Neurological Surgery 脳神経外科37巻1号

2009年01月発行

解剖を中心とした脳神経手術手技

島限を温存した経シルビウス裂到達法の選択的海馬扁桃体摘出術―手術手技と海馬硬化症70例に対する術後の高次脳機能について

著者： 森野道晴¹ 一ノ瀬努¹ 大藤さとこ² 近藤亨子² 大畑建治¹

所属機関： ¹大阪市立大学大学院医学研究科脳神経外科学 ²大阪市立大学大学院医学研究科公衆衛生学

ページ範囲：P.15 - P.23

Ⅰ．はじめに

　側頭葉てんかんは外科治療による発作抑制率が高く，その手術法には最も標準的に行われている前側頭葉切除による海馬扁桃体摘出術（anterior temporal lobectomy：ATL）と側頭葉内側構造のみを摘出する選択的海馬扁桃体摘出術（selective amygdalohippocampectomy：SA）がある．ATLは，特に言語優位側の手術では，術後の言語性記銘力の低下や側頭葉内の視放線の一部損傷による自覚症状は認めないが，対側の上1/4盲の出現が問題となる．これらのATLの合併症を回避するためにSAが開発されたが，海馬扁桃体を中心とする側頭葉内側部への到達経路により，種々の手術法が報告されている．SAの最初の報告は1958年のNiemeyer ¹⁹⁾の中側頭回経由の経皮質到達法である．その後，Wiser とYasargil ²⁸⁾が経シルビウス裂到達法による選択的海馬扁桃体摘出術（transsylvian SA：TSA）を発表した．しかし，彼らのTSAにおいては側頭幹を切断することと島限の直下を走行するuncinate fasciculusを離断することにより，記銘力温存に不利益をもたらしていると報告されている⁸⁾．

　当施設では2001年より側頭葉てんかんに対して，島限を温存した経シルビウス裂到達法による選択的海馬扁桃体摘出術（TSA preserving the limen insula：TSA-PLI）を行い，発作予後および術後の高次脳機能について良好な結果を得ている．そこで本稿では代表例の術中写真を提示しながら，本手術法の要点と海馬硬化症70例の発作予後および術前後の高次脳機能を含む手術治療成績について述べる．

参考文献

1）Clusmann H, Schramm J, Kral T, Helmstaedter C, Ostertun B, Fimmers R, Haun D, Elger CE：Prognostic factors and outcome after different types of resection for temporal lobe epilepsy. J Neurosurg 97：1131-1141, 2002

2）Cohen-Gadol AA, Bradley CC, Williamson A, Kim JH, Westerveld M, Duckrow RB, Spencer DD：Normal magnetic resonance imaging and medial temporal lobe epilepsy：the clinical syndrome of paradoxical temporal lobe epilepsy. J Neurosurg 102：902-909, 2005

3）Engel J Jr, Van Ness PC, Rasmussen TB, Ojemann LM：Outcome with respect to epilepstic seizures. pp609-622 (Engel J Jr ed：Surgical Treatment of the Epilepsies. Raven Press, New York, 1993)

4）Gleissner U, Helmstaedter C, Schramm J, Elger CE：Memory outcome after selective amygdalohippocampectomy：a study in 140 patients with temporal lobe epilepsy. Epilepsia 43：87-95, 2002

5）Gleissner U, Helmstaedter C, Schramm J, Elger CE：Memory outcome after selective amygdalohippocampectomy in patients with temporal lobe epilepsy：one-year follow-up. Epilepsia 45：960-962, 2004

6）Goldstein LH, Polkey CE：Short-term cognitive changes after unilateral temporal lobectomy or unilateral amygdalo-hippocampectomy for the relief of temporal lobe epilepsy. J Neurol Neurosurg Psychiatry 56：135-140, 1993

7）Helmstaedter C, Elger CE, Hufnagel A, Zentner J, Schramm J：Different effects of left anterior temporal lobectomy, selective amygdalohippocampectomy, and temporal cortical lesionectomy on verbal learning, memory, and recognition. J Epilepsy 9：39-45, 1996

8）Helmstaedter C Richter S, Röske S, Oltmanns F, Schramm J, Lehmann TN：Differential effects of temporal pole resection with amygdalohippocampectomy versus selective amygdalohippocampectomy on material-specific memory in patients with mesial temporal lobe epilepsy. Epilepsia 49：88-97, 2008

9）Helmstaedter C, Van Roost D, Clusmann H, Urbach H, Elger CE, Schramm J：Collateral brain damage, a potential source of cognitive impairment after selective surgery for control of mesial temporal lobe epilepsy. J Neurol Neurosurg Psychiatry 75：323-326, 2004

