Temporal lobe arteriovenous malformations: anatomical subtypes, surgical strategy, and outcomes

Clinical article

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Object

Descriptions of temporal lobe arteriovenous malformations (AVMs) are inconsistent. To standardize reporting, the authors blended existing descriptions in the literature into an intuitive classification with 5 anatomical subtypes: lateral, medial, basal, sylvian, and ventricular. The authors' surgical experience with temporal lobe AVMs was reviewed according to these subtypes.

Methods

Eighty-eight patients with temporal lobe AVMs were treated surgically.

Results

Lateral temporal lobe AVMs were the most common (58 AVMs, 66%). Thirteen AVMs (15%) were medial, 9 (10%) were basal, and 5 (6%) were sylvian. Ventricular AVMs were least common (3 AVMs, 3%). A temporal craniotomy based over the ear was used in 64%. Complete AVM resection was achieved in 82 patients (93%). Four patients (5%) died in the perioperative period (6 in all were lost to follow-up); 71 (87%) of the remaining 82 patients had good outcomes (modified Rankin Scale scores 0–2); and 68 (83%) were unchanged or improved after surgery.

Conclusions

Categorization of temporal AVMs into subtypes can assist with surgical planning and also standardize reporting. Lateral AVMs are the easiest to expose surgically, with circumferential access to feeding arteries and draining veins at the AVM margins. Basal AVMs require a subtemporal approach, often with some transcortical dissection through the inferior temporal gyrus. Medial AVMs are exposed tangentially with an orbitozygomatic craniotomy and transsylvian dissection of anterior choroidal artery and posterior cerebral artery feeders in the medial cisterns. Medial AVMs posterior to the cerebral peduncle require transcortical approaches through the temporo-occipital gyrus. Sylvian AVMs require a wide sylvian fissure split and differentiation of normal arteries, terminal feeding arteries, and transit arteries. Ventricular AVMs require a transcortical approach through the inferior temporal gyrus that avoids the Meyer loop. Surgical results with temporal lobe AVMs are generally good, and classifying them does not offer any prediction of surgical risk.

Abbreviations used in this paper:AChA = anterior choroidal artery; ACoA = anterior communicating artery; ATA = anterior temporal artery; AVM = arteriovenous malformation; BA = basilar artery; BVR = basal vein of Rosenthal; DSA = digital subtraction angiogram; ICA = internal carotid artery; LSA = lenticulostriate artery; MCA = middle cerebral artery; MMA = middle meningeal artery; mRS = modified Rankin Scale; MTA = middle temporal artery; PCA = posterior cerebral artery; PCoA = posterior communicating artery; PTA = posterior temporal artery; STA = superior temporal artery; UCSF = University of California, San Francisco; VA = vertebral artery.

Article Information

Address correspondence to: Michael T. Lawton, M.D., Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Ave., M780, San Francisco, CA 94143-0112. email: lawtonm@neurosurg.ucsf.edu.

Please include this information when citing this paper: published online July 12, 2013; DOI: 10.3171/2013.6.JNS122333.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Lateral temporal AVMs are located on the lateral convexity (upper, lateral view of left hemisphere; lower, superior view of coronally transected left temporal lobe). The lesions are supplied by ATA (AntTempA) and MTA (MidTempA) branches from the inferior trunk of the MCA, as well as PTAs (PostTempA) from the PCA. These AVMs are drained anteriorly by superficial sylvian veins (SupSylV) and posteriorly by the vein of Labbé. ISS = inferior sagittal sinus; MidTempV = middle temporal vein; SigmS = sigmoid sinus; TrvS = transverse sinus.

  • View in gallery

    Basal temporal AVMs are located on the basal temporal surface (left, inferior view of right hemisphere; right, superior view of coronally transected right temporal lobe). The lesions are supplied by ATA and MTA branches from the inferior trunk of the MCA, as well as PTAs from the PCA. These AVMs drain anteriorly to deep sylvian veins (DeepSylV) and posteriorly to temporal basal veins (TempBasV). II = second cranial nerve; MedTempV = medial temporal vein; M2 = insular segment of MCA; M3 = opercular segment of MCA; VoG = Vein of Galen.

