J Neurol Surg B Skull Base 2023; 84(01): 105-111
DOI: 10.1055/s-0042-1743464
Original Article

Minipterional Approach for Middle Fossa Skull Base Lesions: Technical Note

Jorge M. Mura
1   Department of Neurological Sciences, University of Chile, Santiago, Chile
7   Department of Cerebrovascular and Skull Base Surgery, Institute of Neurosurgery Asenjo, Providencia, Chile
Nícollas N. Rabelo
2   Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
2   Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
Tomás Poblete
3   Department of Neurological Sciences, University of Chile, Santiago, Chile
Víctor Hernández-Álvarez
4   Department of Neurosurgery, Hospital Barros Luco Trudeau, Santiago, Chile
5   Department of Neurosurgery, Universidad Santiago de Chile, Santiago, Chile
Sebastián Muñoz
4   Department of Neurosurgery, Hospital Barros Luco Trudeau, Santiago, Chile
6   Department of Neurosurgery, Hospital de Coyhaique, Coyhaique, Chile
Eberval G. Figueiredo
2   Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
› Author Affiliations


Surgical access to the middle fossa can be technically challenging. As neurosurgery evolves to minimally invasive approaches, the objective of this study is to demonstrate the extension of the Minipterional approach to access the middle fossa. We present a new surgical approach to the middle fossa for the treatment of secondary trigeminal neuralgia. Three cases are reported to illustrate the following techniques: a patient with petrotentorial meningioma and trigeminal neuralgia, a patient with an arachnoid cyst compressing the fifth nerve, and a patient with a middle cerebral artery aneurysm and a long history of TN (trigeminal neuralgia) refractory to medical and surgical treatments. All three experienced full symptom controls with no permanent neurological deficits. Therefore, the Minipterional technique might represent a feasible, effective, and safe option to treat refractory secondary TN. It also allows approaching these lesions when the posterior fossa approach is compromised by anatomical distortion and enables the simultaneous treatment of secondary trigeminal neuralgia and other lesions, such as aneurysms and meningiomas.

Ethical Approval

This study is retrospective and, therefore, is not required to have ethical board approval.

Informed Consent

No patients can be identified from the figures and video.

Publication History

Received: 24 November 2020

Accepted: 06 January 2022

Article published online:
10 March 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

