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TECHNIQUE ASSESSMENT

“TANGENTIAL” RESECTION OF MEDIAL TEMPORAL LOBE


ARTERIOVENOUS MALFORMATIONS WITH THE
ORBITOZYGOMATIC APPROACH
Rose Du, M.D., Ph.D. OBJECTIVE: Arteriovenous malformations (AVMs) of the medial temporal lobe are
Department of Neurological usually resected through subtemporal-transcortical approaches that provide a trajec-
Surgery, University of California,
San Francisco, San Francisco,
tory that is perpendicular to the plane of the AVM. The pterional approach is some-
California times used for AVMs in the uncus and amygdala, but it is not recommended for AVMs
in the hippocampal region because it provides a “tangential” approach with limited
William L. Young, M.D. access to posterior feeding arteries and draining veins. The orbitozygomatic approach
Departments of Neurological enhances exposure along this tangential trajectory and was used in a consecutive
Surgery and Anesthesiology, series of 10 patients to determine its advantages.
University of California, San
Francisco, San Francisco, METHODS: During a 5.7-year period, 43 patients underwent resection of temporal
California lobe AVMs, 10 of which were located in the medial temporal lobe (amygdala and
uncus [Region A] or hippocampus, parahippocampus, and fusiform gyrus [Region B]).
Michael T. Lawton, M.D. AVMs were evenly distributed by region and by hemispheric dominance and included
Department of Neurological
Surgery, University of California,
two Spetzler-Martin Grade IV lesions. An orbitozygomatic approach was used in all
San Francisco, San Francisco, cases.
California RESULTS: Complete resection was accomplished in nine patients, and one patient
Reprint requests:
underwent multimodality management with postoperative stereotactic radiosurgery.
Michael T. Lawton, M.D., Good outcomes (Rankin outcome score ⱕ2) were observed in all patients, and six
Department of Neurological patients were improved neurologically at late follow-up (mean, 1.3 yr). No permanent
Surgery, University of California,
San Francisco, 505 Parnassus
language deficits were produced by this approach.
Avenue, M-780C, San Francisco, CONCLUSION: The orbitozygomatic approach maximizes the exposure of the tan-
CA 94143-0112. gential approach to medial temporal lobe AVMs and has advantages over traditional
Email:
lawtonm@neurosurg.ucsf.edu lateral approaches. It provides early access to critical feeding arteries from the anterior
choroidal artery, posterior cerebral artery, and posterior communicating artery; it
Received, July 18, 2003. minimizes temporal lobe retraction and risk to the vein of Labbé; and it avoids
Accepted, November 6, 2003. transcortical incisions or lobectomy that might impact language and memory function.
For these reasons, it may be the optimal approach for small- and medium-sized
compact AVMs in the dominant medial temporal lobe.
KEY WORDS: Arteriovenous malformation, Microsurgical resection, Orbitozygomatic approach, Tangential
approach

Neurosurgery 54:645-652, 2004 DOI: 10.1227/01.NEU.0000109043.56063.BA www.neurosurgery-online.com

A
rteriovenous malformations (AVMs) of the medial tem- regions in the anterior temporal lobe. There are subtle differ-
poral lobe, involving just the hippocampal area and not ences in the exact route through the fusiform or parahip-
the lateral or anterior temporal lobe, are not common. pocampal gyrus, with some neurosurgeons favoring the infe-
Published operative experience with these lesions is limited to rior temporal gyrus approach and others favoring a more
several small series (5, 7, 14, 16, 21). This region can be difficult medial approach (16, 20, 21). These approaches depend upon
to access surgically because, although cortical, its projection is varying degrees of temporal lobe retraction and present vary-
medial, and overlying lateral cortex in the dominant hemi- ing degrees of risk to the vein of Labbé. They provide a
sphere harbors Wernicke’s speech area. Surgical approaches to trajectory to the AVM that has been described by Stein (21) as
these AVMs are usually transcortical, capitalizing on the silent perpendicular to the plane of the AVM, enabling the feeding

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DU ET AL.

