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GENERAL

Surgical Anatomy and Technique

Lateral Supraorbital Approach vs Pterional Approach: An Anatomic Qualitative and Quantitative Evaluation
Asem Salma, MD* Abdulrahman Alkandari, MD* Steffen Sammet, MD, PhD Mario Ammirati, MD, MBA*
Departments of *Neurological Surgery and Radiology, Ohio State University Medical Center, Columbus, Ohio Correspondence: Asem Salma, MD, Department of Neurological Surgery, The Ohio State University Medical Center, 032 Hamilton Hall, 1645 Neil Avenue, Columbus, OH 43210. E-mail: asem.salma @osumc.edu Received, January 27, 2010. Accepted, October 21, 2010. Copyright 2011 by the Congress of Neurological Surgeons

BACKGROUND: Several minimally invasive modifications of the standard pterional approach have been proposed recently. The lateral supraorbital approach is one of these modifications. OBJECTIVE: To provide a qualitative and quantitative anatomic comparison of the surgical exposure and the operability afforded by the standard pterional approach and the lateral supraorbital approach. METHODS: Eight pterional approaches and 8 lateral supraorbital approaches were used in 8 fresh human cadaver heads. One qualitative and 2 quantitative tools were used to assess the surgical exposure. RESULTS: Qualitatively, the lateral supraorbital approach has the advantages of reduced trauma to the temporalis muscle and exposure that is comparable to that provided by the standard pterional approach to the sellar and suprasellar regions. This approach offers limited exposure of the interpeduncular fossa compared with the pterional one. Quantitatively, the pterional approach provides a greater surgical volume than the lateral supraorbital approach (32.90 mL vs 23.60 mL with P , .05). Also, the pterional approach provides a greater associated surgical operability than the lateral supraorbital approach (exposure score of 66 and 53, respectively). However, the lateral supraorbital approach offers an equivalent access to the anterior communicating artery complex, optic nerve, optic chiasm, and sellar area (the exposure scores were 19 for both approaches). CONCLUSION: From an anatomic point of view, both approaches provide similar exposure to the sellar, suprasellar, and anterior communicating artery areas. The pterional approach provides better exposure of the retrosellar area. The ability to operate in the retrosellar area, as judged by our model, was higher with the pterional than with the lateral supraorbital approach.
KEY WORDS: Anatomic study, Lateral supraorbital approach, Minimally invasive neurosurgery, Pterional approach
Neurosurgery 68[ONS Suppl 2]:ons364ons372, 2011
DOI: 10.1227/NEU.0b013e318211721f

lthough the standard pterional approach is considered the gold standard neurosurgical route to reach the sellar, parasellar, and retrosellar regions, this approach requires manipulation of the temporalis muscle.1,2 This maneuver may be associated with significant atrophy of the muscle as well as with different degrees of dysfunction of the frontal branch of the facial nerve.3-7 Several surgical modifications have been suggested to reduce this potential problem.8-10 The lateral supraorbital approach described by Hernesniemi et al11-14 is

one such alternative approach. Hernesniemi et al12,13 propose this approach to operate on intracranial lesions located in the sellar and suprasellar regions, in the sylvian fissure, and in the retrosellar regions such as the superior part of the basilar artery and the interpeduncular fossa. This modified technique has the advantages of being a short skin incision that does not reach the front of the ear like the incision when using the standard pterional approach,12,15 thus causing less trauma to the temporalis muscle. Additionally, there is no risk of injury to the upper branch of

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the facial nerve because the use of a myocutaneous flap protects this nerve. This incision also has an excellent cosmetic result because it is usually hidden behind the hair line.13 Although the clinical outcomes of neurosurgical operations that have used the lateral supraorbital approach have been reported,11-15 there is no anatomic study that investigates and compares, in a controlled laboratory setting, the exposure afforded by the lateral supraorbital approach and the pterional approach. The purpose of this study was to provide reliable anatomic data that may highlight the differences between these approaches, stressing the anatomic space exposed by each approach and the operability-related features linked to each surgical route. Although the anatomic structures accessible by either approach may be well-known to the most experienced neurosurgeons, the information provided in this article may be useful to the wider neurosurgical community. This information may assist in the decision-making process of selecting which of these surgical routes will provide the best anatomic exposure for a given intracranial lesion. Although we concentrated on evaluating the differences between these 2 surgical routes, there are other complex cranial base approaches that blur the distinction between these 2 approaches by incorporating elements of either one.

