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18

18
Temporopolar (Half-and-Half) Approach to the
Basilar Artery and the Retrosellar Space

INDICATIONS PROCEDURE
• Transsylvian approaches enter the parasellar cisterns on a
superior-to-inferior trajectory, forcing the surgeon to work Frontal branch
past the carotid artery through the opticocarotid or carotid-­ of facial nerve
oculomotor triangles to access this region, making access of
the midbasilar 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 Zygomatic
basilar apex aneurysms or tumors with significant superior arch root
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 Superficial
lobe, which is retracted posteriorly and laterally to add the temporal a.
exposure of the tentorial incisura to the visualization obtained Hairline
with a transsylvian approach.
Widow’s peak

CONTRAINDICATIONS Skin incision


• Treatment of laterally projecting posterior communicating
artery aneurysms or middle cerebral artery aneurysms is con-
traindicated with this approach, as they may be attached to the
temporal lobe and rupture from retraction.
Fig. 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
PLANNING AND POSITIONING approach. The scalp flap is elevated, and pericranium is harvested for
• The patient is positioned supine. closure.
• The head is pinned similarly to the orbitozygomatic approach.
• The malar eminence needs to be the highest point in the field.

Fig. 18.1 Positioning for the temporopolar approach.

87
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88 Part 1  Cranial

1 Deep cut
2 Anterior cut
3 Posterior cut
4 Superior cut
Inferior
orbital 2
fissure
Fat pad 1 3
Orbital opening
of McCarty
Temporalis keyhole

2
Superior Executed Lateral
temporal line 1
Cuts to superior orbital rim
temporalis orbital cuts 4

Supraorbital
notch

Fig. 18.5 Zygomatic or orbitozygomatic osteotomy (if necessary).


Although the temporopolar approach was initially described as
Fig. 18.3 Soft tissue elevation and identification of landmarks. an extension of a pterional craniotomy, we have found additional
The temporalis fat pad is mobilized similarly to the orbitozygomatic osteotomies indispensable in this approach. Removal of the zygomatic
approach to protect the frontalis branch of the facial nerve. The arch permits additional temporalis dissection and assists with temporal
temporalis muscle is elevated down the root of the zygoma inferiorly lobe mobilization. Removal of the superolateral orbital rim allows for a
and the inferior orbital fissure anteriorly. It is wise to attempt to preserve flatter, more anterior trajectory, which is invaluable in visualization of the
the superficial temporal artery if possible. If an orbitozygomatic basilar apex.
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 Chapter 15.

Periorbita

Roof of orbit
1
Squamous and temporal
2 bone additional craniectomy

Sphenoid wing
additional craniectomy
Superior orbit
additional craniectomy
with rongeur

Fig. 18.6 Removal of lesser sphenoid wing. Regardless of whether


an orbitozygomatic osteotomy is performed, it is necessary to drill the
lesser sphenoid wing and orbital roof as flat as possible down to the
Fig. 18.4 Frontotemporal craniotomy. The craniotomy performed anterior clinoid process. To perform this, the dura is first stripped from
for the temporopolar approach is identical to the frontotemporal the orbit and sphenoid wing using a No. 1 Penfield dissector. The bony
craniotomy performed for the pterional or orbitozygomatic approach. elevation of this region is achieved using a side-cutting drill that is held
Aggressive craniectomy of the squamous temporal bone—from the parallel to the orbital bone with the hand resting on the temporalis
temporal pole back to the root of the zygoma until it is flush with the muscle. The drilling should avoid entering the orbit but should thin the
middle fossa floor—is particularly important for this approach. This bone in this region as close to this as possible. In deeper portions, thin
craniectomy is critical for safely mobilizing the temporal lobe posteriorly spicules of bone need to be removed using a fine rongeur.
and working along the middle fossa floor.

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CHAPTER 18  Temporopolar (Half-and-Half) Approach to the Basilar Artery and the Retrosellar Space 89

Sphenoid Wing
18

Frontal Operculum Temporal Operculum

Pcomm

A1
Sylvian Fissure Basilar

M1

Fig. 18.7 Sylvian dissection. After dural opening, the arachnoid Fig. 18.9 Temporal lobe mobilization. At this point, attention should
bridging from frontal to temporal lobe over the anterior sylvian fissure be turned to the temporal pole and subtemporal region. With gentle
should be meticulously divided using microscissors, No. 6 Rhoton posterior temporal retraction, any veins bridging from the temporal
dissector, and bipolar cautery, as necessary. By continuing laterally from pole to the sphenoparietal sinus should be identified and divided.
the carotid, the middle cerebral artery or a middle cerebral vein can be Additionally, the subtemporal space should be inspected for bridging
identified and followed into the sylvian fissure. Arachnoid dissection veins, which should be divided. With the increased relaxation provided
continues until the frontal and temporal lobes are separated roughly by the opening of the cisterns, the temporal lobe should be retracted
back to the limen insulae. slightly posterolaterally so that the arachnoid overlying the uncus can
be identified. After mobilization of the temporal lobe, the posterior
communicating artery should be followed posteriorly along the tentorial
incisura. This can be followed to the membrane of Liliequist, which can
be opened to expose the basilar apex and retrosellar space.

TIPS FROM THE MASTERS


• The dura needs to be tightly sutured flat against the bone so
Frontal Lobe ICA Temporal Lobe
that it does not obscure visualization.
• Often the frontal and temporal operculum can overlap, mak-
A1
M1 ing entering an arachnoid plane difficult. It is usually wise in
these situations to elevate the frontal lobe gently, identify the
Limen Insula
opticocarotid cistern, and open this sharply to drain cerebro-
spinal fluid and identify the supraclinoid carotid artery.
Sylvian Fissure
• The cerebrum should be routinely protected at this point be-
cause these procedures can take some time.

PITFALLS
It should never be necessary to take an artery crossing the fissure
because these can always be separated to one lobe or another
Fig. 18.8 Cisternal dissection. After completion of the sylvian fissure through careful dissection.
dissection, the arachnoid surrounding all visible cisternal spaces
should be opened sharply with microscissors. This dissection improves
visualization and provides further brain relaxation. The posterior
communicating artery should be identified exiting from the supraclinoid BAILOUT OPTIONS
carotid artery, and the arachnoid of the opticocarotid and carotid-
• If more posterior exposure of the ambient cistern is needed,
oculomotor triangle should be opened so that its course is clearly
the temporal lobe can be retracted upward, converting this
visualized and can be followed posteriorly.
approach to a subtemporal approach.

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