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The place for surgical treatment for AVM involving the temporal lobe

  • Clinical Article
  • Published:
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Abstract

Objective

The objective of this study was to analyze preoperative symptoms and late clinical outcomes in patients who underwent surgical treatment of arterio-venous malformations (AVMs) of the temporal lobe, including those involving the Sylvian fissure (SF) and the lateral wall of the inferior ventricular horns—with special respect to postoperative hemiparesis and visual field defects (VFD).

Methods

Between 1990 and 2007, 44 patients (n = 22 women, n = 22 men) with a mean age of 41 (12–67) years were operated on an AVM of the temporal lobe. All data had been collected prospectively. Patients’ charts, as well as surgical reports and outpatient files, were analyzed. Thirteen patients showed an involvement of the SF, and six were localized partially in the lateral wall of the temporal horn. Eight AVMs were located in the temporo-mesial region. Fourteen patients had an AVM located mainly within the visual pathway. In 24 cases, the AVM was located in the dominant hemisphere. The AVMs were classified by the Spetzler–Martin grading system (SM). Visual fields were assessed in all patients pre- and postoperatively by independent ophthalmological examiners.

Results

The initial symptoms leading to the diagnosis of the AVM were seizures in 20 cases (45%), headache without hemorrhage in six cases (14%), incidental finding in five cases (11%), and tinnitus in two cases (5%). Hemorrhage had occurred in 15 cases (34%). Based on SM, 7 AVMs were grade I, 17 grade II, 17 grade III, and 3 grade IV. Preoperatively, seven patients presented with a VFD and two with a hemiparesis. Postoperatively, 8 of 44 (18%) patients presented with a new hemiparesis, remaining permanent in 3 of 44 (7%). In two of these patients, the AVMs were localized temporo-mesially (n = 2/8, 25%). Seven patients (19%) showed a new significant postoperative VFD, and in addition, three patients had worsening of their preexisting VFD (3/7, 43%). Postoperative angiography verified complete AVM occlusion in 43 of 44 (98%) cases. One patient needed reoperation for residual AVM; hence, in all patients, complete occlusion before discharge was achieved.

Conclusion

Treatment of temporal lobe AVMs is demanding due to their close spatio-anatomical relationship with important neurovascular structures and the optic radiation. In this surgically treated series, morbidity for a new permanent hemiparesis was 7% and preservation of the visual field could be achieved in almost 90% of all cases. This is a calculable risk for most patients that renders microsurgical resection a justifiable option, even in light of other treatment modalities. The risk for new permanent motor deficits is elevated in temporo-mesial AVMs, and these patients have to be advised accordingly for surgical treatment.

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Authors and Affiliations

  1. Department of Neurosurgery, University of Bonn Medical School, Sigmund-Freud-Str. 25, 53105, Bonn, Germany

    Azize Boström, Jeanine Seifert & Johannes Schramm

  2. Department of Neurosurgery, University of Geneva Medical Center, Geneva, Switzerland

    Karl Schaller

Authors
  1. Azize Boström
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  2. Karl Schaller
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  3. Jeanine Seifert
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  4. Johannes Schramm
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Correspondence to Azize Boström.

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Comment

Arteriovenous malformations are challenging lesions to treat, even for experienced vascular neurosurgeons. Temporal AVMs have the additional difficulty of being often in the close vicinity of the optic radiation and vascular supply to eloquent areas. Those in the dominant hemisphere may be associated with Wernicke’s area. This paper describes a single-center experience of 44 patients with temporal AVMs who underwent a microneurosurgical excision. The results of this series reflect the challenges of the treatment: 7% of the patients suffered from a new permanent hemiparesis and 19% of a new visual field deficit. On the other hand, a complete angiographically verified removal of the lesion was achieved in every case. Since endovascular treatment or radiosurgery of AVMs in eloquent areas carry significant risks as well, while the probability of complete obliteration with these modalities is by far <100%, microneurosurgical treatment by an experienced cerebrovascular surgeon remains a very viable option. Surgery has the added benefit of obliterating the lesion immediately. Incomplete embolization may even increase the risk of AVM rupture, and the complete occlusion of AVM after radiosurgery (when achieved) may take 2–3 years, leaving the patient at risk of rupture for quite a long time.

Contrary to the experience of the authors, however, we have found preoperative Onyx embolization often helpful, especially in larger AVMs. When multimodal treatment is chosen, we plan the surgery as soon as possible after the embolization (even on the same day) to minimize the time the AVM remains only partially occluded to prevent hemorrhagic complications. But we do agree with the authors that multimodal treatment should only be chosen when it provides true benefits that outweigh the combined risks of multiple treatment sessions.

Aki Laakso

Mika Niemelä

Juha Hernesniemi

Helsinki, Finland

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Boström, A., Schaller, K., Seifert, J. et al. The place for surgical treatment for AVM involving the temporal lobe. Acta Neurochir 153, 271–278 (2011). https://doi.org/10.1007/s00701-010-0885-1

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  • DOI: https://doi.org/10.1007/s00701-010-0885-1

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