Mini-invasive Anterior Petrosal Intertentorial Approach for Trigeminal Neuralgia: Rationale and Limits of the Technique

Abstract

Background and Objectives

The retrosigmoid approach (RSA) is considered the standard surgical choice to address a neurovascular conflict involving the trigeminal nerve. The subtemporal transtentorial approach (STA) represents the main alternative. We describe here the mini-invasive anterior petrosal intertentorial approach with a view to reduce complications associated with the standard STA.

Methods

Mini-invasive anterior petrosal intertentorial approach (M-APIA) was described for a case of refractory trigeminal neuralgia. This approach includes a very limited amount of drilling of the petrous ridge to expose the posterior fossa dura and the superior petrosal sinus to facilitate the subsequent tentorial peeling. Tentorial peeling enables to develop an intertentorial plane between the temporal tentorial leaf (TTL) and the posterior fossa tentorial leaf (PFTL). A linear incision over the posterior fossa dura and the PFTL offers a wide exposure of the neurovascular conflict.

Results

M-APIA enables to expose the root entry zone (REZ) of the trigeminal nerve without exposing the temporal lobe or the cerebellum.

Conclusion

M-APIA can be considered as a safe alternative to the RSA or STA for trigeminal microvascular decompression (MVD), especially for select cases. Additional studies are needed for a better understanding of its advantages and disadvantages.

Keywords

anterior petrosal intertentorial approach - trigeminal neuralgia - microvascular decompression - tentorial peeling

Consent

Informed consent to participate and for publication was obtained from all individual participants included in the study.

