Subtemporal Approach and Its Infratentorial Extension: Review and a Comparative Analysis of Different Techniques

Tomasz Andrzej Dziedzic; Kumar Abhinav; Juan C. Fernandez-Miranda

doi:10.1055/s-0041-1741566

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2023; 84(01): 089-097
DOI: 10.1055/s-0041-1741566

Original Article

Subtemporal Approach and Its Infratentorial Extension: Review and a Comparative Analysis of Different Techniques

Authors

Tomasz Andrzej Dziedzic

¹Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
Kumar Abhinav

²Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Center for Skull Base and Pituitary Neurosurgery, Southmead Hospital, Bristol, United Kingdom
Juan C. Fernandez-Miranda

³Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States

Abstract

Introduction Surgical resection of lesions occupying the incisural space is challenging. In a comparative fashion, we aimed to describe the anatomy and surgical approaches to the tentorial incisura and to the rostral brainstem via the intradural subtemporal approach and its infratentorial extensions.

Methods Six fresh human head specimens (12 sides) were prepared for the microscopic dissection of the tentorial incisura using the intradural subtemporal approach and its infratentorial extensions. Endoscope was used to examine the anatomy of the region inadequately exposed with the microscope. Image-guided navigation was used to confirm bony structures visualized around the petrous apex.

Results Standard subtemporal approach provides surgical access to the supratentorial brainstem above the pontomesencephalic sulcus and to the lateral surface of the cerebral peduncle. The linear or triangular tentorial divisions can provide access to the infratentorial space below the pontomesencephalic sulcus. The triangular tentorial flap in comparison with the linear incision obstructs the exposure of anterior incisural space and of the prepontine cistern. Visualization of the brainstem below the trigeminal nerve can be achieved by the anterior petrosectomy.

Conclusion Infratentorial extension of the intradural subtemporal approach is technically demanding due to critical neurovascular structures and a relatively narrow corridor. In-depth anatomical knowledge is essential for the selection of the appropriate operative approach and safe surgical resections of lesions.

Keywords

subtemporal approach - skull base - tentorial incisura - brainstem - anterior petrosectomy

Full Text

References

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