A 26-year-old woman with focal impaired-awareness seizures since age 14 presents with a history of a prolonged febrile seizure at 18 months. She experiences a rising epigastric aura, déjà vu, and fear, followed by oroalimentary automatisms and dystonic posturing. Despite adequate therapeutic trials of levetiracetam, lacosamide, and lamotrigine, she continues to have 4–6 seizures per month. MRI brain with dedicated epilepsy protocol shows the structure marked **A** (atrophic T2-hyperintense hippocampus) with loss of internal architecture and temporal horn dilation. Video-EEG telemetry confirms left anterior temporal spikes. Which of the following is the most appropriate definitive management for this patient's drug-resistant mesial temporal lobe epilepsy?

Why anterior temporal lobectomy with amygdalohippocampectomy is right

The structure marked A — the atrophic T2-hyperintense hippocampus with loss of internal architecture — is pathognomonic for mesial temporal sclerosis (MTS) in the setting of drug-resistant mesial temporal lobe epilepsy (MTLE). This patient meets ILAE criteria for drug-resistant epilepsy (failure of ≥2 appropriate ASMs at therapeutic doses). Harrison's 21e and the landmark Wiebe 2001 RCT establish that anterior temporal lobectomy with amygdalohippocampectomy is the treatment of choice for drug-resistant MTLE, achieving seizure freedom (Engel Class I) in 65–80% at 1 year, compared to <10% with continued medical management. The resection extent is 4–4.5 cm on the dominant side (to preserve language) or up to 5.5 cm on the non-dominant side.

Why each distractor is wrong

Harrison's 21e, Seizures and Epilepsy; Wiebe et al. 2001 RCT on temporal lobe epilepsy surgery