The Frontotemporal (Pterional) Approach

Neurosurgery ◽  
2012 ◽  
Vol 71 (2) ◽  
pp. 481-492 ◽  
Author(s):  
Tamer Altay ◽  
William T. Couldwell
Keyword(s):  
Vascular Lesions ◽  
Past Century ◽  
Temporal Region ◽  
Pterional Approach ◽  
Superior Orbital Fissure ◽  
Current Form ◽  
Orbital Roof ◽  
Transcranial Approach ◽  
Related Derivative ◽  
Cranial Fossa

Abstract The frontotemporal, so-called pterional, approach has evolved with the contribution of many neurosurgeons over the past century. It has stood the test of time and has been the most commonly used transcranial approach in neurosurgery. In its current form, drilling the sphenoid wing as far down as the superior orbital fissure with or without the removal of the anterior clinoid, thinning the orbital roof, and opening the Sylvian fissure and basal cisterns are the hallmarks of this approach. Tumoral and vascular lesions involving the sellar/parasellar area, anterior and anterolateral circle of Willis, middle cerebral artery, anterior brainstem, upper basilar artery, insula, basal ganglia, mesial temporal region, anterior cranial fossa, orbit, and optic nerve are within the reach of the frontotemporal approach. In this article, we review the origins, evolution, and modifications of the frontotemporal approach and update the discussion of some of the related derivative procedures.

Endoscopic supraorbital extradural approach to the cavernous sinus: a cadaver study

2011 ◽  
Vol 114 (5) ◽  
pp. 1331-1337 ◽  
Author(s):  
Fuminari Komatsu ◽  
Mika Komatsu ◽  
Tooru Inoue ◽  
Manfred Tschabitscher
Keyword(s):  
Cavernous Sinus ◽  
Complex Structure ◽  
Lateral Wall ◽  
Middle Cranial Fossa ◽  
Cadaver Study ◽  
Minimal Invasiveness ◽  
Small Complex ◽  
Transcranial Approach ◽  
Cranial Fossa ◽  
Extradural Approach

Object The cavernous sinus is a small complex structure located at the central base of the skull. Recent extensive use of endoscopy has provided less invasive approaches to the cavernous sinus via endonasal routes, although transcranial routes play an important role in the approach to the cavernous sinus. The aims of this study were to evaluate the feasibility of the purely endoscopic transcranial approach to the cavernous sinus through the supraorbital keyhole and to better understand the distorted anatomy of the cavernous sinus via endoscopy. Methods Eight fresh cadavers were studied using 4-mm 0° and 30° endoscopes to develop a surgical approach and to identify surgical landmarks. Results The endoscopic supraorbital extradural approach was divided into 4 stages: entry into the extradural anterior cranial fossa, exposure of the middle cranial fossa and the periorbita, exposure of the superior cavernous sinus, and exposure of the lateral cavernous sinus. This approach provided superb views of the cavernous sinus structures, especially through the clinoidal (Dolenc) triangle. The lateral wall of the cavernous sinus, including the infratrochlear (Parkinson) triangle and anteromedial (Mullan) triangle, was also clearly demonstrated. Conclusions An endoscopic supraorbital extradural approach offers excellent exposure of the superior and lateral walls of the cavernous sinus with minimal invasiveness via the transcranial route. This approach could be an alternative to the conventional transcranial approach.

Refined and Simplified Surgical Landmarks for the MacCarty Keyhole and Orbitozygomatic Craniotomy

2010 ◽  
Vol 66 (suppl_2) ◽  
pp. ons230-ons233 ◽  
Author(s):  
R. Shane Tubbs ◽  
Marios Loukas ◽  
M.M. Shoja ◽  
Aaron A. Cohen-Gadol
Keyword(s):  
Frontal Sinus ◽  
Lateral Wall ◽  
Burr Hole ◽  
Anterior Cranial Fossa ◽  
Orbital Roof ◽  
Alternative Method ◽  
Lateral Extent ◽  
Cranial Fossa ◽  
Burr Holes ◽  
External Landmark