arteries and draining veins to be accessed at the margins of the ral pole, sylvian fissure, temporal horn of the lateral ventricle,
nidus. Such an approach is generally referred to as “tangen- or extending to the frontal lobe) were not included in this
tial”; in this approach, circumferential access is not available study, even if an orbitozygomatic approach was used in their
and some feeding arteries and draining veins are inaccessible treatment.
or outside the visible corridor of the approach. Conceptually,
tangential approaches can be dangerous when resecting Patients
AVMs and are usually avoided. Between August 1997 and March 2003 (5.7 yr), 208 patients
The orbitozygomatic approach provides a magnificent tra- with brain AVMs were surgically treated by the senior author
jectory to, and exposure of, the basilar apex and interpedun- (MTL) at the University of California, San Francisco. Ten
cular region, and it has been widely used for aneurysms, patients had medial temporal lobe AVMs in Region A (5
cavernous malformations, and other lesions in these regions patients) or Region B (5 patients) that were surgically treated
(6, 10–12). It also provides a trajectory along the medial tem- with an orbitozygomatic approach. Thirty-three patients had
poral lobe that makes it enticing for medial temporal lobe temporal lobe AVMs outside of Regions A and B and were
AVMs. However, the surgical trajectory is a tangential one, excluded.
with the lateral and posterior margins of the nidus obscured, The mean patient age was 23.7 years (range, 6–60 yr); there
and with potentially important feeding arteries and draining were four male and six female patients. The most common
veins hidden until the later stages of the dissection. In view of presentation was hemorrhage (six patients), with two patients
these increased challenges, the application of the orbitozygo- experiencing multiple hemorrhages. Intraventricular hemor-
matic approach to medial temporal lobe AVMs has not been rhage occurred frequently (five patients), but subarachnoid
previously reported. However, there are significant advan- and intraparenchymal hemorrhages were also observed.
tages to such an approach. First, accessing the medial cortex Three patients presented with intractable seizures. One patient
makes this more of a convexity approach than a transcortical presented with progressive memory deficits, hemiparesis, fa-
approach, obviating the need for corticectomy or lobectomy. cial numbness, and headaches. She had previously undergone
This advantage is particularly important in the dominant tem- gamma knife radiosurgery with little change in the size of her
poral lobe. Second, the approach provides early access to and AVM and further progression of symptoms 2 years after this
occlusion of critical feeding arteries from the anterior choroi- treatment.
dal artery (AChA) and the posterior cerebral artery (PCA).
Third, lateral retraction of the temporal lobe with the orbitozy- AVM Characteristics
gomatic approach appears to be tolerated better than superior
retraction with a subtemporal approach, with decreased risk AVMs were evenly divided between the right and left sides
of injury to the vein of Labbé. The advantages seem to out- and between Regions A and B. The Spetzler-Martin grading
weigh the disadvantages of a tangential approach; therefore, scale was applied, with a point for eloquence given only to
the orbitozygomatic approach was used in a consecutive series those AVMs in Region B on the dominant hemisphere. AVMs
of 10 patients. The surgical technique, results, and assessment in Region A on either side, and those in Region B on the
are presented. On the basis of this limited but favorable expe- nondominant side, were graded as noneloquent. There were
rience, we propose that the orbitozygomatic approach should three Grade I, four Grade II, one Grade III, and two Grade IV
be added to the list of possible surgical exposures of medial AVMs.
temporal lobe AVMs. The mean nidus diameter was 25 mm (range, 10–50 mm),
and no large AVMs were treated. The most frequently ob-
served feeding artery was the AChA, participating in the
PATIENTS AND METHODS supply of all but one AVM. In Region B, the ITA branch from
the PCA also participated in the supply of all AVMs. Deep
Definitions venous drainage through the BVR was encountered in half of
The orbitozygomatic approach was used in patients with the AVMs, with the majority of lesions also having superficial
medial temporal lobe AVMs located in Regions A and B, venous drainage through cortical veins on the inferior surface
according to Stein’s (21) definitions. An AVM in Region A is of the temporal lobe, which drained into the vein of Labbé and
located in the amygdala and uncus; it is supplied by branches transverse-sigmoid sinus junction, or through veins on the
of the AChA, the posterior communicating artery, the middle anterior temporal lobe, which drained into the middle cerebral
cerebral artery (MCA), and thalamoperforators; and it is veins. Nine AVMs had compact niduses, with sharp borders
drained by the basal vein of Rosenthal (BVR). An AVM in with adjacent brain; one had lateral and superior borders that
Region B is located in the hippocampus, parahippocampus, were diffuse.
and fusiform gyrus; it is supplied by the AChA and the
inferior temporal artery (ITA), a branch of the PCA, and it is Surgical Technique
drained by the BVR and veins on the inferior convexity of the The technical details of the orbitozygomatic craniotomy
temporal lobe (inferior temporal vein [ITV]). Other temporal have been described (6, 11, 26). The lateral orbital rim and
lobe AVMs (those located in the lateral temporal lobe, tempo- zygoma are exposed using the subfascial dissection technique.

