Anterior Temporal Lobectomy: Surgical Anatomy - Cleveland Clinic

Anterior Temporal Lobectomy:
Surgical Anatomy
Steven N. Roper, M.D.
Department of Neurological Surgery
and McKnight Brain Institute
University of Florida

ATL:Overview
Lateral resection
– Sylvian fissure to collateral sulcus
– 3cm dominant, 4 cm non-dominant
Medial resection
– Hippocampus
–Uncus
– Lateral amygdala

ATL: Lateral Resection

Lateral Temporal Lobe

Ang.G. Ang.G
Sylvian F.
Inf.Temp. Inf.Temp.
G.
SMG
SMG
Inf.Temp G.
Postcent.G.
Postcent.G
ITS
ITS
Sup.Temp. Sup.Temp.
G.
Mid.Temp. Mid.Temp.
G.
Mid.Temp. Mid.Temp.
G.
Cent.Sul. Cent.Sul
Precent.G. Precent.G
Pars
Oper. Oper
STS
Postcent. Postcent.
G.
Ins.
Pars Tri.
Pars Orb.
Cent.Sul. Cent.Sul
Sylvian F. Pars
Oper. Oper
Sup.Temp. Sup.Temp.
G.
STS
Ins.
Inferior
Frontal
S.

P.Com. A.
CN III
Bas. A.
S.C.A.
Ant. Ch. A.
Basal V.
Lat. Gen. Body
Basal V.
A.Chr.A.
CN II
P.C.A.
A1
I.C.A.
P.C.A.
I.C.A.
CN II
M1
M2
Temp. Horn
M1
A.C.A.
M3
M2
M2
Frontal Lobe
M2
Rec. A.
Planum Temp.
M3
M2
Genu
M3
Heschl’s Gyr.
Genu
Int. Cer. V.
Glob. Pall
Optic Tr.
A1
I.C.A.
Chiasm
I.C.A.
Chiasm
CN II
Post. Clin.
S.C.A.
CN III
P.C.A.
Early Fr. Br.
CN II
Tent.
Early Temp. Br.
LSAs
MCA Bif.
Inf. Tr.
Sup. Tr.
A1
I.C.A.
M1
Putamen
LSAs
M1
I.C.A.
CN II
A.C.A.
Sylvian Point
Ant. Limb
M3
M3
M2
Limen Ins.
Genu
Chiasm
Olf. Tr.
Frontal Lobe

V. Trolard
Cent. Sul.
Post. Par. A.
Ang.A.
Cent.A.
Temp. Occ. A.
Post. Temp. A.
Mid. Temp. A.
Precent. A.
Sup.Syl.V.
Cent. Ins. Sul. MSG
PSG
Cent.A.
Stem A.
Inf. Lim. Sul.
Early Temp. Br.
ALG
DMCV
Precent. A.
Orbfr.A.
Prefr. A.
Ant. Temp. A.
Temp. Pol. A.
V. Labbe
Precent. Ins. Sul.
ASG
Prefr.A.
Apex
Orbfr.A.
Sup.Tr.
MCA Bif.
Inf.Tr.
Post. Par. A.
Cent. A.
Ang.A.
Temp. Occ. A.
Post. Temp. A.
Mid.Temp.A.
V. Trolard
Post. Par. A.
Ang. A.
Ant. Par. A.
Temp. Occ. A.
Post. Temp. A.
V. Labbe
Ant.Par.A.
Precent.A.
Prefr.A.
Orbfr.A.
Sup.Tr.
Inf.Tr.
Early Br.
Ant. Temp. A.
Temp. Pol. A.
Cent. Sul.
Precent. A.
Cent. A.
Prefr. A..
Orbfr.A.
Ant.Temp. A.
Mid. Temp. A.

Lateral TL and Hippocampus

Inferior Temporal Lobe

Medial Temporal Resection
Open temporal horn
Elevate choroid plexus
Remove fimbria
Transect hippocampal sulcus (hippo art.)
Transect hippo and PG ant and post
Subpial resection of subiculum
Transect pia over PG (temporal art.)
Resect uncus and lateral amygdala

Medial Temporal Lobe Anatomy

Hippocampal Resection

Choroidal Fissure

Choroidal Fissure

Post-sup. Ins. Angle
Cal. Avis
Hippo. Tail
Coll. Trig.
Coll. Emin.
Pulvinar
Basal V.
P.C.A.
Crus Fornix
Coll. Trig.
Hippo. Body
Hippo. Body
ALG
Ch. plex.
PSG
Sup. Lim. Sul.
MSG
Cent. Ins. Sul.
Inf. Lim. Sul.
Hippo. Head
Ant. Ch. A.
Basal V.
Sup. Lim. Sul.
Ch. plex.
Ant. Ch. A.
Basal V.
P.C.A.
Parahip. Gyr.
Fimbria
Lat. Gen. Body
Basal V.
Fimbria
Pulvinar
PSG
Hippo. Head
Hippo. Body
MSG
Ant. Lim. Sul.
ASG
Apex
M.C.A. Bif.
Uncal Recess
Uncus Post. Seg.
Hippo. Head
Inf. Vent. V.
P.C.A.

Hippocampal sulcus

Hippocampal arteries

Tail
Body
Post. Seg.
Head
Ant. Seg.
Origin
Temp.
Horn.
AChA
Lat. Gen. Body
Basal V.
Chor. Plex.
P2p
P1
P2a
Optic Ch.
CN III
P2a
P2p
P3
LPChA
P2p
P2a
P1
Calcarine A.
Quadrageminal cist.
LPChA
Ambient cist.
Parahippo. Gyrus
P2p
Chor. Plex.
Crural cist.
Interpeduncular cist.
CN III
PCoA
CN III
SCA
Inf. Temp. A.

Transect Hippocampus and PG

Temporal Arteries from PCA

Finishing Up: Uncus and Amygdala

Uncus and the Crural Cistern

Par. Occip. Occip.
S.
Calcarine S.
Cuneus
Lingula
Cuneus
Coll. S.
Isthmus
Calcarine S.
Parahippo. Parahippo.
G.
Parahippo. Parahippo.
G.
Occ. Occ.
Temp. G.
Par. Occip. Occip.
S.
Cingulate G.
Splenium
Uncus
Crus of Fornix
Fimbria of Fornix
Uncus
Uncal Notch
Post. Seg. Seg
Uncus
Apex
Ant. Seg. Seg

Uncus: medial aspect

Uncus: arterial supply

Amygdala

Amygdala: part of basal ganglia

Summary
Lateral T-lobe
– Sylvian Fissure, collateral sulcus
–MCA, PCA
Medial T-lobe
– collateral sulcus, temporal horn, crural and ambient
cisterns
– PCA, anterior choroidal
3D relationships
Angle of approach: start inferior, end superior
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