Immersive Surgical Anatomy of the Pterional Approach.

Roberto Rodriguez Rubio,Ricky Chae,Adib A Abla,Vera Vigo,Michael Mcdermott

doi:10.7759/cureus.5216

Abstract

The pterional approach (PA) is a versatile anterolateral neurosurgical technique that enables access to reach different structures contained in the cranial fossae. It is essential for neurosurgical practice to dominate and be familiarized with its multilayer anatomy. Recent advances in three-dimensional (3D) technology can be combined with dissections to better understand the spatial relationships between anatomical landmarks and neurovascular structures that are encountered during the surgical procedure. The present study aims to create a stereoscopic collection of volumetric models (VM) obtained from cadaveric dissections that depict the relevant anatomy and surgical techniques of the PA. Five embalmed heads and two dry skulls were used to record and simulate the PA. Relevant steps and anatomy of the PA were recorded using 3D scanning technology (e.g. photogrammetry, structured light scanner) to construct high-resolution VM. Stereoscopic images, videos, and VM were generated to demonstrate major anatomical landmarks for PA. Modifications of the standard PA, including the mini-pterional and two-part pterional approaches, were also described. The PA was divided into seven major steps: positioning, incision of the skin, dissection of skin flap, dissection of temporal fascia, craniotomy, drilling of basal structures, and dural opening. Emphasis was placed on preserving the temporal branches of the facial nerve and carefully dissecting the temporalis muscle. The interactive models presented in this article allow for clear visualization of the surgical anatomy and windows in 360-degrees and VR. This new modality of recording neuroanatomical dissections renders a closer look at every nuance of the topography experienced by our team in the laboratory. By accurately depicting essential landmarks, stereoscopy and VM can be valuable resources for anatomical education and surgical planning.

Highlights

The pterional or frontotemporalsphenoidal craniotomy is an extensively used neurosurgical technique to expose the Sylvian fissure (SF)
Understanding the 3D relationship of the anatomical structures found during a fronto-temporo-sphenoidal exposure is paramount to creating safe surgical corridors while using pterional approach (PA) or any of its variations
The PA is one of the most common and flexible approaches in neurosurgery, and it has quickly evolved with the advent of new neurosurgical technologies and the experience that surgeons have acquired throughout dealing with an immense variety of pathologies

Summary

Introduction

The pterional or frontotemporalsphenoidal craniotomy is an extensively used neurosurgical technique to expose the Sylvian fissure (SF). The pterional approach (PA) is performed around the pterion, which represents the intersection of the frontal, temporal, parietal, and sphenoid bones. The term is derived from the Greek root pteron and refers to the wings that were attached to the head of Hermes, the messenger of the Greek gods [1]. This approach aims to minimize brain retraction and increase the exposure of the neurovascular structures within the anterior basal cistern by carefully dissecting the temporalis muscle and drilling the sphenoid wing [2]. By allowing users to actively interact with the structures, VMs represent a useful tool for anatomical education and surgical planning. The use of virtual reality (VR) and augmented reality (AR)ready systems (e.g., computers and smartphones) are strongly recommended to have a fully immersive experience of the models included in this article

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