History

Conceived Walter Dandy

George J Heuer ?

Popularised by Mahmut G Yasargil

Pterional?
Based around the
pterion
Area where the frontal
bone, parietal bone,
squamous part of
temporal bone and the
greater sphenoid wing
adjoin one another
Overlie the anterior
branch of the middle
meningeal artery
Indications
1. Most anterior circulation aneurysms
except pericallosal
2. Some posterior circulation aneurysm:
basilar apex & superior cerebellar artery
3. Suprasellar tumours
4. Sphenoid wing tumours
5. Some frontal tumours
Anaesthesia
Hyperventilation PCO2 = 32 kPa
Arterial line
Decadron IV 10 mg
Prophylactic antibiotics 30 min prior to
incision
Mannitol 0.5-1g/kg at time of skin incision
Phenytoin loading dose or maintenance
Positioning
Supine position in Mayfield
head holder
Pins? Single/double?
Hairline
Rotated 100-600
depending on surgery
Head above heart
Positioning
Gentle flexion of neck

Extension of head to bring

malar eminence superior
to the brow
Variable extension: less for
paraclinoidal aneurysms
and more for distal basilar
aneurysms
 Minimal shave
Disposable razor
3 cm strip along anterior border of hair line
widows peak to sideburn
Or
1 cm strip behind hair line: better cosmesis
short term
Sterile scrub and drape
Betadine/hibitane detergent scrub with
sterile gloves 5 minutes
Alcohol to remove detergent
Dry sterile towel
Incision marked
Infiltrate? Can be done now or after
draping prior to incision
Drape can be stitched or stapled to scalp
Scalp incision
Frontotemporal
From midline at anterior
edge of hairline to
inferiorly to within 1 cm
of the superior aspect of
zygoma and 1 cm
anterior to EAM
Scalp incision
Bicoronal(Souttar) incision
for receding hairline
Avoid injury to the anterior
division of the superficial
temporal artery blunt
dissection with gauze swab
Incision made stepwise with
haemostasis using Raney
clips or Dandy forceps as
the incision progresses to
minimise bleeding
Muscle dissection
Two methods:
1. Muscle and fascia Incised and dissected off with the
galeal flap, the Bovie can be used to make initial cut
then the muscle is elevated off the bone with a periosteal
elevator to minimise temporal muscle wasting
Muscle dissection
2. The scalp flap is incised and reflected separately, the
muscle is dissected along the temporalis fascial plane until
the subgaleal fat pad is identified, the fascia is then
incised and reflected anteriorly to avoid damage to the
frontalis zygomatic branches of the facial nerve
Muscle dissection
The flaps are secured anteriorly using small
towel clips or fish hooks with rubber bands
or springs over a rolled up gauze swab to
avoid kinking of the blood vessels
Mollisons and Weitlander retractors can also
be used
Method 1 is quicker and easier
Method 2 provides a lower trajectory for
better visualisation
Muscle dissection
Complete when the following exposed are:
1 the keyhole
2 the root of the zygoma
3 the supraorbital notch
Burr Holes & Craniotomy

Single or multiple burr holes

Single:
Large burr hole in temporal squamosa
High speed drill with footplate to turn craniotomy
Avoid frontal sinus correlate with CT scan
Stop with first sign of resistance in region of keyhole
Remainder is scored with a burr
The flap is the elevated carefully, stripping the dura
on the undersurface as the flap is elevated
The flap is fractured by hinging it along the scored
wing
Alternatively a second burr hole can be placed at
the keyhole
Middle meningeal artery cauterised and divided
and sphenoid wing waxed
Burr Holes & Craniotomy

Multiple burr holes

Required if using Gigli saw
3 to 5 burr holes can be made
The dura stripped with Gigli guide(invented by De Martel in 1908)
Removal of the Sphenoid
Wing
Leksell Rongeur is used to
remove the remaining
squamosa
The dura is dissected of
the sphenoid wing using
Penfield dissector/Gigli
guide/McDonald
The sphenoid wing is
then drilled or nibbled
with a rongeur to the
orbitomenningeal artery
Dural Opening

