The subtemporal approach is applied to the middle cranial fossa and infratemporal fossa in addition to the. Subtemporal approach to posterior cerebral artery aneurysms. We report our experience in the surgical management of these lesions exclusively using a lateral, subtemporal transtentorial approach in high pontine lesions and an anterior petrosal approach in low pontine lesions. The subtemporal approach is a wellknown neurosurgical approach that is rarely described in children. Pontine cavernomas are benign vascular lesions whose surgical treatment is challenging due to their localization. A subtemporal preauricular infratemporal approach was also completed.
A 26yearold woman presented with a 6month history of left occipitoparietal headache. Quantitative anatomic comparison of the extended pterional. The subtemporal approach is historically known as the standard approach for the treatment of tumoral, vascular and inflammatory lesions of the middle cranial fossa, the tentorium, the anterior and middle tentorial incisura, the upperthird of the clivus and the petroclival region. Watanbe, kazuo si24 cerebrovascular disorders tuesday, 8 july 1997 tuesday, 8 july 1997 14. A subtemporal approach was done and the lateral mesencephalic sulcus and vein were important anatomical landmarks to guide the safe entry zone. Subtemporal approach for a p2p3 junction aneurysm of the. Subtemporal approach for treatment of basilar bifurcation. After aspirating cerebrospinal fluid and slackening the temporal lobe, 23 pieces of gelatin sponge are inserted between the dura and surfaces of the anterior and posterior parts of the temporal. The authors very nicely outlined the anatomic considerations in choosing the subtemporal technique in. A collection of core cranial procedures for the neurosurgeon 2015 prose award first prize winner. The subtemporal approach provides a wide operative corridor to the floor of the middle fossa and upper petroclival territories and their associated cisterns. Subtemporal approach to retroinfundibular craniopharyngiomas. Contrastenhanced reformatted mr images for preoperative. Keyhole supracerebellar transtentorial transcollateral sulcus.
The traditional subtemporal approach, originally adopted for trigeminal rhizotomy and later modified with anterior petrosectomy to access the internal auditory canal iac and adjacent structures, represents a short and direct pathway to access the temporal base, the parasellar and retrochiasmatic regions, and the anterolateral petroclival region. The middle fossa approach for the removal of a trochlear. Core techniques in operative neurosurgery, 2nd edition, provides the tools needed to hone existing surgical skills and learn new techniques, helping you minimize risk and achieve optimal outcomes for every procedure. The subtemporal approach allows safer and easier division of the pcoma near the junction to the pca compared with the pterional approach, and the present procedure is more suitable for the subtemporal approach. The subtemporal approach is indicated for basilar tip aneurysms located at the level of the floor of the sella. Temporalsubtemporal craniotomy the neurosurgical atlas, by. Therefore, the area of interest in a subtemporal approach is actually above the plane of the lateral skull base and middle fossa floor. Anterior transpetrosal and subtemporal transtentorial.
The subtemporal approach is indicated for basilar tip aneurysms located at. Subtemporal approach for the resection of a midbrain cavernous. A 34yearold woman with brainstem cavernous malformation. Pdf zygomatic anterior subtemporal approach for lesions in the.
A very lowpositioned bifurcation may be significantly hampered by narrow corridor even with the tentorial incision, and the dome of the aneurysm often obscures surgeons path to. A combined transsylvian and subtemporal approach for basilar bifurcation aneurysms a combined transsylvian and subtemporal approach for basilar bifurcation aneurysms goto, hiromo. Transtemporal approaches to posterior cranial fossa. The subtemporal approach with division of the posterior communicating artery pcoma is described for treating aneurysms of the basilar tip. Many operative approaches have been utilized for lesion resection, but the advantages of the anterior transpetrosal approach are numerous and include excellent exposure, minimal extradural retraction of the temporal lobe, and minimal cerebrospinal fluid leaks. Extended lateral subtemporal approach for petroclival. Medical definition of subtemporal decompression merriam. First described by naffziger in 1928, this approach is commonly used for treatment of small uppermiddle clival tumor, epidermoid cyst, and aneurysm of the basilar tip or trunk 29. Standard subtemporal, lateral transpetrosal, and transsylvian procedures are significantly hindered by the bone and dural attachments of the posterior clinoid, clivus, and petrous apex 1, 4, 11, 12, 14. The temporopolar approach consists in pulling back the temporal pole, creating and enlarging an anterolateral view of the interpeduncular fossa.
