Please be advsed this video contains images of neurosurgical procedures which may be usetting for some and therefore viewer discretion is required.
The subtemporal approach was first developed to treat trigeminal neuralgia and was popularised as an approach to treat basilar apex aneurysms. While this video addresses an aneurysm repair, in my practice today this approach is most often used to access pathology of the upper brainstem e.g. cavernoma or arteriovenous malformations.
This video reviews the surgical anatomy of the perimesencephalic cisterns through the unusual case of a patient who developed sudden onset diplopia from a partially thrombosed, eccentric fusiform aneurysm causing a right trochlear nerve palsy. After opting for surgical repair rather than endovascular treatment to ensure nerve decompression, a subtemporal approach was utilized. The discussion highlights critical technical details including craniotomy placement, lumbar CSF drain usage for gravity retraction, the protection of draining veins, navigating a foetal pattern posterior communicating artery by opening the Liliequist membrane, and the preservation of vital thalamoperforating vessels such as the tubulothalamic trunk.
My thanks to the patient who agreed to the publication of this video.
The full video can be viewed here:
