Operative Nuances

The Minipterional Craniotomy for Anterior

Circulation Aneurysms: Initial Experience With
72 Patients
Justin M. Caplan, MD
Kyriakos Papadimitriou, MD
Wuyang Yang, MD
Geoffrey P. Colby, MD, PhD
Alexander L. Coon, MD
Alessandro Olivi, MD
Rafael J. Tamargo, MD
Judy Huang, MD
Department of Neurosurgery, Division of
Cerebrovascular Neurosurgery, Johns
Hopkins University School of Medicine,
Baltimore, Maryland
Correspondence:
Judy Huang, MD,
Associate Professor of Neurosurgery,
Johns Hopkins University School of
Medicine,
Johns Hopkins Hospital,
1800 Orleans Street, Zayed Tower 6115F,
Baltimore, MD 21287.
Phone: 410-502-5767,
Fax: 443-287-0683.
E-mail: jhuang24@jhmi.edu
Received, September 30, 2013.
Accepted, January 16, 2014.
Published Online, March 12, 2014.
Copyright 2014 by the
Congress of Neurological Surgeons.
BACKGROUND: The pterional craniotomy is well established for microsurgical clipping
of most anterior circulation aneurysms. The incision and temporalis muscle dissection
impacts postoperative recovery and cosmetic outcomes. The minipterional (MPT) cra-
niotomy offers similar microsurgical corridors, with a substantially shorter incision, less
muscle dissection, and a smaller craniotomy flap.
OBJECTIVE: To report our experience with the MPT craniotomy in select unruptured
anterior circulation aneurysms.
METHODS: From January 2009 to July 2013, 82 unruptured aneurysms were treated in 72
patients, with 74 MPT craniotomies. Seven patients had multiple aneurysms treated with
a single MPT craniotomy. The average patient age was 56 years (range: 24-87). Aneurysms
were located along the middle cerebral artery (n = 36), posterior communicating (n = 22),
paraophthalmic (n = 22), choroidal (n = 1), and dorsal ICA segments (n = 1). The MPT
craniotomy utilized an incision just posterior to the hairline and a single myocutaneous flap.
RESULTS: The average aneurysm size was 5.45 mm (range: 1-14). There were no instances
of compromised operative corridors requiring craniotomy extension. Three significant early
postoperative complications included epidural and subdural hematomas requiring evacu-
ation, and a middle cerebral artery infarction. Average length of hospitalization was 3.96
days (range: 2-20). Two patients required reoperation for wound infections. Average follow-
up was 421 days (range: 5-1618). Minimal to no temporalis muscle wasting was noted in
96% of patients.
CONCLUSION: The MPT craniotomy is a worthwhile alternative to the standard pter-
ional craniotomy. There were no instances of suboptimal operative corridors and clip
applications when the MPT craniotomy was utilized in the treatment of unruptured
middle cerebral artery and supraclinoid internal carotid artery aneurysms proximal to
the terminal internal carotid artery bifurcation.
KEY WORDS: Cerebral aneurysms, Craniotomy, Minimally invasive surgery, Surgical technique
Operative Neurosurgery 10:200207, 2014 DOI: 10.1227/NEU.0000000000000348

T
he pterional craniotomy is a well-established
approach for the treatment of a variety of in-
tracranial pathologies, including most intra-
cranial aneurysms.1-3 This approach provides
exposure to the anterior and middle cranial fossa,
superior aspect of the posterior cranial fossa, the
sellar and parasellar regions, superior orbital
fissure and cavernous sinus.2-4 Despite the ad-
vantages of the pterional craniotomy, there are
ABBREVIATIONS: Acomm, anterior communicat-
ing; MPT, minipterional; Pcomm, posterior com-
municating; SAH, subarachnoid hemorrhage
several limitations of this approach, which include
temporalis muscle atrophy and damage to the
frontal branch of the facial nerve.
To address these limitations, several technique
modifications of the pterional approach have been
developed to minimize temporalis muscle atrophy
and decrease the risk of frontal branch injury. These
modifications rely on alternative dissection and
reconstruction techniques. We have previously
described a technique using a frontozygomatic
titanium cranioplasty to prevent frontozygomatic
fossa depression following the pterional approach.5
Others have advocated raising a myocutaneous flap,
while leaving a fascial cuff for reattachment.6 In

