in 1 case. Routine pre-surgical laboratory results were normal. Surgical technique consisted on a classic 3-5 cm ATL and 3 cm AH in all cases; a subgaleal suctor drain was placed in all patients. Within the first 24hr post-operative period all patients presented unusully drowsy, which ultimately lead to a diagnostic CT scan. The cerebellar hemorrhage was unilteral in 2 patients and bilateral in one. Surgical drainage was not necessary in any of the patients. All patients were discharged between the 4th and 10th PO day. Pre-discharge CT scans showed partial bleeding resolution in all cases. Long-term follow-up imaging showed complete reabsortion of the hemorrhages and the neuro-examination was normal em all patients. Two patients remained seizure-free at a 7 month follow-up and seizures relapsed in one patient. All pathology specimens were confirmed mesial temporal sclerosis cases.
Cerebellar hemorrhage following ATL/HS is a relatively rare complication and its pathophysiology is yet to be entirely understood. Systemic hypertension, head positioning during the surgery and the use of sodium valproate are currently not supported by the literature are potential etiologies for such kind of bleeding. The most accepted theory to the date is an association between cerebral spinal fluid overdraining and the excision of non-expanding encephalic tissue. Most cases are associated with an excellent prognosis.