The supraorbital endoscopic approach for aneurysms

Standard Orbitozygomatic Craniotomy versus Mini Orbitozygomatic Craniotomy via an Eyebrow Incision for Microsurgical Treatment of Anterior Communicating Artery Aneurysms

Background  Skull base approaches are utilized to improve microsurgical treatment of cerebral aneurysms. Advantages include early proximal and distal control, increased visualization, and minimal brain retraction. Orbitozygomatic (OZ) craniotomies via pterional incision are commonly used for the treatment of anterior communicating artery (ACoA) aneurysms. A smaller, less invasive OZ craniotomy performed through an eyebrow incision may provide several advantages over a standard OZ approach. Objective  We compare surgical outcomes of the standard and eyebrow OZ for the treatment of ACoA aneurysms. Design  All patients who underwent microsurgical treatment for ACoA aneurysms by a single surgeon over an 8-year period were included in this retrospective analysis. Patient demographics and clinical data were collected. Participants  Thirty-seven consecutive patients were identified, with 15 receiving eyebrow OZ and 22 receiving standard OZ. Main Outcome Measures Data were collected on patient demographics, pathology, intraoperative and perioperative data, and 30-day morbidity. Results  A total of 100% of the eyebrow OZ group and 95.5% of the standard OZ group had complete aneurysmal occlusion. Four eyebrow OZ and six standard OZ patients had an intraoperative rupture. All were managed without complication. Two eyebrow OZ and one standard OZ patient died within 30 days of surgery. No patients in either group had aneurysm recurrence, required retreatment, or were limited intraoperatively by exposure. Conclusions  The OZ approach via an eyebrow incision has similar outcomes to a standard OZ approach and is a safe option for the treatment of ACoA aneurysms.

Endoscopic Eyebrow Approach for Aneurysms

INTRODUCTION

Considerable effort has been made to reduce surgical invasiveness, since Axel Perneczky introduced the supraorbital eyebrow approach as a core part of his keyhole concept in neurosurgery. But a limited approach does not facilitate an already serious and demanding task as aneurysm surgery. In this regard, the enhancement of the visual field before, during, and after microsurgical aneurysm occlusion is a safe and effective method to increase the quality of treatment. Indications/Contraindications: Based on the individual anatomical findings, the supraorbital keyhole approach provides access to most aneurysms of the anterior circulation. The approach is not recommended in large complex aneurysms, giant aneurysms, BA aneurysms located beneath the dorsum sellae, as well as cases of severe subarachnoid hemorrhage (SAH) and expected brain edema.

COMPLICATIONS

Experience with endoscopic procedures in aneurysm surgery is limited to several clinical retrospective articles, and no major complications in conjunction with the endoscope were observed. Outcome and Prognosis: The supraorbital eyebrow approach has a low rate of complications and provides highly favorable cosmetic results. Endoscopic inspection prior to clipping might reduce overexposure and mobilization of the aneurysm. It was found that the rate of intraoperative rupture was decreased. The endoscopic post-clipping control helped significantly to reduce aneurysm remnants and unattended parent, branch, or perforator occlusion.

CONCLUSION

The supraorbital eyebrow approach is a safe, effective and elegant approach in the treatment of most aneurysms of the anterior circulation. The additional enhancement of the visual field provided by the endoscope before, during, and after microsurgical aneurysm clipping might decrease the rate of intraoperative aneurysm ruptures and unexpected findings concerning aneurysm remnant occlusion and compromise of involved parent, branching, and perforating vessels.

Surgical Clipping of Intracranial Aneurysms Using a Transcranial Neuroendoscopic Approach

OBJECTIVE

This retrospective study was performed to evaluate the feasibility and safety of surgically clipping intracranial aneurysms using a transcranial neuroendoscopic approach.

METHODS

A total of 229 patients with cerebral aneurysms were included in our study, all of whom were treated with clamping surgery at Wuhan University People's Hospital. They were divided into neuroendoscopic and microscopic groups, according to whether or not neuroendoscopy was used for the clamping surgery. We statistically analyzed the patients' baseline data, surgical outcomes, and complications, which were then evaluated to assess the treatment effect.

RESULTS

The baseline characteristics were not statistically significant, except for gender, for which the proportions of female patients in the two groups were 69 (56.1%) and 46 (43.4%). There were no patients with incomplete aneurysm clamping or parent vessel occlusion in the neuroendoscopic group, and there were 4 (3.8%) and 2 (1.9%) in the microscopic group, respectively; however, there was no statistically significant difference in the comparison of the two groups. The mean operative times of the two groups were 181 min and 154 min, respectively, and were statistically different. However, the mRS scores of the two groups showed no significant difference in patient prognosis. The differences in complications (including limb hemiplegia, hydrocephalus, vision loss, and intracranial infection) were not statistically significant, except for cerebral ischemia, for which the proportions of patients in the two groups were 8 (6.5%) and 16 (15.1%).

CONCLUSIONS

Neuroendoscopy can provide clear visualization and multi-angle views during aneurysm clipping, which is helpful for ensuring adequate clipping and preventing complications.