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order to minimize muscle atrophy, a subperiosteal retrograde
dissection technique may be used.7 To limit frontal branch injury,
both an interfascial dissection of the temporalis fascia and a subfascial
dissection have been described as alternatives aimed at avoiding
injury of the frontal branch of the facial nerve.8,9
In addition to the technique modifications, entirely different surgical
approaches have also been described as alternatives to the pterional
approach. These include the lateral supraorbital approach, mini
supraorbital approach, the supraorbital keyhole approach, sphenoid
ridge keyhole approach, minipterional craniotomy, modified pterional
with temporalis muscle splitting, and eyebrow approaches.10-18 These
approaches offer alternative incisions and craniotomies that aim to
provide similar surgical access that the pterional craniotomy would
provide for select intracranial pathology, but with smaller incisions,
craniotomies and improved cosmetic results.
The minipterional (MPT) craniotomy was developed as an
alternative to the standard pterional craniotomy that offers similar
surgical corridors through a smaller incision and craniotomy.14
Figueiredo and coworkers were the first to present their findings
in cadaveric anatomic studies and 3 case illustrations. However,
to date, no large patient series have been published using this
technique. In this report, we describe our experience with 74
MPT craniotomies performed in 72 consecutive patients using
a modification of the minipterional technique for the treatment
of 82 selected unruptured anterior circulation aneurysms.
METHODS
Patient Review
Seventy-four consecutive MPT craniotomies were performed by
a single surgeon (J.H.) between January 2009 and July 2013 at the
Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center.
All patients were prospectively entered into the Johns Hopkins Medical
Institutional Review Board-approved aneurysm database. Patients
received routine follow-up at scheduled intervals, with standard assess-
ments of the patients neurological status and cosmetic outcome. The
electronic medical records of all patients undergoing the MPT
craniotomy were reviewed.
Patient Selection
Patient selection for the MPT proceeded as follows: Patients were first
screened for aneurysm location and presence of subarachnoid hemorrhage.
All patients presenting with aneurysmal subarachnoid hemorrhage (SAH)
were excluded from consideration for the MPT approach. Aneurysm
location was then assessed. All patients were considered for the MPT
approach if they had middle cerebral artery (MCA) aneurysms, posterior
communicating artery (Pcomm) and paraophthalmic artery aneurysms.
Aneurysms with partial thrombosis were often not selected for the MPT
craniotomy due to anticipated complexity such as possible need for
thrombectomy in which a smaller bony exposure would be potentially
restrictive. Patients with internal carotid artery (ICA) terminus aneurysms,
anterior communicating (Acomm) artery aneurysms, basilar apex, and
superior cerebellar artery aneurysms were not chosen for the MPT
craniotomy and underwent standard pterional craniotomy. In patients with
multiple aneurysms planned for microsurgical treatment via a single
OPERATIVE NEUROSURGERY
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MINIPTERIONAL CRANIOTOMY FOR ANEURYSM TREATMENT
craniotomy, a standard pterional approach was utilized if 1 of the aneurysms
was located at the anterior communicating artery or ICA termination.
MPT Craniotomy Technique
The MPT craniotomy has been described previously by Figueiredo
et al.14 We performed the MPT craniotomy with modifications as
described below. The patient was positioned supine with ipsilateral
shoulder elevation for a standard pterional craniotomy and placed in
a radiolucent skull clamp to allow for intraoperative angiography.19 The
patients head was then translated forward, extended and rotated to bring
the maxillary eminence to the most superior position of the surgical field.
Head rotation varied with aneurysm location. The incision began 1 cm
superior to the root of the zygoma to 1 cm medial to the linea temporalis.
The incision was planned immediately posterior to, and followed the
curvature of the patients hairline (Figure 1). The incision was significantly
shorter than a standard pterional craniotomy incision. A minimal strip
hair shave was performed. After the sterile surgical prep and drapes were
applied, the skin was incised and a single myocutaneous flap was raised
which incorporated the temporalis muscle. Particular attention was paid to
achieving meticulous hemostasis at this point. Hemostatic scalp clips were
not applied to the skin edges in order to minimize bulky intrusions to the
operative field. The myocutaneous flap was held in place using scalp hooks
connected to a Leyla (Integra LifeSciences, Plainsboro, New Jersey) bar
secured directly to the operating room table.
Two burr holes were placed, 1 just inferior to the frontozygomatic process
and a second at the inferior aspect of the incision. A craniotomy flap was
then turned with the craniotome (Figure 1). During this maneuver the
assistant provided the necessary scalp retraction to allow for a craniotomy
that extended beyond the incision. While the craniotomy flap was still
connected at the sphenoid ridge, cranial fixation hardware using a
combination of burr hole covers and straight bars were used to create pilot
screw holes in the skull and bone flap in order to ensure correct anatomic
alignment of the craniotomy flap during closure. The bone flap was then
elevated using a periosteal elevator to separate its medial attachment at the
sphenoid wing. The sphenoid ridge was then drilled to the level of the
superior orbital fissure as in a standard pterional craniotomy. A curvilinear
dural opening was performed and tented at the sphenoid wing. At this
point the operating microscope was brought into the field allowing for
microsurgical access (Figure 2).
At the end of the microsurgical portion of the case, the dura was
closed and the bone flap was replaced using the pre-drilled pilot holes
to ensure optimal anatomic alignment. A Medpor pterional implant
(Stryker, Kalamazoo, Michigan) was secured in place with 5 mm
screws and HydroSet (Stryker, Kalamazoo, Michigan) was applied to
fill in the grooves between the skull and bone flap. The temporalis
muscle was reapproximated using absorbable sutures, followed
by closing of the galea, and then skin staples were applied. A subgaleal
drain was not used. A small Telfa (Covidien, Mansfield, Massachu-
setts) strip dressing was stapled in place to avoid tape to the hair
and skin.
RESULTS
A total of 74 MPT craniotomies were performed on 72 patients
to treat a total of 82 aneurysms. The majority of the patients were
female (76%) and the average patient age was 56 years old (range:
24-87). Sixty-seven patients had a craniotomy for treatment of
a single aneurysm, with 6 craniotomies performed to treat 2
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FIGURE 1. Artists rendering of skin incision (dashed line) and craniotomy (green) for performing the MPT
craniotomy. Note the relationship of the bone flap and the location of the aneurysms treated (1. MCA
aneurysms; 2. PComA aneurysms; and 3. Ophthalmic artery aneurysms.). a., artery; Inf., inferior; n., nerve;
MCA, middle cerebral artery; PComA, posterior communicating artery; Post., posterior; sup., superior.