FIGURE 2. Pterional approach: initial brain exposure.

MATERIALS AND METHODS


Specimen Characteristics and Surgical Procedures
Eight fresh human cadaver heads were used in this study. Eight pterional approaches were performed as described by Yasargil et al1,2

(Figures 1 and 2) and 8 lateral supraorbital approaches were executed as described by Hernesniemi et al1315 (Figures 1 and 3). To minimize the effect of anatomic variation of the specimens, we executed the pterional approaches in 4 cadaver heads on the right side and in 4 on the left side. We did the same for the lateral supraorbital approach. The cadaver specimens were held in the surgical position using a Spetzler head rest (V. Mueller, McGaw Park, Illinois). A surgical microscope (OPMI-CS; Carl Zeiss, Oberkochen, Germany) and standard microsurgical instruments were used in all procedures.

Evaluation Methods
We used 3 different methods to assess exposure. The first method used the observations and impressions reported by the senior authors (M.A. and A.S.) during the execution of each approach and was therefore a qualitative method. The second method (quantitative) relied on a laboratory model, developed by us, that provides information

FIGURE 1. The bone flap margins, in the lateral supraorbital approach (discontinuous line) compared to the pterional approach (continuous line).

FIGURE 3. Lateral supraorbital approach: initial brain exposure.

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describing the volume and shape of the surgical space for each approach. In addition, this method also offered for each surgical approach anatomoradiological correlations between the exposed anatomic area and its radiological counterpart. The third method (quantitative) evaluated for each approach some operability-related features and graded each approach using a numerical score. A detailed description of the last 2 methods is provided in the following.

TABLE 1. Surgical Exposure Grading System Score 0 1 Exposure No exposure Visualization of a structure but inability to operate. In the case of paired structures, only the structure homolateral to the approach is visualized (you can see on the homolateral side only, but you cannot operate). Multiangled exposure; surgical maneuvers are possible but difficult. In the case of paired structures, only the structure homolateral to the approach is visualized (you can see and operate with difficulty on the homolateral side only). Multiangled exposure; surgical maneuvers are facilitated. In the case of paired structures, only the structure homolateral to the approach is visualized (you can see and operate with ease on the homolateral side only). There is multiangled exposure of the structure homolateral to the approach and visualization of the contralateral structure. Surgical maneuvers are facilitated on the homolateral side (you can see on both sides, but operate on the homolateral side only). There is multiangled exposure of the structure homolateral and contralateral to the approach. Surgical maneuvers are facilitated on the homolateral and on the contralateral side (you can see and operate on both sides).

Evaluation of the Volume/Shape and Anatomoradiological Correlations of the Surgical Space