The endoscopic approach provided sufficient access to the superior portion of the parapharyngeal space. Objective to assess the feasibility, advantages, and disadvantages of subtemporal approach in. P2 and p3 aneurysms are usually managed by the subtemporal approach. Objective in the context of discussions on the optimal cognitive outcome of temporal lobe epilepsy surgery, and stimulated by recent reports on the beneficial effects of a selective subtemporal approach to memory function, this study evaluated the cognitive consequences of subtemporal versus transsylvian selective amygdalohippocampectomy sah in patients with mesial temporal lobe epilepsy. Microsurgical subtemporal approach to aneurysms on the p 2. Get stepbystep, expert guidance on fundamental procedures in neurosurgery both in print and on video. Subtemporal approach for the resection of a midbrain. It is in many ways similar to the subtemporal transtentorial approach, with the added advantage of drilling the anterior petrous ridge. Extended lateral subtemporal approach for petroclival meningiomas. Subtemporal approach to basilar tip aneurysm with division of. Neuropsychological outcome after subtemporal versus.
The infratemporal fossa itf is an anatomical lateral skull base space composed by the zygoma, temporal, and the greater wing of the sphenoid bone. Historically, the first form of subtemporal approach had been described for the treatment of trigeminal neuralgia early. Subtemporal approach to basilar bifurcation aneurysms. This approach uses a combination of the extended middle fossa approach with the addition of intradural resection of the tentorium to allow wider posterior fossa exposure. The temporopolar approach was first described by sano in 19807. Core techniques in operative neurosurgery 2nd edition pdf. Before clip placement, a decrease in the optical magnification is preferable to provide a panoramic view and visualization of all the components of the working canal. Due to its difficult approach, surgical intervention at the itf has remained a heavy burden to surgeons. Computed tomography ct scan, magnetic resonance imaging mri and cerebral angiography revealed a 2cm aneurysm at the p2p3 junction of the left pca. A brain retraction technique using gelatin sponge pieces was developed to minimize intraoperative brain retraction during the subtemporal approach. The subtemporal approach is historically known as the standard approach for the treatment of tumoral, vascular and. Sep 09, 2019 temporal craniotomy is a simple approach that has vast applicability to intraaxial and extraaxial pathologies. The lateral subtemporal approach is short and straight from the petroclival region, but with unsatisfactory exposure for being blocked by the petrous part of the temporal bone.
Nuances of technique and surgical pearls related to the safe entry zones of the midbrain are discussed and illustrated in this operative video. The clinical manifestations, angiograms, and surgical operation were retrospectively analyzed. Anatomic study, petroclival region, pterional approach, subtemporal approach, skull base. Lowlying basilar apex or upper basilar trunk aneurysms represent major challenges to conventional surgical approaches. A very lowpositioned bifurcation may be significantly hampered by narrow corridor even with the tentorial incision, and the dome of the aneurysm often obscures surgeons path to the neck. Method 47 patients were randomised to subtemporal versus transsylvian approaches. The subtemporal approach allows the surgeon to get to posterior cerebral artery aneurysms in proximity to the tentorium coronal computed tomography angiography, fusiform p2 segment aneurysm of the posterior cerebral artery. Technical nuances of subtemporal approach for the treatment. Jan 11, 2019 the infratemporal fossa itf is an anatomical lateral skull base space composed by the zygoma, temporal, and the greater wing of the sphenoid bone. However, a significant disadvantage lies in the integrity of the lateral sinus via this approach. The main struc tures that help decide the approach to midbasilar middle fifth of the ba aneurysms are the free edge. The subtemporal approach is historically known as the standard approach for the treatment of tumoral, vascular and inflammatory lesions of the middle cranial fossa, the tentorium, the anterior and.