Cosmetic Outcomes of Supraorbital Keyhole Craniotomy Via Eyebrow Incision: A Systematic Review and Meta-Analysis

Background  Supraorbital eyebrow craniotomy is a minimally invasive alternative to a frontotemporal craniotomy and is often used for tumor and vascular pathologies. The purpose of this study was to investigate how patient cosmetic outcomes are affected by technique variations of this approach. Methods  PubMed, Embase, and Scopus databases were systematically searched, and results were reported according to PRISMA guidelines. For the meta-analysis portion, the DerSimonian-Laird random effects model was used, and the primary end points were patient satisfaction and percentage of permanent cosmetic complications. Results  A total of 2,629 manuscripts were identified. Of those, 124 studies (8,241 surgical cases) met the inclusion criteria. Overall, 93.04 ± 11.93% of patients reported favorable cosmetic outcome following supraorbital craniotomy, and mean number of cases with permanent cosmetic complications was 6.62 ± 12.53%. We found that vascular cases are associated with more favorable cosmetic outcomes than tumor cases ( p  = 0.0001). Addition of orbital osteotomy or use of a drain is associated with adverse cosmetic outcomes ( p  = 0.001 and p  = 0.0001, respectively). The location of incision, size of craniotomy, utilization of an endoscope, method of cranial reconstruction, skin closure, use of antibiotics, and addition of pressure dressing did not significantly impact cosmetic outcomes ( p  > 0.05 for all). Conclusions  Supraorbital craniotomy is a minimally invasive technique associated with generally high favorable cosmetic outcomes. While certain techniques used in supraorbital keyhole approach do not pose significant cosmetic risks, utilization of an orbital osteotomy and the addition of a drain correlate with unfavorable cosmetic outcomes.

Surgical Limitations of the Microscopic Transciliary Supraorbital Keyhole Approach to the Anterior and Middle Skull Base

BACKGROUND

The microscopic transciliary SupraOrbital keyhole (mtSO) approach has been used for a wide variety of anterior and middle fossa pathologies, including aneurysms, meningiomas, craniopharyngiomas, and other skull-base tumors. Several clinical series have proven its efficacy and safety, but detailed anatomical demarcations of the anterior and middle cranial base exposure are lacking. Our aim was to define the surgical limitations of the mtSO approach to the ipsilateral and contralateral anterior and middle skull base.

METHODS

Five cadaveric specimens (10 sides) were studied with image guidance to illustrate the limits of the surgical exposure. In addition, 30 dry skulls were used to measure the working distances between the craniotomy and key bony landmarks of the mtSO approach.

RESULTS

Surgical exposure at the anterior skull base covered the area between the medial half of the contra- and the medial two-thirds of the ipsilateral sphenoid wing including both optic nerves and interoptic space. The anterior limit at the midline was the sphenoethmoidal suture. Ipsilateral anterior clinoidectomy permitted exposure of the superior orbital fissure, which defined the anteromedial limit at the middle fossa, whereas the anterolateral limit was defined by the ophthalmic branch of the trigeminal nerve. Moreover, the posteromedial and posterolateral limits were the posterior clinoid process and the petrous ridge, respectively.

CONCLUSIONS

Our findings define the surgical limitations of the mtSO approach for the treatment of anterior and middle cranial base pathologies. These limits can be reliably identified on imaging studies allowing assessment of exposure to guide preoperative case selection.

Endoscope-assisted microneurosurgery for intracranial aneurysms: A systematic review and meta-analysis

BACKGROUND

In the surgical approach to treat deep-seated intracranial lesions, endoscopes can be used to assist microsurgical operations and improve outcomes. This technique is often called endoscope-assisted microneurosurgery (EAM). This systematic review and meta-analysis aimed to evaluate the feasibility, safety, and effectiveness of EAM.

METHODS

We performed a meta-analysis of relevant articles identified using PubMed, Embase, and the Cochrane Central Register to assess the efficacy of EAM according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Primary outcomes were repositioning of the definitive clip, better surgical field, the overall and endoscope-related complication rates, mortality, and the rate of follow up.

RESULTS

A total of 10 studies of 1,432 patients with 1,717 aneurysms treated with EAM were included. EAM led to repositioning of the definitive clip in 13% (95% CI, 9%-17%; I₂ = 72.61%; p < 0.001); 77% of aneurysms treated with endoscopically assisted vision and information had a better outcome than that with standard surgery (95% CI, 52%-95%; I₂ = 97.63%; p < 0.001). There was an overall complication rate of 6% (95% CI, 1%-13%; I₂ = 91.39%; p < 0.001). The incidence of endoscope-related complications was 0% (95% CI, 0%-1%; I₂ = 64%; p < 0.001). The mortality was 0% (95% CI, 0-1%; I₂ = 0.0%); and 94% of patients had an excellent to good recovery and good outcome (95% CI, 88%-98%; I₂ = 88.42%; p < 0.001).

CONCLUSIONS

Our comprehensive study showed that EAM for intracranial aneurysms is feasible, the safety of the surgery is good, and the patients have a good prognosis, Therefore, we think EAM can be more widely adopted in the future.

Supraorbital Keyhole Craniotomy via Eyebrow Incision: A Systematic Review and Meta-Analysis

BACKGROUND

Supraorbital eyebrow keyhole craniotomy is a minimally invasive alternative to a frontotemporal craniotomy and is often used for tumor resection and aneurysm clipping. The purpose of this study is to provide a contemporary review on the outcomes related to this approach and to determine whether they vary with the type of pathology and the addition of an endoscope.

METHODS

PubMed, Embase, and Scopus databases were systematically searched, and results were reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. For the meta-analysis portion, the DerSimonian-Laird random effects model was used.

