Neurosurgical

Approach
SAMSUL ASHARI, M.D
Anterior Fossa

Subfrontal
Pterional
COZ
Convexity and Parasagital Approach
Frontal and Bifrontal Craniotomy

This approach affords an ideal corridor for basal frontal, anterior

fossa and periorbital, perisellar/suprasellar pathologies while
minimizing brain retraction and maximizing exposure bilaterally.
Bifrontal
Craniotomy
Frontal and bifrontal craniotomy
 Pterional
Exposure of lesions affecting:
sylvian fissure;
frontal, temporal lobes;
anterior and middle fossa;
circle of Willis;
cavernous sinus area;
midbrain;
orbit; superior orbital fissure;
certain sellar/suprasellar lesions
Pterional Approach
Pterional Approach
Pterional Approach
Cranio-Orbito Zygomatic
 Frontotemporal - orbitozygomatic
a.Frontal
b.Orbitopterional
c.Temporal
d.Full FTOZ
 Lateral Variation

Not only placement of the keyhole

craniotomy, but also partial removal of
the lesser sphenoid wing exposing
frontal and temporal dura mater
Exposes anteromedial temporal lobe,
frontal latero-basal cortex, Sylvian fissure
Safe dissection of the anterior part of the
cavernous sinus
Interhemispheric Approach
This approach is useful for accessing lesions situated in the
anterior aspect of the third ventricle, including lesions
extending out of the third ventricle into the lateral ventricles
Anterior (frontal) subcallosal
variation of the interhemispheric
approach
Different variation of the anterior
subcallosal interhemispheric approach
Median skull base (superior, red)
Suprasellar area (middle, green)
Anterior third ventricle (inferior, blue)
Transforaminal Approach

Lesions of the anterior third ventricle and

the basilar tip should be approached
through a posteriorly placed craniotomy
(A)
The posterior chamber of the third
ventricle can be optimally exposed
through an anteriorly placed approach (B)
 Anatomical corridor of the
interhemispheric fissure sufficient to
visualize the deep seated arease

Generally lesions of the corpus callosum,

the lateral and third ventricles, the pineal
region, and the midline skull base are
deep seated
Posterior subcallosal modification
of the interhemispheric approach
Craniotomy and skin incision
Posterior subcallosal modification
of the interhemispheric approach
Can be recommended for lesions situated above the great cerebral vein of Galen (A)
Lesions situated beneath the deep venous system are reached best through the
infratentorial supracerebellar approach (B)
Middle fossa approach

Temporal approach
Subtemporal approach
 Temporal approach
Performed to access the mesial
temporal lobe, amygdala,
hippocampus, and anterior
temporal lobe.
Temporal approach

A. Opening galea and periosteum

B. Craniotomy site
Subtemporal approach
Skin incision & Craniotomy
margin
A Standard subtemporal
B. Anterior / extended subtemporal
Subtemporal approach
Posterior fossa
PRESIGMOID
Transcochlear
Translabyrinthine
Retrolabyrinthine

RETROSIGMOID
Suboccipital

MID LINE
Presigmoid

To obtain surgical access to the midbasilar artery, vertebrobasilar

junction, anterior brainstem, clivus
To better visualize cranial nerves in the posterior fossa
Shorter distance to the petroclival region
Greater access to anterior posterior fossa and clivallesions, thus
providing more ventral approach to the brainstem with less
retraction than the traditional retrosigmoid suboccipital
craniotomy
Presigmoid
Retrosigmoid

The approach affords the simplest access to the cerebellopontine

angle and lateral clivus.
Exposure of the cerebellopontine angle and its contents including
cranial nerves (CNs) V, VIII, IX. X. and XI
Exposure of the superior cerebellar, vertebral, and anteroinferior
and posteroinferior cerebellar arteries
Retrosigmoid
Skin incision & craniotomy
Retrosigmoid
Dural opening
Retrosigmoid

Exposed neurovascular
structures of retrosigmoid
approach
Lateral suboccipital craniotomy

Exposure of the lateral cerebellar hemisphere,anterolateral

brainstem, posterior aspect of petrous bone, craniovertebral
junction, and upper cervical spinal cord
provides vertebral artery (VA) controL
provide access to lesions below the jugular tubercle, to the
lareral and sometimes ventral brainstem and cerebellum with
minimal retraction
Lateral suboccipital craniotomy
Lateral suboccipital craniotomy
Far lateral

Control and mobilization of the vertebral artery (VA)

Allows better visibility anterior to the brainstem, thus influendng
favorably the safety and completeness of the operation.
Provides exposure of the lower third of the clivus, the foramen
magnum, and the upper cervical spine
The extreme far lateral approach also decreases the need of
brainstem, cerebellar, and upper cervical cord retraction required
to visualize the lower clivus and anterior foramen magnum.
Far lateral
Far lateral

Posterior mobilization of VA
and drilling of occipital
condyle to expose anterior
brainstem structures,
including basilar and vertebral
artery
Midline suboccipital

Access to lesions of the posterior fossa including the cerebellar

hemispheres, fourth ventricle, pineal region, exophytic tumors of
the posterior brainstem, or lesions of the cranial base
To address surgically midline or paramidline lesions
For decompression of posterior fossa
For treatment ofobstructive hydrocephalus
Midline suboccipital
A. Trajectory to a midline
posterior fossa

B. Fourth ventricular lession

approach via telovelar
approach
TERIMA KASIH