Pterional Approach: Technical Variations, Functional, and Cosmetic Outcome in a Series of 1000 Patients

Abstract

INTRODUCTION
 Most of the versatility of the pterional approach depends on a series of variations progressively reported by several groups, but little emphasized over the years.
 The present study condenses the technical notes which the authors adopted in their practice to maximize the surgical freedom of the pterional approach, at once lessening the approach-related complication rate.
 METHODS 
 Data of a series of patients who underwent a pterional approach between January 2011 and May 2021 were retrospectively reviewed focusing on the technical variations compared to the original Yaşargil’s description. The anatomical rationale, technique, and advantages were outlined and validated through the appraisal of functional and cosmetic complications. 
 RESULTS
 994 patients were reviewed. Head extension was avoided in the case of anterior clinoidectomy. A single double-layered galea-pericranium flap was used for duraplasty. The submuscular technique, with compulsive preservation of deep temporal fascia and deep temporal arteries, was preferred for temporalis muscle dissection. McCarty keyhole was never used, thus avoiding exposing the orbit if unnecessary. Widening of the superior orbital fissure and thinning of the orbital roof allowed to significantly increase the working area. The average follow-up was 7.2 years. The overall rate of functional and cosmetic complications was 2.1.
 DISCUSSION
 In the authors' experience, the gradual adoption of technical variations related to the patient's positioning, soft tissue dissection, bony work, dura opening, and reconstruction allowed to enhance the versatility of the pterional approach concurrently decreasing the risk of functional and cosmetic complications.

Jugular Foramen Tumors: Surgical Strategies and Representative Cases

“…The far-lateral approach is a more inferior extension of the retrosigmoid approach and involves extending further laterally from the lateral suboccipital approach [13,14]. It provides a better access to the foramen magnum and craniocervical junction, extending the corridor inferior and lateral to the lower cranial nerves [15].…”

“…It provides a better access to the foramen magnum and craniocervical junction, extending the corridor inferior and lateral to the lower cranial nerves [15]. Its primary indication is tumors that extend to the foramen magnum anteriorly or laterally to the lower brainstem at the craniocervical junction [13,14]. The jugular foramen is exposed posteriorly [3].…”

“…The percentage of condyle to be removed can vary from only the posterior one third with no instability of the craniovertebral junction to as far as the posterior half, which will require fixation of the craniovertebral junction due to instability of the atlanto-occipital joint [21,22]. The complete trans-condylar approach during which the posterior two thirds of the condyle is removed will have the hypoglossal canal as the anterior limit and can provide a dramatic increase in petroclival exposure, especially if the jugular tuberculum is also removed [13,20]. This approach is generally used to reach the premedullary area [13,23].…”

Microneurosurgical anatomy of the basal cisterns: A brief review for cisternostomy

“…Among them, the one used in previous randomized trials for cisternostomy, is the frontotemporal approach or modification of the pterional approach. [2,17,25,26,30,34] e main target for this approach is the wide exposure of the superficial sylvian fissure, to allow proper manipulation in a swollen brain and then sstart a cisternal pathway and dissection [Figures 4A-C]. Special care must be taken to remove bone from the sphenoidal ridge to have a good visualization at deeper levels.…”

The Party Wall: Redefining the Indications of Transcranial Approaches for Giant Pituitary Adenomas in Endoscopic Era

“…The extended trans-sphenoidal transpterygoid approach provides limited exposure of the portion of the tumor lying lateral to the ICA [ 140 ]. The pterional or COZ approach, based on the surgical maneuverability required to safely remove the parasellar part of the tumor [ 141 , 142 , 143 , 144 , 145 ], has been used as a standalone or staged combination with the trans-sphenoidal corridor.…”