RESULTS

A total of 2629 manuscripts were identified. of those, 124 studies (8241 surgical cases) met the inclusion criteria. Mean total complication rate was 26.7 ± 25.7% and the mean approach-related mortality rate was 1.3 ± 2.8%. Technical success, defined as gross total tumor resection or complete aneurysm clipping, was achieved in 83.6 ± 21.5% of the cases. Vascular pathologies were associated with greater technical success, lower total complications, and longer length of hospital stay compared with tumor cases (P < 0.05 for all). For vascular cases, addition of the endoscope yielded lower technical success (P = 0.001) and lower complication rate (P = 0.041). The use of the endoscope for tumor pathologies did not affect technical success, complications, mortality, length of hospital stay, operative time, or reoperation rate (P > 0.05).

CONCLUSIONS

The supraorbital craniotomy via an eyebrow incision is a feasible minimally invasive approach with an overall high technical success rate for both vascular and tumor pathologies.

Case series of 100 supraorbital mini-craniotomies in patients with good grade aneurysmal subarachnoid haemorrhage at a single neurosurgical Centre

BACKGROUND

Endovascular techniques are becoming more common for cerebral aneurysms, but not all patients are suitable and open surgery is necessary for some. The traditional pterional approach requires a large craniotomy and this carries some morbidity in itself. With the growing expectation for minimally invasive surgery, we present our experience in supraorbital mini-craniotomy for good grade aneurysmal subarachnoid haemorrhage.

METHODS

Data on good-grade subarachnoid haemorrhage patients having aneurysms clipped via this approach were collected prospectively. Aneurysms at all anterior circulation sites were included, with the exception of the pericallosal artery, which was not within reach. A long-term follow-up questionnaire was sent to patients who had a supraorbital approach to clip the aneurysm at more than 1 year from hospital discharge.

RESULTS

Our results demonstrate mortality of 1% and severe residual disability in 10% of patients. Approach-related complications were low and it was considered that the operating space was not restricted in any of our cases. Return to work was achieved in 70% of patients who were working at the time of their haemorrhage.

CONCLUSIONS

Supraorbital micro-craniotomy is a safe approach for patients with proximal anterior circulation aneurysms, with low mortality and morbidity.

Application of the Endoscopic Micro-Inspection Tool QEVO® in the Surgical Treatment of Anterior Circulation Aneurysms-A Technical Note and Case Series

Introduction: The application of neuro-endoscopes in cerebral aneurysm surgery may help to avoid unintended aneurysm remnants and the accidental clipping of perforating arteries and aid the detection of blood collecting in the subdural spaces. Here, we present our experience with the novel endoscopic micro-inspection tool QEVO® (Carl Zeiss Meditec, Germany) in aneurysm surgery.

Materials and Equipment: In all patients the surgical microscope KINEVO® (Carl Zeiss Meditec, Germany) and the Microinspection tool QEVO® were applied.

Methods: The case series comprises 22 unruptured cerebral aneurysms of the anterior circulation. All aneurysms were treated surgically. All patients routinely underwent computed tomography and digital subtraction angiography within 10 days after surgery.

Results: No aneurysm remnants, cerebral ischemic deficits, or subdural hematomas were detected.

Discussion: In this technical note, we discuss the benefits and limitations of the QEVO® tool and illustrate the major paradigms by means of intraoperative photographs.

Adverse intraoperative events during surgical repair of ruptured cerebral aneurysms: a systematic review

Compared with endovascular techniques, clipping of ruptured cerebral aneurysms has been shown to associate with increased morbidity in several studies. Despite this, clipping remains the preferred option for many aneurysms. The objective of this study is to describe the reported adverse events of open repair of ruptured cerebral aneurysms and their impact on patient outcome. The PubMed, Embase and Cochrane databases were searched between June 1999 and June 2019 to identify original studies of at least 100 patients undergoing surgical repair of ruptured cerebral aneurysms and in which adverse event rates were reported. Thirty-six studies reporting adverse events in a total of 12,410 operations for repair of ruptured cerebral aneurysms were included. Surgical adverse events were common with 36 event types reported including intraoperative rupture (median rate of 16.6%), arterial injury (median rate of 3.8%) and brain swelling (median rate 5.6%). Only 6 surgical events were statistically shown to associate with poor outcomes by any author and for intraoperative rupture (the most frequently analysed), there was an even split between authors finding a statistical association with poor outcome and those finding no association. Even with modern surgical techniques, the technical demands of surgical aneurysm repair continue to lead to a high rate of intraoperative adverse events. Despite this, it is not known which of these intraoperative events are the most important contributors to the poor outcomes often seen in these patients. More research directed towards identifying the events that most drive operative morbidity has the potential to improve outcomes for these patients.

Keyhole clipping of a low-lying basilar apex aneurysm without posterior clinoidectomy utilizing endoscopic indocyanine green video angiography

Background:

Basilar apex (BX) aneurysms are surgically challenging due to their anatomic location, need to traverse neurovascular structures, and proximity to multiple perforator arteries. Surgical approaches often require extensive bone resection and neurovascular manipulation. Visualization of low-lying BX aneurysms is typically obscured by the posterior clinoid and upper clivus and poses a unique challenge. Subtemporal or anterolateral approaches with a posterior clinoidectomy are often required to achieve adequate exposure, though these maneuvers can add invasiveness, risk, and morbidity to the procedure. Endoscopes and, more recently, fluoroscopic angiography capable endoscopes offer the possibility of providing improved visualization with less exposure allowing for minimally invasive clipping.

