(48-396x /87/2104.0474802.00/0 INevRestrGeR Vol, 21. No.4 1987 Comrieht © L9R7 hy the Congres of Neurological Surpcons Prnied in USA, Supraorbital-Pterional Approach to Skull Base Lesions Osama Al-Mefty, M.D. Department of Neurosurgery, University of Mississippi Medical Center Jackson, Missssippt AA surgical approach to the skull base is described. It allows excellent exposure of the cranial base with minimal brain retraction. Deep lesions can be handled via subfontal, transsylvian, or subtemporal routes during the same operation This approach is most suitable for large lesions in the suprasella, parasellar, and retrosellar areas and for those that extend into the cavernous sinus, along the tentorial notch, or into the orbit. After the single bone flap is replaced, there is little or no functional, anatomical, or cosmetic deficit. Our experience in 16 cases and suggestion for the use of this approach are presented. (Neurosurgery 21:474-877, 1987) Key words: Basilar aneurysm, Cranial base, Craniopharyngioma, Meningioma, Orbital tumor, Supraorbital-pterional approach, INTRODUCTION Although advances in neuroanesthesia, microtechnique, cerebrospinal fluid drainage, steroid medication, and intra- operative dehydrating agents have decreased the brain retrac- tion required 10 approach deep-seated lesions, postoperative complications due to excessive retraction persist when stand- ard approaches are used (I). Neurosurgeon continue t0 de~ velop surgical approaches that minimize brain retraction and. facilitate exposure of the cranial base (2. 7, 12, 13). Both McArthur (11) in 1912 and Frazier (6) in 1913 removed the supraorbital arch in their frontal approach to the hypophysis, More recently, Jane et al. have refined this supraorbital ap- proach and consider it the approach of choice for orbital tumors (9). The pterional approach was first used in 1918 by Heuer to approach suprasellar lesions (8). It was modified by Dandy in 1941 in approaching anterior communicating artery aneurysms (4) and was refined by Yasargil et al. with drilling Of the sphenoid ridge and on occasion removal of part of the orbital ridge and roof if the orbital roof had a pronounced femporal burr hole ‘upward extension (14). It is routinely used at present (5). ‘either approach alone may be adequate for large lesions located at the brain base and extending into multiple com- partments, We are describing an approach that offers the following advantages: (a) it brings the surgeon closer to the deep-seated lesion, allowing dissection over the shortest pos- sible distance: (6) it permits a surgical attack via multiple routes (subfrontal, transsylvian, and subtemporal): and (c) it consists of a single bone flap, alleviating the need for recon- ah a struction and associated functional anatomical or cosmetic , deficits. wate’) TECHNIQUE yj The scalp flap is turned after a bicoronal incision is made behind the hairline. The incision extends from the level of ~ the zygomatic arch on the side of the tumor to as far as the superior temporal line on the other side. Every effort is made to preserve the superficial temporal artery and the frontalis branches of the facial nerve. The temporalis muscle is de~ tached from its insertion anteriorly to as far down as the zygomatic arch; the muscle then is retracted posteriorly and FiG, 2. Diagram illustrating the three steps in removal of the bone inferiorly. exposingthe junction ofthe zygomatic, sphenoidsl, gap. /, cranstome connecting the fFontal and posterior temporal and frontal bones. The periosteum of the frontal bone is hurr hoes 2-line of connection between te temporal and Keyhole incised posteriorly. dissected forward, and reflected over the bur holes. 3, Gigli saw incising the oo of the oxi 414 FAG. 1, Skull mode! illustrating the three burr hole positions. F. paramedian frontal burr hole; K, MacCarty keyhole; 7, posteriorOctober 1987 anteriorly turned scalp flap. The intact base of this perios- teum, in continuation with the periorbita, is dissected free from the margin of the roof and the lateral wall of the orbit as described previously (2). The supraorbital nerve is freed from the supraorbital notch by drilling around the notch with a high speed air drill Three burt holes are drilled (Fig. 1). The first is made in the frontal bone above the nasion. This hole should be kept as small as possible for cosmetic reasons, In adults, this burr hole will pass through the anterior and posterior wall of the frontal sinus. The mucosa of the frontal sinus is exenterated, and the sinus is packed with a piece of temporalis muscle. ‘The second burr hole (MacCarty keyhole (10)) is made in the temporal fossa at the frontosphenoidal junction just behind the zygomatic process of the frontal bone, The upper half of this burr hole will expose the dura mater, while the lower half exposes the periorbita, the two membranes being separated by the roof ofthe orbit. The third burr hole is made posteriorly near the floor of the temporal fossa. The bone between burr holes is severed. The paramedian frontal burr hole and the posterior temporal burr hole are connected by the use of the craniotome; its blade passes through the frontal and temporal Fic, 3, Diagrammatic illustration of the supraorbital-pterional single bone Map. SUPRAORBITAL-PTERIONAL APPROACH — 475, bone about 5 em above the supraorbital rim, as shown in the first step in Figure 2. The posterior temporal burr hole and the keyhole likewise are