aneurysms, and 1 additional patient had 3 aneurysms treated
through a single MPT craniotomy. Two patients had bilateral MPT
craniotomies performed. Of the aneurysms treated, 69 (84.2%)
were clipped, 11 (13.4%) were wrapped with cotton and fibrin glue
and 2 (2.4%) paraophthalmic aneurysms were found to be
extradural.
Middle cerebral artery aneurysms compromised the largest
proportion of patients (n = 36, 44%), followed by Pcomm artery
aneurysms (n = 22, 27%), and paraophthalmic artery region
aneurysms (n = 22, 27%) (Figure 3). There was 1 anterior
choroidal artery aneurysm and 1 dorsal ICA aneurysm (Table).
Three patients with Pcomm artery aneurysms presented with
third nerve palsies. The average size of all aneurysms operated on
was 5.45 mm (range: 1-14 mm).
The average hospital length of stay was 3.96 days (range: 2-20
days). The average length of follow-up following surgery was 421
days (range: 5-1618 days). All wounds healed well. However, 2
patients required further surgery for incision and drainage of an
infected wound. Temporalis muscle wasting was rated as none
to minimal in 71 (96%) of the cases.
There were 10 patients with complications that developed prior
to hospital discharge. Six patients had an optic neuropathy
following surgery on a paraophthalmic region aneurysm, which
ranged from a field cut to complete loss of light perception. There
was 1 large MCA infarct in a patient with 2 MCA aneurysms.
There was 1 epidural hematoma requiring evacuation. One
patient had a contralateral stroke intraoperatively distal to a
previous carotid endarterectomy and required anticoagulation.
This patient subsequently developed a subdural hematoma at
the craniotomy site necessitating evacuation. One patient had
seizures and 1 patient developed a third nerve palsy that
subsequently resolved.
There were 4 late postoperative complications that devel-
oped after hospital discharge. Two patients developed

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 MINIPTERIONAL CRANIOTOMY FOR ANEURYSM TREATMENT

FIGURE 2. Artists rendering of intracranial view of surgical corridor achieved via the MPT approach. This
approach readily provides access to MCA, Pcomm and ophthalmic artery region aneurysms. (1. Middle
cerebral artery aneurysms, 2. Posterior communicating artery aneurysms, and 3. Ophthalmic artery
aneurysms.). Ant., anterior; a., artery; Int., interior; M1, M1 segment of the middle cerebral artery; M2, M2
segment of the middle cerebral artery; MCA, middle cerebral artery; Post. communicating a., posterior
communicating artery; Post., posterior.