Abstract BACKGROUND Precise placement of the MacCarty keyhole, a burr hole simultaneously exposing the anterior cranial fossa floor and orbit, provides accurate, efficient entry for orbitozygomatic and supraorbital craniotomies. To locate the optimal keyhole site, previous studies have used superficial landmarks that, in our experience, are not always visible or consistent on older crania. OBJECTIVE Therefore, we present a technique for accurate keyhole placement using landmarks that are easily visible across age ranges. METHODS From inside the cranium, 1-mm burr holes were placed along the anterior junction of the floor and lateral wall of the anterior cranial fossa in 50 adult skulls (100 sides, with calvaria removed). Additionally, from inside the orbit, 1-mm burr holes were placed into the lateral orbital roof. Exit sites of intracranial and intraorbital burr holes were referenced to the frontozygomatic suture. The center of the site between the exiting intracranial and intraorbital holes was deemed the best location for the keyhole. RESULTS The keyhole center was 6.8 mm (mean) superior and 4.5 mm (mean) posterior to the frontozygomatic suture, which was easily identified on all specimens. Although this keyhole center was slightly more superior on right sides than left, this was not statistically significant. In a minority of specimens, the keyhole was located near the meningo-orbital foramen (22%) and the lateral extent of the frontal sinus (2%). CONCLUSIONS We defined an alternative method for locating the MacCarty keyhole, based on a reliable external landmark, approximately 7 mm superior and 5 mm posterior to the frontozygomatic suture.

Anatomical study of the superior orbital fissure as seen during a pterional approach

2007 ◽  
Vol 106 (1) ◽  
pp. 151-156 ◽  
Author(s):  
Mario Ammirati ◽  
Antonio Bernardo
Keyword(s):  
Anatomical Study ◽  
Pterional Approach ◽  
Superior Orbital Fissure ◽  
Specific Sequence ◽  
Anterior Portion ◽  
Important Landmark ◽  
Controlled Exposure ◽  
Surrounding Areas ◽  
Brain Retraction ◽  
Good Exposure

Object The superior orbital fissure (SOF) is an important landmark in the neurosurgical pterional approach, but the anatomical features of the SOF and the procedures necessary to fully expose it and its contents have not been detailed. Although the pterional approach is commonly used during skull base or vascular surgery by neurosurgeons who may already be familiar with its nuances and anatomical relationships to the SOF, this knowledge may also be useful to the wider neurosurgical community. The authors describe the spatial relationships of the contents of the SOF and suggest a specific sequence of steps for exposing the SOF region in a pterional approach. Methods Using standard microsurgical equipment and instruments, the authors performed 20 pterional approaches in 10 embalmed cadaver heads in which the vascular systems had been injected with colored material. Five sequential steps were delineated for approaching and dissecting the SOF and its contents: 1) drilling the sphenoidal ridge, anterior clinoidal process, and part of the greater and lesser wings of the sphenoid; 2) resecting the dural bridge; 3) detaching the hemispheric dura mater, thereby exposing the anterior portion of the cavernous sinus and the neural component entering the SOF; 4) identifying and dissecting the extraanular structures; and 5) opening the anulus of Zinn and identifying its neural constituents. Conclusions Knowing the 3D relationships of the contents of the SOF encountered in the pterional approach enables safe neurosurgical access to the area. The proposed sequence of steps allows a controlled exposure of the SOF and surrounding areas. Untethering the frontotemporal lobe by transecting the dural bridge connecting the dura to the perior-bita allows good exposure of the basal frontotemporal lobes, both intra- and extradurally, and reduces brain retraction.