Case Description:

We present the case of a 42-year-old female with incidentally found 5 mm middle cerebral artery and 5 mm BX aneurysms. She underwent a minimally invasive supraorbital keyhole craniotomy for the clipping of both aneurysms. While the posterior clinoid obstructed the necessary visualization for the BX aneurysm, use of endoscopy and endoscopic fluoroscopic angiography allowed for safe and successful clipping without the need for a posterior clinoidectomy.

Conclusion:

This represents the first reported case of a BX aneurysm clipping through a minimally invasive keyhole craniotomy using endoscopic indocyanine green video angiography. Use of endoscopic indocyanine green angiography, combined with keyhole endoscopic approaches, allows for safe minimally invasive clipping of challenging posterior circulation aneurysms.

Facial Nerve Preservation for Supraorbital Approaches: Anatomical Mapping Based on Consistent Landmarks

BACKGROUND

The supraorbital keyhole approach (SOKA) provides a safe and advantageous access to the anterior cranial fossa. The implemented skin incision varies depending on surgeon's preferences and requirements. Facial nerve (FN) injury might appear in up to 5.6% of patients. There is a lack of validated tenets for avoiding FN injury.

OBJECTIVE

To define a safety area for FN preservation during a SOKA.

METHODS

Ten dried skulls and 5 injected cadaveric heads (10 sides) were used. A Cartesian frame was created with its horizontal axis at the level of the supraorbital notch and the vertical axis just lateral to the frontozygomatic junction (FZj). FNs were dissected and points along their course were registered and transferred to the Cartesian frame.

RESULTS

Ten microscopic dissections of the FN were performed preserving all branches. A safety area could be defined 8 mm superior and 10 mm inferior to the FZj extending medially to the supraorbital notch and beyond. A 20 mm2 area superior and lateral to the FZj provided low probability (≤10%) of injuring the FN. Similarly, starting 4 mm inferior to the FZj, a lateral safety area was also found. A probabilistic colored heat map was built to represent the results.

CONCLUSION

We provide a "safety zone" for a SOKA incision in which the probability to encounter the FN is low. Clinical studies following our method may validate our findings and add evidence to the tenets for minimizing morbidity related to the SOKA incision.

Potential Risks and Limited Indications of the Supraorbital Keyhole Approach for Clipping Internal Carotid Artery Aneurysms

Background

Internal carotid artery (ICA) aneurysm may be a good target for supraorbital keyhole clipping. We discuss the surgical indications and risks of keyhole clipping for ICA aneurysms based on long-term clinical and radiologic results.

Methods

This was a retrospective analysis of 51 patients (aged 35–75 years, mean 62 years) with ICA aneurysms (mean 5.8 ± 1.8 mm) who underwent clipping via the supraorbital keyhole approach between 2005 and 2017. Neurologic and cognitive functions were examined by several methods, including the modified Rankin Scale and Mini-Mental Status Examination. The state of clipping was assessed 1 year and then every few years after the operation.

Results

Complete clipping was confirmed in 45 patients (88.2%), dog-ear remnants behind the clip persisted in 4 patients, and wrapping was performed in 2 patients. Mean duration of postoperative hospitalization was 3.4 ± 6.9 days. The mean clinical follow-up period was 6.6 ± 3.2 years. The overall mortality was 0, and overall morbidity (modified Rankin Scale score ≥2 or Mini-Mental Status Examination <24) was 3.9%. Completely clipped aneurysms did not show any recurrence during the mean follow-up period of 6.3 ± 3.1 years, but the 2 (3.9%) aneurysms with neck remnants showed regrowth.

Conclusions

The risk of neck remnant behind the clip blade is a drawback of supraorbital keyhole clipping. The surgical indication requires preoperative simulation and careful checking of the clip blade state is essential.

A New Clip Generation for Microsurgical Treatment of Intracranial Aneurysms-The First Case Series

OBJECTIVE

Considerable effort has been made in order to reduce surgical invasiveness while maintaining optimal exploiting of the operative space in aneurysm surgery. One aspect of this evolution is represented by the Lazic (Peter Lazic GmbH, Tuttlingen, Germany) aneurysm clip system. The purpose of this study was to illustrate the new generation clip system in practiced aneurysm surgery.

METHODS

A retrospective analysis of all aneurysm surgeries in our departments between December 2015 and January 2018 using the new D-Clip system was performed. Evaluation included standardized retrospective review of the main surgeon, the nursing staff, as well as an analysis of surgical video documentation by objective reviewers.

RESULTS

Forty-five patients with 50 intracranial aneurysms underwent surgical clipping using the D-Clip system. A total of 64 permanent and 19 temporary D-Clips were applied. Nine clips needed to be replaced. All aneurysms could be occluded totally. Surgeons considered handling and manoeuvrability of clip application as feasible and good in all cases (100%), even under impaired visibility circumstances (14%). Objective video analysis revealed comparable results. Nursing staff scored handling and practicability of D-Clips equivalent to the preceding L-Clip generation. There were no intraoperative complications. Surgery-related postoperative morbidity was 6.7%.

CONCLUSIONS

The new D-Clip system combines an attenuated design for minimally invasive clipping procedures with traditional mechanisms of common clip systems. It therefore appears to be highly versatile in the context of variable different aneurysm morphologies and locations while maintaining high standard surgical safety and efficacy.

[A comparative study of the efficacy and safety of the eyebrow supraorbital approach in cerebral aneurysm surgery]

OBJECTIVE

The study objective was to compare the efficacy and safety of supraorbital eyebrow (SEA) and pterional (PA) approaches in surgery of anterior circle of Willis (ACW) aneurysms and to determine the advantages and disadvantages of SEA in aneurysm clipping.