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MEDIAL TEMPORAL ARTERIOVENOUS MALFORMATIONS

The orbital and zygomatic osteotomies are made after a stan- this deep draining vein, superficial draining veins are coagu-
dard pterional craniotomy, resulting in a bone flap and a lated as the dissection deepens and the AVM darkens.
separate orbitozygomatic unit. The cranial exposure is wid- During the dissection, systemic blood pressure is main-
ened inferiorly to the middle fossa floor, and posteriorly to the tained in the patient’s usual range to ensure adequate perfu-
level of the zygomatic root. With the operating microscope, sion in territories under retraction that might be affected by
the sylvian fissure is widely split to expose the internal carotid the perfusion pressure alterations from arteriovenous shunt-
artery and the MCA. Feeding arteries from the anterior tem- ing (25). Accordingly, induced hypotension is avoided unless
poral artery can be identified, coagulated, and divided. The there exists a specific indication, such as excessive bleeding
temporal lobe is mobilized, and temporal pole veins bridging from friable deep white matter vessels.
to the cavernous or sphenoparietal sinuses are sometimes
coagulated and divided. Arachnoidal planes around the ten-
torial incisura are opened, and the dissection deepens along Outcome
the course of the AChA and PCA. The AChA is followed out Outcome status (Table 1) was determined by clinical evalu-
to the choroidal fissure. These maneuvers allow the anterior ation, using the modified Rankin scale, 3 months after surgery
temporal lobe to be gently retracted laterally to visualize the and at the latest follow-up examination. Outcomes were inde-
medial temporal lobe, ambient cistern, anterolateral midbrain, pendently assessed by the research nurse for the University of
and tentorium. The medial surface of the AVM is usually California, San Francisco Brain Arteriovenous Malformation
visualized through this exposure, but it may also be just below Study Project.
a thin, overlying layer of cortex. Feeding arteries originating
from the AChA and PCA are identified, coagulated, and di-
vided. The planes around the nidus are dissected circumfer- RESULTS
entially, with attention directed toward feeding arteries from
the lateral margin, often through the ventricle. The draining Eight AVMs were embolized preoperatively with polyvinyl
BVR is often not visualized until the end of the dissection and alcohol particles. The two AVMs not embolized were small
must not be mistaken for a feeding artery. To get around to Grade I AVMs in Region A, with easily accessible feeding

TABLE 1. Summary of patient characteristicsa


Age
Patient Size Spetzler-Martin Postoperative F/U
(yr)/ Side Region Arterial supply Venous drainage Presentation ROS Change
no. (mm) grade deficit (yr)
sex

1 13/M L A 10 I S1V0E0 AChA, ATA, ITA ITV Seizure 0 Unchanged 0.5

2 16/F R A 15 I S1V0E0 AChA, PComA ITV, SPS Hemorrhage 1 Unchanged 0.3


(IVH, SAH)

3 33/F R A 23 I S1V0E0 ATA, ITA ITV Hemorrhage 0 Improved 1.7


(ICH, 2)

4 60/M L A 15 II S1V1E0 AChA, ATA BVR, ITV Seizure 0 Unchanged 0.3

5 7/F R A 16 II S1V1E0 AChA BVR Hemorrhage 2 Improved 3.3


(IVH)

6 13/M R B 33 II S2V0E0 AChA, ATA, ITA, ITV, MCV Hemorrhage 0 Improved 2.1
PCA (ICH, IVH)