connected, with the craniotome pass- ing just above the floor of the temporal fossa (Fig. 2, Step 2) Then the paramedian frontal burr hole and the keyhole are interconnected by a Gigli saw. A Gigli saw guide is passed between the two burr holes over the roof of the orbit in the epidural space. The orbit is cut with the Gigli saw as shown in Step 3 in Figure 2. This bony incision is carried laterally and inferiorly and is continued through the lateral orbital rim. ‘The contents of the orbit are protected with a brain spatula during this process, Particular attention should be given to keeping the periorbita intact. Injury to the supraorbital nerve and the trochlear attachment of the superior oblique muscle should be avoided. ‘The craniotomy flap then is freed by fracturing it loose at the sphenoid base. The removed and preserved bone flap thus includes the superior and lateral orbital rim, the anterior portion of the orbital roof, and the adjacent frontal and temporal bones (Fig, 3). The sphenoid wing is then drilled with a high speed air drill to the base of the anterior clinoid process (Fig. 4). The dura mater is opened with a semicircular incision centered on the pterion with extension branches off Fic. 5. Diagrammatic illustration of the exposure obtained through this approach, Fic. 4, Diagrammatic illustration of sphenoid ridge drilling after ‘removal ofthe bone flap. The drilling is extensive and continues 10 the base of the anterior clinoid process. Fi. 6 4. medial sphenoid ridge meningioma exposed through the described approach, 4, preoperative axial computed tomographic (CT) sean; B, postoperative anial CT scan,416 AL-MEFTY Neurosurgery, Vol. 21, No. 4 ed the main incision down to the floor of the temporal fossa posteriorly. This approach provides excellent wide exposure (Fig. 5). Afler the dura mater is closed, the bone fap is positioned and secured with heavy sutures. The frontal epi- cranium is turned over the frontal sinus and sutured to the dura mater to avoid thinorthea, The temporalis muscle is sutured to the fascia at the lateral orbital rim, and the skin is closed in two layers DISCUSSION Because of their deep location, the involvement of vital neurovascular structures, and their extensions in multiple cranial compartments, total removal of cranial base tumors. presents a formidable challenge. Medial sphenoid wing m ningiomas and sphenoorbital meningiomas are examples of such lesions, The approach described, coupled with microsur gical operative techniques, permits vital neurovascular struc tures to be dissected and preserved. The cavernous sinus is ‘more easily reached, and interpeduncular extensions are more comfortably handled. If needed, the orbit and the optic canal can be unfoofed and orbital tumor extensions may be re- moved, Craniopharyngiomas, growing retrochiasmatically with a prelixed chiasm, are vexing lesions. They require inspection and dissection laterally or through the lamina terminalis (3). The supraorbital-pterional approach is particularly helpful in such cases because it offers multiple access, thus alleviating the need for multiple operations. Giant aneurysms, parti larly of the basilar artery, can be better exposed and dissected through this approach. The extensive reconstruction needed in other approaches (7, 12)isalleviated with our technique, which requires a single bone flap, We utilized this approach in 16 cases (11 medial sphenoid wing meningiomas, 2 sphenoorbital meningiomas, 2 retrochiasmatic craniopharyngiomas, and | hypothalamic glioma). Fourteen patients were operated upon at King Faisal Specialist Hospital, and 2 patients underwent operation at the University of Mississippi Medical Center. One patient had Fic. 7. A sphenoorbital meningioma operated by this approach. 4, preoperative axial CT scan; B, postoperative axial CT scans. me / Fic, 8, Large craniopharyngiomain a patient with a prefixed optic cchiasm, The desenbed approach provides multiple routes for explo fation and dissection, preoperative axial CT scan: B, postoperative anial CT scan, both a right medial sphenoid ridge meningioma and an inci- dental right internal carotid aneurysm. The aneurysm was clipped after total tumor removal. Figures 6 to 8 are examples of lesions that we have exposed by this approach. ACKNOWLEDGMENTS The illustrations were drawn by Alice McKenzie at the King Faisal Specialist Hospital, Riyadh, Saudi Arabia. 1 also thank Lucia Griffin for her assistance in preparing the man- useript. Received for publication, October 26, 1986; accepted, February 10, 1987. Reprint eequests: Ossama Al-Mefty, M., Deparment of Neuro: surgety, University of Mississippi Medical Center, 2500 North State Sureet, Jackson, Mississippi 39216-4505. REFERENCES 1, Albin MS, Bunegin L, Dujovny M, Bennett MH, Jannetta PJ. Wisotzkey HW: Brain retractor pressure during intracranial pro cedures. Surg Forum 26:499-S00, 1975October 1987 [AlMefty 0. Fox JL: Superotateral orbital exposure and recon: struction. Surg Neurol 23:609-613, 1985. AL-Mefiy 0, Hassounah M, Weaver, Sakati N, Jinkins JR, Fox JL: Microsurgery for giant craniopharyngiomas in children, Neu- rosurgery 17:385-595, 1985. Dandy WE: Aneurysms of the anterior cerebral artery, JAMA, 119:1253-1284, 1942 Fox JL: Iniracranial Aneurysms. New York, Springer-Verlag, 1983, pp 2756-2757. Frazier Ci: An approach to the hypophysis through the anterior cranial fossa, Ann Surg 57:145-150, 1913. 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