The definition of combined approaches is broad. This can include multiple portals to the same or different region in the skull base. The “pull-through technique is a versatile, dual-keyhole approach developed to attach tumors that extend between the temporal and occipital poles. This approach is complex, as it entails a knowledge of the intricate anatomy and eloquent cortical and subcortical structures in this region. This combined approach is tailed to minimize peripheral brain damage while providing a direct route to the pathology. This chapter discusses the indications, the anatomy, the patient selection, and the surgical nuances of this approach.

Lesions requiring resection in the posterior mediobasal temporal or adjacent occipital lobe can be difficult to access surgically. An extra-axial supracerebellar approach utilizing an opening in the tentorium can be accomplished through a keyhole suboccipital paramedian craniotomy to give the surgeon adequate exposure to address lesions in this location. Herein we describe the keyhole technique for a supracerebellar-transtentorial approach to posterior mediobasal temporal lesions and the associated benefits, challenges, and clinical pearls.