Once the skin flap is turned down to expose the skull and temporalis muscle the muscle is reflected down of the frontal temporal and sphenoid bones leaving a cuff of muscle to suture the muscle back to at the end of the procedure.
At the end of the procedure, standard cranial reconstruction using titanium plates and screws is undertaken, followed by normal closure of the retracted superficial tissue. This technique does not increase surgical time, but results in a superior reconstructive and thus cosmetic result. The drill is used to cut between the burr holes so as to exposure the dura of the frontal and temporal lobes by creating a frontal temporal sphenoid bone flap (Figures 5-6). When using a single binocular attachment with a side extension, the head can be extended more if desired but too much extension will make it difficult to see as far up the anterior fossa base.
This is not absolutely necessary. Department of Neurological Surgery, University of California, San Francisco, UCSF Dept of Neurosurgery, UCSF Dept of Otolaryngology - Head and Neck Surgery, Department of Neurological Surgery, University of California, San Francisco, San Francisco, USA. This allows access to the cervical dura at the level of the C2 nerve roots. Having mastered endoscopic skull base approaches in our center, endoscopic- assisted tumor resection during a pterional craniotomy is often used for better visualization and additional tumor resection. Reconstruction is done connecting the two pieces back together with titanium plates and screws yielding a good cosmetic result. Drilling down of the sphenoid creates a defect that requires repair.
More rotation is sometimes used for a middle cerebral artery aneurysm and less for an anterior communicating artery aneurysm. Published via the UCSF Neurological Surgery Channel.
The dura is then sutured watertight to prevent a spinal fluid leak. SIQ™ assesses article importance and quality by embracing the collective intelligence of the Cureus community-at-large. A: Left exocranial view of the skull showing the modified bone flaps in the two part pterional craniotomy.
November 24, 2012 For the patient, improved cosmesis may result from preservation of the sphenoid bone supporting the temporalis muscle, avoiding the depression just behind the orbit. B: Detail of the right classic McCarty Keyhole and relative position of the frontal burr hole for the two-part pterional craniotomy.
The greater wing of the sphenoid forms the anterior wall of the middle fossa, whereas the lesser wing forms the posterior part of the floor of the anterior fossa.
A frontal temporal sphenoidal bone flap is created by cutting the bone back in a V-shape around the sphenoid wing.
Keywords: aneurysm, cerebral aneurysm, craniotomy, frontotemporal, pterional. The temporal muscle was incised 1 cm from its attachment along the superior temporal line to leave a muscle cuff in order to ease closure and optimize postoperative muscle function. The scalp and temporalis muscle are reflected forward as one layer. Also, we insert a ventricular drain into the frontal horn of the lateral ventricle once the dura is open in almost all patients with SAH. For unruptured cases, I usually infiltrate the skin and subcutaneous tissue with about 8 mL of 1% xylocaine without epinephrine. Once wing identified dura dissected off to dural fold over lateral aspect of superior orbital fissure. To minimize complications and maximize patient safety, intraoperative image navigation is used for customized incision and craniotomy planning, exact tumor location and avoidance of large underlying blood vessels. This creates a bony defect which must be repaired in order to achieve a good cosmetic result for the patient [6-11]. Yasagril MG, Antic J, Laciga R, Jain KK, Hodosh RM, Smith RD: Vishteh AG, Marciano FF, David CA, Baskin JJ, Spetzler RF: Wen HT, Oliveira E, Tedeschi H, Andrade FC Jr, Rhoton AL Jr: Figueiredo EG, Deshmukh P, Nakaji P, et al. Abuse, Toxicology and the Resurgence of Propylhexedrine: A Case Report and Review of Literature, A Case of Trazodone Overdose Successfully Rescued With Lipid Emulsion Therapy, A Portrait of Current Radiation Oncology Twitter Influencers, Baylor Scott & White Medical Center Department of Neurosurgery, California Institute of Behavioral Neurosciences & Psychology, Contemporary Reviews in Neurology and Neurosurgery, The Florida Medical Student Research Publications, University of Florida-Jacksonville Neurosurgery, American Red Cross Scientific Advisory Council, Canadian Association of Radiation Oncology, International Liaison Committee on Resuscitation, International Pediatric Simulation Society, Strategies to Promote Long-Term Cardiac Implant Site