Comparison of selective amygdalohippocampectomy and anterior temporal lobectomy for mesial temporal lobe epilepsy: a systematic review and meta-analysis

Abstract

Background

Anterior temporal lobectomy (ATL) and selective amygdalohippocampectomy (SAH) are the two most widely adopted surgical approaches for drug-resistant mesial temporal lobe epilepsy (MTLE). Although both procedures target seizure control, they differ in extent of resection and potential morbidity. The relative effectiveness of ATL and SAH remains debated, particularly regarding seizure freedom, visual field deficits, and postoperative complications.

Objective

To systematically compare seizure freedom (Engel I) rates, Engel III-IV outcomes, visual field deficits, and postoperative complications between ATL and SAH.

Methods

A systematic review and meta-analysis were performed according to PRISMA guidelines. Searches included PubMed, Embase, Web of Science, and Scopus (1996–2023). Statistical analyses were conducted using R (version 4.3.2) with the meta and metafor packages. Random-effects or fixed-effects models were applied based on heterogeneity. Risk of bias was assessed using ROBINS-I V2. Twenty-two studies were included, totaling 2,482 patients.

Results

• Seizure freedom (Engel I): SAH demonstrated an 8% lower chance of postoperative seizure freedom compared with ATL (RR = 0.92, 95% CI 0.87–0.97; p = 0.05; I² = 32%).

• Engel III–IV outcome: SAH showed a nonsignificant trend toward higher risk of poor seizure control (RR = 1.22, 95% CI 1.00–1.50; p > 0.05; I² = 28%).

• Postoperative complications: SAH was associated with a 38% lower complication risk (RR = 0.62, 95% CI 0.47–0.83; p < 0.05; I² = 32%).

• Visual field deficits (Goldmann): SAH resulted in a 15% lower risk of visual field defects (RR = 0.85, 95% CI 0.73–0.99; p < 0.05).

Conclusions

ATL provides superior seizure control compared to SAH, whereas SAH offers measurable advantages in visual and perioperative morbidity. The nonsignificant trend toward poorer seizure outcomes in SAH highlights the importance of patient selection and anatomical considerations. These findings support individualized surgical decision-making for drug-resistant MTLE, balancing seizure freedom against visual and postoperative risks.