Technical nuances of subtemporal approach for the treatment of. The effect of clipping treatment was satisfactory in 2 patients. In such case, frontotemporal transsylvian approach could be preferred to the subtemporal approach. Subtemporal transtentorial petrosalapex approach for giant. For instance, the ftoz with a transsylvian approach provides the surgeon with a flatter view of the midbrain than a pterional approach. Brain retraction technique using gelatin sponge in the. A te m poral cranioto m y is m ade with two thirds of it anterior to the exte r nal auditory m eatus and one third posterior to the m eatus the temporal dura is gently separated from the floor of the middle cranial fossa to expose the teg m en tympani the arcuate eminence the middle meningeal through the for am en spinosu m the lateral margin of the foramen. A comprehensive anatomical and clinical analysis of the surgical corridors is done to decide the safest route.
The subtemporal approach offers a lateral view of the interpenducular fossa by retracting the temporal lobe supe riorly. Temporal craniotomy is a simple approach that has vast applicability to intraaxial and extraaxial pathologies. Subtemporal transtentorial approach in mesencephalic and. Brain cranial approaches professor alhakam abdul mawla. In our opinion, the subtemporal approach is a simple, rapid and safe approach for experienced surgeon to treat aneurysms on the p 2 segment of the pca. An approach through the posterior middle temporal gyrus risks language impairment. Oct 18, 2008 selection file type icon file name description size revision time user. Anterior subtemporal, medial transpetrosal approach to the.
Here, a successful clipping of a large p2p3 junction aneurysm via a subtemporal approach is reported. May 17, 20 a subtemporal preauricular infratemporal approach was also completed. The subtemporal approach has the advantage over the transsylvian approach in that the surgeon is looking from inferior to superior following the upsloping tentorium. Objective in the context of discussions on the optimal cognitive outcome of temporal lobe epilepsy surgery, and stimulated by recent reports on the beneficial effects of a selective subtemporal approach to memory function, this study evaluated the cognitive consequences of subtemporal versus transsylvian selective amygdalohippocampectomy sah in patients with mesial temporal lobe. The classic subtemporal transtentorial approach is one of the most commonly performed neurosurgical procedures fig 3. Combining a subtemporal with a retrosigmoid approach provides better access to the petroclival junction than either approach alone. The sttcs approach provides a short direct approach to the.
Objective to compare the effects of different surgical approaches for selective amygdalohippocampectomy in patients with pharmacoresistant mesial temporal lobe epilepsy with regard to the neuropsychological outcome and to replicate an earlier study employing a matchedpair design. However, the subtemporal approach did provide improved access to the petrous portion of the internal carotid artery. Louis gives, i believe, exceptional opportunities for the study of intracranial injuries. In this videoabstract, we present the helsinki neurosurgery one burrhole craniotomy standard subtemporal approach to the floor of the middle fossa and the interpeduncular space. This procedure facilitates access to the multiple structures. Small aneurysms are more prevalent than large aneurysms in patients with ruptured aneurysms. When the ipsilateral posterior cerebral artery pca interferes with visibility and manipulation around the aneurysm neck and the artery is tethered by the pcoma and not mobilized, the pcoma can be divided. Pdf technical nuances of subtemporal approach for the treatment.
May 24, 2018 subtemporalretrosigmoid petrosal approach. Neurosurgical approach final free download as powerpoint presentation. However, in case of larger aneurysms with outward growth, with subtemporal approaches one may have to handle the top of the aneurysm first which often may have severe adhesion after hemorrhage. The subtemporal approach provides such optimal positioning of the clip placement, and we consider that this a particular advantage of this surgical route for basilar tip aneurysms. The subtemporal transtentorial petrosalapex approach has obvious advantages, such as tendency of microinvasive operation and better outcome. The authors very nicely outlined the anatomic considerations in choosing the subtemporal technique in their very complete discussion section. Medical definition of subtemporal decompression merriamwebster. Subtemporal approach for distal basilar occlusion for giant. This is subtemporal approach by surgical neurology international on vimeo, the home for high quality videos and the people who love them. Cranial presents core surgical procedures in a concise, highly didactic format, enabling surgeons to quickly grasp their essence from the bulleted text and superb illustrations that accompany them.
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