Top 5 common types of Cranial neurosurgery 

Cranial approaches in neurosurgery are like tools in a craftsman’s hand, each designed for specific tasks. Just as you wouldn’t use a hammer to screw in a lightbulb, you shouldn’t use the wrong cranial approach for a particular brain condition. In this article, let’s explore with UpSurgeOn the top 5 common types of cranial neurosurgery, demystify their purpose and indications, and the procedures behind them 

1. Pterional approach

Definition: The pterional approach is a surgical technique used in neurosurgery to access the brain and skull base. It involves making an incision in the scalp and removing a portion of the skull to access the brain [1 – 3].

Purpose: The purpose of the pterional approach is to provide wide access to the skull base, which makes it appropriate for most neurosurgical procedures [1]. The approach is used for a variety of neurosurgical procedures, including tumor resection, clipping of cerebral aneurysms, and epilepsy surgery [1 – 3].

Indications: The pterional approach is indicated for lesions in the following areas:

• Skull base tumors 
• Cerebral aneurysms 
• Epilepsy surgery 
• Access to the anterior cranial fossa 
• Access to the peri-sellar and suprasellar region 
• Access to the anterior third of the frontal and temporal opercula 
• Access to the orbital gyri  [1 – 3]

Procedures: The pterional approach involves making an incision in the scalp and removing a portion of the skull to access the brain [1 – 3]. The procedure is performed under general anesthesia. The neurosurgeon may use a microscope or endoscope to visualize the operative field [1]. The pterional approach can be modified by or combined with other approaches, such as the orbitozygomatic osteotomy, to provide even wider exposure [3]. Before performing the pterional approach, the surgeon should carefully study available images (CT, MR) to be prepared for anatomical rarities and try to find the best route to the lesion with an avoidance of the excessive exposure and the retraction of brain tissue [1].

2. Frontolateral approach

Definition: The frontolateral approach is a surgical technique used in neurosurgery to access the anterior cranial base. It involves making an incision in the scalp and removing a portion of the skull to access the frontal and temporal lobes of the brain [4].

Purpose: The purpose of the frontolateral approach is to provide access to the anterior cranial base, which allows for addressing lesions in the frontal and temporal lobes of the brain [4]. The approach is used for a variety of neurosurgical procedures, including tumor resection, clipping of cerebral aneurysms, and epilepsy surgery [4] [5].

Indications: The frontolateral approach is indicated for lesions in the frontal and temporal lobes of the brain, including:

• Tumor resection
• Clipping of cerebral aneurysms 
• Epilepsy surgery 
• Access to the frontal and temporal operculum 
• Access to the Sylvian fissure
• Access to the supra-sellar cisterns [4 – 7]

Procedures: The frontolateral approach involves making an incision in the scalp and removing a portion of the skull to access the frontal and temporal lobes of the brain [4]. The procedure is performed under general anesthesia. The neurosurgeon may use a microscope or endoscope to visualize the operative field. The frontolateral approach can be modified by or combined with other approaches, such as the orbitozygomatic osteotomy, to provide even wider exposure [5]. The procedure itself has been modernized and will continue to do so with the advent of new technology as it is developed [6].

3. Transsphenoidal approach

Definition: The transsphenoidal approach is a surgical technique used in neurosurgery to remove tumors that arise from the pituitary gland. Rather than opening up the skull in a traditional craniotomy, the neurosurgeon reaches the tumor through the nasal passages and the sphenoid sinus [8 – 10].

Purpose: The purpose of the transsphenoidal approach is to remove tumors that arise from the pituitary gland. This less-invasive approach allows the neurosurgeon to avoid important brain structures by accessing the pituitary gland from underneath the brain [8 – 10]. The transsphenoidal approach leaves no visible scar, minimizes the risk of complications, and enables faster recovery [9] [10].

Indications: The transsphenoidal approach is indicated for tumors that arise from the pituitary gland, including:

• Pituitary adenomas 
• Craniopharyngiomas 
• Rathke’s cleft cysts 
• Meningiomas 
• Chordomas [8 – 10] 

Procedures: The transsphenoidal approach involves making a small incision in the back wall of the nasal passages to enter the sphenoid sinus and then opening up the sella turcica, the bony cavity that contains the pituitary gland [8 – 10]. A thin tube with a light and camera at the tip, called an endoscope, allows the surgeon to see through the small incision and view the magnified operative field on a television screen [8 – 10]. The procedure is performed under general anesthesia [10]. The transsphenoidal approach can be performed using a microscopic or endoscopic technique [8 – 10]. The neurosurgeon may use image guidance with MRI or CT scans before surgery to learn as much as they can about the tumor and nearby structures [10].

4. Suboccipital lateral approach

Definition: The suboccipital lateral approach is a surgical technique used in neurosurgery to access the cerebellum and brainstem [11] [12]. It involves making an incision in the scalp and removing a portion of the skull to access the posterior fossa of the brain [12].