After executing the approach, the surgical cavity was filled with a computed tomographyimageable mixture consisting of pieces of fat soaked in iohexol (to make the fat visible on the computed tomography images) and then mixed with silicone rubber. The surgical cavity was created following standard microneurosurgical techniques and packed without exerting any additional retraction to respect the surgical space created by the approach. In other words, the arachnoid membranes and the natural planes provided by the sphenoid ridge and the roof of the orbit were respected when executing the approach and hence when creating the surgical space to be later assessed.16 The mixture was enclosed with a thin layer of dry cotton before being packed to minimize any potential leak. For the same reason, a dry piece of cotton was placed between the dura and the fat-silicon before the dura and the wound were closed. After that, each specimen underwent a highresolution computed tomography scan (1-mm slice thickness, contiguous nonoverlapping slices; gantry setting of 0 degrees; 225-mm scan window diameter; pixel size greater than 0.44 3 0.44). Next, the imaged mixture occupying the surgical space was segmented and volumetrically assessed using neuronavigation software (iNtellect Cranial; Stryker Instrument, Kalamazoo, Michigan). The purpose of the scan and the segmentation was to evaluate the volume/shape of the surgical space as well as the anatomoradiological correlations between the packed surgical space and its neuroradiological counterpart. To decrease the uncertainty (the error) and to increase the validity of this method the following steps were performed:  The cadavers used were fresh (the time from harvesting to use was no longer than 3 days) to minimize the tissue deformation.  The filling protocol was held constant during the study.  We kept constant the other factors that could influence the volume of the surgical space, such as the degree of head tilt and the degree of brain retraction.  To decrease the interobserver variability, we had a single operator perform the filling of the surgical space.  We took measurements of the surgical volume on the same day that the approach was executed to decrease tissue deformation.  We changed the side of the approach so that in half the specimens, the pterional approach was used on the right and in half on the left side.  The same was true for the lateral supraorbital approach. We did that to decrease the intra- and inter-specimen anatomic variation.

3a

a The maximum score for an unpaired midline structures, whereas 4 and 5 apply only to paired structures.

Evaluation of Operability in the Exposed Surgical Space


The operability was assessed using a numerical grading system (Table 1). This numerical grading system was based on a modification of the Ammirati and Bernardo grading system17 to increase its sensitivity. This modification was done by adding an additional score for the ability of exposing and conducting surgical maneuvers on contralateral structure.

Also, in this modification, we distinguished between unpaired midline structures and paired structures. A value of zero in our new scoring system refers to a structure that is not exposed, whereas a maximal value of 3 to 5 indicates that the target structure is fully exposed from different angles with the ability to perform simulated surgical maneuvers respectively for unpaired and paired structures. We evaluated the ability to perform common neurosurgical maneuvers on the neurovascular structures exposed. These maneuvers included the ability to apply surgical clips to vascular structures and the ability to reconstruct vascular/neural structures. In addition, we evaluated the ability to expose (and dissect) neurovascular structures contained in the surgical space from different angles (see Table 2 for a list of neurovascular structures evaluated). We reasoned that multiangled exposure of neurovascular structures facilitates surgical maneuvers and hence operability. Specifically, we evaluated the ability to (1) control the entire circumference of the structure and perform neurovascular (suture) reconstruction; (2) control the entire length of the structure and (suture) repair a longitudinal incision executed in it; and (3) apply clips to the vascular structure. When at least 2 of these maneuvers were possible, we considered the surgical maneuver as facilitated, whereas when only 1 maneuver was performed successfully, the surgical maneuvers were considered possible but difficult. These assessments were conducted by the senior authors (M.A. and A.S.) separately, and then the average score was recorded.

Statistical Analysis
We used the commercially available MedCalc software for Windows, version 9.6.3.0 (MedCalc Software, Mariakerke, Belgium) to compare,

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TABLE 2. Surgical Exposure and Associated Operability Exposure Score Anatomic Structure Optic nerve Supraclinoid portion of the internal carotid artery Ophthalmic artery Olfactory nerve Posterior communicating artery, origin Anterior choroidal artery, origin Internal carotid artery, bifurcation Third nerve Fourth nerve Sixth nerve Anterior communicating artery Anterior cerebral artery (A1) Anterior cerebral artery (A2) Anterior cerebral artery (A3) Middle cerebral artery (M1) Middle cerebral artery (M2) Middle cerebral artery (M3) Pituitary gland Infundibulum Posterior cerebral artery (P1) Posterior cerebral artery (P2) Superior cerebellar artery, origin Basilar artery, tip Lateral Supraorbital 5 3 1 4 1 1 4 2 0 0 3 5 5 0 3 3 0 3 3 4 1 1 1 Pterional 5 4 2 4 3 3 3 3 0 0 3 5 5 0 3 3 3 3 3 4 3 2 2

FIGURE 4. Microscopic view showing the optic chasm as seen through the lateral supraorbital approach. L.on, left optic nerve; R.on, right optic nerve.

using a paired t test, the volume of the surgical exposure for both approaches. A P value of ,.05 was considered significant.