7 9/F R B 35 II S2V0E0 AChA, ATA, ITA ITV, MCV Seizure T 1 Unchanged 2.7

8 6/F L B 23 III S1V1E1 AChA, ITA BVR, ITV Hemorrhage 0 Improved 0.5
(IVH)

9 50/M L B 32 IV S2V1E1 AChA, ATA, PCA, BVR, ITV Hemorrhage T 1 Improved 0.5
ITA (IVH & SAH, 2)

10 30/F L B 50 IV S2V1E1 AChA, ATA, PCA, BVR, MCV, CS Hemiparesis, T 1 Improved 1.5
ITA 2 memory
a
ROS, Rankin outcome score; F/U, follow-up duration; L, left; R, right; S1, size of nidus diameter ⬍3 cm; S2, size of nidus diameter 3– 6 cm; S3, size of nidus diameter ⬎6 cm; V0, superficial
venous drainage; V1, deep venous drainage; E0, arteriovenous malformation (AVM) location in eloquent brain; E1, AVM location in noneloquent brain; AChA, anterior choroidal artery; ATA,
anterior temporal artery; ITA, inferior temporal artery; PComA, posterior communicating artery; PCA, posterior cerebral artery; ITV, inferior temporal vein; SPS, superior petrosal sinus; BVR,
basal vein of Rosenthal; MCV, middle cerebral vein; CS, cavernous sinus; IVH, intraventricular hemorrhage; SAH, subarachnoid hemorrhage; 2, decrease; T, temporary.

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DU ET AL.

arteries. One patient had a new, mild, receptive aphasia


postembolization.
All 10 patients had orbitozygomatic craniotomies, with the
intent to fully resect the AVM. Complete resection was accom-
plished in nine patients. The incomplete resection was in the
patient with a diffuse Grade IV AVM in the dominant hemi-
sphere. The posterosuperior margin was difficult to visualize
and had feeding arteries that were difficult to control; there-
fore, the nidus was circumscribed on all but this margin and
was subsequently treated with gamma knife radiosurgery.
Angiography confirmed complete resection in nine patients.
Three patients experienced transient treatment-associated
neurological deterioration. One patient had a mild hemipare-
sis, and two patients had word-finding difficulty, which re-
solved at early follow-up examination.
Good outcomes (Rankin outcome scores [ROSs] ⱕ2) were
observed in all 10 patients: ROS 0, 5 patients (50%); ROS 1, 4
patients (40%); and ROS 2, 1 patient (10%). The mean
follow-up duration was 1.3 years (range, 0.1–3.3 yr). With
respect to their preoperative neurological condition, four pa-
tients were unchanged and six patients were improved. Im-
provement was typically observed in patients recovering from
hemorrhage. In the five patients with dominant hemisphere
AVMs, no new permanent speech deficits were produced.

Illustrative Cases
Patient 8
A 6-year-old girl presented with sudden vomiting and lethargy; the
neurological examination disclosed nothing abnormal. A computed
tomographic scan of the head showed intraventricular hemorrhage,
primarily in the temporal horn of the left lateral ventricle (Fig. 1).
Cerebral angiography revealed a Spetzler-Martin Grade III AVM (23
⫻ 20 ⫻ 15 mm, Region B), fed by the ITA and the AChA. The AVM
drained into the BVR and an ITV that coursed anteriorly to the
sphenoparietal sinus. The patient was managed with an external
ventricular drain and discharged home after 10 days.
She was readmitted 4 weeks later for preoperative embolization of
two branches of the ITA feeding the AVM. The lesion was approached
through an orbitozygomatic craniotomy with a wide sylvian fissure
opening (Fig. 2). The AChA was dissected along its course to the
choroidal fissure, and the branches that contributed to the AVM were
FIGURE 1. Patient 8. A, computed tomographic scan of the head demon-
coagulated and divided. The PCA was followed along the tentorial
strating an intraparenchymal hemorrhage with intraventricular extension
edge, and the feeding arteries were coagulated and divided. The large
into the left temporal horn. B and C, axial (B) and coronal (C)
draining vein running beneath the temporal lobe was carefully pre-
T2-weighted MRI scans of the brain showing the AVM in the left amyg-
served until the BVR was better visualized, after which it was divided
dala and hippocampus (Region B). D and E, left vertebral artery angio-
to mobilize the nidus. The AVM was dissected circumferentially,
grams in the lateral (D) and anteroposterior (E) projections demonstrating
converging on the BVR.
a Spetzler-Martin Grade III AVM (23 ⫻ 20 ⫻ 15 mm), fed by the ITA
Postoperative angiography showed complete resection of the AVM.
and AChA and drained by the BVR and ITV. F, postoperative left verte-
The patient remained neurologically intact postoperatively and had
bral artery angiogram (left anterior oblique view) revealing no residual
recovered completely at the 3-month follow-up.
AVM.
Patient 9
A 50-year-old man presented with a sudden, severe headache. A the current admission and was treated with a ventriculoperitoneal
head computed tomographic scan demonstrated intraventricular shunt at an outside institution. After this second hemorrhage, he was
hemorrhage in the left temporal horn. A medial temporal AVM had transferred for definitive treatment of the AVM.
been diagnosed 20 years earlier, after the patient experienced a sei- Cerebral angiography showed a Spetzler-Martin Grade IV AVM (22
zure. His first hemorrhage from the AVM occurred 3 months before ⫻ 24 ⫻ 32 mm, Region B) fed by the AChA, the anterior temporal

