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
2. Most anterior circulation aneurysms
except pericallosal
3. Some posterior circulation aneurysm:
basilar apex & superior cerebellar
artery
4. Suprasellar tumours
5. Sphenoid wing tumours
6. 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 – widow’s 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:
3. 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
Mollison’s 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

2. Lesions of the frontal lobe

3. CSF fistula repair
4. Olfactory groove tumours
5. 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/craniofi
x 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 Dandy’s 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
 Choroidplexus
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