The pterional approach: Surgical anatomy, operative technique, and rationale

The pterional or the frontotemporosphenoidal approach is one of the most commonly used surgical approaches in neurosurgery. Designed and popularized by Yasargil in the 1970s, this approach consists of approaching the brain and the anterior skull base through their lateral aspect by removing the frontal and temporal bones and the greater wing of the sphenoid. The depth of the anterior part of the brain with its neural and vascular components can be considered as treasures located along a hallway and locked up behind a door: The door is the bony structures on the lateral surface of the skull; the sylvian fissure is the hallway; and the pterional approach can be considered as the key to the door. The key steps of the pterional approach are positioning, skin incision, interfascial dissection, craniotomy, drilling of the sphenoid wing, and the dural opening. After the bone removal, the pterional approach proceeds with the opening of the sylvian fissure and the basal cisterns. The extensive spectrum of the neural and the vascular structures within the reach of the pterional approach includes insula, basal ganglia, lateral ventricle, middle cerebral artery, temporal operculum, frontal and parietal opercula, uncus, orbit, anterior cranial fossa, optic nerve, internal carotid artery and branches, lamina terminalis, and interpeduncular fossa.