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MEDIAL TEMPORAL ARTERIOVENOUS MALFORMATIONS

FIGURE 2. Patient 8. Intraoperative photographs. A, exposure through


the orbitozygomatic approach after widely splitting the sylvian fissure. B,
gentle lateral retraction on the pole of the temporal lobe exposed the tento-
rium and tentorial incisura, where feeding arteries (C) from the ITA and
AChA were identified and coagulated. D, after dividing these feeding
arteries, the AVM was mobilized to visualize the posterior margins of the
nidus and BVR.

artery from the left MCA, and branches from the PCA, including the
ITA (Fig. 3). The AVM drained into the BVR and the ITV. Feeding
arteries from the AChA and the MCA were embolized preoperatively,
after which the patient developed a new aphasia. Magnetic resonance
imaging (MRI) of the brain showed an acute left temporal infarct. The
patient’s aphasia gradually improved during the following week, and
he underwent orbitozygomatic craniotomy and AVM resection. Me-
dial feeding arteries from the AChA, ITA, and PCA were easily
occluded early in the dissection. The posterior pole of the AVM was
diffuse, and the feeding arteries were difficult to coagulate; conse-
quently, a complete resection was not pursued. The posterior draining
BVR was preserved.
The postoperative angiogram demonstrated filling of the AVM
from small PCA and MCA branches. The patient’s preoperative apha-
sia resolved completely, and he underwent gamma knife radiosurgery
for the residual AVM.

DISCUSSION
FIGURE 3. Patient 9. A, axial T1-weighted MRI scan of the brain with
Traditional Approaches to Medial Temporal Lobe AVMs gadolinium demonstrating a left medial temporal lobe AVM (Region B).
B–D, left internal carotid artery angiograms in the anteroposterior (B) and
AVMs located in the medial temporal lobe are typically
lateral (C) views and left vertebral artery angiogram in the anteroposterior
resected through transcortical, subtemporal, or pterional ap- view (D) revealing a Spetzler-Martin Grade IV AVM (22 ⫻ 24 ⫻ 32
proaches (5, 7, 14, 16, 20, 21, 24). Direct transcortical ap- mm), fed by the AChA, the anterior temporal artery, and the ITA, and
proaches through the superior or middle temporal gyrus are drained by the BVR and the ITV. The posterior portion of the AVM was
associated with visual field deficits resulting from interrup- diffuse, and a complete resection was not pursued. E and F, postoperative
tion of visual radiation pathways and Meyer’s loop (7). In the left internal carotid artery angiogram (E, lateral view) and right vertebral
dominant hemisphere, this route is also associated with Wer- artery angiogram (F, anteroposterior view) demonstrating the residual fill-
nicke’s aphasia from injury to the sensory speech area and is ing of the AVM that was treated with gamma knife radiosurgery.
consequently avoided (7). The subtemporal approach circum-
vents these structures but, in Heros’ words, “necessitates con- rior temporal gyrus or fusiform gyrus to minimize this retrac-
siderable temporal lobe retraction and carries substantial risk tion. Head fixation in a lateral and dependent position al-
of damage to the vein of Labbé” (7, p 49). Heros combined the lowed gravity to retract the temporal lobe, while cerebrospinal
subtemporal approach with transcortical incisions in the infe- fluid drainage and mannitol facilitated the exposure (7). So-