2 optic nerves and between the homolateral optic nerve and the internal carotid artery. The standard pterional approach provides a shorter route to the basilar tip than the lateral supraorbital approach. Furthermore, the pterional approach reaches the basilar tip using the surgical corridor between the internal carotid artery and the third nerve,

RESULTS
Qualitative Observations Figures 4 to 7 show the main anatomic views provided by the lateral supraorbital and pterional approaches. Compared with the standard pterional approach, the lateral supraorbital approach is noticeably less traumatic to the temporalis muscle. Both approaches offered access to approximately the same range of anatomic structures, yet there were various differences between them. The main differences may be summarized as follows. The pterional approach provides surgical access mainly according to a lateral trajectory (Figure 8), whereas the surgical access trajectory of the lateral supraorbital technique is more anterior (Figure 8). As a result of these different trajectories, the pterional approach offers better exposure of the origin of the posterior communicating artery and the anterior choroidal artery. On the other hand, both optic nerves and the anterior communicating artery complex are well exposed using both approaches. The lateral supraorbital approach provides excellent surgical control of the sellar region, using the corridors between the

FIGURE 5. Microscopic view showing the main surgical anatomic view provided by the lateral supraorbital approach. A1, A1 segment of the anterior cerebral artery; ca, internal carotid artery; M1, M1 segment of the middle cerebral artery; R.on, right optic nerve.

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FIGURE 8. The main surgical trajectories of the lateral supraorbital (pink arrow) and the pterional approaches (green arrow).

FIGURE 6. Microscopic view showing the optic chasm as seen through the pterional approach. A1, A1 segment of the anterior cerebral artery; ca, internal carotid artery; L.on, left optic nerve; R.on, right optic nerve.

a space that is usually wider than the opticocarotid corridor used by the lateral supraorbital approach. Therefore, we found that the pterional approach resulted in better surgical control of the retrosellar area than the lateral supraorbital approach. Generally, the surgical maneuvers were easier to be performed using the pterional approach than the lateral supraorbital approach. Also, during execution of the lateral supraorbital approach, a considerable amount of frontal lobe retraction was needed before reaching the suprachiasmic and carotid cisterns. In contrast, the pterional approach provided early access to the Sylvian

FIGURE 7. Microscopic view showing the main surgical anatomical view provided by pterional approach. Ca, internal carotid artery; pcp, posterior clinoid process; R.on, right optic nerve.

FIGURE 9. Graph showing the mean volume of the surgical space of the pterional and lateral supraorbital approaches. The surgical volume associated with the pterional approach is significantly greater that that with the lateral supraorbital approach (P , .05).

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Shape of the Surgical Exposure and Anatomoradiological Correlations Figures 10 and 11 illustrate the 3-dimensional objects that represent the surgical space provided by each approach and the relationship between this space and the axial planes of the brain (Figures 10 and 11). The shape of the surgical exposure space provided by the lateral supraorbital approach was cylindrical, whereas that of the pterional approach was pyramidal. The relationships between the surgical exposure and the brain axial plans demonstrate that both approaches provide exposure to lesions located in the anterior cranial fossa, sellar, parasellar, and retrosellar areas (Figures 10 and 11). Operability Evaluation Table 2 shows the results of the operability score linked to each approach. According to this table, the maximum absolute score achievable is 115. This maximum absolute score represents the score given to a surgical area where all the structures obscuring a targeted anatomic landmark are completely removed. The maximum absolute score represents an ideal/theoretical situation. There is no approach that can yield 100% of the absolute exposure because in a clinical setting, it is not possible to remove all structures obscuring a selected target. The overall score of the lateral supraorbital approach was 53, which represents 49.53% of the maximum achievable score. In contrast, the overall score of the pterional approach was 66, which represents 61.68% of the maximum score.