MATERIAL AND METHODS

The analysis included 166 patients with ACW aneurysms aged 18 to 70 years who were treated in the Neurosurgery Department of the Interregional Clinical Diagnostic Center (Kazan) in the period from 2013 to 2016. At the first stage of the study, factors affecting surgical outcomes were compared (by using the Glasgow outcome scale (GOS)) in subpopulations of patients operated on using SEA (n=49) and PA (n=117). At the second stage, we compared the efficacy and safety of approaches using a case-control subanalysis in appropriate subgroups of the SEA (n=37) and PA (n=37) groups. The subgroups were comparable in the following factors: gender, age, severity of subarachnoid hemorrhage (SAH) on (Fisher scale), severity of the patient's condition (Hunt-Hess scale), size and location of the aneurysm, surgery duration, intraoperative aneurysm rupture (IOAR), amount of blood loss, rate of frontal sinus surgery, rate of nasal CSF leak, rate of intraoperative and postoperative complications, hemorrhagic and ischemic complications according to postoperative CT, patient's satisfaction with the cosmetic result of surgery (visual analogue scale - VAS), and treatment outcomes (GOS). Treatment outcomes (GOS) and patient's satisfaction with the cosmetic result of surgery (VAS) were considered as the efficacy parameters. The safety parameters included the amount of blood loss, rate of frontal sinus surgery, rate of nasal CSF leak, and rate of intraoperative and postoperative (hemorrhagic and ischemic) complications.

RESULTS

At the first stage of the study, we found that the amount of intraoperative blood loss in the subpopulation of patients with ACW aneurysms who were operated on using SEA was statistically significantly less than that in the PA group (p=0.0000002). In the postoperative period, patients who underwent surgery using SEA less frequently experienced neurological deficit (p=0.003), less frequently developed first epileptic seizures (p=0.035), and had a lower rate of hemorrhagic complications (p=0.003) and better treatment outcomes (GOS) (p=0.01). Comparison of appropriate subgroups in the SEA and PA groups, which were selected according to the case-control methodology and were comparable in the main factors affecting treatment outcomes, confirmed statistically significantly lower blood loss for SEA (p=0.0000002) than for PA. Compared to the SEA group, the PA group was characterized by more frequent, but not statistically significantly different, IOAR (p=1), postoperative worsening of neurological deficit (p=0.115), newly developed epileptic seizures (p=0.493), and hemorrhagic complications (p=0.0557). There were no deaths in both groups. In the SEA group, the treatment outcome was scored 4 and 5 (GOS, favorable outcome); in the PA group, the treatment outcome was scored 3 (GOS) in 2 (5.4%) patients and 4 or 5 in 35 (94.6%) patients (p=0.063). The mean subjective score of satisfaction with the treatment result (VAS) in the SEA group was significantly higher (9.4±1) than in the PA group (8.8±1; p=0.01).

CONCLUSION

SEA is an adequate approach for clipping ACW aneurysms, in particular ACA-AComA and MCA aneurysms, which is as effective and safe as the pterional approach.

Keyhole approaches for surgical treatment of intracranial aneurysms: a short review

Objective: To clarify the reported experience with keyhole approaches for the treatment of intracranial aneurysms. Methods: The PubMed and Embase databases were searched up to December 2017 for full-text publications that report the treatment of aneurysms with the eyebrow variant of the supraorbital craniotomy (SOC), the minipterional craniotomy, or the eyelid variant of the SOC. The anatomical distribution of aneurysms, the postoperative aneurysm occlusion rate, and the type and rate of complications were examined using univariate analysis. Results: Sixty-seven publications covering treatment of 5770 aneurysms met the eligibility criteria. The reported experience was the largest for the eyebrow variant of the SOC (69.4% of aneurysms), followed by the minipterional approach (28.2%), and the eyelid variant of the SOC (2.4%). The anterior communicating artery (ACoA) was the most frequent aneurysm location for the SOC (eyebrow variant: 33.2%; eyelid variant: 31.2%). The middle cerebral artery (MCA) was the most frequent aneurysm location in the minipterional cohort (55.2%). In the eyelid variant of the SOC cohort, the rate of complete aneurysm occlusion was the lowest (eyelid variant: 90.8%; eyebrow variant: 97.8%, p < 0.001; minipterional approach: 97.9%, p < 0.001), and the postoperative infarction rate was the highest (eyelid variant: 7.2%; eyebrow variant: 3.5%, p = 0.025; minipterional approach: 2.6%, p = 0.003). Conclusion: Each approach has a specific safety and efficacy profile. Surgeons selected the eyebrow variant of the SOC for many aneurysm locations including in particular the ACoA. There is a recent tendency however to opt for the minipterional approach above all for MCA aneurysms. Abbreviations: SOC: Supraorbital Craniotomy; MPT: Minipterional; MCA: Middle Cerebral Artery; ACoA: Anterior Communicating Artery; PCoA: Posterior Communicating Artery; aSAH: Aneurysmal Subarachnoid Hemorrhage; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; MINORS: Methodological Index For Non-Randomized Studies.

Method for temporal keyhole lobectomies in resection of low- and high-grade gliomas

OBJECTIVE

The purpose of this study was to describe a method of resecting temporal gliomas through a keyhole lobectomy and to share the results of using this technique.

