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Pterional Craniotomy: Improving the Efficiency of Exposure

February 04, 2015


This is another video describing the technical nuances for a Pterial Craniotomy. Obviously the patient is placed in a spam position. The fixation of the head clamp is demonstrated. The incision starts a 1cm anterior to the tragus and generally stays behind the hairline toward the midline and the contralateral midpupillary line. The turn of the head depends on the location of the pathology relative to the midline. The initial part of the incision is performed over the frontal lobe. Hemostasis is obtained. The skin and scalp was injected with local anesthetic, and epinephrine at the beginning of the procedure during the prepping. I use a spatula to elevate the galea and cool a cut over the spatula while the spatula is used as you can see using this toggling maneuver to complete the incision. Next the superficial temporal artery is found and its dominant branch is protected. The scalp is reflected anteriorly over this superior or superficial temporal fascia. The zygoma is palpated, fish hooks are used to mobilize the scalp, a subfascial technique is used to mobilize the fat pad. You will see that I used a monopolar cautery to dissect the deep fascia until the muscle is evident, and the fat pad is reflected anteriorly. It's important not to cut across the fat pad here. A cuff of muscle is left behind for adequate fixation of the muscle at the time of the closure. The area of the keyhole is obviously well exposed. The muscle is elevated. Electrocautery may be minimized to avoid injury to the neurovascular bundles at the bottom surface of the muscle, potentially minimizing the risk of cosmetic deformity and muscle atrophy. Again, the muscle is mobilized as much anterior and fairly as possible. I'll have to place the burr hole just behind the superior temporal line, along the posterior aspect of the bony exposure. A generous burr hole is created, and the dura is well dissected from the inner surface of the calvarial. Placement of the burr hole in this location is quite effective because it minimizes the bone loss in the area of the keyhole. Also dissection of the dura can be sometimes difficult since the no.3 pen field has limited space for movement because the scalp and the muscle and the zygoma can interfere with its activity in order to dissect the dura generously. A similar limitation is apparent along the root of the zygoma here. Next, first craniotomy is performed over the frontal area. A craniotome cannot make sharp turns and therefore one has to prepare for the turn of the craniotome so that the drill can be advanced effortlessly. Next, the drill is advanced until its progress is further prevented by the sphenoid wing. Next the drill is turned around itself and is removed first through the heel of the drill. The next cut is performed along the temporal area very similarly. Again the drill is turned around itself at the level of the pterion. A B1 without a foot plate is used next to disconnect the bone from the lateral sphenoid wing. The bone flap is elevated. The dura is mobilized away from the area of the pterion and the lateral sphenoid wing is resected. Any overhanging one over their frontal area is removed so that an unobstructed trajectory over the sub frontal area is available. Again, here is the resection of the lateral sphenoid wing. Subtemporal craniotomy may be necessary as well. As you can see here, where the meningeal artery is controlled. Tack up stitches are placed one in the frontal area and one over the temporal area. Additional drilling may be necessary. So that disfigured wing will not interfere with operative maneuvers. Again the amount of resection of the bone depends on the pathology at hand. Here is the extent of exposure of temporal frontal area exposed. This patient harbored a lateral sphenoid meningioma. The dura is open in a curvilinear fashion. I placed the sutures or the retention sutures at the root of the dura in order to mobilize the dura out of my working zone as much as possible. Here you can see the location of the tumor just along the anterior sylvian fissure. The closure is relatively simple as you can see the fixation of the bone via mini plates in three points. Here's the temporalis muscle that has been reflected in its position and will be sutured to the cuff of the muscle left behind at the level of the superior temporal line. The rest of the closure can be performed in the anatomical layers. Thank you.

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