Catálogo de publicaciones - libros

For years, surgeons have been developing surgical approaches attempting to achieve maximal surgical exposure with minimal brain retraction, advantages found within the frontotemporal or pterional approach, first described by Yasargil, four decades ago [1–3]. Compared to its predecessors, this approach allowed for wider frontobasal exposure, secondary to more significant drilling away sphenoid wing; in addition to that surgeon could dissect and split Sylvian fissure wider [1]. Consequently, it was applicable for clipping of both basilar tip and anterior circulation aneurysms, with an excellent safety-efficacy profile [1]. Later on, the approach will be modified and combined with others, and its indications are only growing in number.

The concept of keyhole neurosurgery is not only to perform small incision and reduce the craniotomy size for the sake of a small opening as we called “keyhole,” but it is rather to make “minimum craniotomy” required to access deep intracranial lesions at the end of the route. Standard craniotomy forms a “funnel-shaped surgical corridor” to reach deeper area of the brain. In contrast, keyhole mini craniotomy forms a “reverse funnel-shaped surgical corridor” that provides adequate working space through a small incision and bone window to reach the target. The concept of this approach is that the deep area of the brain can be accessed through smaller craniotomy since the superficial optical field is widened if the size of craniotomy is bigger (Fig. 2.1).

Surgical management of Skull –base pathologies remains one of the most challenging interventions for neurosurgeons. Advances in neuroimaging and surgical technologies coupled with promotion of tailored neurosurgical approaches promote precise clinical diagnosis, surgical planning and enhance neurosurgical outcome. The fronto-orbito-zygomatic (FOZ) approach with its variation welds multiple surgical avenues that facilitate better exposure and safe removal of the pathology. This approach is recommended for handling complex skull base tumors or vascular lesions located around the central skull base, cavernous sinus and upper clivus. The manuscript highlights detailed information about (FOZ) approach and how to master it.

The lateral supraorbital (LSO) approach is the most common craniotomy used in Helsinki by Professor Juha Hernesniemi. He has used the LSO approach for more than 30 years and in more than 6000 surgeries. This approach is a simpler, faster, and less invasive modification of the classically established pterional approach described by Yasargil. It provides excellent exposure of anterior fossa lesions, suprasellar lesions, and most anterior circulation aneurysms.

The interhemispheric (IH) approach is the best access to lesions located in the midline along the corpus callosum and can be used also for lesions in the lateral and third ventricles and in the pineal region.

Historically, the first form of subtemporal approach had been described for the treatment of trigeminal neuralgia early in the twentieth century. Temporal craniotomies had offered surgical corridor to the various lesions situated in middle cranial fossa. By the 1960s, subtemporal approach entered in flourishing period by Drake’s pioneering work of surgical treatment for more than 1700 basilar and posterior circulation aneurysms. Subsequently, modifications of subtemporal route, such as subtemporal key hole approach, extended exposure with zygomatic resection, or removal of petrous apex, were developed to reach peri-mesencephalic and mid-clival regions.

After first description by Fedor Krause in 1903 [1], the unilateral approach to the cerebellopontine angle (CPA) have been developed and modified further by many surgeons. These include the transmastoid-translabyrinthine approach, the transtemporal extradural approach, and the lateral suboccipital (retrosigmoid) approach.

It is very important to understand the anatomical landmark of this approach (Fig. 8.1). There are some well-known triangle and skin incisions related to retrolabyrinthine and translabyrinthine approaches (Fig. 8.1a, b).

The extradural subtemporal approach through the middle fossa (MF) has become one of the most frequently used operative procedures in contemporary skull base of surgery. This approach is commonly used for exposing lateral wall of the cavernous sinus, to resect anterior petrous bone or to open the internal auditory canal. The MF surgery will be utilized for excision of intracanalicular acoustic neuromas, petrous and infracavernous chordomas, trigeminal neuromas, and small to medium size petroclival meningiomas. Full understanding of microanatomical structure of the cavernous sinus region, middle fossa, and the rhomboid construct is essential for this approach. Through this exercise the surgeon will acquire operative techniques to perform the anterior petrosectomy and also to expose the IAC through the middle fossa.

Aneurysm coiling is a method to exclude the aneurysm from circulation. If the aneurysm can be excluded from the circulation, the thrombosis process will be initiated within the aneurysm, and lately it is hoped that there will be an endothelialization on the neck of the aneurysm.