Pterional craniotomy

The resulting bone flap is centered over the depression of the sphenoid ridge. Approximately 33% of the craniotomy is anterior to the anterior margin of temporalis muscle insertion, ≈ and 66% is posterior.

With the craniotome, starting at the frontal burr hole the craniotomy is taken anteriorly across the anterior margin of the superior temporal line, staying as low as possible on the orbit (to obviate having to rongeur bone, which is unsightly on the forehead). The distance “B” from the medial extent of the craniotomy to the frontal burr hole is 3 cm for anterior circulation aneurysms. For the approaches to skull base (e.g. Dolenc approach), distance “B” is larger and takes the opening to ≈ the mid-orbit. Then from point “B,” a sharp superior turn is made and the opening is taken back to point “A.” The height (“H”) of the craniotomy needs to be only ≈ 3 cm for aneurysms of the Circle of Willis, and slightly larger (≈ 5 cm) for the middle cerebral artery aneurysms. Minimal exposure of the temporal cortex is necessary for aneurysms of the skull base region. For large flaps (e.g. for tumors), “H” is made larger to expose more temporal lobe.

The resulting bone flap is centered over the depression of the sphenoid ridge. Approximately 33% of the craniotomy is anterior to the anterior margin of temporalis muscle insertion, ≈ 66% is posterior.

With the craniotome, starting at the frontal burr hole the craniotomy is taken anteriorly across the anterior margin of the superior temporal line, staying as low as possible on the orbit (to obviate having to rongeur bone, which is unsightly on the forehead). The distance “B” from the medial extent of the craniotomy to the frontal burr hole is 3 cm for anterior circulation aneurysms. For the approaches to skull base (e.g. Dolenc approach), distance “B” is larger and takes the opening to ≈ the mid orbit. Then from point “B,” a sharp superior turn is made and the opening is taken back to point “A.” The height (“H”) of the craniotomy needs to be only ≈ 3 cm for aneurysms of the Circle of Willis, and slightly larger (≈ 5 cm) for the middle cerebral artery aneurysms. Minimal exposure of the temporal cortex is necessary for aneurysms of the skull base region. For large flaps (e.g. for tumors), “H” is made larger to expose more temporal lobe.

Frontotemporal craniotomy under regional anesthesia during awake craniotomies provides better pain control, a reduction in opioid use, and less somnolence in the early postoperative period ¹⁾

Frontotemporal craniotomy, also known as “pterional craniotomy” (PC), provides an optimal microscopic exposure and a wide open working space for manipulation of intracranial structures, and it has been widely used in the field of neurosurgery for treatment of lesions in the anterior and posterior circulations ²⁾.

The pterional craniotomy provides wide, multidirectional access to the anterior and middle cranial fossae as well as many structures of the interpeduncular fossae.

Other frontotemporal craniotomies derived from the pterional ^{3) 4)} and supraorbital ⁵⁾ craniotomies, as are the combined epi- and subdural approach with anterior clinoid removal ^{6) 7)} and the orbitozygomatic extension of the pterional craniotomy ^{8) 9)}.

The pterional craniotomy is well established for microsurgical clipping of most anterior circulation aneurysms. The incision and temporalis muscle dissection impacts postoperative recovery and cosmetic outcomes.

The minipterional (MPT) craniotomy offers similar microsurgical corridors, with a substantially shorter incision, less muscle dissection, and a smaller craniotomy flap.

Although pterional craniotomy and its variants are the most used approaches in neurosurgery, few studies have evaluated their precise indications.

da Silva et al., evaluated the pterional (PT), pretemporal (PreT), and orbitozygomatic (OZ) approaches through quantitative measurements of area, linear, and angular exposures of the major intracranial vascular structures.

Eight fresh, adult cadavers were operated with the PT, followed by the PreT, and ending with the OZ approach. The working area, angular exposure of vascular structures and linear exposure of the basilar artery were measured.

The OZ approach presented a wider area (1301.3 ± 215.9 mm2) with an increase of 456.7 mm2 compared with the PT and of 167.4 mm2 to the PreT (P = 0.011). The extension from PT to PreT and OZ increases linear exposure of the basilar artery. When comparing the PreT and OZ, they founded an increase in the horizontal and vertical angle to the bifurcation of the ipsilateral middle cerebral artery (P = 0.005 and P = 0.032, respectively), horizontal angle to the basilar artery tip (P = 0.02), and horizontal angle to the contralateral ICA bifurcation (P = 0.048).

The OZ approach offered notable surgical advantages compared with the traditional PT and PreT regarding to the area of exposure and linear exposure to basilar artery. Regarding angle of attack, the orbital rim and zygomatic arch removal provided quantitatively wider exposure and increased surgical freedom. A detailed anatomic study for each patient and surgeon experience must be considered for individualized surgical approach indication ¹⁰⁾.

Some types of keyhole approaches have been developed as alternatives to the conventional pterional craniotomy. However, most reported approaches are via supraorbital or subfrontal routes ^{11) 12) 13)} and have drawbacks including a narrow surgical corridor, need for special microsurgical instruments, and damage to the supraorbital nerve ¹⁴⁾.

Esposito et al. from the Department of Neurosurgery, Clinical Neuroscience Center Zurich, report on a consecutive case-series of 50 patients who received clipping of 54 ruptured/unruptured middle cerebral artery aneurysm (MCA-aneurysms) by means of lateral supraorbital approach (LS) or minipterional craniotomy. The distance between MCA (M1)-origin and the aneurysmal neck is key to select the approach: LS was used for MCA-aneurysm located <15mm of the M1-origin and MP for MCA-aneurysms located ≥15mm of the M1-origin.

The strategy for selecting the keyhole approach based on the depth of the aneurysm within the Sylvian fissure was efficient and safe. They suggest the use of LS approach when the aneurysm is located <15mm from the M1-origin and MP approach when the aneurysm is located ≥15mm from the M1-origin ¹⁵⁾.

see pterional approach.

Pterional craniotomy complications.

Mini-pterional craniotomy