Microanatomical Investigation of the Subtemporal Transtentorial Approach

CHENG Jinchao, WANG Qifu, LI Chen, RONG Jun, LI Tingzheng, LI Min, BAI Ruijun

Abstract

Objective To study the microanatomic structure of the subtemporal transtentorial approach to the lateral side of the brainstem, and to provide anatomical information that will assist clinicians to perform surgeries on the lateral, circumferential, and petroclival regions of the brainstem.
Methods Anatomical investigations were conducted on 8 cadaveric head specimens (16 sides) using the infratemporal transtentorial approach. The heads were tilted to one side, with the zygomatic arch at its highest point. Then, a horseshoe incision was made above the auricle. The incision extended from the midpoint of the zygomatic arch to one third of the mesolateral length of the transverse sinus, with the flap turned towards the temporal part. After removing the bone, the arachnoid and the soft meninges were carefully stripped under the microscope. The exposure range of the surgical approach was observed and the positional relationships of relevant nerves and blood vessels in the approach were clarified. Important structures were photographed and the relevant parameters were measured.
Results The upper edge of the zygomatic arch root could be used to accurately locate the base of the middle cranial fossa. The average distances of the star point to the apex of mastoid, the star point to the superior ridge of external auditory canal, the anterior angle of parietomastoid suture to the superior ridge of external auditory canal, and the anterior angle of parietomastoid suture to the star point of the 10 adult skull specimens were 47.23 mm, 45.27 mm, 26.16 mm, and 23.08 mm, respectively. The subtemporal approach could fully expose the area from as high as the posterior clinoid process to as low as the petrous ridge and the arcuate protuberance after cutting through the cerebellar tentorium. The approach makes it possible to handle lesions on the ventral or lateral sides of the middle clivus, the cistern ambiens, the midbrain, midbrain, and pons. In addition, the approach can significantly expand the exposure area of the upper part of the tentorium cerebelli through cheekbone excision and expand the exposure range of the lower part of the tentorium cerebelli through rock bone grinding technology. The total length of the trochlear nerve, distance of the trochlear nerve to the tentorial edge of cerebellum, length of its shape in the tentorial mezzanine, and its lower part of entering into the tentorium cerebelli to the petrosal ridge were (16.95±4.74) mm, (1.27±0.73) mm, (5.72±1.37) mm, and (4.51±0.39) mm, respectively. The cerebellar tentorium could be safely opened through the posterior clinoid process or arcuate protrusion for localization. The oculomotor nerve could serve as an anatomical landmark to locate the posterior cerebral artery and superior cerebellar artery.
Conclusion Through microanatomic investigation, the exposure range and intraoperative difficulties of the infratemporal transtentorial approach can be clarified, which facilitates clinicians to accurately and safely plan surgical methods and reduce surgical complications.

 

Keywords: Subtemporal approach, Tentorium cerebelli, Middle cranial fossa, Trochlear nerve, Microanatomy  

 

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References


RUDER L， SCHINA R， KANODIA H， et al. A functional map for diverse forelimb actions within brainstem circuitry. Nature，2021， 590(7846): 445–450. doi: 10.1038/s41586-020-03080-z.

ABLA A A， LEKOVIC G P， GARRETT M， et al. Cavernous malformations of the brainstem presenting in childhood: surgical experience in 40 patients. Neurosurgery，2010，67(6): 1589–1598. doi: 10. 1227/NEU.0b013e3181f8d1b2.

SCHACKERT G， LENK M， KIRSCH M， et al. Surgical results of 158 petroclival meningiomas with special focus on standard craniotomies. J Neurooncol，2022，160(1): 55–65. doi: 10.1007/s11060-022-04105-5.

XU Z， WANG W， ZHANG J， et al. Subtemporal-anterior transtentoral approach to middle cranial fossa microsurgical anatomy. J Craniofac Surg，2014，25(6): 2220–2222. doi: 10.1097/scs.0000000000001073.

CAVALCANTI D D， MORAIS B A， FIGUEIREDO E G， et al. Accessing the anterior mesencephalic zone: orbitozygomatic versus subtemporal approach. World Neurosurg，2018，119: e818–e824. doi: 10.1016/j.wneu. 2018.07.272.