infections requiring reoperation. Two patients developed DISCUSSION

seizures; however, 1 of the patients had a prior history of
seizures and the other patients seizure was in the setting of The standard pterional craniotomy is a well-established approach
likely cocaine use. to a large variety of intracranial pathologies, including most anterior
circulation aneurysms. However, its long incision and temporalis
muscle dissection impacts immediate and long-term recovery.
TABLE. Aneurysms Treated in 74 Minipterional Craniotomies Temporalis muscle atrophy and damage to the frontal branch of
No. of Treated (% of Total the facial nerve are both possible complications from the muscle
Aneurysm Location Aneurysms) dissection. Like the standard pterional approach, the MPT
Middle cerebral artery 36 (44) craniotomy is centered over the lesser wing of the sphenoid and
Posterior communicating 22 (27) offers safe surgical access to many intracranial lesions. However, the
artery
MPT craniotomy offers an alternative to the standard pterional
Paraophthalmic region 22 (27)
Anterior Choroidal artery 1 (1) craniotomy with similar operative corridors through use of a smaller
Dorsal internal carotid artery 1 (1) incision, less muscle dissection and a smaller craniotomy.14 These
factors are important for postoperative pain, wound healing and

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CAPLAN ET AL

FIGURE 3. Artists rendering of the intraoperative view allowed by a right-sided MPT craniotomy of the 3
most common locations for aneurysms treated via this approach. ACA, anterior cerebral artery; Ant., anterior; a.,
artery; M1, M1 segment of the middle cerebral artery; M2, M2 segment of the middle cerebral artery; MCA,
middle cerebral artery; n., nerve; Post. communicating a., posterior communicating artery; Post., posterior.

cosmesis. We present our favorable experience with 74 MPT
craniotomies in 72 consecutive patients over a 4.5-year period
treating 82 unruptured aneurysms.
We found that MCA, Pcomm and paraophthalmic aneurysms
are all readily treated using the MPT approach. Aneurysms up to
14 mm in size were treated successfully. Of the 82 aneurysms
treated, 11 were wrapped. This included 5 aneurysms too small to
hold a clip, 4 small Pcomm or paraophthalmic aneurysms where
clipping would have resulted in vessel occlusion, 1 calcified
ophthalmic aneurysm that would not hold a clip, and 1 para-
ophthalmic aneurysm where a significant portion of the neck was
extradural and clipping would risk avulsing the thin walled
intradural neck. In no instances did we feel that the exposure
provided by the MPT limited the ability to treat these aneurysms.
This finding is supported by anatomic studies, of which several
have been published comparing the standard pterional crani-
otomy to its various modifications both in clinical series and in
cadaveric dissections.11,14,20-22 Figueiredo et al4 used com-
puterized tracking to assess the extent of exposure in the
pterional-transsylvian approach. They found that dissection of
the sylvian fissure distal to the anterior ascendant ramus does
not provide additional exposure of the basal cisterns or circle of
Willis. This important point is 1 of the tenets underlying the
MPT approach.
The MPT craniotomy is a suitable alternative over the standard
pterional craniotomy for unruptured MCA, Pcomm, and Para-
ophthalmic aneurysms. We do not advocate for the use of the
MPT for ICA terminus or Acomm region aneurysms given the
relatively more brain retraction that is commonly required for
those aneurysms. Furthermore, the MPT craniotomy was not
selected for patients with aneurysmal SAH, as the smaller bony
exposure in the setting of significant brain edema would be severely
limiting. We did find, however, that the MPT craniotomy worked
well in patients with a previous history of aneurysmal sub-
arachnoid hemorrhage who had other untreated aneurysms
requiring surgery at a later date.
The supraorbital approach is another minimally invasive
alternative to the standard pterional craniotomy. This approach,
often through an eyebrow skin incision, has been used extensively
for aneurysms, although some find the limited corridor through
this approach challenging to maneuver, particularly in instances
of brain swelling.16,17 Furthermore, given the small size of the
craniotomy, there is less room for error in placement of the
craniotomy, and endoscopy may sometimes be necessary to assist
in visualization.12 While the supraorbital approach can be highly
effective, its utility is yet to be widely established, as it remains to
be adopted by more neurosurgeons. Alternatively, the MPT
craniotomy builds upon the principles of the standard pterional,

