Retrosellar Surgical Access: A Quantitative Comparison of Subtemporal, Transpetrosal, and Anterolateral Approaches

Background: Surgical access to the retrosellar and retrochiasmatic retroclival spaces can be challenging when resecting lesions that extend into this narrow area encased by bone, dense neurovasculature, and the midbrain/pons. Surgical approach selection is dictated by the location of the bulk of the lesion, but the ability of the common approaches to reach lesional extensions into the upper retrosellar and retrochiasmatic areas has yet to be quantitatively compared. Objective: We quantitatively assess access to this region provided by the subtemporal, subtemporal transtentorial, anterior transpetrosal transtentorial, frontotemporal (pterional), and frontotemporal-orbital approaches, and compare the length of exposed neurovasculature and working area in order to assist in optimal surgical approach selection. Methods: Four cadaveric heads (8 sides) underwent subtemporal, subtemporal transtentorial, anterior transpetrosal transtentorial, and frontotemporal (pterional) and frontotemporal-orbital approaches. The anterolateral approaches were completed with posterior clinoidectomies. The area of exposure of and the working angle within the retrosellar area were evaluated in each, as well as the length of all exposed neurovascular structures. Results: The subtemporal transtentorial and frontotemporal-orbital approaches provided the widest overall exposure. The working angle in the subtemporal approach was limited by the need for temporal lobe retraction. The anterior transpetrosal transtentorial approach provided wide access of the upper petroclival and retrosellar regions, and clival drilling allowed for increased medial exposure. The anterolateral approaches with posterior clinoidectomy provided wide exposure and access to the upper retrosellar and retrochiasmatic spaces. Conclusion: Petroclival lesions medial to the CN VII-VIII complex that extend superiorly into the retrosellar region can be accessed via the anterior transpetrosal transtentorial approach. Lesions limited to the upper clivus, with or without lateral extension, can be accessed by the subtemporal approach; cutting the tentorium provides infratentorial access inferiorly to the petrous apex. Sellar or upper clival lesions that extend superiorly can be accessed via the frontotemporal approaches with posterior clinoidectomy. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany