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

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

Publication History

Received: 17 August 2021

Accepted: 03 December 2021

Article published online:
11 January 2022

• References

• 1 Ono M, Ono M, Rhoton Jr AL, Barry M. Microsurgical anatomy of the region of the tentorial incisura. J Neurosurg 1984; 60 (02) 365-399
• 2 McLaughlin N, Martin NA. Extended subtemporal transtentorial approach to the anterior incisural space and upper clival region: experience with posterior circulation aneurysms. Neurosurgery 2014; 10 (Suppl. 01) 15-23 , discussion 23–24
• 3 MacDonald JD, Antonelli P, Day AL. The anterior subtemporal, medial transpetrosal approach to the upper basilar artery and ponto-mesencephalic junction. Neurosurgery 1998; 43 (01) 84-89
• 4 Kawase T, Shiobara R, Toya S. Anterior transpetrosal-transtentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients. Neurosurgery 1991; 28 (06) 869-875 , discussion 875–876
• 5 Steiger HJ, Hänggi D, Stummer W, Winkler PA. Custom-tailored transdural anterior transpetrosal approach to ventral pons and retroclival regions. J Neurosurg 2006; 104 (01) 38-46
• 6 Fernandez-Miranda JC. Extended Middle fossa approach with anterior petrosectomy and anterior clinoidectomy for resection of spheno-cavernous-tentorial meningioma: the Hakuba-Kawase-Dolenc approach: 3-dimensional operative video. Oper Neurosurg (Hagerstown) 2017; 13 (02) 281
• 7 Drake CG. Bleeding aneurysms of the basilar artery. Direct surgical management in four cases. J Neurosurg 1961; 18: 230-238
• 8 Goel A. Extended lateral subtemporal approach for petroclival meningiomas: report of experience with 24 cases. Br J Neurosurg 1999; 13 (03) 270-275
• 9 Goehre F, Lehecka M, Jahromi BR. et al. Subtemporal approach to posterior cerebral artery aneurysms. World Neurosurg 2015; 83 (05) 842-851
• 10 Hashemi M, Schick U, Hassler W, Hefti M. Tentorial meningiomas with special aspect to the tentorial fold: management, surgical technique, and outcome. Acta Neurochir (Wien) 2010; 152 (05) 827-834
• 11 Ogiwara T, Goto T, Kusano Y. et al. Subtemporal transtentorial approach for recurrent trigeminal neuralgia after microvascular decompression via the lateral suboccipital approach: case report. J Neurosurg 2015; 122 (06) 1429-1432
• 12 Steňo J, Bízik I, Steňová J, Timárová G. Subtemporal transtentorial resection of cavernous malformations involving the pyramidal tract in the upper pons and mesencephalon. Acta Neurochir (Wien) 2011; 153 (10) 1955-1962 , discussion 1962
• 13 Zenonos GA, Fernandes-Cabral D, Nunez M, Lieber S, Fernandez-Miranda JC, Friedlander RM. et al. The epitrigeminal approach to the brainstem. J Neurosurg 2018; 128 (05) 1512-1521
• 14 Rhoton Jr AL. The cerebral veins. Neurosurgery 2002; 51 (Suppl. 04) S159-S205
• 15 Sugita K, Kobayashi S, Yokoo A. Preservation of large bridging veins during brain retraction. Technical note. J Neurosurg 1982; 57 (06) 856-858
• 16 Heros RC. Brain resection for exposure of deep extracerebral and paraventricular lesions. Surg Neurol 1990; 34 (03) 188-195
• 17 Kyoshima K, Oikawa S, Kobayashi S. Preservation of large bridging veins of the cranial base: technical note. Neurosurgery 2001; 48 (02) 447-449
• 18 Joo W, Rhoton Jr AL. Microsurgical anatomy of the trochlear nerve. Clin Anat 2015; 28 (07) 857-864
• 19 Iaconetta G, de Notaris M, Benet A. et al. The trochlear nerve: microanatomic and endoscopic study. Neurosurg Rev 2013; 36 (02) 227-237 , discussion 237–238