Surgicel strips are inserted between the dura

and the bone
Tent sutures
Dura opened in curvilinear manner across
the sylvian fissure with dura hook and a 15
blade or an 11 blade turned up
The opening is completed using
Metzenbaum scissors over a wet
cottonoid patty
The flap is reflected over the muscle and
secured with a 4/0 suture separate from
the muscle
Patties all around and dark towel to reduce
microscope glare
 Gelfoam /spongistan are placed at the
dural margins to avoid subdural
extension of intraoperative bleeding
Tefla for cortical protection

READY TO START
Closure

Dura close 4/0 suture: interrupted or continuous

Unable to close? pericranium graft or rather leave large holes
with underlay of graft or compressed gelfoam or bicol to avoid
one-way valve effect
Surgicel blanket if oozy
Tent sutures tightened
Bone flap secured
Muscle approximated
Suction drainage under muscle
Scalp closed with interrupted or continuous sutures
Clips to skip
Dressings TBCo
Or crepe bandage head gear
Remove clips in 5 days
Complications
Intraoperative
1. breach of frontal sinus may result in CSF leak
Remedy : exenteration of sinus and cover with vascularised pericranium
2. Entry into orbit may cause post op eye swelling
Remedy: wax
Postoperative
Subgaleal collection
Porto-vac
Tap and wrap - sometimes steroid taper
TMJ Syndrome
Soft diet and NSAID
Wound infection
Superficial antibiotics
Deep open debridement
 Indications
1. Lesions of the frontal lobe
2. CSF fistula repair
3. Olfactory groove tumours
4. Sellar-area tumours
Anaesthesia
hyperventilation PCO2 = 32 kPa
Arterial line
Decadron IV 10 mg
Prophylactic antibiotics 30 min prior to
incision
Mannitol 0.5-1g/kg at time of skin incision
Phenytoin loading dose or maintenance
Positioning

Supine
Head and trunk elevated 200
Neutral
or
turned 200-400 to contralateral
side
Neck flexed slightly
Head extended or flexed:
Flexed 150 and rotated 150 to
contralateral side for optic nerve
and orbital roof exposure.
Minimal shave
3 cm strip along incision
Prep as for std approach
Ear plugs
Incision
Ear to Ear ( truebicoronal )
Ear to superior temporal line of
contralateral side( Modified Bicoronal)
Same precaution as for Pterional
craniotomy: 1cm anterior to tragus and 1
cm superior to zygomatic arch
Frontal branch of superficial temporal
artery
Incision
Incision with knife
Fascia cut with scissors or Bovie
Muscle elevated with Bovie or periosteal
elevator
Periosteum elevated with periosteal
elevator to preserve a large vascularised
pericranial flap
Galea, skin and pericranium reflected
anteriorly over roll and secured with towel
clips or fish hooks
 Supraorbital nerve
Supratrochlear
nerve
Notch or foramen
Drill bone to
preserve nerves
Burr Holes
Unilateral
Burr hole 1 cm lateral to
superior sagittal sinus
Burr holes
If exposure of the sinus is
required the burr holes
can be drilled directly
over the sinus