FIGURE 10. Three-dimensional shape of the surgical space of the pterional approach and its anatomoradiological correlation with the axial plan of the brain. The surgical space has a pyramidal shape.

and carotid cisterns, therefore decreasing, at least at the beginning of the procedure, the amount of brain retraction needed to expose the anatomic structures. Volume of the Surgical Exposure For every specimen, the standard pterional approach generated a greater surgical exposure volume (Figure 9).The mean volume of the surgical space was 23.60 mL (standard deviation, 3.4; range, 20.37-28.22) for the lateral supraorbital approach and 32.90 mL (standard deviation, 4.11; range, 28.53-37.78) for the standard pterional approach (Figure 9). The difference between these 2 volumes was statistically significant (P , .05) (Figure 9).

DISCUSSION
Standard Pterional Approach vs Minimalistic Approaches to the Sellar/Parasellar Areas The standard pterional approach has been accepted as a gold standard to gain strategic access to a range of neurosurgical intracranial lesions.9,13,18,19 Yasargil et al1,2,16 advocates this approach to achieve surgical control of anterior circulation as well as basilar tip aneurysms. Moreover, the standard pterional approach is appropriate not only for vascular pathology, but also for lesions located in or around the cavernous sinus, sella, and parasellar and subfrontal regions.17 Although it is the preferred approach to treat various intracranial lesions, the standard pterional approach has been recently reevaluated critically and compared with other approaches such as the supraorbital eyebrow incision approach,20-22 the mini-pterional approach,9 the mini-supraorbital approach,23 and the lateral supraorbital approach.13 In general, the impetus for these approaches has been their minimal interference with the temporalis muscle/ sphenoid wing as well as cosmetic considerations such as hiding the skin incision in the eyebrow. However, a sound neurosurgical approach needs to strive to achieve a careful balance between minimizing tissue trauma and maximizing anatomic exposure and safe operability.9 Careful understanding of these modified (often referred to as minimally invasive approaches) surgical routes, of the

FIGURE 11. Three-dimensional shape of the surgical space of the lateral supraorbital approach and its anatomoradiological correlation with the axial plan of the brain. The surgical space has a cylindrical shape.

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anatomic areas to which they offer access, and of the operability associated with them is important for recognizing the limitations and advantages of these approaches. Knowing the limitations of these procedures aids in determining the correct indications for each procedure, and using the advantageous features of these approaches will help to deliver the treatment that is the most appropriate for each individual patient. Our Study Observational Results Based on the impression of the observations gathered during the execution of both approaches, we believe that the lateral supraorbital approach is less invasive than the standard pterional approach to reach the majority of sellar and suprasellar structures because these structures can be accessed and exposed with less temporal muscle manipulation and a smaller bone flap. We noted that the lateral supraorbital technique affords easy exposure of the optic chiasm, both optic nerves, and the anterior communicating artery complex. On the other hand, the basilar tip area may be better approached by using the pterional approach. This is because the pterional approach affords complete opening of the sylvian fissure, whereas the lateral supraorbital approach exposes the fissure only to the level of the limen insulae, and therefore necessitates more brain retraction to reach the basilar tip area. In addition, the pterional approach has a shorter distance to the basilar tip and the carotid-oculomotor corridor that may be used by the pterional approach offers a wider space and different angles of approach to the basilar tip area. Shape and Volume of the Surgical Exposure as Important Parameters in Describing Neurosurgical Approaches Shape The figures in our article demonstrate the pyramidal shape of the pterional approaches as well as the cylindrical shape of the lateral supraorbital approach. This may further characterize these 2 approaches, both from an operator point of view and from a teaching point of view. The visual conceptualization of surgical approaches may help the surgical thinking by drawing attention to the target and to its relationships to the surgical space. The visual illustration of the surgical space (even if approximate) shown here may help in enhancing the understanding of neurosurgical approaches and in increasing the quality of strategic thinking to intra cranial lesions attack. This knowledge by itself could be helpful during actual surgery. The advantages of the cylindrical vs the pyramidal surgical space or vice versa can only be demonstrated by clinical work. However, we speculate that having a pyramidal work space with the apex centered at the targeted structures is more advantageous than a cylindrical work space. This is because the pyramidal work space, everything else being equal, enables the neurosurgeon to use more angles and more direction to attack the target.

