Anatomic consideration for transsylvian approach

Abstract

We describe basic knowledge necessary for the transsylvian approach. From a surgical point of view, diverse patterns of sylvian veins can be treated as two distinct but connected venous pathways consisting of superficial sylvian veins and deep middle cerebral vein system. In contrast to previous understanding, many technical drawbacks inherent to standard pterional approach can be overcome by working on temporal region rather than just working on the frontal region. For example, dissection of sylvian veins should be carried out between the superior temporal gyrus and frontosylvian vein when frontoorbital veins are to be preserved. Veins and arteries on the mesial temporal lobe (Planum polare) should be skeletonized to retract mesial temporal lobe toward posterolateral direction. This manipulation provides abundant working space with less frontal retraction in aneurysm surgery. Understanding microanatomy in various disease processes is of paramount importance to practice microsurgery, and we must put mphasis on intensive practice-based learning to acquire the necessary skills to implement the transsylvian approach.