20 Intradural Subtemporal Approach The subtemporal approach is a lateral approach that provides access to the middle cranial fossa through a single burr hole craniotomy. This approach can be used to access peri-peduncular segments of the posterior cerebral artery (as demonstrated here), as well as for aneurysms of the superior cerebellar and basilar arteries and tumors found within this neuroanatomical location. This approach also provides extensive access to the temporal lobe for epilepsy surgery. • Basilar apex aneurysm. • Posterior cerebral artery aneurysm. • Superior cerebellar and basilar artery aneurysm. • Anteromedial tentorial meningiomas. • Petroclival tumors. • Posterior cavernous sinus lesion. • Epilepsy surgery. • Either the lateral or supine position can be used for this approach. • The Authors prefer the full lateral as it is felt that gravity can be used to have the temporal lobe “fall away” more with less retraction needed to reach its undersurface. • Position: The patient is positioned in the full lateral position with the dependent arm and shoulder superior to the edge of the operating table supported in a sling. The axilla is cushioned with a roll. The superior shoulder is gently displaced inferiorly. The recumbent malleolus is padded. • Head: The head is pinned in the anterior-posterior direction in the Mayfield clamp. The head is tilted 90° to be parallel with the floor. The head is then tilted 10° toward the floor. • A 2 cm wide strip is shaved along the planned incision. • Position: The patient is positioned supine with the ipsilateral shoulder supported with a shoulder roll. • Head: The head is pinned in the anterior-posterior direction in the Mayfield clamp. The head is tilted 90° to be parallel with the floor. The head is then tilted 20° toward the floor with the zygoma as the most superior point in the surgical field. Different skin incisions are possible. Our preference is to use a straight vertical incision as it is easier to reconstruct and cosmetically more acceptable with less chances of skin breakdown. • Vertical incision ◦ Starting point: Incision starts at the superior temporal line. ◦ Course: Incision line runs perpendicular to the zygoma and extends inferiorly to the level of the zygomatic arch, anterior to the tragus. ◦ Ending point: It ends at the level of the zygomatic arch. • Horseshoe incision ◦ Starting point: Incision starts at the root of the zygoma anterior to the tragus. ◦ Course: Incision line runs superiorly to the superior temporal line and then extends posteriorly above the pinna curving 2 cm behind the mastoid. ◦ Ending point: It ends at the level of the mastoid.
20.1 Introduction
20.2 Indications
20.3 Patient Positioning
20.3.1 Full Lateral
20.3.2 Supine
20.4 Skin Incision (Fig. 20.1)
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