Holes over sinus

Burr Holes
Bilateral approach
Burr holes drilled over the squama first then
two directly over sinus or 4 burr holes 1 cm
on either side of the superior sagittal sinus
 Underlying
dura
stripped
using Gigli
guide
Craniotomy
Craniotome or
Gigli saw
Avoid injury to
venous sinus
Frontal sinus almost
inevitably opened
Exenterate or
obliterate sinus
and repair with
pericranium at the
end of surgery
Dural Opening
Tent sutures
Surgicel
U-shaped flap or cruciate opening
Double ligation of venous sinus at its origin at the frontal base before separation
Separation of falx cerebri
 Patties
Dark towels
Retractors
Ready To GO
Closure
Repair sinus breach
Vascularised pericranial flap
Watertight closure
Tighten tent sutures
Surgicel blanket
Bone flap secured
appropriately;
wire/ethibond/plates/craniofix
etc
Suction drain
Complications
Injury to Supratrochlear and supraorbital nerve
Injury to Superior Sagittal Sinus with craniotomy instrument: Small -
Pack with Surgicel or gelfoam
Large Ligate if anterior 1/3 of sinus
Inadequate haemostasis of bridging veins
Injury to cerebral arteries in the midline
Subdural/extradural haematomas
Frontal sinus entry: repair as described
Seizures
Sepsis- use separate instrument to isolate and cranialise frontal
sinus
CSF leak
History
Dandy
Indications
Tumours of the third ventricle
Lesions of the lateral ventricle
Corpus callosotomy
Large tumours of the pineal
Anaesthesia
Hyperventilation PCO2 = 32 kPa(25-30)
Arterial line
Decadron IV 10 mg
Prophylactic antibiotics 30 min prior to
incision
Mannitol 0.5-1g/kg at time of skin incision
Phenytoin loading dose or maintenance
Positioning
Supine
Head and trunk elevated 200
Neutral/straight
Neck flexed slightly
Head extended 100
Minimal shave
3 cm strip along planned
incision
Always on the right side
Disposable razor
Incision
Based around coronal suture
L shaped/bicoronal/U-flap
Need to expose 6 cm anterior
and 3cm posterior to coronal
suture
Flapped / retraction with fish
hooks or towel clips
Raney clips or Dandys and
artery forceps for haemostasis
Burr holes & Craniotomy
To cross midline or not Controversial
Crossing midline may cause injury
and compression of superior sagittal
sinus resulting in venous infarction
Burr holes as shown
Bone flap centered 2/3anterior and
1/3 posterior to coronal suture
No more than 2 cm posterior to
coronal suture
Laterally4 to 5 cm
Medial bone edge nibbled to edge
of sinus
Dural opening
Tent sutures and surgicel for
haemostasis
Durotomy u shaped based on
superior sagittal sinus
Use microscope and
microdissection to preserve pial
integrity and avoid injury to cortical
vein and granulations
Extend of dural opening only to 2
cm from midline minimise damage
to cortex during retraction
Cortical veins may limit dural
opening posterior to coronal suture
3-4 cm of frontal cortical exposure is
sufficient
Routine field preparation patties
dark towel and gelfoam
Interhemispheric dissection
Sharp dissection of the interhemispheric
fissure
Separation of arachnoid adhesion with
bipolar between the hemisphere and
the superior sagittal sinus
Small bridging veins may be sacrificed if
anterior to the coronal suture, larger
ones much be preserve
Careful dissection can mobilise another
3-5 mm
Interhemispheric dissection
The dissection is continued
along the falx inferiorly
CSF may be tapped from
the right frontal horn
The pericallosal and callosal
marginal arteries are
identified
The pericallosal arteries are
either separated or moved
to one side together
The corpus callosum is
identified by its pearly white
colour
 The corpus callosum
is then incised
1.5-2.5 cm
Deepened with
suction and bipolar
1 cm wide
 Ependyma identified
CSF drained slowly especially in
patient with hydrocephalus to
minimise the risk if subdural bleed
Then identify the ventricle right or
left by locating the choroid plexus
Left ventricle entry- further lateral
resection of corpus callosum or
fenestrate the septum
Not visible-frontal horn change
angle of microscope to a more
posterior position
 Choroid plexus
followed to foramen of
Monro
Entry into third ventricle
Through Foramen of Monro if dilated
Incise fornix at superior margin of FoM - 1
Entry into third ventricle
Transforniceal - incision along the body of the fornix in the midline 2
Interforniceal the interforniceal raphe is identified by division of the
septal leaves of coagulating the septum down to the fornix
Max 2 cm posterior to FoM hippocampal commissure
Entry into third ventricle
Transchoroidal incision of tela fornicis
3( rather than tela choroida, the latter is
more vascular)
 Internal cerebral veins in the roof of the
third must be preserved
Ready to GO
Closure
Cavity filled with warm saline
Haemostasis with bipolar no surgicel
EVD if needed
Water tight dural closure
Surgicel blanket
Bone flap secured
Std closure
Complications
Injury to superior sagittal sinus repair it or tie it
Inadvertent Sacrifice of major bridging veins causing venous
infarction
Sagittal sinus thrombosis from excessive retraction
Injury t anterior cerebral arteries in the midline
Excessive retraction of bilateral cingulate gyri causing mutism
Excessive opening of forniceal raphe causing memory deficits
IVH
Excessive opening of corpus callosum posteriorly causing
disconnection syndrome
Seizures due to frontal lobe retraction damage or venous infarct
Sepsis
Hydrocephalus
CSF leak
READY TO GO PARTY