TANG Y， WANG H D， MA C Y， et al. Quantitative anatomic comparison of the extended pterional transtemporal transtentorial approach and the subtemporal transtentorial approach to the petroclival region. Turk Neurosurg，2015，25(1): 9–15. doi: 10.5137/1019-5149.Jtn. 7450-13.1.

LIU Q L， WANG Z C， ZHANG J T. Analysis of speech with the Labbe vein ligated in tempoccipital operation. Chin J Neurosurg，1997，13(2): 34–36. doi: 10.3760/j.issn:1001-2346.1997.02.015.

CANDANEDO C， MOSCOVICI S， SPEKTOR S. The infratranstentorial subtemporal approach (ITSTA): a valuable skull base approach to deep-seated non-skull base pathology. Acta Neurochir (Wien)，2019，161(11): 2335–2342. doi: 10.1007/s00701-019-04050-9.

WANG X， TONG X G. Combined with the management strategy of related venous structures and dura mater in the transpetrosal approach. Chin J Neurosurg，2023，39(12): 1189–1194. doi: 10.3760/cma.j.cn112050-20230311-00071.

GARCÍA-PÉREZ D， ABARCA J， GONZÁLEZ-LÓPEZ P， et al. A frontal route to middle and posterior cranial fossa: quantitative study for the lateral transorbital endoscopic approach and comparison with the subtemporal approach. World Neurosurg，2022，167: e236–e250. doi: 10. 1016/j.wneu.2022.07.129.

JOO W， RHOTON A L， Jr. Microsurgical anatomy of the trochlear nerve. Clin Anat，2015，28(7): 857–864. doi: 10.1002/ca.22602.

LI X M， SHU G W， WANG Y. Study of applied anatomy related to neurosurgery through subtemporal transtentorial approach to superior petroclival region. Chin J Clin Neurosurg，2009，14(4): 219–221. doi: 10. 13798/j.issn.1009-153x.2009.04.003.

CHEN Y H， BAI X B， TIAN Y H， et al. The microsurgical anatomy study of basilar artery apex via subtcmporal approach. J Brain Ner Dis， 2013，21(2): 145–148. doi: 10.3969/j.issn.1006-351X.2013.02.021.

KIM S M， PAEK S H， LEE J H. Infratemporal fossa approach: the modified zygomatico-transmandibular approach. Maxillofac Plast Reconstr Surg，2019，41(1): 3. doi: 10.1186/s40902-018-0185-x.

KIM M， PARK S K， LEE S， et al. Prevention of superior petrosal vein injury during microvascular decompression for trigeminal neuralgia: operative nuances. J Neurol Surg B Skull Base，2022，83(Suppl 2): e284–e290. doi: 10.1055/s-0041-1725036.

YOKOSAKO S， KIKUCHI A， OHBUCHI H， et al. Venous flow conversion technique for sacrificing the superior petrosal vein during microvascular decompression for trigeminal neuralgia. Oper Neurosurg (Hagerstown)，2022，23(4): e232–e236. doi: 10.1227/ons.00000000 00000333.

KELEŞ A， ARMSTRONG S A， SAYYAHMELLI S， et al. Microsurgical resection of a large petroclival meningioma via translabyrinthine approach combined with middle fossa craniotomy. Neurosurg Focus Video，2022，6(2): V11. doi: 10.3171/2022.1.Focvid21253.

OGIWARA T， GOTO T， KUSANO Y， et al. Subtemporal transtentorial approach for recurrent trigeminal neuralgia after microvascular decompression via the lateral suboccipital approach: case report. J Neurosurg，2015，122(6): 1429–1432. doi: 10.3171/2014.10.Jns132643.

Von RHEIN B， NELLES M， URBACh H， et al. Neuropsychological outcome after selective amygdalohippocampectomy: subtemporal versus transsylvian approach. J Neurol Neurosurg Psychiatry，2012，83(9): 887–893. doi: 10.1136/jnnp-2011-302025.

LAMKI T， SALMA A， BAIDYA N， et al. Path to the interpeduncular fossa: anatomical comparison of endoscopic-assisted versus standard subtemporal approach. J Neurol Surg B Skull Base，2012，73(4): 261–264. doi: 10.1055/s-0032-1312717.


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