The infratranstentorial subtemporal approach (ITSTA): a valuable skull base approach to deep-seated non-skull base pathology

  • Carlos Candanedo
  • Samuel Moscovici
  • Sergey SpektorEmail author
Original Article - Neurosurgery general
Part of the following topical collections:
  1. Neurosurgery general



Surgical access to space-occupying lesions such as tumors and vascular malformations located in the area of the tentorial notch, mediobasal temporal lobe, and para-midbrain is difficult. Lesions in this area are typically resected with supratentorial approaches demanding significant elevation of the temporal lobe or even partial lobectomy, or via a supracerebellar transtentorial approach. We introduce an alternative, the skull base infratranstentorial subtemporal approach (ITSTA), which provides excellent exposure of the incisural area while minimizing risk to the temporal lobe.


We included consecutive patients with pathology involving the area of the tentorial incisura, para-midbrain, and mediobasal temporal area who underwent surgery via ITSTA from 2012 to 2018. The approach includes partial mastoidectomy, temporal craniotomy, and tentorial section. Space obtained by mastoidectomy provides a sharp high-rising angle-of-attack, significantly diminishing the need for temporal lobe retraction. Surgeries were performed using microsurgical techniques, neuronavigation, and electrophysiological monitoring. Clinical presentation, tumor characteristics, extent of resection, complications, and outcome were retrospectively reviewed under a waiver of informed consent.


Nine patients met inclusion criteria (five female, four male; mean age 44 years, range 7–72). They underwent surgery for removal of para-midbrain arteriovenous malformation (AVM, 3/9), medial tentorial meningioma (2/9), mediobasal epidermoid cyst (2/9), oculomotor schwannoma (1/9), or pleomorphic xanthoastrocytoma (PXA) of the fusiform gyrus (1/9). Three AVMs were removed completely; among six patients with tumors, gross total resection was achieved in three and subtotal resection in three. All surgeries were uneventful without complications. There were no new permanent neurological deficits. At late follow-up (mean 42.5 months), eight patients had a Glasgow Outcome Score (GOS) of 5. One 66-year-old female died 18 months after surgery for reasons not related to her disease or surgery.


The ITSTA is a valuable skull base approach for removal of non-skull base pathologies located in the difficult tentorial-incisural parabrainstem area.


Arteriovenous malformation Incisura Skull base Subtemporal Tentorial notch Transtentorial 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

For this type of study, formal consent was not required.


  1. 1.
    Ansari SF, Young RL, Bohnstedt BN, Cohen-Gadol AA (2014) The extended supracerebellar transtentorial approach for resection of medial tentorial meningiomas. Surg Neurol Int 5:35CrossRefGoogle Scholar
  2. 2.
    Campero A, Troccoli G, Martins C, Fernandez-Miranda JC, Yasuda A, Rhoton AL Jr (2006) Microsurgical approaches to the medial temporal region: an anatomical study. Neurosurgery 59:ONS279–ONS307; discussion ONS307-278Google Scholar
  3. 3.
    de Oliveira JG, Parraga RG, Chaddad-Neto F, Ribas GC, de Oliveira EP (2012) Supracerebellar transtentorial approach-resection of the tentorium instead of an opening-to provide broad exposure of the mediobasal temporal lobe: anatomical aspects and surgical applications: clinical article. J Neurosurg 116:764–772CrossRefGoogle Scholar
  4. 4.
    Goel A, Muzumdar D (2004) Conventional posterior fossa approach for surgery on petroclival meningiomas: a report on an experience with 28 cases. Surg Neurol 62:332–338 discussion 338-340CrossRefGoogle Scholar
  5. 5.
    Guppy KH, Origitano TC, Reichman OH, Segal S (1997) Venous drainage of the inferolateral temporal lobe in relationship to transtemporal/transtentorial approaches to the cranial base. Neurosurgery 41:615–619; discussion 619-620Google Scholar
  6. 6.
    Lee EJ, Park ES, Cho YH, Hong SH, Kim JH, Kim CJ (2015) Transzygomatic approach with anteriorly limited inferior temporal gyrectomy for large medial tentorial meningiomas. Acta Neurochir 157:1747–1755 discussion 1756CrossRefGoogle Scholar
  7. 7.
    Matsushima T, Rhoton AL Jr, de Oliveira E, Peace D (1983) Microsurgical anatomy of the veins of the posterior fossa. J Neurosurg 59:63–105CrossRefGoogle Scholar
  8. 8.
    Spetzler RF, Martin NA (1986) A proposed grading system for arteriovenous malformations. J Neurosurg 65:476–483CrossRefGoogle Scholar
  9. 9.
    Türe U, Harput MV, Kaya AH, Baimedi P, Firat Z, Türe H, Bingöl CA (2012) The paramedian supracerebellar-transtentorial approach to the entire length of the mediobasal temporal region: an anatomical and clinical study. Laboratory investigation. J Neurosurg 116:773–791CrossRefGoogle Scholar
  10. 10.
    Voigt K, Yaşargil MG (1976) Cerebral cavernous haemangiomas or cavernomas. Incidence, pathology, localization, diagnosis, clinical features and treatment. Review of the literature and report of an unusual case. Neurochirurgia (Stuttg) 19:59–68Google Scholar
  11. 11.
    Yang J, Liu YH, Ma SC, Wei L, Lin RS, Qi JF, Hu YS, Yu CJ (2012) Subtemporal transtentorial petrosalapex approach for giant petroclival meningiomas: analyzation and evaluation of the clinical application. J Neurol Surg B Skull Base 73:54–63CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of NeurosurgeryHadassah-Hebrew University Medical CenterJerusalemIsrael

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