Anterior Temporal Lobectomy for Transchoroidal Microsurgical Resection of a Left Medial Temporal Arteriovenous Malformation: 2-Dimensional Operative Video

Medial temporal lobe arteriovenous malformations (AVMs) require nuanced approach selection because of their deep location and proximity to areas associated with higher cognitive function, including memory and learning, language and auditory reception, and vision.1-5 A man in his early 20s who presented with a severe headache was diagnosed with a ruptured left medial temporal AVM, classified as Spetzler-Martin grade IV (size, 2; deep venous drainage, 1; and eloquence, 1) and Lawton-Young grade II (age, 2; bleeding, 0; and compactness, 0), with a supplemented grade of 6.6,7 Written informed consent was obtained. The patient underwent preoperative embolization andWada testing. After a left pterional craniotomy, an anterior temporal lobectomy was performed, followed by wide splitting of the choroidal fissure along the fornix. The dissection progressed through the choroidal fissure to identify the posterior cerebral artery and feeding branches, which were divided. The dissection planes were developed laterally, while working medial to the atrium of the lateral ventricle and ascending toward the atrium. The final feeders from the posterior cerebral artery and the choroidal arteries were divided, which facilitated removal of the AVM. Postoperatively, the patient had a new right homonymous superior quadrant anopsia. At the 1-year follow-up, the patient continued to work, with a well-compensated visual deficit. This video demonstrates the resection of a medial temporal AVM through an anterior temporal lobectomy and transchoroidal approach. Because of the AVM's high-rising location, a meticulous dissection of the choroidal fissure along the fornix was undertaken, followed by a gradual ascent toward the atrium to successfully expose the AVM.