title: Transsylvian-transinsular approaches to the insula and basal ganglia: operative techniques and results with vascular lesions.
abstract: BACKGROUND
  Lesions in the insula and basal ganglia can be risky to resect because of their depth and proximity to critical structures, particularly in the dominant hemisphere. Transsylvian approaches shorten the surgical distance to these lesions, preserve perisylvian temporal and frontal cortex, and minimize brain transgression.
  
  
  OBJECTIVE
  To report our experience with transsylvian-transinsular approaches to vascular lesions.
  
  
  METHODS
  The anterior approach opened the sphenoidal and insular portions of the sylvian fissure and exposed the limen insulae and short gyri, whereas the posterior approach opened the insular and opercular portions of the sylvian fissure and exposed the circular sulcus and long gyri.
  
  
  RESULTS
  Forty-one patients with vascular lesions (24 arteriovenous malformations [AVMs] and 17 cavernous malformations) were treated surgically with a transsylvian-transinsular approach. Complete resection was obtained in 87.5% of AVMs and 95% of cavernous malformations. Permanent neurological morbidity related to surgery was observed in 2 AVM patients (5%), with the remaining 39 patients (95%) improved or unchanged postoperatively (modified Rankin Scale scores 0-2 in 83%). There were no new language deficits in patients with dominant hemisphere lesions.
  
  
  CONCLUSIONS
  Transsylvian-transinsular approaches safely expose vascular pathology in or deep to the insula while preserving overlying eloquent cortex in the frontal and temporal lobes. The anterior transsylvian-transinsular approach can be differentiated from the posterior approach based on technical differences in splitting the sylvian fissure and anatomic differences in final exposure. Discriminating patient selection and careful microsurgical technique are essential.
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco, California 94143-0112, USA.
authors.forename: Matthew B
authors.initials: MB
authors.lastname: Potts
authors.forename: Edward F
authors.initials: EF
authors.lastname: Chang
authors.forename: William L
authors.initials: WL
authors.lastname: Young
authors.forename: Michael T
authors.initials: MT
authors.lastname: Lawton
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001932:Brain Neoplasms / Q000098:blood supply / Q000601:surgery*; D002648:Child; D005260:Female; D020786:Hemangioma, Cavernous, Central Nervous System / Q000097:blood / Q000601:surgery*; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000097:blood / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009389:Neovascularization, Pathologic; D019635:Neurosurgical Procedures / Q000379:methods*; D055815:Young Adult