METHODS

The authors performed a retrospective review of data obtained in all patients in whom the senior author performed resection of temporal gliomas between 2012 and 2015. The authors describe their technique for resecting dominant and nondominant gliomas, using both awake and asleep keyhole craniotomy techniques.

RESULTS

Fifty-two patients were included in the study. Twenty-six patients (50%) had not received prior surgery. Seventeen patients (33%) were diagnosed with WHO Grade II/III tumors, and 35 patients (67%) were diagnosed with a glioblastoma. Thirty tumors were left sided (58%). Thirty procedures (58%) were performed while the patient was awake. The median extent of resection was 95%, and at least 90% of the tumor was resected in 35 cases (67%). Five of 49 patients (10%) with clinical follow-up experienced permanent deficits, including 3 patients (6%) with hydrocephalus requiring placement of a ventriculoperitoneal shunt and 2 patients (4%) with weakness. Three patients experienced early postoperative anomia, but no patients had a new speech deficit at clinical follow-up.

CONCLUSIONS

The authors provide their experience using a keyhole lobectomy for resecting temporal gliomas. Their data demonstrate the feasibility of using less invasive techniques to safely and aggressively treat these tumors.

[The trans-eyebrow supraorbital approach for removal of anterior cranial fossa and suprasellar meningiomas]

Over the past two decades, improvements in surgical tools, navigation systems, and endoscopic techniques have resulted in the widespread use of keyhole surgery for a wide range of skull base tumors. Currently, the trans-eyebrow supraorbital approach is being increasingly used in surgery for anterior cranial fossa and parasellar tumors.

MATERIAL AND METHODS

The study included 7 patients who underwent surgery for meningioma using the trans-eyebrow supraorbital approach at the Burdenko Neurosurgical Institute in the period between 2013 and 2017. The age of patients ranged from 51 to 75 years (median, 60 years); there were 5 females and 2 males. The maximum diameter of resected tumors ranged from 20 to 60 mm (median 40 mm).

RESULTS

Total resection of the tumor was achieved in all 7 cases, which was confirmed by postoperative MRI control. All 7 patients had a good cosmetic result. In 1 case, there was postoperative cerebrospinal fluid rhinorrhea due to incomplete closure of the frontal sinus, which required the patient to be re-operated. None of 7 cases was associated with injury to the main vessels or cavernous sinus.

CONCLUSION

Supraorbital trans-eyebrow craniotomy provides a minimally invasive approach for removing most anterior cranial fossa base and suprasellar tumors. The advantages of keyhole surgery, in comparison with traditional craniotomies, are minimal complications associated with the approach.

Validation of effectiveness of keyhole clipping in nonfrail elderly patients with unruptured intracranial aneurysms

OBJECTIVE

Advanced age is known to be associated with a poor prognosis after surgical clipping of unruptured intracranial aneurysms (UIAs). Keyhole clipping techniques have been introduced for less invasive treatment of UIAs. In this study, the authors compared the complications and clinical and radiological outcomes after keyhole clipping between nonfrail elderly patients (≥ 70 years) and nonelderly patients.

METHODS

Keyhole clipping (either supraorbital or pterional) was performed to treat 260 cases of relatively small (≤ 10 mm) anterior circulation UIAs. There were 62 cases in the nonfrail elderly group (mean age 72.9 ± 2.6 years [± SD]) and 198 cases in the nonelderly group (mean age 59.5 ± 7.6 years). The authors evaluated mortality and morbidity (modified Rankin Scale score > 2 or Mini–Mental State Examination [MMSE] score < 24) at 3 months and 1 year after the operation, the general cognitive function by MMSE at 3 months and 1 year, anxiety and depression by the Beck Depression Inventory (BDI) and Hamilton Rating Scale for Depression (HAM-D) at 3 months, and radiological abnormalities and recurrence at 1 year.

RESULTS

Basic characteristics including comorbidities, frailty, and BDI and HAM-D scores were not significantly different between the 2 groups, whereas the MMSE score was slightly but significantly lower in the elderly group. Aneurysm location, largest diameter, type of keyhole surgery, neck clipping rate, and hospitalization period were not significantly different between the 2 groups. The incidence of chronic subdural hematoma was not significantly higher in the elderly group than in the nonelderly group (8.1% vs 4.5%, p = 0.332); rates of other complications including stroke and epilepsy were not significantly different. Lacunar infarction occurred in 3.2% of the elderly group and 3.0% of the nonelderly group. No patient in the elderly group required re-treatment or demonstrated recurrence of clipped aneurysms. The MMSE score at 3 months significantly improved in the nonelderly group but did not change in the elderly group. The BDI and HAM-D scores at 3 months were significantly improved in both groups. No patient died in either group. The morbidity at 3 months and 1 year in the elderly group (1.6% and 4.8%, respectively) was not significantly different from that in the nonelderly group (2.0% and 1.5%, respectively).

CONCLUSIONS

Keyhole clipping for nonfrail elderly patients with relatively small anterior circulation UIAs did not significantly increase the complication, mortality, or morbidity rate; hospitalization period; or aneurysm recurrence compared with nonelderly patients, and it was associated with improvement in anxiety and depression. Keyhole clipping to treat UIAs in the nonfrail elderly is an effective and long-lasting treatment.

Supraorbital Keyhole Approach to the Sella and Anterior Skull Base via a Forehead Wrinkle Incision

OBJECTIVE

To evaluate safety and effectiveness of supraorbital keyhole approach to the sella and anterior skull base via a forehead wrinkle incision.