• 20 Tubbs RS, Oakes WJ. Relationships of the cisternal segment of the trochlear nerve. J Neurosurg 1998; 89 (06) 1015-1019
• 21 Umeoka K, Takusakawa Y, Kominami S, Kobayashi S, Morita A. The meningeal branches of the superior cerebellar artery: a surgical observation study. J Neurosurg 2016; 124 (01) 244-247
• 22 Griessenauer CJ, Loukas M, Scott JA, Tubbs RS, Cohen-Gadol AA. The artery of Davidoff and Schechter: an anatomical study with neurosurgical case correlates. Br J Neurosurg 2013; 27 (06) 815-818
• 23 Goel A. Tentorial dural flap for transtentorial surgery. Br J Neurosurg 1995; 9 (06) 785-786
• 24 Gupta SK, Salunke P. Intradural anterior petrosectomy for petroclival meningiomas: a new surgical technique and results in 5 patients: technical note. J Neurosurg 2012; 117 (06) 1007-1012
• 25 Ichimura S, Hori S, Hecht N, Czabanka M, Vajkoczy P. Intradural anterior transpetrosal approach. Neurosurg Rev 2016; 39 (04) 625-631
• 26 Koerbel A, Gharabaghi A, Safavi-Abbasi S. et al. Venous complications following petrosal vein sectioning in surgery of petrous apex meningiomas. Eur J Surg Oncol 2009; 35 (07) 773-779
• 27 Tanriover N, Abe H, Rhoton Jr AL, Kawashima M, Sanus GZ, Akar Z. Microsurgical anatomy of the superior petrosal venous complex: new classifications and implications for subtemporal transtentorial and retrosigmoid suprameatal approaches. J Neurosurg 2007; 106 (06) 1041-1050
• 28 Fernández-Miranda JC, de Oliveira E, Rubino PA, Wen HT, Rhoton Jr AL. Microvascular anatomy of the medial temporal region: part 1: its application to arteriovenous malformation surgery. Neurosurgery 2010;67(suppl operative 3):ons237–ons276, discussion ons276
• 29 Tubbs RS, Nguyen HS, Shoja MM, Benninger B, Loukas M, Cohen-Gadol AA. The medial tentorial artery of Bernasconi-Cassinari: a comprehensive review of its anatomy and neurosurgical importance. Acta Neurochir (Wien) 2011; 153 (12) 2485-2490
• 30 Ulm AJ, Tanriover N, Kawashima M, Campero A, Bova FJ, Rhoton Jr A. Microsurgical approaches to the perimesencephalic cisterns and related segments of the posterior cerebral artery: comparison using a novel application of image guidance. Neurosurgery 2004; 54 (06) 1313-1327 , discussion 1327–1328
• 31 Hernesniemi J, Ishii K, Karatas A. et al. Surgical technique to retract the tentorial edge during subtemporal approach: technical note. Neurosurgery 2005; 57 (Suppl. 04) E408 , discussion E408
• 32 Nanda A, Patra DP, Savardekar A. et al. Tentorial meningiomas: reappraisal of surgical approaches and their outcomes. World Neurosurg 2018; 110: e177-e196
• 33 Li D, Tang J, Ren C, Wu Z, Zhang LW, Zhang JT. Surgical management of medium and large petroclival meningiomas: a single institution's experience of 199 cases with long-term follow-up. Acta Neurochir (Wien) 2016; 158 (03) 409-425 , discussion 425
• 34 Taha JM, Tew Jr JM, van Loveren HR, Keller JT, el-Kalliny M. Comparison of conventional and skull base surgical approaches for the excision of trigeminal neurinomas. J Neurosurg 1995; 82 (05) 719-725
• 35 Wong RH, De Los Reyes K, Alikhani P. et al. The subtemporal approach to retroinfundibular craniopharyngiomas: a new look at an old approach. Oper Neurosurg (Hagerstown) 2015; 11 (04) 495-503
• 36 Fernandez-Miranda JC, Gardner PA, Snyderman CH. et al. Craniopharyngioma: a pathologic, clinical, and surgical review. Head Neck 2012; 34 (07) 1036-1044
• 37 Ammerman JM, Lonser RR, Oldfield EH. Posterior subtemporal transtentorial approach to intraparenchymal lesions of the anteromedial region of the superior cerebellum. J Neurosurg 2005; 103 (05) 783-788