  • View in gallery

    Medial temporal AVMs are based on the medial surface (left, inferior view of right hemisphere; right, superior view of coronally transected right temporal lobe). The lesions are supplied by the temporopolar artery, PCoA, AChA, and PTAs from the PCA. These AVMs drain to the BVR and vein of Galen. M1 = sphenoidal segment of MCA; SCA = superior cerebellar artery.

  • View in gallery

    Sylvian temporal AVMs are based on the lateral surface of the sylvian fissure (upper, anterolateral view of the left temporal lobe, with lateral left frontal lobe transected parasagittally to expose insular cortex; lower, superior view of coronally transected left temporal lobe). The lesions are supplied by ATA, MTA, and PTA branches from the inferior trunk of the MCA. These AVMs drain to deep and superficial sylvian veins, as well as anterior, middle, and posterior temporal veins on the lateral convexity.

  • View in gallery

    Temporal horn AVMs are located in the lateral ventricle, based on the choroidal fissure. The lesions are supplied by the AChA and the lateral posterior choroidal artery (LPChA). These AVMs drain to the hippocampal vein (HippoV) and the BVR. ACA = anterior cerebral artery.

  • View in gallery

    Lateral temporal AVM. This AVM (Spetzler-Martin Grade III+, supplementary Grade III) was supplied by large feeding arteries from the inferior trunk, as seen on DSAs (left ICA injection; lateral [A] and anteroposterior [B] views) after preoperative embolization with coils and glue. The lateral temporal lobe AVM (C) was exposed through an orbitozygomatic craniotomy for perpendicular access to its borders. The deep plane extended to the ependymal surface of the temporal horn of the lateral ventricle, where the AChA supplied the medial border.

  • View in gallery

    Basal temporal AVM. This AVM (Spetzler-Martin Grade III−, supplementary Grade III) was based on the basal surface of the temporal lobe (A), as seen on a coronal T2-weighted MRI study, and was supplied by posterior temporal branches of the PCA, as seen on DSAs (left VA injection; anteroposterior [B] and lateral [C] views). Basal temporal AVMs are not visible on the lateral temporal lobe, as exposed through a temporal craniotomy. Subtemporal dissection exposes the posterior temporal feeding arteries and draining temporal basal veins (D).

  • View in gallery

    Medial temporal AVM. This AVM (Spetzler-Martin Grade III, supplementary Grade I) in a 3-year-old girl occupied the medial temporal lobe (A), as seen on an axial T2-weighted MRI study. It was supplied by AChA and PCoA branches as well as anterior and middle temporal branches of the MCA, as seen on DSAs (right ICA injection; lateral [B] and anteroposterior [C] views). Note the deep venous drainage to the BVR, which has a distal varix and drains into a persistent prosencephalic vein/falcine sinus. Posterior temporal branches from the PCA also fed the nidus (D), as seen on DSAs (right VA injection, anterior oblique view). The AVM was embolized extensively and exposed surgically through a temporal craniotomy, with resection of inferior temporal and occipitotemporal gyri to access the parahippocampus, lateral ventricle, and tentorial incisura. This transcortical dissection exposed the AVM's lateral margin (E). A large posterior temporal feeding artery filled with coils was transected to access medial feeders from AChA, PCoA, and PCA. The arterialized BVR is seen under the sucker.

  • View in gallery

    Sylvian temporal AVM. This AVM (Spetzler-Martin Grade III−, supplementary Grade III) is located on the sylvian surface of the temporal lobe, facing the sylvian fissure (A), as seen on an axial T1-weighted MRI study. The AVM is supplied by insular branches of the MCA, as seen on DSAs (left ICA injection; lateral [B] and anteroposterior [C] views). Left pterional craniotomy and wide splitting of the sylvian fissure exposed the MCA trifurcation and the arterialized vein beneath (D). By following the vein into the planum polare of the temporal lobe, the nidus was identified and circumdissected lateral to the inferior trunk, sparing the insula and frontal lobe.

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