The pretemporal approach: Surgical anatomy, operative technique, and rationale

Abstract

As a variant of the classic pterional approach, the pretemporal approach aims to combine the advantages of the pterional, temporopolar, and subtemporal approaches, offering enhanced angles of the view and the action of the surgeon: whether the straight downward view of the pterional approach, the anterolateral temporopolar view obtained by pulling back the temporal pole, or the lateral view offered by the subtemporal approach. This enhanced view is accomplished by adding a more extended and basal temporal exposure to the classic pterional craniotomy, as low as the floor of the middle fossa, and exposing completely the temporal pole. The sylvian fissure is split widely, the basal cisterns are opened widely, and the arachnoid adhesions among the frontal and the temporal lobes, tentorial edge, and cranial nerve III are sectioned completely. When necessary, the superficial sylvian vein or veins binding the temporal pole to the sphenoparietal sinus are sacrificed, allowing a posterior retraction (temporopolar exposure) or a superior retraction (subtemporal exposure) of the temporal lobe. The interpeduncular, upper petroclival, middle fossa, sellar and parasellar regions, and anterior portion of the tentorial incisura are within the reach of the pretemporal approach. The inclusion of an orbitozygomatic osteotomy to the pretemporal approach can greatly improve the surgical exposure of such areas. The more basal exposure of the anterior and middle cranial fossae provided by the orbitozygomatic craniotomy allows the treatment of lesions that either arise or extend to the extradural compartment of these regions. The sphenoid, frontal and ethmoidal sinuses, components of the orbit, cavernous sinus, infratemporal fossa, petrous apex, intrapetrous internal carotid artery, and remainder of the middle cranial fossa can be accessed with this approach.