Publication History

Received: 16 November 2024

Accepted: 11 April 2025

Accepted Manuscript online:
15 April 2025

Article published online:
02 May 2025

• References

• 1 Kundu B, Rolston JD. Nationwide shift from percutaneous rhizotomy to microvascular decompression for treatment of trigeminal and other cranial nerve neuralgias. Headache 2018; 58 (10) 1675-1679
• 2 Ogiwara T, Goto T, Kusano Y. et al. Subtemporal transtentorial approach for recurrent trigeminal neuralgia after microvascular decompression via the lateral suboccipital approach: case report. J Neurosurg 2015; 122 (06) 1429-1432
• 3 Starnoni D, Peters D, Giammattei L. et al. Anterior petrosectomy with intertentorial approach. Oper Neurosurg (Hagerstown) 2024; 26 (03) 301-308
• 4 Di Carlo DT, Benedetto N, Perrini P. Clinical outcome after microvascular decompression for trigeminal neuralgia: a systematic review and meta-analysis. Neurosurg Rev 2022; 46 (01) 8
• 5 Herta J, Schmied T, Loidl TB. et al. Microvascular decompression in trigeminal neuralgia: predictors of pain relief, complication avoidance, and lessons learned. Acta Neurochir (Wien) 2021; 163 (12) 3321-3336
• 6 Dziedzic TA, Abhinav K, Fernandez-Miranda JC. Subtemporal approach and its infratentorial extension: review and a comparative analysis of different techniques. J Neurol Surg B Skull Base 2022; 84 (01) 89-97
• 7 McLaughlin N, Ma Q, Emerson J, Malkasian DR, Martin NA. The extended subtemporal transtentorial approach: the impact of trochlear nerve dissection and tentorial incision. J Clin Neurosci 2013; 20 (08) 1139-1143
• 8 Jittapiromsak P, Wu A, Nakaji P, Spetzler RF, Preul MC. The challenge of access to the pontomesencephalic junction: an anatomical study of lateral approach and exposure. Skull Base 2010; 20 (05) 311-320
• 9 Goehre F, Lehecka M, Jahromi BR. et al. Subtemporal approach to posterior cerebral artery aneurysms. World Neurosurg 2015; 83 (05) 842-851
• 10 Li D, Zeng M, Yao Y, Zhang N, Yang T, Xia C. Retractorless surgery for petroclival meningiomas via the subtemporal approach: a try to reduce brain retraction injury. Comput Math Methods Med 2022; 2022: 6436542
• 11 Sabatino G, Rigante L, Marchese E. et al. Anterior subtemporal approach for posterolateral brainstem cavernomas: report of ten cases. Acta Neurochir (Wien) 2012; 154 (11) 2009-2016
• 12 Smith ER, Chapman PH, Ogilvy CS. Far posterior subtemporal approach to the dorsolateral brainstem and tentorial ring: technique and clinical experience. Neurosurgery 2003; 52 (02) 364-368 , discussion 368–369
• 13 Steňo J, Bízik I, Steňová J, Timárová G. Subtemporal transtentorial resection of cavernous malformations involving the pyramidal tract in the upper pons and mesencephalon. Acta Neurochir (Wien) 2011; 153 (10) 1955-1962 , discussion 1962
• 14 Zieliński G, Sajjad EA, Robak Ł, Koziarski A. Subtemporal approach for gross total resection of retrochiasmatic craniopharyngiomas: our experience on 30 cases. World Neurosurg 2018; 109: e265-e273
• 15 Kaufmann AM, Price AV. A history of the Jannetta procedure. J Neurosurg 2019; 132 (02) 639-646
• 16 Chen L, Shang Y, Zhang Y, Zhao Y. Endoscopic microvascular decompression versus microscopic microvascular decompression for trigeminal neuralgia: a systematic review and meta-analysis. J Clin Neurosci 2023; 117: 73-78
• 17 Teo C, Nakaji P, Mobbs RJ. Endoscope-assisted microvascular decompression for trigeminal neuralgia: technical case report. Neurosurgery 2006; 59 (4, Suppl 2): ONSE489-90 , discussion ONSE490
• 18 Giammattei L, Passeri T, Abbritti R. et al. Surgical morbidity of the extradural anterior petrosal approach: the Lariboisière experience. J Neurosurg 2022; 138 (01) 276-286
• 19 Chang SW, Wu A, Gore P. et al. Quantitative comparison of Kawase's approach versus the retrosigmoid approach: implications for tumors involving both middle and posterior fossae. Neurosurgery 2009; 64 (3, Suppl): ons44-ons51 , discussion ons51–ons52
• 20 Tomio R, Horiguchi T, Borghei-Razavi H, Tamura R, Yoshida K, Kawase T. Anterior transpetrosal approach: experiences in 274 cases over 33 years. Technical variations, operated patients, and approach-related complications. J Neurosurg 2021; 136 (02) 413-421
• 21 Shibao S, Toda M, Orii M, Fujiwara H, Yoshida K. Various patterns of the middle cerebral vein and preservation of venous drainage during the anterior transpetrosal approach. J Neurosurg 2016; 124 (02) 432-439
• 22 Shibao S, Yoshida K. Simplified anterior transpetrosal approach without superior petrosal sinus and tentorial incision for lesions centered in Meckel's cave. Acta Neurochir (Wien) 2023; 165 (07) 1833-1839
• 23 Gutierrez S, Iwanaga J, Dumont AS, Tubbs RS. Direct drainage of the basal vein of Rosenthal into the superior petrosal sinus: a literature review. Anat Cell Biol 2020; 53 (04) 379-384
• 24 Przepiorka L, Wójtowicz K, Camlet K. et al. Postoperative cerebral venous sinus thrombosis following a retrosigmoid craniotomy—a clinical and radiological analysis. Brain Sci 2023; 13 (07) 1039
• 25 Sattari SA, Shahbandi A, Xu R. et al. Sacrifice or preserve the superior petrosal vein in microvascular decompression surgery: a systematic review and meta-analysis. J Neurosurg 2022; 138 (02) 390-398
• 26 Cheng L. Complications after obliteration of the superior petrosal vein: are they rare or just underreported?. J Clin Neurosci 2016; 31: 1-3
• 27 Xia L, Liu M-X, Zhong J. et al. Fatal complications following microvascular decompression: could it be avoided and salvaged?. Neurosurg Rev 2017; 40 (03) 389-396
• 28 Bartindale M, Mohamed A, Bell J. et al. Neurotologic complications following microvascular decompression: a retrospective study. J Neurol Surg B Skull Base 2020; 81 (01) 37-42