• Xuequan Feng, Michael T Lawton, Jordina Rincon-Torroella, Ivan H El-Sayed, Ali Tayebi Meybodi, and Arnau Benet.
• Departments of *Neurological Surgery, ‡Cerebrovascular and Skull Base Laboratory, and ¶Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California; §Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland.
• Neurosurgery. 2015 Nov 3.

BackgroundThe challenge of locating and isolating the internal maxillary artery (IMA) hinders its potential use as an arterial donor for extracranial-to-intracranial bypass surgery.ObjectiveTo introduce a new approach through the middle cranial fossa for easy access and safe exposure of the IMA.MethodsTen specimens were prepared for surgical simulation. After the pterional craniotomy, a 2-step drilling technique was performed (lateral triangle). First, a triangular craniectomy was completed anterolateral to the foramen spinosum. By following the middle meningeal artery and dividing the lateral pterygoid muscle, the proximal part of IMA was located. Second, a bone slot was drilled in a posterior-to-anterior direction from the anterior aspect of the first craniectomy. By tracing of the proximal part, the main trunk of the IMA was obtained. The size of the 2 craniectomies, the depth of IMA from the surface of the middle fossa, and the length of exposed IMA were measured.ResultsDrilling within the lateral triangle allowed safe exposure of both the trunk and the branches of the mandibular nerve of the IMA. The total craniectomy measured 27.8 ± 4.2 mm in the anterior-posterior direction, and the posterior portion measured 13.3 ± 1.5 mm in the lateral-medial direction. The depth from the middle fossa to the IMA (16.8 ± 3.2 mm, mean ± SD) was equal to the length of IMA exposed (17.6 ± 3.3 mm, mean ± SD; P > .05).ConclusionThis new approach provides an efficient and safe method to consistently find and isolate a segment of the IMA suitable for extracranial-to-intracranial bypass.AbbreviationsIMA, internal maxillary arteryLP, lateral pterygoidMMA, middle meningeal artery.

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