
Pterional approach
Mental Skills Required



Manual Skills Required




Pterional approach
Mental Skills Required



Manual Skills Required



Pterional approach

Mental Skills Required



Manual Skills Required



Tools involved:
Needed for this topic
Tools involved:
Tools involved:
Basic information
- The most useful neurosurgical approach
- Provides an adequate exposure of the entire Sylvian fissure and allows its dissection
- Probably the resident’s first craniotomy
Access to:
- The anterior cranial fossa
- Peri-sellar and suprasellar region
- Anterior third of the frontal and temporal opercula
- Orbital gyri
Keep in mind
- Consider whether the patient/location of the lesion are suitable for this type of approach
- Study carefully available images (CT, MR) to be prepared for anatomical rarities, use different section and projection
- Try to find the best route to the lesion with an avoidance of the excessive exposure and the retraction of brain tissue, otherwise use a different approach to reach the pathology
- Keep in mind the general anatomy (skin layers, temporal muscle, skull bones, brain surface, carotido-optic triangle, the circle of Willis)
- Be aware of possible slight distortion of the anatomy (patient is in the supine position and the head is rotated – effect of the gravity)
- Try to project the anatomy on the skin surface
Basic information
- The most useful neurosurgical approach
- Provides an adequate exposure of the entire Sylvian fissure and allows its dissection
- Probably the resident’s first craniotomy
Access to:
- The anterior cranial fossa
- Peri-sellar and suprasellar region
- Anterior third of the frontal and temporal opercula
- Orbital gyri
Keep in mind
- Consider whether the patient/location of the lesion are suitable for this type of approach
- Study carefully available images (CT, MR) to be prepared for anatomical rarities, use different section and projection
- Try to find the best route to the lesion with an avoidance of the excessive exposure and the retraction of brain tissue, otherwise use a different approach to reach the pathology
- Keep in mind the general anatomy (skin layers, temporal muscle, skull bones, brain surface, carotido-optic triangle, the circle of Willis)
- Be aware of possible slight distortion of the anatomy (patient is in the supine position and the head is rotated – effect of the gravity)
- Try to project the anatomy on the skin surface
Basic information
- The most useful neurosurgical approach
- Provides an adequate exposure of the entire Sylvian fissure and allows its dissection
- Probably the resident’s first craniotomy
Access to:
- The anterior cranial fossa
- Peri-sellar and suprasellar region
- Anterior third of the frontal and temporal opercula
- Orbital gyri
Keep in mind
- Consider whether the patient/location of the lesion are suitable for this type of approach
- Study carefully available images (CT, MR) to be prepared for anatomical rarities, use different section and projection
- Try to find the best route to the lesion with an avoidance of the excessive exposure and the retraction of brain tissue, otherwise use a different approach to reach the pathology
- Keep in mind the general anatomy (skin layers, temporal muscle, skull bones, brain surface, carotido-optic triangle, the circle of Willis)
- Be aware of possible slight distortion of the anatomy (patient is in the supine position and the head is rotated – effect of the gravity)
- Try to project the anatomy on the skin surface

Indications

Indications

Indications

Anatomy and important anatomical landmarks
- Skull bones – frontal, sphenoid, temporal, parietal, zygomatic, zygomatic arch, pterion
- Sphenoid wing
- Tragus, temporal muscle line
- Temporal muscle, facial nerve, superficial temporal artery, middle meningeal artery
- Brain surface (temporal, frontal lobe)
- Sylvian fissure
- Carotico-optic triangle, carotico-oculomotor triangle
- Circle of Willis
- Contralateral structures (optic nerve, carotid artery)

Anatomy and important anatomical landmarks
- Skull bones – frontal, sphenoid, temporal, parietal, zygomatic, zygomatic arch, pterion
- Sphenoid wing
- Tragus, temporal muscle line
- Temporal muscle, facial nerve, superficial temporal artery, middle meningeal artery
- Brain surface (temporal, frontal lobe)
- Sylvian fissure
- Carotico-optic triangle, carotico-oculomotor triangle
- Circle of Willis
- Contralateral structures (optic nerve, carotid artery)

Anatomy and important anatomical landmarks
- Skull bones – frontal, sphenoid, temporal, parietal, zygomatic, zygomatic arch, pterion
- Sphenoid wing
- Tragus, temporal muscle line
- Temporal muscle, facial nerve, superficial temporal artery, middle meningeal artery
- Brain surface (temporal, frontal lobe)
- Sylvian fissure
- Carotico-optic triangle, carotico-oculomotor triangle
- Circle of Willis
- Contralateral structures (optic nerve, carotid artery)

Positioning
- Usually, the supine position is preferred
- The head rotation is adapted to the exact location of the lesion
- Put the Mayfield fixation with sparing of the skin incision location
Body positioning – supine (0°), supine lateral (45°)

In case of extreme contralateral rotations of the head (generally more than 50°), a supine lateral position has to be considered in order to avoid venous compression

Head positioning: contralateral rotation (40°), lateral tilt (10°), extension (12°)


Extension:
From 10° to 30°

of 10° is needed to orient the vertex down

the final head rotation and extension are dependent on the position of the pathology (in general, more posterior and basal targets need more rotation)
Red Flags

Positioning
- Usually, the supine position is preferred
- The head rotation is adapted to the exact location of the lesion
- Put the Mayfield fixation with sparing of the skin incision location
Body positioning – supine (0°), supine lateral (45°)


Head positioning: contralateral rotation (40°), lateral tilt (10°), extension (12°)

Rotation:
from 15° to 60°

Extension:
From 10° to 30°

of 10° is needed to orient the vertex down

the final head rotation and extension are dependent on the position of the pathology (in general, more posterior and basal targets need more rotation)
Red Flags

Positioning
- Usually, the supine position is preferred
- The head rotation is adapted to the exact location of the lesion
- Put the Mayfield fixation with sparing of the skin incision location
Body positioning – supine (0°), supine lateral (45°)


Head positioning: contralateral rotation (40°), lateral tilt (10°), extension (12°)

from 15° to 60°

Extension:
From 10° to 30°

of 10° is needed to orient the vertex down

the final head rotation and extension are dependent on the position of the pathology (in general, more posterior and basal targets need more rotation)
Red Flags

Surgery
1. Skin incision


Red Flags
2. Initial dissection of the skin flap with elevator

3. Placement of hemostatic clips

4. Skin flap elevation with elevator

5. Dissection of temporal muscle



6. Incision and dissection of pericranium and temporal muscle



7. Burr hole with perforator

8. Preparation of the burr holes with dura separator

9. Craniotomy with high-speed drill

10. Edge drilling with high-speed drill

11. Dural tenting sutures

12. Dura incision with N°10 scalpel blade and scissors

Dura should be incised in a C-shape and reflected toward the cranial base

Surgery
1.Skin incision


Red Flags
2. Initial dissection of the skin flap with elevator

3. Placement of hemostatic clips

4. Skin flap elevation with elevator

5. Dissection of temporal muscle



6. Incision and dissection of pericranium and temporal muscle



7. Burr hole with perforator

8. Preparation of the burr holes with dura separator

9. Craniotomy with high-speed drill

10. Edge drilling with high-speed drill

11. Dural tenting sutures

12. Dura incision with N°10 scalpel blade and scissors


Surgery
1. Skin incision


Red Flags
2. Initial dissection of the skin flap with elevator

3. Placement of hemostatic clips

4. Skin flap elevation with elevator

5. Dissection of temporal muscle



6. Incision and dissection of pericranium and temporal muscle



7. Burr hole with perforator

8. Preparation of the burr holes with dura separator

9. Craniotomy with high-speed drill

10. Edge drilling with high-speed drill

11. Dural tenting sutures

12. Dura incision with N°10 scalpel blade and scissors


Closure
1. Dura reconstruction

2. Bone fixation with microscrews

3. Muscle reconstruction

4. Subcutaneous/skin suture

Aesthetic skin reconstruction is always mandatory.
Articles related to this topic:
Consequences of temporal muscle injury /superficial temporal artery/
https://thejns.org/view/journals/j-neurosurg/118/2/article-p309.xml
Consequences of facial nerve injury
https://thejns.org/view/journals/j-neurosurg/67/3/article-p463.xml

Closure
1. Dura reconstruction

2. Bone fixation with microscrews

3. Muscle reconstruction

4. Subcutaneous/skin suture

Articles related to this topic:
Consequences of temporal muscle injury /superficial temporal artery/
https://thejns.org/view/journals/j-neurosurg/118/2/article-p309.xml
Consequences of facial nerve injury
https://thejns.org/view/journals/j-neurosurg/67/3/article-p463.xml

Closure
1. Dura reconstruction

2. Bone fixation with microscrews

3. Muscle reconstruction

4. Subcutaneous/skin suture

Articles related to this topic:
Consequences of temporal muscle injury /superficial temporal artery
https://thejns.org/view/journals/j-neurosurg/118/2/article-p309.xml
Consequences of facial nerve injury
https://thejns.org/view/journals/j-neurosurg/67/3/article-p463.xml

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The UpSurgeOn Store offers you a series of virtual and physical technologies to give you the best training experience EVER

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Supported by the European Union
This project has received funding from the Eropean Union's H2020 Research and Innovation Programme under grant agreement n.880895

Supported by the European Union
This project has received funding from the Eropean Union's H2020 Research and Innovation Programme under grant agreement n.880895
Supported by the European Union
This project has received funding from the Eropean Union’s H2020 Research and Innovation Programme under grant agreement n.880895

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