Volume We propose that the volume of the surgically exposed space is a more relevant parameter in describing and evaluating neurosurgical approach than 2-dimensional measurements. This is because microscopic surgery takes place in a 3-dimensional environment with the hands of the neurosurgeon and the surgical instruments moving in a 3-dimensional space, hence the relevance of 3-dimensional vs 2-dimensional space when dealing with microscopic approaches. Clearly, this tenet does not apply to endoscopic approaches that provide 2-dimensional views. In this study, we demonstrated the ability to measure this parameter; we also demonstrated that the volume of the pterional surgical space is greater than that of the lateral supraorbital one (23.60 mL vs 32.90 mL). Considering these parameters of the volume and shape of the surgical space, the pterional approach seems to provide, in our model, better surgical operability by virtue of its larger surgical space and the shape of its surgical space, which may facilitate surgical maneuvers (by providing more angles from which to attack the targets). Clearly, these considerations apply when other factors affecting operability in the real (patient) world, such as the surgeons skills and individual lesion features, are kept constant. Surgical Exposure and the Associated Operability Having a comprehensive understanding of the anatomic exposure linked to a given neurosurgical approach may enhance the decision-making process during selection of a specific neurosurgical approach. However, it must be kept in mind that simple observation of an anatomic structure is not synonymous with the possibility of safely performing appropriate surgical maneuvers on the same structure. In vivo operability is a complex output of many factors, some of which, such as the surgeons skill and the individual pathology, are difficult to quantify. Still, some of the factors that we analyzed in our operability evaluation are relevant to demonstrate the anatomic capacity of different neurosurgical approaches, highlighting and quantifying the possibility of safely performing appropriate surgical maneuvers. Clearly, the ability to carry on this information from a cadaver environment to a live surgery environment needs to be validated clinically. However, our results were consistent with regard to the larger surgical volume and what we consider a more advantageous surgical shape of the pterional approach and were validated by an overall better operability score of the same approach when compared with the lateral supraorbital approach. Careful evaluation of Table 2, however, confirms that the lateral supraorbital approach offers an equivalent access to the anterior communicating artery complex, optic nerves, optic chasm, and sellar area (the exposure scores were 19 for both approaches). Limitations of This Study This study has 2 types of limitations; the first set of limitations is related to the fact that this is a cadaver study. Consequently, all different types of drawbacks linked to all cadaver studies are present, such as the lack of cerebrospinal fluid, lack of blood, and

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nonphysiological tissue consistency. The second type of limitation is specific to the methodology of the study. Although we sought to keep the second and third methods as quantitative as possible, both methods have some degree of subjective evaluation and variables that are difficult to control, such as the nonuniform degrees of tissue plasticity/consistency because of the different qualities of each individual specimen. Furthermore, because there is no standard method to evaluate the volume of the exposure and/or operability, our results should be viewed more as comparative rather than absolute.

CONCLUSION
On the basis of our study, the lateral supraorbital approach would be anatomically indicated mainly for treating sellar and suprasellar lesions and anterior communicating artery aneurysms, where it could be used as a less invasive approach to these areas than the standard pterional approach. However, the standard pterional approach, by virtue of the shape and volume of its surgical space, could offer more overall theoretical surgical operability. Hence, the standard pterional approach is anatomically suited for complex lesions of the sellar and parasellar spaces, especially when these lesions involve the interpeduncular cistern. Even with the intrinsic limitations of a cadaver environment, the results of our study highlight differences between the 2 approaches considered. In addition, our study proposes a helpful methodology to describe and contrast microneurosurgical approach in a laboratory environment. Disclosure
This study was funded by the Dardinger Center Fund for Neurooncology Research at Arthur G. James Cancer Hospital, Ohio State University Medical Center. The authors have no personal financial or institutional interest in any of the drugs, materials, and devices described in this article.