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an approach that is an established tool in the armamentarium of
all neurosurgeons. As the MPT craniotomy is based on the same
fundamental principles as the standard pterional craniotomy, it is
ideal for a minimally invasive approach with which many
neurosurgeons will immediately be comfortable, yet which
affords the patient a smaller and cosmetically satisfactory incision.
Figure 1 illustrates the skin incision and craniotomy used for the
MPT approach. For comparison, we have previously published
our technique for a standard pterional craniotomy.5,23
We used the MPT technique described by Figueiredo et al14 and
made several modifications based upon our experience with the
MPT in the operating room. Firstly, we did not perform an
interfascial dissection of the temporalis muscle, but rather raised
a single myocutaneous flap. One benefit of the subfascial or
interfascial dissection, in addition to helping to preserve the frontal
branch of the facial nerve, is that it allows for mobilization of the
temporalis inferiorly to limit the bulk of muscle along the scalp
flap.8,9,24 An alternative is to raise a single myocutaneous flap,
which avoids risking the frontalis branch completely as the
dissection does not elevate the scalp from the temporalis fascia
where the nerve resides. One disadvantage to this maneuver is that
the temporalis muscle creates bulk along the scalp flap, which can
limit visualization when looking superiorly and posteriorly during
the microsurgical portion of the case. Given the small size of the
incision and thus muscle dissection, we did not find this extra
muscle bulk to be limiting for exposure of the aneurysms at the
selected locations. Furthermore, the small incision, which was
significantly smaller than the standard pterional craniotomy
incision, and the simple muscle dissection allowed for a rapid
wound closure at the end of the case. A myocutaneous flap with
a MPT craniotomy may not be suitable for Acomm or ICA
terminus aneurysms; thus, unruptured aneurysms at these locations
were not attempted using the MPT craniotomy. These locations,
we feel, are better approached with a standard pterional craniotomy.
A second modification of the originally described MPT
technique involves a slightly larger craniotomy. We found that
with appropriate skin retraction by an assistant, the craniotomy
could be made larger than the opening of the skin incision. The
medial extent of the craniotomy was superior to the superior
temporal line. The temporal aspect of the craniotomy did not
extend as far laterally as a standard pterional craniotomy. With
pre-plating of the bone flap, and cranioplasty techniques
employing the implantation of bone filler and a porous poly-
ethylene prosthesis, good cosmetic results were achieved via
anatomic bone realignment and elimination of palpable gaps on
the forehead. The use of the Medpor system provided a buttress
of the temporalis muscle, which was used to replace the sphenoid
bone that had been drilled away. This also helped to prevent any
significant temporal hollowing in the patients in this series.
We placed a second burr hole in addition to the one near the
frontozygomatic suture, at the inferior margin of the incision. This
helped to facilitate the dural dissection from the inner table of the
bone prior to creation of the bone flap with the high-speed
craniotome. A burr hole in this location is well concealed by the
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MINIPTERIONAL CRANIOTOMY FOR ANEURYSM TREATMENT
temporalis muscle. Overall, we achieved favorable cosmetic results
in 96% of the MPT craniotomies performed. Importantly, in no
instances did the MPT craniotomy limit the surgical exposure
necessary for optimal aneurysm treatment.
Overall, the MPT craniotomy was well tolerated. The most
common complication was the development of an optic neurop-
athy. All of these were in patients with paraophthalmic aneurysms.
Of the 22 patients operated on with paraophthalmic aneurysms, 6
developed an optic neuropathy (27.3%). This is similar to our
previously published rate of 34% after consensus-based treatment
of ophthalmic artery segment aneurysms.25 Of the 6 patients with
visual complications, all had immediate visual decline. All 6
patients had anterior clinoidectomies performed. Despite metic-
ulous attention to copious irrigation, it is possible that these visual
complications are related to the heat associated with clinoidal
drilling. Furthermore, optic nerve ischemia from manipulation of
the nerve is possible as well. In 2 patients, there was some visual
improvement at the time of follow-up.
In addition, the other early postoperative complications (MCA
stroke, epidural hematoma, contralateral stroke and ipsilateral
subdural hematoma, postoperative seizure and transient third-
nerve palsy) were not related to the MPT technique. For example,
1 patient suffered an intraoperative stroke contralateral to the
operative site as the result of a cervical carotid occlusion from
a prior carotid endarterectomy site. She subsequently underwent
endovascular thrombectomy immediately following the craniot-
omy, and then was placed on systemic anticoagulation. This
resulted in a subdural hematoma at the craniotomy site, requiring