Health, Clinical and Economic Benefits of Autologous Epidermal Grafting, Clinical Applications and Benefits Using Closed-Incision Negative Pressure Therapy for Incision and Surrounding Soft Tissue Management, Defining Health in the Era of Value-Based Care, MR-Guided Radiation Therapy: Clinical Applications & Experiences, Multiple Brain Metastases: Exceptional Outcomes from Stereotactic Radiosurgery, Negative Pressure Wound Therapy with Instillation, NPWT with Instillation and Dwell: Clinical Results in Cleansing and Removal of Infectious Material with Novel Dressings, Optimization Strategies for Organ Donation and Utilization, Proton Therapy: Advanced Applications for the Most Challenging Cases, Radiation Therapy as a Modality to Create Abscopal Effects: Current and Future Practices, Microsurgical Pterional Approach to Aneurysms of the Basilar Bifurcation, Preservation of the frontotemporal branch of the facial nerve using the interfascial temporal flap for pterional craniotomy: technical article, The pterional approach: surgical anatomy, operative technique and rationale, Cosmetic Reconstruction of Temporal Defect following Peritonal craniotomy, Reconstruction of the temporalis muscle for pterional and cranio-orbital craniotomies, Medpor Craniotomy Gap Wedge Designed to Fill Small Bone Defects along Cranial Bone Flap, Less invasive reconstruction of the temporalis muscle for pterional craniotomy: modified procedures, Frontozygomatic titanium cranioplasty in frontosphenotemporal (“pterional”) craniotomy, Reconstruction of the temporalis muscle for the pterional craniotomy: Technical note, Pterional craniotomy without keyhole to supratentorial cerebral aneurysms: Technical note, The mini-pterional craniotomy: Technical description and anatomic assessment, Working area and angle of attack in the three cranial base approaches: Pterional, orbitozygomatic, and maxillary extension of the orbitozygomatic approach, The combined pterional/anterior temporal approach for aneurysms of the upper basilar complex: Technical report, The comparison of conventional pterional and transciliary keyhold approaches: Pro and con. To learn more about RMC, please visit the Understanding Retromastoid Craniectomy page on the UPMC.com website. There is no evidence to support giving anticonvulsants to all craniotomy patients. The patient is placed in a fixed head holder then placed prone on the operating room table. 4.1).
2 An arterial line and urinary catheter are used in all patients.
• Craniotomy defines a procedure where the cranial cavity is accessed through removal of bone to perform a variety of brain surgeries. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
For laterally-based tumors, the pterional approach minimizes brain retraction and provides the shortest distance to much of the superficial skull base and brain. First part (green) and the second part craniotomy (Orange).
Nimodipine is commenced after diagnosis in patients with subarachnoid hemorrhage (SAH). I often do an angiogram by retrograde injection through the superficial temporal artery so this can be palpated to locate it prior to marking the location of the incision.
Modifications have continued to arise, and the beauty of the pterional approach has been that it is a procedure adept at managing a large spectrum of disorders ranging from neoplastic pathologies to vascular lesions arising anywhere on the circle of Willis [12-16]. Exposure of the cervical carotid artery may be used to gain proximal control in these cases. Once the procedure is complete, you will begin your recovery.
The dura is opened in the middle of the exposure to expose the lateral spinal cord and dorsal exiting roots.
The head position in the standard position for a pterional craniotomy is rotated about 30 degrees, raised up above the body and extended so the orbital rim and malar eminence are at the same level horizontally ( Fig.
4.1 (a) Positioning for a pterional craniotomy, with the operating table flexed so that the head is elevated 15 degrees and is above the heart.
Once the surgery is completed, the bone flap is returned to its previous position.
If the aneurysm is ruptured and insertion of an EVD is anticipated, then shave an additional swath of hair back from the incision at the level of the superior temporal line.
2. The first burr hole is placed behind the standard key point, and a second is located posteriorly in the temporal bone (Figures 3-4). 4.2). The head position in the standard position for a pterional craniotomy is rotated about 30 degrees, raised up above the body and extended so the orbital rim and malar eminence are at the same level horizontally ( ▶ Fig. 4.1).
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