Transsylvian–Transcisternal Approach. A, Coronal cut through the right temporal lobe showing the route of the approach (red arrows). After widely opening the sylvian fissure and chiasmatic, carotid, interpeduncular, and crural cisterns, the uncus of temporal lobe is removed and the temporal horn is accessed. For epilepsy, the selective disconnection will be through the choroidal fissure medially and through the collateral eminence and collateral sulcus laterally. The amygdala, uncus, hippocampus, and parahippocampal gyrus are removed (horizontal blue lines). B–F, Stepwise cadaveric dissection showing the transsylvian transcisternal approach. B, Right sylvian and pretemporal exposure. The bridging veins passing from the temporal pole to the sphenoparietal or cavernous sinuses are divided to allow mobilization of the medial temporal lobe. C, The sylvian fissure has been opened widely and the M1 segment of the middle cerebral artery has been elevated to expose the anterior segment of the uncus. The lenticulostriate arteries are preserved carefully. D, The arachnoid fibers between the uncus, oculomotor nerve, and the vessels in the carotid and crural cisterns have been divided to expose the anterior choroidal, posterior communicating, superior cerebellar, and posterior cerebral arteries. The optic tract is exposed above the anterior choroidal artery. E, The segment of the uncus medial to a line between the cisternal portion of the anterior choroidal artery and rhinal sulcus is exposed along the line of the planned resection (interrupted line). F, The uncus, amygdala, and head and anterior part of the body of the hippocampus have been removed. The temporal horn is accessed from anterior and medially. The insert shows the medial surface of the resected medial temporal lobe, including the anterior and posterior segment of the uncus and the uncal notch. G, Preoperative magnetic resonance imaging scans (upper left, coronal; upper right, axial) and lateral views of a (lower left) carotid and (lower right) vertebral angiograms of a 29-year-old man, disclosing an arteriovenous malformation in the anterior portion of the right medial temporal lobe. H, Postoperative (left) anteroposterior and (right) lateral carotid angiogram after a transsylvian transcisternal approach revealing no residual lesion. (Images courtesy of AL Rhoton, Jr.)