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lomon and Stein (20) used a similar subtemporal-transcortical he circumscribes the lesion by incision” (21, p 24). The expe-
approach through either the inferior temporal, fusiform, or rience with 10 medial temporal AVMs reported here suggests
parahippocampal gyrus but noted that “a great deal of normal that this limitation may be overstated. Feeding arteries along
cerebral tissue is [still] traversed via this route before the the lateral and superior margins of the nidus can be difficult to
malformation is encountered” (20, p 713). Drake (5) observed access, particularly with a large, diffuse AVM. This limitation
that the vein of Labbé, in addition to being at risk for retraction of the tangential approach probably contributed to the one
injury, sometimes crosses the path of the cortical incision, incomplete resection in this patient series, but this was a
necessitating separate incisions in front of and behind the vein Spetzler-Martin Grade IV AVM. In addition, deep draining
to preserve it. In their review of temporal lobe AVMs, Malik et veins (e.g., the BVR) are often hidden until the end of the
al. (14) performed a limited temporal lobectomy (anterior, 3 resection. Nonetheless, the limitations of a tangential orbitozy-
cm) in some patients to enhance the operative exposure. Oth- gomatic approach were easily overcome and did not adversely
ers have used a transcortical-transventricular route to reach affect patient outcomes. Medial feeding arteries from the PCA
these AVMs, working through the choroidal fissure of the and the AChA were accessed easily and early. After eliminat-
temporal horn (9). The pterional or pretemporal approach ing this supply, the nidus could be mobilized to better expose
with a wide sylvian fissure split is another option for AVMs in the lateral and superior borders. In contrast, medial feeding
the anterior temporal lobe, amygdala, and uncus, opening a arteries often remain inaccessible from lateral subtemporal-
more anterior trajectory to the lesion (Region A) (3, 4, 19, 21, transcortical approaches until the end of the dissection. This
23). initial experience with a tangential approach demonstrates
Complication rates associated with these traditional ap- that its advantages may outweigh its disadvantages when
proaches are low. Postoperative speech deficits are uncom- dealing with small- and medium-sized compact AVMs. It may
mon but have been observed (14, 16). The fusiform and lingual not be optimal for medium- and large-sized diffuse AVMs,
gyri in the dominant hemisphere have been implicated in and it may also be contraindicated when the AVM extends
language function with direct intraoperative electrical stimu- beyond the cerebral peduncle to wrap around the posterolat-
lation and functional MRI studies (1, 13, 22). The superior eral midbrain, where visualization of the venous drainage is
portion of the inferior temporal gyrus has also been shown to impaired further. For these lesions, an alternative exposure or
have some involvement in speech, although infrequently (13). stereotactic radiosurgery may be required.
When corticectomy in the middle temporal gyrus is performed The greatest potential advantage of the orbitozygomatic
in patients with a preexisting visual field defect, postoperative tangential approach is that it minimizes risk to language and
speech disturbance has been observed (16), demonstrating memory function in patients with dominant hemisphere
that the anterior middle temporal gyrus is sometimes involved AVMs. The technique requires no corticectomy or lobectomy,
in verbal memory (15). The effects of AVM resection on cog- and anterolateral temporal lobe retraction appears to be toler-
nitive function and, in particular, memory have been under- ated better than the superior temporal lobe retraction with
reported and poorly characterized, but subtle deficits resulting subtemporal approaches. The subtemporal approach to the
from interruption of hippocampal and parahippocampal path- parahippocampal gyrus has been shown to cause retraction
ways are likely, especially when dealing with larger lesions injury to the fusiform gyrus and inferior temporal gyrus, as
(2). demonstrated on postoperative MRI (17). The vein of Labbé
does not cross the trajectory of the orbitozygomatic approach,
and temporal lobe retraction poses no threat to it. Wernicke’s
Tangential Orbitozygomatic Approach to Medial area is avoided completely. Five patients in this patient series
Temporal Lobe AVMs had dominant hemisphere AVMs, and none had lasting
The advantages of the orbitozygomatic approach have been speech deficits. Two patients had mild temporary Wernicke’s
documented extensively in anatomic and clinical studies. aphasias that were attributed to cerebral edema in one patient
When compared with the subtemporal and pterional ap- and to preoperative embolization in the other. The orbitozy-
proaches, the orbitozygomatic approach provides a more an- gomatic approach also eliminates the risk of injury to the
terior trajectory, a shorter working distance to the target (2.5–3 visual pathways that have been reported with other ap-
cm less), and a widened area of exposure (increased from 26% proaches (7, 14). Therefore, in patients with medial temporal
to 39%) (6, 8, 18). Consequently, this approach has found wide lobe AVMs in the dominant hemisphere, the tangential or-
application in the management of basilar apex aneurysms, bitozygomatic approach may minimize the risk of speech and
upper brainstem cavernous malformations, parasellar tumors, memory deficit postoperatively and maximize the neurosur-
and other lesions. The orbitozygomatic approach to medial geon’s confidence in confronting these AVMs.
temporal lobe AVMs gives the neurosurgeon a trajectory
along the lesion’s medial edge and necessitates a tangential
resection. Stein (21) described the difficulty with tangential, as REFERENCES
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DU ET AL.

