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Pterional approach

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 wingas far down as the superior orbital fissure with or without the removal of the anterior clinoid process, thinning the orbital roof, and opening the Sylvian fissure and basal cisterns are the hallmarks of this approach.



The pterional approach to aneurysms of the circle of Willis is one of the most common approaches in vascular neurosurgery 1) 2) 3).

The aim of the pterional approach is to use a naturally occurring plane, through the sylvian fissure (SF), to approach an aneurysm without extensive brain retraction 4).

see Pterional approach for anterior communicating artery aneurysm

Tumoral lesions

Involving the sellar/parasellar region, 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 5).

Olfactory groove meningioma 6).

Cavernous sinus meningioma

Meckel Cave

Traditionally, a pterional approach is utilized to access the Meckel cave. Depending on the tumor location, extradural dissection of the Gasserian ganglion can be performed. An endoscopic endonasal access could potentially avoid a craniotomy in these cases 7).

Cavernous sinus hemangiomas (CSH)

The microsurgery through modified pterional approach combined with fronto-temporal preauricular subtemporal approach is an effective procedure for CSH 8).


Orbital Rim (ORo) Zygomatic Arch (ZAo) and Orbito-Zygomatic (OZo) osteotomies can be useful adjuncts to the classical Fronto-Pteriono-Temporal craniotomy in facilitating the exposure of deep seated skull base lesions, sparing brain retraction injuries.

There are different variants of the pterional approach described, such as the orbito-cranial approach as an extended and the sphenoid ridge keyhole approach as a less invasive approach 9) 10).

Gupta et al., report the experience with cranial fixation plate removal because of pain and protrusion in patients who underwent craniotomy without orbitozygomatic osteotomy, particularly frontotemporal craniotomy. In an attempt to reduce this complication, they recently stopped placing a full-size burr hole in the keyhole area of a frontotemporal craniotomy, eliminating the need for a titanium burr hole cover plate 11).

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Day AL. Aneurysms of the ophthalmic segment: A clinical and anatomical analysis. J Neurosurg. 1990;72:667–91
4) , 10)
Nathal E, Gomez-Amador JL. Anatomic and surgical basis of the sphenoid ridge keyhole approach for cerebral aneurysms. J Neurosurg. 2005;56:178–85.
Altay T, Couldwell WT. The frontotemporal (pterional) approach: an historical perspective. Neurosurgery. 2012 Aug;71(2):481-91; discussion 491-2. doi: 10.1227/NEU.0b013e318256c25a. PubMed PMID: 22472552.
Bitter AD, Stavrinou LC, Ntoulias G, Petridis AK, Dukagjin M, Scholz M, Hassler W. The Role of the Pterional Approach in the Surgical Treatment of Olfactory Groove Meningiomas: A 20-year Experience. J Neurol Surg B Skull Base. 2013 Apr;74(2):97-102. doi: 10.1055/s-0033-1333618. Epub 2013 Jan 22. PubMed PMID: 24436895.
Van Rompaey J, Bush C, Khabbaz E, Vender J, Panizza B, Solares CA. What is the Best Route to the Meckel Cave? Anatomical Comparison between the Endoscopic Endonasal Approach and a Lateral Approach. J Neurol Surg B Skull Base. 2013 Dec;74(6):331-6. doi: 10.1055/s-0033-1342989. Epub 2013 Apr 5. PubMed PMID: 24436933.
Wei Z, Yue-Ming Z, Zhong-Zhou S, Feng P. Magnetic resonance imaging diagnosis and microsurgical treatment of cavernous sinus hemangiomas. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2013 Dec;35(6):677-82. doi: 10.3881/j.issn.1000-503X.2013.06.017. PubMed PMID: 24382249.
Mizunari T, Murai Y, Kobayashi S, Hoshino S, Teramoto A. Utility of the orbitocranial approach for clipping of anterior communicating artery aneurysms: Significance of dissection of the interhemispheric fissure and the sylvian fissure. J Nippon Med Sch. 2011;78:77–83.
Gupta R, Adeeb N, Griessenauer CJ, Moore JM, Patel AS, Thomas AJ, Ogilvy CS. Removal of symptomatic titanium fixation plates after craniotomy. Acta Neurochir (Wien). 2016 Oct;158(10):1845-8. doi: 10.1007/s00701-016-2929-7. Epub 2016 Aug 12. PubMed PMID: 27520360.
pterional_approach.txt · Last modified: 2016/10/09 16:06 (external edit)