subsequent evacuation. In fact, given the small size of the
craniotomy with the MPT technique, it is possible the subdural
hematoma would have been larger had the patient underwent
a standard pterional approach. In addition, the in-hospital
postoperative seizure rate was 1.35% (n = 1), which is similar
to other published data.26 Late postoperative complications
included 2 wound infections and 2 patients with seizures. Again,
we do not feel these complications were any more or less likely to
occur than in a standard pterional approach.
CONCLUSION
The pterional craniotomy permits a well-established surgical
approach that offers surgical corridors to pathology in the anterior,
middle and posterior cranial fossae. As length of hospital stay,
length of recovery and cosmetic outcome become increasingly
important in the treatment of unruptured intracranial aneurysms,
minimally invasive approaches have been developed that aim to
reduce the craniotomy-associated recovery period associated with
aneurysm treatment and improve cosmesis. Several such surgical
approaches have evolved as modifications of the standard
pterional craniotomy. The MPT craniotomy is one such
approach which aims to offer comparable surgical corridors with
a smaller incision, smaller craniotomy and less temporalis muscle
dissection, all of which serve to improve cosmesis, decrease
incisional discomfort and shorten recovery. It is paramount that
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CAPLAN ET AL
any new approach does not impede surgical efficacy or increase
neurological morbidity for the sake of shorter recovery or
improved cosmetic result. We report our favorable experience
with the MPT in 72 patients with select anterior circulation
aneurysms. In all patients selected for the MPT, effective
microsurgical clipping was accomplished in the same manner
as if had we performed a standard pterional craniotomy. Patient
satisfaction was high due to the favorable cosmetic results. The
MPT craniotomy is well suited as an alternative to the standard
pterional craniotomy for treating unruptured MCA, Pcomm and
paraophthalmic aneurysms.
Disclosure
Financial support/industry affiliations: Alexander Coon, MD: Covidien. The
other authors have no personal financial or institutional interest in any of the drugs,
materials, or devices described in this article.
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Acknowledgment
The authors thank Dr Ian Suk, MD, for the illustrations.
COMMENTS
M
any variations of the pterional craniotomy have been attempted to
clip cerebral aneurysms. The biggest problem with these craniot-
omies is the condition of the temporalis muscle after surgery. Pain,
wasting, and cosmetic deformity, are all potential problems that often
complicate an otherwise straightforward surgical procedure. In this study,
the mini-pterional craniotomy was used successfully to improve the post-
operative healing of the temporalis muscle, without compromising the
surgical approach to unruptured aneurysms. I have also used a variation of
the described techniques for small MCA aneurysms with good results. Any
approach to minimize the disturbance to the muscle is a welcomed
addition to our surgical approach to cerebral aneurysms.
Robert A. Solomon
New York, New York
T
he authors describe a modification of the mini-pterional approach. As
they mention in the article there are a variety of approaches centered in
this region such as the lateral supraorbital approach and keyhole approaches.
Basically the described approach in this paper provides some minor mod-
ifications to the pterional approach which differ little from other descrip-
tions of mini and standard pterional approaches. The authors provide their
successful employing this approach in their patient population.
Carlos David
Burlington, Massachusetts
www.neurosurgery-online.com

T he authors describe their experience using a short fronto temporal
skin incision, a myocutaneous flap elevation and a small pterional
(minipterional) craniotomy for the open surgical treatment of selected
anterior circulation aneurysms. Not surprisingly they have excellent
cosmetic results in terms of fronto-temporal branch injury and tem-
poral muscle atrophy/dysfunction. They have thoughtfully described
the clinical situations when such an approach may yield comparable
exposure to the well-established pterional craniotomy. In the present
climate where minimally invasive approaches are often and times
enthusiastically embraced for all pathologies, the authors are to
be commended on pointing out the constrains of this minipterional crani-
otomy (unruptured MCA, PComm and Paraophthalmic aneurysms). Their
OPERATIVE NEUROSURGERY
Copyright Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
MINIPTERIONAL CRANIOTOMY FOR ANEURYSM TREATMENT
report also highlights the likely thermal injury to the optic nerve during
drilling of the anterior clinoid process, an event that is probably
underestimated.1
Mario Ammirati
Columbus, Ohio
1. Kshettry V, Jiang X, Chotai S, Ammirati M. Optic nerve surface temperature
during intradural anterior clinoidectomy: a comparison between high-speed
diamond burr and ultrasonic bone curette. In Print Neurosurgical Review,
2014.
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