10）Hermann BP, Wyler AR, Richey ET, Rea JM：Memory function and verbal learning ability in patients with complex partial seizures of temporal lobe origin. Epilepsia 28：547-554, 1987

11）Hori T, Tabuchi S, Kurosaki M, Kondo S, Takenobu A, Watanabe T：Subtemporal amygdalohippocampectomy for treating medically intractable temporal lobe epilepsy. Neurosurgery 33：50-57, 1994

12）Hori T, Yamane F, Ochiai T, Kondo S, Shimizu S, Ishii K, Miyata H：Selective subtemporal amygdalohippocampectomy for refractory temporal lobe epilepsy：operative and neuropsychological outcomes. J Neurosurg 106：134-141, 2007

13）Ikeda A, Miyamoyo S, Tomimoto H, Mikuni N, Fukuyama H, Hashimoto N：Effects of trans-sylvian approach to basal forebrain projection fibers：verbal memory decline after selective amygdalohippocampectomy. Epilepsia 46：334；author reply 334-335, 2005

14）Lutz MT, Clusmann H, Elger CE, Schramm J, Helmstaedter C：Neuropsychological outcome after selective amygdalohippocampectomy with transsylvian versus transcortical approach：a randomized prospective clinical trial of surgery for temporal lobe epilepsy. Epilepsia 45：809-816, 2004

15）Mikuni N, Miyamoto S, Ikeda A, Satow T, Taki J, Takahashi J, Ohigashi Y, Hashimoto N：Subtemporal hippocampectomy preserving the basal temporal language area for intractable mesial temporal lobe epilepsy：preliminary results. Epilepsia 47：1347-1353, 2006

16）Miyagi Y, Shima F, Ishido K, Araki T, Taniwaki Y, Okamoto I, Kamikaseda K：Inferior temporal sulcus approach for amygdalohippocampectomy guided by a laser beam of stereotactic navigator. Neurosurgery 52：1117-1124, 2003

17）Morino M, Uda T, Naito K, Yoshimura M, Ishibashi K, Goto T, Ohata K, Hara M：Comparison of neuropsychological outcomes after selective amygdalohippocampectomy versus anterior temporal lobectomy. Epilepsy Behav 9：95-100, 2006

18）Mungas D, Ehlers C, Walton N, McCutchen CB：Verbal learning differences in epileptic patients with left and right temporal lobe foci. Epilepsia 26：340-345, 1985

19）Niemeyer P：The transventricular amygdala-hippocampectomy in the temporal lobe epilepsy. pp461-482 (Baldwin M, Bailey P eds：Temporal Lobe Epilepsy. Charles C Thomas, Springfield, 1958)

20）Olivier A：Transcortical selective amygdalohippocampectomy in temporal lobe epilepsy. Can J Neurol Sci 27 Suppl 1：S68-S76, S92-S96, 2000

21）Paglioli E, Palmini A, Portuguez M, Paglioli E, Azambuja N, Da Costa JC, Da Silva Filho HF, Martinez JV, Hoeffel JR：Seizure and memory outcome following temporal lobe surgery：selective compared with nonselective approaches for hippocampal sclerosis. J Neurosurg 104：70-78, 2006

22）Park TS, Bourgeois BFD, Silbergeld DL, Dodson WE：Subtemporal transparahippocampal amygdalohippocampectomy for surgical treatment of mesial temporal lobe epilepsy：technical note. J Neurosurg 85：1172-1176, 1996

23）Pauli E, Pickel S, Schulemann H, Buchfelder M, Stefan H：Neuropsychologic findings depending on the type of the resection in temporal lobe epilepsy. Adv Neurol 81：371-377, 1999

24）Rausch R, Crandall PH：Psychological status related to surgical control of temporal lobe seizures. Epilepsia 23：191-202, 1982

25）Shimizu H, Kawai K, Sunaga S, Sugano H, Yamada T：Hippocampal transection for treatment of left temporal lobe epilepsy with preservation of verbal memory. J Clin Neurosci 13：322-328, 2006

26）Wieser HG：Selective amygdalohippocampectomy for temporal lobe epilepsy. Epilepsia 29：100-113, 1988

27）Wieser HG：Selective amygdalohippocampectomy：indications, investigative technique and results. Adv Techn Stand Neurosurg 13：39-133, 1986

28）Wieser HG, Yasargil MG：Selective amygdalohippocampectomy as a surgical treatment of mesiobasal limbic epilepsy. Surg Neurol 17：445-457, 1982

29）Yasargil MG, Teddy PJ, Roth P. Selective amygdalo-hippocampectomy. Operative anatomy and surgical technique. Adv Tech Stand Neurosurg 12：93-123, 1985