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. Subtemporal transtentorial petrosalapex approach for giant. An approach through the posterior middle temporal gyrus risks language impairment. Subtemporal approach for the resection of a midbrain. Technical nuances of subtemporal approach for the treatment. Subtemporal approach for a p2p3 junction aneurysm of the. The temporopolar approach consists in pulling back the temporal pole, creating and enlarging an anterolateral view of the interpeduncular fossa. Medical definition of subtemporal decompression merriamwebster.
Aneurysms of the p2p segment of posterior cerebral artery. Regional pedicled flaps appear to be the best option. Brain retraction technique using gelatin sponge in the. Technical nuances of subtemporal approach for the treatment of. A comprehensive anatomical and clinical analysis of the surgical corridors is done to decide the safest route. Historically, the first form of subtemporal approach had been described for the treatment of trigeminal neuralgia early. 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. Here, a successful clipping of a large p2p3 junction aneurysm via a subtemporal approach is reported. 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 basilar tip aneurysm with division of. Computed tomography ct scan, magnetic resonance imaging mri and cerebral angiography revealed a 2cm aneurysm at the p2p3 junction of the left pca.
Neurosurgical approach final free download as powerpoint presentation. However, the subtemporal approach did provide improved access to the petrous portion of the internal carotid artery. The subtemporal approach has the advantage over the transsylvian approach in that the surgeon is looking from inferior to superior following the upsloping tentorium. Medical definition of subtemporal decompression merriam. In the two years, 1910 and 1912 during which i was on the visitingstaff, i devoted my spare time to a study of them. A subtemporal preauricular infratemporal approach was also completed. 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. Subtemporalanterior transtentoral approach to middle cranial. A collection of core cranial procedures for the neurosurgeon 2015 prose award first prize winner. Subtemporal approach to basilar bifurcation aneurysms. 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. Objective to assess the feasibility, advantages, and disadvantages of subtemporal approach in.
Contrastenhanced reformatted mr images for preoperative. Brain cranial approaches professor alhakam abdul mawla. The subtemporal approach is applied to the middle cranial fossa and infratemporal fossa in addition to the. The subtemporal approach offers a lateral view of the interpenducular fossa by retracting the temporal lobe supe riorly. The sttcs approach provides a short direct approach to the. Temporalsubtemporal craniotomy the neurosurgical atlas, by. 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. 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. The subtemporal approach is historically known as the standard approach for the treatment of tumoral, vascular and. Pontine cavernomas are benign vascular lesions whose surgical treatment is challenging due to their localization. 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. Temporal craniotomy is a simple approach that has vast applicability to intraaxial and extraaxial pathologies. Due to its difficult approach, surgical intervention at the itf has remained a heavy burden to surgeons.
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. 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. 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. 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. The posterior cerebral artery pca is divided into 4 segments. Extended lateral subtemporal approach for petroclival. A 34yearold woman with brainstem cavernous malformation. 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. Transtemporal approaches to posterior cranial fossa. Anatomic study, petroclival region, pterional approach, subtemporal approach, skull base. Neurosurgical approach final brainstem spinal cord. Subtemporal approach for the resection of a midbrain cavernous. Anterior transpetrosal and subtemporal transtentorial.
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. Subtemporal approach to retroinfundibular craniopharyngiomas. A 26yearold woman presented with a 6month history of left occipitoparietal headache. 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 subtemporal approach with division of the posterior communicating artery pcoma is described for treating aneurysms of the basilar tip. 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. Combining a subtemporal with a retrosigmoid approach provides better access to the petroclival junction than either approach alone. Nuances of technique and surgical pearls related to the safe entry zones of the midbrain are discussed and illustrated in this operative video. The study was to explore the operative experience in 3 patients with basilar bifurcation aneurysms treated with microsurgery via subtemporal approach. The clinical manifestations, angiograms, and surgical operation were retrospectively analyzed. Neuropsychological outcome after subtemporal versus.
Pdf zygomatic anterior subtemporal approach for lesions in the. May 17, 20 a subtemporal preauricular infratemporal approach was also completed. 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. Selection file type icon file name description size revision time user. The middle fossa approach for the removal of a trochlear. P2 and p3 aneurysms are usually managed by the subtemporal approach. 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. A brain retraction technique using gelatin sponge pieces was developed to minimize intraoperative brain retraction during the subtemporal approach. However, a significant disadvantage lies in the integrity of the lateral sinus via this approach.
For instance, the ftoz with a transsylvian approach provides the surgeon with a flatter view of the midbrain than a pterional approach. Schwannomas originating from the trochlear nerve are extremely rare. This procedure facilitates access to the multiple structures. The infratemporal fossa itf is an anatomical lateral skull base space composed by the zygoma, temporal, and the greater wing of the sphenoid bone. 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. Subtemporal approach to posterior cerebral artery aneurysms. The main struc tures that help decide the approach to midbasilar middle fifth of the ba aneurysms are the free edge. Anterior subtemporal, medial transpetrosal approach to the. This is a case report of rupture saccular aneurysm. 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.
Lowlying basilar apex or upper basilar trunk aneurysms represent major challenges to conventional surgical approaches. May 24, 2018 subtemporalretrosigmoid petrosal approach. Core techniques in operative neurosurgery 2nd edition pdf. Subtemporal approach for treatment of basilar bifurcation.
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. Sep 09, 2019 temporal craniotomy is a simple approach that has vast applicability to intraaxial and extraaxial pathologies. The effect of clipping treatment was satisfactory in 2 patients. Therefore, the area of interest in a subtemporal approach is actually above the plane of the lateral skull base and middle fossa floor. 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. A combined transsylvian and subtemporal approach for basilar bifurcation aneurysms a combined transsylvian and subtemporal approach for basilar bifurcation aneurysms goto, hiromo. A subtemporal approach was done and the lateral mesencephalic sulcus and vein were important anatomical landmarks to guide the safe entry zone. 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 subtemporal approach is indicated for basilar tip aneurysms located at the level of the floor of the sella. Keyhole supracerebellar transtentorial transcollateral sulcus.
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. Pdf technical nuances of subtemporal approach for the treatment. Get stepbystep, expert guidance on fundamental procedures in neurosurgery both in print and on video. Louis gives, i believe, exceptional opportunities for the study of intracranial injuries. Oct 18, 2008 selection file type icon file name description size revision time user. The classic subtemporal transtentorial approach is one of the most commonly performed neurosurgical procedures fig 3. This is subtemporal approach by surgical neurology international on vimeo, the home for high quality videos and the people who love them. 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. In such case, frontotemporal transsylvian approach could be preferred to the subtemporal approach. Microsurgical subtemporal approach to aneurysms on the p 2. Extended lateral subtemporal approach for petroclival meningiomas. The subtemporal transtentorial petrosalapex approach has obvious advantages, such as tendency of microinvasive operation and better outcome. 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 temporopolar approach was first described by sano in 19807.
Subtemporal approach for distal basilar occlusion for giant. The authors very nicely outlined the anatomic considerations in choosing the subtemporal technique in their very complete discussion section. The subtemporal approach is indicated for basilar tip aneurysms located at. The endoscopic approach provided sufficient access to the superior portion of the parapharyngeal space. 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. Quantitative anatomic comparison of the extended pterional.
Subtemporal transtentorial approach in mesencephalic and. It is in many ways similar to the subtemporal transtentorial approach, with the added advantage of drilling the anterior petrous ridge. 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. Small aneurysms are more prevalent than large aneurysms in patients with ruptured aneurysms. Watanbe, kazuo si24 cerebrovascular disorders tuesday, 8 july 1997 tuesday, 8 july 1997 14.