Purpose: The purpose of the suboccipital lateral approach is to provide access to the cerebellum and brainstem, which allows for addressing lesions in the posterior fossa of the brain [11] [12]. The approach is used for a variety of neurosurgical procedures, including tumor resection, decompression of the cranial nerves, and treatment of vascular malformations [11] [12].

Indications: The suboccipital lateral approach is indicated for lesions in the posterior fossa of the brain, including:

• Tumor resection 
• Decompression of the cranial nerves
• Treatment of vascular malformations
• Chiari malformation 
• Syringomyelia [11] [12]

Procedures: The suboccipital lateral approach involves making an incision in the scalp and removing a portion of the skull to access the posterior fossa of the brain [12]. The procedure is performed under general anesthesia [12]. The neurosurgeon may use a microscope or endoscope to visualize the operative field [12]. The suboccipital lateral approach can be modified by or combined with other approaches, such as the far-lateral approach, to provide even wider exposure [13]. The procedure itself has been modernized and will continue to do so with the advent of new technology as it is developed [11].

5. Interhemispheric approach

Definition: The interhemispheric approach is a surgical technique used in neurosurgery to access deep midline parafalcine and paraventricular structures through the interhemispheric fissure [14].

Purpose: The purpose of the interhemispheric approach is to provide access to deep midline parafalcine and paraventricular structures, which allows addressing lesions in the interhemispheric region of the brain [14]. The approach is used for a variety of neurosurgical procedures, including tumor resection, clipping of cerebral aneurysms, and epilepsy surgery [14 – 16].

Indications: The interhemispheric approach is indicated for lesions in the interhemispheric region of the brain, including:

• Tumor resection  
• Clipping of cerebral aneurysms 
• Epilepsy surgery 
• Access to the corpus callosum 
• Access to the anterior cerebral artery 
• Access to the suprasellar region [14 – 16].

Procedures: The interhemispheric approach involves making an incision in the scalp and removing a portion of the skull to access the interhemispheric fissure [14] . The procedure is performed under general anesthesia. The neurosurgeon may use a microscope or endoscope to visualize the operative field [16]. The interhemispheric approach can be modified by or combined with other approaches, such as the contralateral transfalcine approach, to provide even wider exposure [15]. The procedure itself has been modernized and will continue to do so with the advent of new technology as it is developed [14].

Conclusion

To sum up, the selection of a cranial approach is an art, requiring your surgical acumen. Patient outcomes hinge on your expertise, meticulous planning, and the ability to align the approach with the intricacies of each case. Mastery of these approaches empowers you to provide the highest level of care for those entrusting their well-being to your skilled hands. UpSurgeOn is your trusted partner in this transformative journey. Our surgical simulation technologies were created with the mission of empowering surgeons to do their mission with confidence, precision and skill. Let’s embark on the journey to explore the transformative power of surgical simulation with UpSurgeOn and stay ahead in the ever-evolving field of surgery! 

References: 

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3. Cohen-Gadol, A., MD. (2023b). Pterional craniotomy. The Neurosurgical Atlas. https://www.neurosurgicalatlas.com/volumes/cranial-approaches/pterional-craniotomy
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9. Barrow Neurological Institute. (2022, August 3). What is Transsphenoidal Surgery? | Pituitary Center | Barrow Neurological Institute. https://www.barrowneuro.org/treatment/transsphenoidal-surgery
10. Endoscopic pituitary surgery. (2019, November 19). Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/endoscopic-pituitary-surgery
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12. Facs, R. C. D. M. (n.d.-b). Surgical Neurotology: Background, indications, contraindications. https://emedicine.medscape.com/article/2051599-overview
13. Chaddad-Neto, F., Dória-Netto, H. L., De Campos Filho, J. M., Neto, M. R., Rothon, A. L., & De Oliveira, E. (2014). The far-lateral craniotomy: tips and tricks. Arquivos De Neuro-psiquiatria, 72(9), 699–705. https://doi.org/10.1590/0004-282×2014013
14. Anetsberger, S., González-López, P., Elsawaf, Y., Lucifero, A. G., Luzzi, S., & Elbabaa, S. K. (2022). Interhemispheric approach. PubMed, 92(S4), e2021351. https://doi.org/10.23750/abm.v92is4.12801
15. García-García, S., González-Sánchez, J. J., Gandhi, S., Tabani, H., Meybodi, A. T., Kakaizada, S., Lawton, M. T., & Benet, A. (2018). Contralateral transfalcine versus ipsilateral anterior interhemispheric approach for midline arteriovenous malformations: surgical and anatomical assessment. World Neurosurgery, 119, e1041–e1051. https://doi.org/10.1016/j.wneu.2018.08.074
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