follow-up. Complete resection was achieved in all but one The orbitozygomatic approach provides early control of
patient with a Grade IV AVM with diffuse feeders at the feeding arteries (anterior choroidal, posterior communicating,
posterior aspect of the nidus. No permanent speech difficulties and middle cerebral arteries) and also provides late exposure
were observed. of the basal vein of Rosenthal, which usually constitutes the
AVMs at the mesial temporal lobe are different from other drainage of these lesions. The venous portion remains hidden
temporal lobe AVMs because they are deep and access is until the end of the procedure, once the nidus and the arterial
limited by healthy brain. Multiple approaches have been de- supply have been controlled.
scribed for attacking them: from the lateral aspect entering the The orbitozygomatic approach also attacks the AVM from a
brain through the inferior temporalis sulcus, inferiorly tangential angle. “Blind spots” may be present at the posterior
through the collateral sulcus or occipitotemporal gyrus, and and lateral aspects of the temporal lobe. The authors describe
from above through the circular gyrus after opening the syl- this problem as one of the potential causes of partial obliter-
vian fissure and exposing the insular cortex. These approaches ation in one patient. This approach is indicated for small,
potentially threaten the vein of Labbé, Wernicke’s area, and compact lesions that indent or are closer to the medial surface
Meyer’s loop, causing potential venous hemorrhages, aphasia, of the temporal lobe.
and visual field cuts, respectively. Surgical approaches should be tailored on the basis of indi-
The orbitozygomatic approach offers a direct line of sight vidual anatomy (arterial feeders and drainage) and specific
and the shortest route without violating normal brain to ex- lesion location. Frameless stereotactic image guidance and
pose the mesial temporal lobe; it provides significantly wider intraoperative angiography constitute an invaluable resource
exposure than the traditional pterional approach. The addi- to ensure complete resection. The orbitozygomatic approach
tional exposure facilitates dissection because the anatomy is should be included in the neurosurgical armamentarium for
closer and there is more space to manipulate instruments. A the treatment of mesial temporal lobe AVMs.
wider exposure reduces the amount of retraction, which in
L. Fernando Gonzalez
this particular case represents fewer language problems on the
Robert F. Spetzler
dominant side.
Phoenix, Arizona
We quantified (1) the amount of exposure obtained with the
orbitozygomatic approach and found it especially useful for
approaching the ambient cistern and the P2 segment of the
1. Gonzalez LF, Crawford NR, Horgan MA, Deshmukh P, Zabramski JM,
posterior cerebral artery without exposing the lateral surface Spetzler RF: Working area and angle of attack of three cranial base ap-
of the brain. Because the opening is wider, more distant re- proaches: Pterional, orbitozygomatic, and maxillary extension of the
gions are more easily accessed and retraction is minimized. orbitozygomatic approach. Neurosurgery 50:550–557, 2002.

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