Growing skull fracture of the posterior cranial fossa and of the orbital roof

2003 ◽  
Vol 145 (3) ◽  
pp. 201-208 ◽  
Author(s):  
M. Caffo ◽  
A. German� ◽  
G. Caruso ◽  
F. Meli ◽  
A. Calisto ◽  
...  
Keyword(s):  
Skull Fracture ◽  
Posterior Cranial Fossa ◽  
Growing Skull Fracture ◽  
Orbital Roof ◽  
Cranial Fossa

scholarly journals Spontaneous Temporal Lobe Encephalocele Within the Sphenoid Sinus

2021 ◽  
Vol 18 (1) ◽  
pp. 63-66
Author(s):  
Mohammed Dhaha ◽  
Abdelhafidh Sliman ◽  
Nadhir Karmeni ◽  
Sawsen Dhambri ◽  
Jalel Kallel
Keyword(s):  
Sphenoid Sinus ◽  
Lateral Wall ◽  
Middle Cranial Fossa ◽  
Clinical Aspect ◽  
Csf Leak ◽  
Surgical Approaches ◽  
Skull Defect ◽  
Lethal Complications ◽  
Transcranial Approach ◽  
Cranial Fossa

Encephaloceles are herniation of cranial content arising from a skull defect. Encephaloceles of the lateral wall of the sphenoid sinus (ELWSS) are  uncommon events. In most cases, these cranial hernias are secondary to trauma and craniofacial surgery. Spontaneous forms are evenrarer and not well understood. The most adopted hypothesis is a persisting Sternberg’s canal, an embryonic remnant connecting the middle cranial fossa and the nasopharynx. ELWSS are usually revealed by cerebrospinal fluid (CSF) leak. Diagnosis of this disease necessitates quick management due to the potential of lethal complications such as meningitis. We report the case of a spontaneous ELWSS in a 53-year-old woman revealed by CSF leak which was successfully managed with a conventional transcranial approach. We focus on the clinical aspect and pathogenesis of the disease, and discuss the main possible surgical approaches. Keywords: Spontaneous encephalocele, Sphenoid sinus, CSF leak, Transcranial approach

Anatomy and Significance of the Temporal Fat Pad in Apert Syndrome

1994 ◽  
Vol 31 (3) ◽  
pp. 224-227 ◽  
Author(s):  
Rick J. Smith ◽  
Ian T. Jackson
Keyword(s):  
Lateral Displacement ◽  
Three Dimensional ◽  
Middle Cranial Fossa ◽  
Apert Syndrome ◽  
Temporal Region ◽  
Fat Pad ◽  
Temporalis Muscle ◽  
Temporal Fossa ◽  
Cranial Fossa ◽  
Normal Controls

Abnormal temporal region anatomy In Apert syndrome described in the literature includes inferior and lateral displacement of the middle cranial fossa, effacement of the temporal fossa, and thinning of the temporalis muscle. Four patients with Apert syndrome were noted to have hyperplasia of the bilateral superficial temporal fat pads, which could be contoured surgically. A case is presented with reformatted three-dimensional computed tomography (3-D CT) scans with intraoperative documentation of Increased temporal fat as compared to normal controls.

Adenoid Cystic Carcinoma with Intracranial Extension: Report of Three Cases

Neurosurgery ◽  
1990 ◽  
Vol 26 (6) ◽  
pp. 1060-1065 ◽  
Author(s):  
Shinichiro Wakisaka ◽  
Akitsugu Nonaka ◽  
Yoshihiro Morita ◽  
Masashi Fukui ◽  
Kazuo Kinoshita
Keyword(s):  
Radiation Therapy ◽  
Adenoid Cystic Carcinoma ◽  
Residual Tumor ◽  
Middle Cranial Fossa ◽  
Intracranial Extension ◽  
Gasserian Ganglion ◽  
The Third ◽  
Orbital Roof ◽  
Adenoid Cystic ◽  
Cranial Fossa

Abstract Adenoid cystic carcinoma (cylindroma) usually arises from the salivary, lacrimal, or other exocrine glands, and is rarely encountered by neurosurgeons. The authors describe three cases involving intracranial extension. An intraorbital tumor in a 71-year-old man extended directly into the epidural space of the frontal base and destroyed the orbital roof. In a 53-year-old woman, the tumor arose from the area adjacent to the eustachian tube and invaded the Gasserian ganglion. In the third patient, a 58-year-old man, the tumor originated in the maxillary sinus and extended directly into the middle cranial fossa. In all these cases, the tumors were removed to the fullest extent possible. Although residual tumor was markedly reduced by radiation therapy, recurrence and metastases occurred within a few years. Thus, adenoid cystic carcinoma appears to be radiosensitive, but not curable by irradiation. In treating a recurrent tumor in one patient, we applied the so-called “two-route” chemotherapy (cisplatin and its antidote) in combination with radiation therapy. The tumor responded well to this therapy, although multiple pulmonary and bone metastases eventually led to the patient's death.

