Zygomatic approach for lesions in the interpeduncular cistern

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✓ Lesions in the interpeduncular cistern include basilar tip aneurysms, craniopharyngiomas, and chordomas. The surgical approach to these lesions presents a special technical problem, particularly when they are located high in the interpeduncular fossa. For the purpose of minimizing brain retraction and achieving excellent exposure within the interpeduncular cistern, the authors have developed a new surgical technique which involves detachment of the zygomatic arch.

The patient is placed in the supine position with the head rotated 45° to the contralateral side and tilted down 30° so that the surgeon can see into the interpeduncular cistern obliquely from below. The zygomatic arch of the temporal bone as well as a portion of the lateral orbital rim (the posterior ridge of the frontal process of the zygomatic bone) is removed to expose the anterior temporal base. With posterior retraction of the temporal lobe, the arachnoid membranes covering the Sylvian stem are opened in a retrograde fashion until the tentorial edge is sufficiently exposed. The posterior communicating artery and the optic tract are elevated to enter the interpeduncular cistern, after which the oculomotor nerve is dissected free of its surrounding arachnoid membranes and displaced posteroinferiorly.

Two patients with basilar tip aneurysms were operated on with this zygomatic approach, and a subtemporal modification of the zygomatic approach was used to treat a craniopharyngioma and a chordoma in two other patients. The procedure is described and a short description of its clinical use is given.

Article Information

Address reprint requests to: Kazuhiko Fujitsu, M.D., Department of Neurosurgery, Yokohama City University School of Medicine, 3-46 Urafune-cho, Minami-ku, Yokohama, 232 Japan.

© AANS, except where prohibited by US copyright law.

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Figures

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    A bicoronal skin incision is made beginning just in front of the tragus over the inferior border of the zygomatic arch and terminating at the uppermost level of the contralateral helix. The majority of the superior branches of the facial nerve are placed anteriorly and thus escape the incision. Lines indicate the bone incision, and the location of holes for replacement of the detached zygomatic arch is shown. Right: The temporal muscle, in continuity with the frontal pericranium and the periorbita, is detached from the skull and reflected inferiorly. In order to gain sufficient exposure of the zygomatic bone, the temporal muscle is detached from the fascia and the orbital contents are retracted inferomedially. Wedge-shaped removal of the frontal process of the zygomatic bone is illustrated. The bone cut and holes in the body of the zygomatic bone are also shown.

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    Left: Four burr holes are drilled and the free bone-flap craniotomy is elevated. This craniotomy also permits extensive removal of the sphenoid wing (dotted line), so that the lateral end of the superior orbital fissure may be reached. The dural opening is also indicated (solid line). Right: The bridging veins coming off the tip of the temporal lobe are divided, and the temporal lobe is retracted. The posterior communicating artery and the optic tract are elevated to provide entry to the interpeduncular cistern. Access to the basilar tip, bilateral cerebral peduncles, and the floor of the posterior third ventricle is provided in an oblique upward direction.

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    Preoperative vertebral angiogram showing an aneurysm at the distal bifurcation of the basilar artery. The basilar tip is rather high-placed in this case.

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    Preoperative computerized tomography scan showing a huge intrasellar chordoma encroaching upon the interpeduncular cistern and distorting the upper pons.

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