10. Harland SP, Hussein A, Gullan RW. Modification of the standard pterional approach for aneurysms of the anterior circle of Willis. Br J Neurosurg. 1996;10(2):149-153; discussion 153. 11. Dashti R, Hernesniemi J, Lehto H, et al. Microneurosurgical management of proximal anterior cerebral artery aneurysms. Surg Neurol. 2007;68(4): 366-377. 12. Hernesniemi J, Dashti R, Lehecka M, et al. Microneurosurgical management of anterior communicating artery aneurysms. Surg Neurol. 2008;70(1):8-28; discussion 29. 13. Hernesniemi J, Ishii K, Niemela M, et al. Lateral supraorbital approach as an alternative to the classical pterional approach. Acta Neurochir Suppl. 2005;94:17-21. 14. Lehecka M, Dashti R, Romani R, et al. Microneurosurgical management of internal carotid artery bifurcation aneurysms. Surg Neurol. 2009;71(6): 649-667. 15. Romani R, Lehecka M, Gaal E, et al. Lateral supraorbital approach applied to olfactory groove meningiomas: experience with 66 consecutive patients. Neurosurgery. 2009;65(1):39-52; discussion 52-33. 16. Yasargil MG. Microneurosurgery. Stuttgart:; New York: Georg Thieme Verlag; 1987; p. 215. 17. Ammirati M, Bernardo A. Analytical evaluation of complex anterior approaches to the cranial base: an anatomic study. Neurosurgery. 1998;43(6):1398-1407; discussion 1407-1398. 18. Figueiredo EG, Deshmukh P, Zabramski JM, Preul MC, Crawford NR, Spetzler RF. The pterional-transsylvian approach: an analytical study. Neurosurgery. 2008;62(6 suppl 3):1361-1367. 19. Wongsirisuwan M, Ananthanandorn A, Prachasinchai P. The comparison of conventional pterional and transciliary keyhole approaches: pro and con. J Med Assoc Thai. 2004;87(8):891-897. 20. Reisch R, Perneczky A. Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery. 2005;57(4 suppl):242255; discussion 242-255. 21. Reisch R, Perneczky A, Filippi R. Surgical technique of the supraorbital key-hole craniotomy. Surg Neurol. 2003;59(3):223-227. 22. van Lindert E, Perneczky A, Fries G, Pierangeli E. The supraorbital keyhole approach to supratentorial aneurysms: concept and technique. Surg Neurol. 1998;49(5):481-489; discussion 489-490. 23. Figueiredo EG, Deshmukh V, Nakaji P, et al. An anatomical evaluation of the mini-supraorbital approach and comparison with standard craniotomies. Neurosurgery. 2006;59(4 suppl 2):ONS212-ONS220; discussion ONS220.

COMMENTS
he authors demonstrate the limitations of the lateral supraorbital approach compared with a classic pterional strategy. They accurately point out that the limitation of the lateral supraorbital approach is in obtaining a suitable view of the interpeduncular cistern region owing to limited angles of view. From this more subfrontal trajectory, the view to the interpeduncular fossa is obstructed by the optic chiasm and tract. I agree that lesions involving this space may be better treated with a pterional approach, which affords a more lateral-viewing trajectory. An alternative that may aid in this respect is to use the endoscope to see behind the chiasm. This still may not fully address the challenges of maneuvering instrumentation in the limited space. Other maneuvers that I have used to increase exposure are removal of the anterior clinoid, skeletonizing the optic canal, and reduction of the tuberculum sellae. These strategies of bone removal yield a limited amount of space around the optic nerve and inferior to the chiasm. I do not advocate this for any other than small lesions. The lateral supraorbital approach is in my opinion only to be considered for aneurysms at the anterior communicating artery, middle cerebral artery, and carotid bifurcation. Suprasellar tumors such as pituitary adenomas, craniopharyngiomas, and meningiomas are possible when extension posterior to the level of the dorsum is limited. John Diaz Day Little Rock, Arkansas

