Pterional Craniotomy

Indications

• The pterional craniotomy and the transsylvian approach are the most used techniques in contemporary neurosurgery.

• The pterional craniotomy allows exposure of the frontoparietal and temporal opercula together with the basal subarachnoid cisterns ( Figure 17.1 ). This approach allows opening of the entire sylvian fissure, which allows for exposure of the circle of Willis, sphenoid wing, sella turcica, upper clivus, cavernous sinus and parasellar regions.

  

• Extra-axial tumors of the anterior and middle cranial fossa, and intra-axial tumors of the insula and the lateral fronto-temporo-parietal subcortical areas.

• It is indicated for clipping aneurysms of the anterior and posterior circulation and resecting perisylvian arteriovenous malformations. Also, for emergent evacuation of intraparenchymal hemorrhage in that region or hemorrhage from aneurysms not amenable for treatment through an endovascular procedure.

Contraindications

• Other approaches are more suitable in treating sellar/parasellar tumors in the midline (e.g. endonasal approaches) or with superoanterior extension (e.g. bifrontal craniotomy) and distal lesions from the posterior and anterior cerebral arteries. Lesions that extend into the third ventricle may be better approached with an orbitozygomatic or transcallosal approach. This approach is contraindicated in clipping high-riding basilar aneurysms because of the lack of basilar apex visualization above the posterior clinoid.

Surgical Procedure