scholarly journals Sphenoidal artery: review of the literature and analysis of a dissected arterially injected fetal orbit

2021 ◽  
Vol 43 (3) ◽  
pp. 405-411
Author(s):  
E. Leon Kier ◽  
Amit Mahajan ◽  
Gerald J. Conlogue
Keyword(s):  
Skull Base ◽  
Middle Cranial Fossa ◽  
Review Of The Literature ◽  
Superior Orbital Fissure ◽  
Photographic Image ◽  
Meningeal Arteries ◽  
Anatomic Dissection ◽  
Cranial Fossa ◽  
Diagrammatic Representations ◽  
Arterial Branch

Abstract Purpose The sphenoidal artery is considered a component of the complex and dangerous arterial anastomoses of the human orbitocranial region, particularly with the advent of interventional neuroimaging. The objective of this publication was to analyze the various descriptions of the sphenoidal artery in the literature as related to relevant photographs of a dissected arterially injected fetal middle cranial fossa and orbit. Methods Publications dealing with middle meningeal-ophthalmic arterial anastomoses, focusing on the sphenoidal artery, were reviewed. A relevant dissection of a fetal specimen was analyzed. Results The literature dealing with the sphenoidal artery is at times not in agreement. The nomenclature and anatomy of its passage through the superior orbital fissure or Hyrtl canal have variable descriptions. Photographs of the skull base of a dissected arterially injected fetal specimen show bilateral prominent orbital branches of the middle meningeal arteries. These branches entered both orbits in a course similar to the diagrammatic representations of the sphenoidal artery, and give rise to several major intraorbital arteries. This study provides the only photographic image in the literature of this variation in a human fetal anatomic dissection. Conclusions Review of the literature dealing with the sphenoidal artery shows inconsistent nomenclature and conflicting descriptions of its anastomotic connections, and varying evolutionary and embryologic theories. Analysis of the dissected fetal skull base indicates that the sphenoidal artery is not a distinct artery but just a middle meningeal orbital arterial branch, an important component of the complex and dangerous arterial anastomoses of the human orbitocranial region.

scholarly journals Epidermoid cyst in Anterior, Middle & Extension of Posterior cranial fossa: rare Imaging with review of literature

2016 ◽  
Vol 30 (3) ◽  
pp. 461-466
Author(s):  
Vivek Kumar Kankane ◽  
Gaurav Jaiswal ◽  
Tarun Kumar Gupta
Keyword(s):  
Epidermoid Cyst ◽  
Mass Effect ◽  
Brain Structures ◽  
Posterior Cranial Fossa ◽  
Subtotal Resection ◽  
Temporal Region ◽  
Mri Findings ◽  
Prepontine Cistern ◽  
Epidermoid Cysts ◽  
Cranial Fossa

Abstract Epidermoid cysts are benign slow growing more often extra-axial tumors that insinuate between brain structures, we present the clinical, imaging, and pathological findings in 35 years old female patients with atypical epidermoid cysts which was situated anterior, middle & posterior cranial fossa. NCCT head revealed hypodense lesion over right temporal and perisylvian region with extension in prepontine cistern with mass effect & midline shift and MRI findings revealed a non-enhancing heterogeneous signal intensity cystic lesion in right frontal & temporal region extending into prepontine cistern with restricted diffusion. Patient was detoriated in night of same day of admission, emergency Fronto-temporal craniotomy with anterior peterousectomy and subtotal resection was done. The histological examination confirms the epidermoid cyst. The timing of ectodermal tissue sequestration during fetal development may account for the occurrence of atypical epidermoid cysts.

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