REFERENCES
1. Yasargil MG, Antic J, Laciga R, Jain KK, Hodosh RM, Smith RD. Microsurgical pterional approach to aneurysms of the basilar bifurcation. Surg Neurol. 1976;6(2):83-91. 2. Yasargil MG, Fox JL. The microsurgical approach to intracranial aneurysms. Surg Neurol. 1975;3(1):7-14. 3. Ammirati M, Spallone A, Ma J, Cheatham M, Becker D. Preservation of the temporal branch of the facial nerve in pterional-transzygomatic craniotomy. Acta Neurochir (Wien). 1994;128(1-4):163-165. 4. Aydin IH, Takci E, Kadioglu HH, Kayaoglu CR, Tuzun Y. Pitfalls in the pterional approach to the parasellar area (review). Minim Invasive Neurosurg. 1995;38(4): 146-152. 5. Badie B. Cosmetic reconstruction of temporal defect following pterional [corrected] craniotomy. Surg Neurol. 1996;45(4):383-384. 6. \Miyazawa T. Less invasive reconstruction of the temporalis muscle for pterional craniotomy: modified procedures. Surg Neurol. 1998;50(4):347-351; discussion 351. 7. Yasargil MG, Reichman MV, Kubik S. Preservation of the frontotemporal branch of the facial nerve using the interfascial temporalis flap for pterional craniotomy. Technical article. J Neurosurg. 1987;67(3):463-466. 8. Andaluz N, Romano A, Reddy LV, Zuccarello M. Eyelid approach to the anterior cranial base. J Neurosurg. 2008;109(2):341-346. 9. Figueiredo EG, Deshmukh P, Nakaji P, et al. The minipterional craniotomy: technical description and anatomic assessment. Neurosurgery. 2007;61(5 suppl 2): 256-264;discussion 264-255.

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SALMA ET AL

terional craniotomy is considered the standard approach to various vascular and neoplastic pathologies involving both the anterior and posterior circulations and subfrontal, sellar, and parasellar regions. Concerns about temporal wasting and cosmesis have led to interests in other more minimalistic approaches including a supraorbital approach through an eyebrow incision and a lateral orbital approach. Salma et al presents a cadaveric study comparing the surgical exposure gained through the pterional approach vs that of a lateral supraorbital approach. The authors executed the 2 approaches in fresh cadaver heads and performed a combination of qualitative and quantitative assessments. The approaches were graded based on the impressions of the senior authors, volumetric measurements, and the operability of various neurovascular targets. They concluded that although both approaches provided similar exposure to the sellar, suprasellar, and anterior communicating artery regions, the standard pterional craniotomy provided better visibility of the retrosellar area. Furthermore, although the lateral orbital craniotomy was faster to perform, the pterional approach provided a larger working volume and increased operability than the lateral orbital approach.

This anatomic study represents a blend of impressions from seasoned surgeons augmented by quantitative measurements, including a novel technique of volumetric measurement of surgical working spaces. In essence, this is a qualitative assessment presented in quantitative terms. It is worthy of publication given the lack of established uniform methods for quantitative evaluation of surgical approaches and anatomy. It should provide some guidance when deciding between the 2 approaches, especially when cosmesis may be a concern. There are also numerous adjunctive techniques, such as orbitotomy, clinoidectomy, and wide split of the sylvian fissure, that can be applied to either approach to enhance local exposure when addressing specific targets. Ultimately, the selection of an approach must be directed by the pathology and the goals of the surgery in the treatment of the patient. Michael Huang Harry van Loveren Tampa, Florida

ons372 | VOLUME 68 | OPERATIVE NEUROSURGERY 2 | JUNE 2011

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