  • References

  • 1 Olesen J. Preface to the second edition. Cephalalgia 2004; 24 (1_suppl): 9-10
  • 2 Sweet WH. The history of the development of treatment for trigeminal neuralgia. Clin Neurosurg 1985; 32: 294-318
  • 3 Bederson JB, Wilson CB. Evaluation of microvascular decompression and partial sensory rhizotomy in 252 cases of trigeminal neuralgia. J Neurosurg 1989; 71 (03) 359-367
  • 4 Tyler-Kabara EC, Kassam AB, Horowitz MH. et al. Predictors of outcome in surgically managed patients with typical and atypical trigeminal neuralgia: comparison of results following microvascular decompression. J Neurosurg 2002; 96 (03) 527-531
  • 5 Broggi G, Ferroli P, Franzini A, Servello D, Dones I. Microvascular decompression for trigeminal neuralgia: comments on a series of 250 cases, including 10 patients with multiple sclerosis. J Neurol Neurosurg Psychiatry 2000; 68 (01) 59-64
  • 6 Figueiredo EG, Deshmukh P, Nakaji P. et al. The minipterional craniotomy: technical description and anatomic assessment. Neurosurgery 2007;61(5, suppl 2):256–264, discussion 264–265
  • 7 Gardner WJ, Miklos MV. Response of trigeminal neuralgia to decompression of sensory root; discussion of cause of trigeminal neuralgia. J Am Med Assoc 1959; 170 (15) 1773-1776
  • 8 Jannetta PJ, Rand RW. Transtentorial retrogasserian rhizotomy in trigeminal neuralgia by microneurosurgical technique. Bull Los Angeles Neurol Soc 1966; 31 (03) 93-99
  • 9 Jannetta PJ. Treatment of trigeminal neuralgia by suboccipital and transtentorial cranial operations. Clin Neurosurg 1977; 24: 538-549
  • 10 Ravina K, Strickland B, Rennert R, Bakhsheshian J, Russin J, Giannotta S. Revision microvascular decompression for trigeminal neuralgia and hemifacial spasm: factors associated with surgical failure. J Neurol Surg B Skull Base 2019; 80 (01) 31-39
  • 11 Barker II FG, Jannetta PJ, Bissonette DJ, Larkins MV, Jho HD. The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med 1996; 334 (17) 1077-1083
  • 12 Theodosopoulos PV, Marco E, Applebury C, Lamborn KR, Wilson CB. Predictive model for pain recurrence after posterior fossa surgery for trigeminal neuralgia. Arch Neurol 2002; 59 (08) 1297-1302
  • 13 Tronnier VM, Rasche D, Hamer J, Kienle AL, Kunze S. Treatment of idiopathic trigeminal neuralgia: comparison of long-term outcome after radiofrequency rhizotomy and microvascular decompression. Neurosurgery 2001; 48 (06) 1261-1267 , discussion 1267–1268
  • 14 Sindou M, Howeidy T, Acevedo G. Anatomical observations during microvascular decompression for idiopathic trigeminal neuralgia (with correlations between topography of pain and site of the neurovascular conflict). Prospective study in a series of 579 patients. Acta Neurochir (Wien) 2002; 144 (01) 1-12 , discussion 12–13
  • 15 Amador N, Pollock BE. Repeat posterior fossa exploration for patients with persistent or recurrent idiopathic trigeminal neuralgia. J Neurosurg 2008; 108 (05) 916-920
  • 16 Cho DY, Chang CGS, Wang YC, Wang FH, Shen CC, Yang DY. Repeat operations in failed microvascular decompression for trigeminal neuralgia. Neurosurgery 1994; 35 (04) 665-669 , discussion 669–670
  • 17 Kureshi SA, Wilkins RH. Posterior fossa reexploration for persistent or recurrent trigeminal neuralgia or hemifacial spasm: surgical findings and therapeutic implications. Neurosurgery 1998; 43 (05) 1111-1117
  • 18 Barker II FG, Jannetta PJ, Bissonette DJ, Jho HD. Trigeminal numbness and tic relief after microvascular decompression for typical trigeminal neuralgia. Neurosurgery 1997; 40 (01) 39-45
  • 19 Suero Molina E, Revuelta Barbero JM, Ewelt C, Stummer W, Carrau RL, Prevedello DM. Access to Meckel's cave for biopsies of indeterminate lesions: a systematic review. Neurosurg Rev 2021; 44 (01) 249-259
  • 20 Van Rompaey J, Bush C, Khabbaz E, Vender J, Panizza B, Solares CA. What is the best route to the meckel cave? Anatomical comparison between the endoscopic endonasal approach and a lateral approach. J Neurol Surg B Skull Base 2013; 74 (06) 331-336
  • 21 Seçkin H, Patel N, Avci E, Dempsey RJ, Başkaya MK. Removal of cavernous malformation of the Meckel's cave by extradural pterional approach using Heros muscle dissection technique. Surg Neurol 2009; 72 (06) 733-736 , discussion 736
  • 22 Rabelo NN, Sisnando da Costa BB, Teixeira MJ, Figueiredo EG. Expanding indications for minipterional craniotomy-parasellar meningiomas. World Neurosurg 2018; 120: 594
  • 23 Figueiredo EG, Welling LC, Preul MC. et al. Surgical experience of minipterional craniotomy with 102 ruptured and unruptured anterior circulation aneurysms. J Clin Neurosci 2016; 27: 34-39
  • 24 Welling LC, Figueiredo EG, Wen HT. et al. Prospective randomized study comparing clinical, functional, and aesthetic results of minipterional and classic pterional craniotomies. J Neurosurg 2015; 122 (05) 1012-1019
  • 25 Martinez-Perez R, Jusue-Torres I, Chiarullo M, Mura JM. Surgical clipping of a non-ruptured ophthalmic aneurysm through an extradural micropterional keyhole approach. Acta Neurochir (Wien) 2020; 162 (04) 917-921
  • 26 Martinez-Perez R, Mura JM. The extradural minipterional approach: “think small, play wider”. World Neurosurg 2019; 125: 534-535
  • 27 Martinez-Perez R, Joswig H, Tsimpas A. et al. The extradural minipterional approach for the treatment of paraclinoid aneurysms: a cadaver stepwise dissection and clinical case series. Neurosurg Rev 2020; 43 (01) 361-370
  • 28 Sarkar M, Pillai A. Trans-Sylvian approach to microvascular decompression for trigeminal neuralgia in syndromic cranial base settling. Oper Neurosurg (Hagerstown) 2018; 15 (02) E9-E12