METHODS

We analyzed and reclassified forehead wrinkle types in 100 recruited healthy individuals. Twenty patients with different intracranial lesions in the sella and anterior skull base areas were selected for surgery using the supraorbital keyhole approach via a forehead wrinkle incision by forehead wrinkle type. All clinical patient records were retrospectively reviewed.

RESULTS

Based on the feasibility of the surgical approach, the forehead wrinkles in Chinese individuals were categorized into 2 types: horizontal linear and nonlinear. Gross total removal of the lesions was achieved in 90% of the cases using this approach. All patients had excellent cosmetic results. Except for 2 patients with poor prognoses, a high level of comfort and satisfaction with the forehead wrinkle incisions was obtained based on the scale scores of pain from scars and headaches and satisfaction with the cosmetic results. No permanent approach-related complications occurred.

CONCLUSIONS

The supraorbital keyhole approach via a forehead wrinkle incision was safe and effective. This approach provided a sufficient visual field for lesion resection and satisfactory cosmetic results for patients.

Transorbital endoscopic approach for exposure of the sylvian fissure, middle cerebral artery and crural cistern: an anatomical study

BACKGROUND

The availability of minimal access instrumentation and endoscopic visualization has revolutionized the field of minimally invasive skull base surgery. The transorbital endoscopic approach using an eyelid incision has been proposed as a new minimally invasive technique for the treatment of skull base pathology, mostly extradural tumors. Our study aims to evaluate the anatomical aspects and potential role of the transorbital endoscopic approach for exposure of the sylvian fissure, middle cerebral artery and crural cistern.

METHODS

An anatomical dissection was performed in four freshly injected cadaver heads (8 orbits) using 0- and 30-degree endoscopes. First, an endoscopic endonasal medial orbital decompression was done to facilitate medial retraction of the orbit. An endoscopic transorbital approach through an eyelid incision, with drilling of the posterior wall of the orbit and lesser sphenoidal wing, was then performed to expose the sylvian fissure and crural cisterns. A stepwise anatomical description of the approach and visualized anatomy is detailed.

RESULTS

A superior eyelid incision followed by orbital retraction provided a surgical window of approximately 1.2 cm (range 1.0-1.5 cm) for endoscopic transorbital dissection. The superior (SOF) and inferior (IOF) orbital fissures represent the medial limits of the approach and are identified in the initial part of the procedure. Drilling of the orbital roof (lateral and superior to the SOF), greater sphenoidal wing (lateral to the SOF and IOF) and lesser sphenoidal wing exposed the anterior and middle fossa dura. A square-shaped dural opening provided visualization of the posterior orbital gyri, sylvian fissure and temporal pole. Intradural dissection allowed exposure of the sphenoidal portion of the sylvian fissure, M1, MCA bifurcation and M2 branches and lenticulostriate perforators. Dissection of the medial aspect of the sylvian and carotid cisterns with a 30-degree endoscope allowed exposure of the mesial temporal lobe and crural cistern.

CONCLUSIONS

The transorbital endoscopic approach allows successful exposure of the sphenoidal portion of the sylvian fissure and M1 and M2 segments of the middle cerebral artery. Angled endoscopes may provide visualization of the mesial temporal lobe and crural cistern. Although our anatomical study demonstrates the feasibility of intradural dissection and closure via an endoscopic transorbital approach, further studies are necessary to evaluate its role in the clinical scenario.

Minimally Invasive Transpalpebral ‘‘Eyelid’’ Approach to Unruptured Middle Cerebral Artery Aneurysms

BACKGROUND: Although recent technological advances have led to successful endovascular treatment, middle cerebral artery (MCA) aneurysms are still prone to surgery. Because minimally invasive options are limited and possess several functional and cosmetic drawbacks, a transpalpebral approach is proposed as a new alternative.

OBJECTIVES: To describe and assess surgical results of the minimally invasive transpalpebral approach in patients with MCA aneurysms.

METHODS: The data of 25 patients with unruptured MCA aneurysms from 2013 to 2016 were included in a cohort prospective database. We describe modifications of the approach and technique for MCA aneurysm clipping, in a step-by-step manner. The outcome was based on complications, procedural morbidity and mortality, and clinical and angiographic outcomes.

RESULTS: All procedures were successfully performed in a standardized way, and no major complications related to the new approach were observed. Twenty-two patients were discharged the day after surgery (88%). The majority of aneurysms were 5 to 6 mm in diameter (mean, 7 mm; range 4-21 mm). All patients underwent postoperative angiographic control, which showed no significant residual neck. A 3-mo follow-up was sufficient to show no visible scars with excellent cosmetic results. The mean duration of follow-up was 16 mo.

CONCLUSION: The transpalpebral approach comes as a minimally invasive, safe, definitive, and cosmetically adequate solution for MCA aneurysms at the present time.

Frontal Keyhole Craniotomy for Resection of Low- and High-Grade Gliomas

BACKGROUND

Minimally invasive techniques are increasingly being used to access intra-axial brain lesions.

OBJECTIVE

To describe a method of resecting frontal gliomas through a keyhole craniotomy and share the results with these techniques.

METHODS

We performed a retrospective review of data obtained on all patients undergoing resection of frontal gliomas by the senior author between 2012 and 2015. We describe our technique for resecting dominant and nondominant gliomas utilizing both awake and asleep keyhole craniotomy techniques.

