SUBTEMPORAL APPROACH

The subtemporal approach involves a temporal craniotomy centered at the temporozygomatic junction made flush with the floor of the middle fossa with subsequent gentle superior elevation of the temporal lobe revealing a surgical corridor directed to the lateral surface of the midbrain and interpeduncular fossa. In neurovascular surgery, the subtemporal approach finds its main indication in treatment of aneurysms of the basilar apex lying below the level of the posterior clinoids or arising at the superior cerebellar artery or basilar trunk. However, the utility of the approach has been expanded to include treatment of proximal posterior cerebral artery (PCA) aneurysms, including fusiform type, via aneurysm bypass trapping, and a variety of other pathologies located in the anterior and middle tentorial incisural spaces and anterior or anterolateral midbrain and pons. In this chapter, we review the main technical aspects regarding the subtemporal approach, focusing on the advantages and disadvantages of the classic approach as well as the employment of surgical adjuncts including division of the tentorium, zygomatic osteotomy, and anterior petrosectomy to widen applicability of this approach. We also explore the complications associated with this approach along with the key precautionary measures to avoid them.