Pterional approach

Mental Skills Required

Automatism

Imagination

Strategy

Manual Skills Required

Automatism

Dexterity

Speed

Mental Skills Required

Automatism

Imagination

Strategy

Manual Skills Required

Automatism

Dexterity

Speed

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 

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 the different section and projection  
  • Try to find the best route to the lesion with avoidance of 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

Structures which are easily accessed through the pterional craniotomy: frontal and temporal opercula, the anterior cranial fossa, orbital gyri, peri- and suprasellar regions and vessels creating the circle of Willis.


Anatomy and important anatomical landmarks

  • Skull bones – frontal, sphenoid, temporal, parietal, zygomatic, zygomatic arch, pterion, hypophyseal region /anterior + middle cranial fossa/
  • Sphenoid wing
  • Tragus, temporal muscle line
  • Temporal muscle, facial nerve, superficial temporal artery, middle meningeal artery
  • Brain surface /temporal, frontal lobe/
  • Sylvian fissure /types of it?/ 
  • 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°/

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

Red Flags

Avoid over-rotation of the neck by elevating the ipsilateral shoulder. Regardless of the position of the lesion, the malar eminence must always bet the highest point of the operating field


Surgery

1. Skin incision

Red Flags

Distance from the tragus is fundamental as a too anterior incision can damage the superficial temporal artery and, more importantly, the frontal branch of the facial nerve.

2. Initial dissection of the skin flap with elevator

3. Placement of hemostatic clips

4. Skin flap elevation with elevator

5. Interfascial dissection with dissecting scissors

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

Pterional Box: brain box for pteronial approach

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