Temporopolar (Half-and-Half) Approach to the Basilar Artery and the Retrosellar Space




Indications




  • •

    Transsylvian approaches enter the parasellar cisterns on a superior-to-inferior trajectory, forcing the surgeon to work past the carotid artery through the opticocarotid or carotid-oculomotor triangles to access this region, making access of the mid-basilar and interpeduncular cisterns difficult.


  • •

    Although the subtemporal approach provides a good view of the basilar artery at the level of the tentorium, it is limited in its rostral visualization, which can be necessary for high-riding basilar apex aneurysms or tumors with significant superior extension. Also, the flat trajectory of this approach limits the ability to see the retrosellar space.


  • •

    The temporopolar approach combines these approaches largely through microsurgical mobilization of the temporal lobe, which is retracted posteriorly and laterally to add the exposure of the tentorial incisura to the visualization obtained with a transsylvian approach.





Contraindications




  • •

    Laterally projecting posterior communicating artery or middle cerebral artery aneurysms because these might be attached to the temporal lobe and rupture with retraction.





Planning and positioning




  • •

    The patient is positioned supine.


  • •

    The head is pinned similar to the orbitozygomatic approach.


  • •

    The malar eminence needs to be the highest point in the field.




    Figure 18-1:


    Positioning for the temporopolar approach.





Procedure





Figure 18-2:


The skin incision is C-shaped from the zygomatic root up to the widow’s peak similar to the incision used for the orbitozygomatic approach. The scalp flap is elevated, and pericranium is harvested for closure.



Figure 18-3:


Soft tissue elevation and identification of landmarks. The temporalis fat pad is mobilized similar to the orbitozygomatic approach to protect the frontalis branch of the facial nerve. The temporalis muscle is elevated down the root of the zygoma inferiorly and the inferior orbital fissure anteriorly. It is wise to attempt to preserve the superficial temporal artery if possible. If an orbitozygomatic osteotomy is planned, the attachment of the temporalis fascia to the zygomatic arch should be cut, and the soft tissue should be elevated off the zygoma over the maxillary buttress and frontozygomatic suture. The periorbita should also be freed from the orbital bone. These soft tissue dissection steps are described in more detail in Procedure 15 .

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Jun 15, 2019 | Posted by in NEUROSURGERY | Comments Off on Temporopolar (Half-and-Half) Approach to the Basilar Artery and the Retrosellar Space

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