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  • Elevated Intracranial Pressure (ICP) despite optimal medical management.


Body positioning

  • Supine position
  • Ipsilater shoulder elevated


Head positioning

  • Head turned to the controlateral side
  • Head rested on a foam headrest, in order

Internal Jugular Vein

Care should be taken to avoid compression of the Interal Jugular Vein, which can lead to reduction of ICP.


Anatomical landmark

  • Tragus
  • Midline
  • Zygomatic arch (by palpating)
  • Temporal muscle line (by palpating)


Skin incision

Reverse question mark incision. Starting at the zygomatic arch, approximately 5-10 mm in front of the tragus. Extend behind the ear. Gently curve upward and then anteriorly when few centimeters to midline.

Anterior temporal artery

The anterior temporal artery should be preserved to grant blood supply to the flap. The flap is then reflected anteriorly and fixed with scalp hooks.



3 burr holes are usually recommended and a temporal craniectomy is performed.

Bone flap should be at least 100 cm2 (usually 10x15 cm) in order to provide ad appropriate brain decompression. Bone flap is then removed. A cranioplasty should be considered 3 months after the approach.


Dura opening

Durotomy is usually performed in a cross or a stellate fashion to grant maximal cranial decompression. During the closure, a duroplasty is performed to enlarge the cranial space, granting both decompression and protection to the brain.




Greenberg M. Handbook of neurosurgery. 7th ed. New York: Thieme; 2010.

Jandial R, McCormick PC, Blak PM. Core Techniques in Operative Neurosurgery. Elsevier Saunders; 2011.



Antonio D'Ammando, MD

Neurosurgery Resident
University of Milan (Italy)
"Spedali Civili" Hospital Brescia (Italy)
Scientific Team UpSurgeOn