Original ArticlePreservation and Microsurgical Repair of the Superficial Temporal Artery During Pterional Craniotomy
Introduction
The pterional (i.e., frontotemporal) craniotomy is one of the most common approaches in neurosurgery.1, 2, 3 This approach originally was developed for the microsurgical treatment of cerebral aneurysms of circle of Willis and was later applied as the surgical approach for various lesions around sella, suprasellar and basal frontotemporal region, superior part of the clivus and basilar artery, and anterolateral mesencephalon.
The incision for the classical pterional craniotomy starts at the zygoma and follows the hair implant line more cranially. The incision is usually somewhere superimposed on the course of the superficial temporal artery (STA) (Figure 1). As a consequence, the STA may be damaged or transected during incision and dissection of the skin and muscle flap.
The STA is the most prominent and important artery, supplying the scalp of the forehead and a large portion of the head.3 The STA is a terminal branch of the external carotid artery, and it commonly divides into one frontal and one parietal branch, although there might be great anatomical variability. The diameter of the STA branches ranges from 1 to 2 mm. The artery has excellent flow and tolerates surgical manipulation. For surgical purposes, the STA serves as an important donor artery for not only extracranial–intracranial bypass surgeries such as STA–middle cerebral artery anastomosis but other types of bypass as well (e.g., STA–posterior cerebral or STA–cerebellar superior artery anastomosis).
In accordance with the modern philosophy of performing surgery as atraumatically as possible, it is our goal to preserve the STA in every surgical patient, even if this implies that the STA has to be transected and reanastomosed, to retract the skin flap. Therefore, in this study, we report on 136 consecutive patients who were operated via a pterional craniotomy in which particular attention was paid to the identification and preservation the STA. In case of transection or damage, the STA was repaired microsurgically at the end of the procedure. Postoperatively, the patency rates of STA were documented as well as the rates infection and wound healing.
Section snippets
Materials and Methods
All patients included in this study (n = 136) underwent either an emergency or an elective pterional craniotomy. All surgeries were performed by a single surgeon (T.M.) at a single institution between February 2011 and January 2015. In most cases, the reason of surgery was clipping of an aneurysm followed by resection of a suprasellar mass. The indications for pterional approach are presented in Table 1. The general time per procedure was not recorded and only the time to repair the STA was
Results
The results on the STA identification, preservation, and reconstruction are presented in Figure 4. Of the 136 operated patients, the STA could be identified in 120 cases (88%). Although we carefully injected the superficial subcutaneous space with local anesthetics and adrenaline, in none of the cases there was visible injury to the STA as the result of local infiltration. Of these 120 cases, the artery could be dissected and left undamaged during further reflection of the muscle-skin flap in
Discussion
Because of its location, the STA frequently is encountered when performing frontotemporal or pterional craniotomy,4 which is considered the most used approaches in cranial neurosurgery.1, 2, 3 A significant amount of literature exists on how to preserve the frontal branch of the facial nerve during pterional craniotomy, but reports on the preservation of the STA are sparse.5
In our experience, it is more or less the habit to do the dissection without paying too much attention to the STA. If the
Conclusions
Preserving or reconstructing of the STA during pterional craniotomy is feasible in the majority of the patients (92.5%) with very high rate of anastomosis patency. STA hinders turning the skin/muscle flap in around 38% of the pterional craniotomies and without reconstruction afterwards, it would have been occluded. From educational perspective, anastomosing the STA results in regular, additional microneurovascular exposure for the surgeon. For the patient, the vasculature of scalp is well
Acknowledgments
The authors thank Andy Van Rompaye and Fons Van Dijk for taking intraoperative pictures.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.