RESULTS

After excluding 1 patient who received a biopsy only, 48 patients were included in the study. Twenty-nine patients (60%) had not received prior surgery. Twenty-six patients (54%) were diagnosed with WHO grade II/III tumors, and 22 patients (46%) were diagnosed with glioblastoma. Twenty-five cases (52%) were performed awake. At least 90% of the tumor was resected in 35 cases (73%). Three of 43 patients with clinical follow-up experienced permanent deficits.

CONCLUSION

We provide our experience in using keyhole craniotomies for resecting frontal gliomas. Our data demonstrate the feasibility of using minimally invasive techniques to safely and aggressively treat these tumors.

Keyhole Approach and Neuroendoscopy for Cerebral Aneurysms

Treating diseases in the field of neurosurgery has progressed concomitantly with technical advances. Here, as a surgical armamentarium for the treatment of cerebral aneurysms, the history and present status of the keyhole approach and the use of neuroendoscopy are reviewed, including our clinical data. The major significance of keyhole approach is to expose an essential space toward a target, and to minimize brain exposure and retraction. Among several kinds of keyhole approaches, representative keyhole approaches for anterior circulation aneurysms include superciliary and lateral supraorbital, frontolateral, mini-pterional and mini-interhemispheric approaches. Because only a fixed and limited approach angle toward a target is permitted via the keyhole, however, specialized surgical devices and preoperative planning are very important. Neuroendoscopy has helped to widen the indications of keyhole approaches because it can supply illumination and visualization of structures beyond the straight line of microscopic view. In addition, endoscopic indocyanine green fluorescence angiography is useful to detect and correct any compromise of the perforators and parent arteries, and incomplete clipping. The authors think that keyhole approach and neuroendoscopy are just an intermediate step and robotic neurosurgery would be realized in the near future.

Lateral Orbitotomy Approach for Lesions Involving the Middle Fossa: A Retrospective Review of Thirteen Patients

BACKGROUND: Classically used for treatment of orbital lesions, the lateral orbitotomy with cantholysis can be combined with a temporal craniectomy for lesions involving the middle cranial fossa.

OBJECTIVE: To present a single-center experience with the lateral orbitotomy approach for lesions involving the middle fossa.

METHODS: Twenty-five patients underwent lateral orbitotomies from April 2012 to July 2015. Excluding patients with solely intraorbital pathologies, 13 patients’ clinical and radiographic records were retrospectively reviewed.

RESULTS: Signs/symptoms in the 13 patients (ages 28-81) included proptosis (69%), decreased visual acuity (31%), diplopia (54%), and afferent pupillary defect (69%). Pathologies were meningioma (8), esthesioneuroblastoma, lymphoma, chordoma, Ewing's sarcoma, and squamous cell carcinoma. Surgical goals were maximal safe resection in 8 patients, palliative debulking in 3 patients, and cavernous sinus biopsy in 2 patients. In 8 patients for whom maximal resection was the goal, 2 had gross total resection, while 6 had near-total resection. All patients (3) for whom palliation was the goal had symptomatic improvement. Both cavernous sinus biopsies obtained diagnostic tissue without complications. All patients with proptosis (n = 9) and diplopia (n = 7), and 2 of 4 patients with decreased visual acuity had improvement in their symptoms. No patient reported worsening of their symptoms. Mean follow-up was 12 mo (2-30 mo). Complications included oculorrhea (1), pseudomeningocele (2), transient ptosis (2), and forehead numbness (1).

CONCLUSION: The lateral orbitotomy is a promising approach for carefully selected lesions with involvement of both the lateral orbit and middle cranial fossa. It provides minimally invasive access for biopsy, decompression, or resection.

A Review of the Literature on the Transciliary Supraorbital Keyhole Approach

BACKGROUND

Conventional craniotomy approaches involve substantial soft tissue manipulation that can cause complications. The transciliary supraorbital keyhole approach was developed to avoid these complications. The aim of this review is to evaluate the safety and the effectiveness of the transciliary supraorbital keyhole approach.

METHODS

We searched the PubMed/Medline database for full-text publications from 1996 onward containing data on 100 or more cases of aneurysm clipping or tumor resection by the transciliary supraorbital keyhole approach. The primary outcome was the incidence of approach-related complications. The secondary outcomes were the aneurysm occlusion rate and the extent of tumor resection.

RESULTS

Eight publications met the eligibility criteria. All publications were of the retrospective case-series or case-cohort type without any independent assessment of outcomes. The risk of bias at the individual study level may thus have influenced any conclusions drawn from the overall study population, which included 2783 patients with 3085 lesions (2508 aneurysms and 577 tumors). Approach-related complications included 3.3% cerebrospinal fluid collection or leak, 4.3% permanent and 1.6% temporary supraorbital hypesthesia, 2.9% permanent and 1% temporary facial nerve palsy, and 1% wound healing disturbance or wound infection. Complete aneurysm clipping was achieved in 97% of cases. Complete tumor resection in 90% of cases. The overall surgical revision rate was 2.5%. The esthetic outcome was typically reported as highly acceptable.

CONCLUSIONS

This approach may represent a safe, effective, and less invasive alternative to conventional craniotomies in experienced hands and for a well-selected subset of patients. However, higher-level evidence is needed to confirm this hypothesis.

The Expanded Endoscopic Endonasal Approach to Anterior Communicating Artery Aneurysms: A Cadaveric Morphometric Study

OBJECTIVE

The purpose of this study was to explore the endoscopic endonasal approach to the anterior communicating artery complex.

DESIGN

Anatomic, morphometric analysis of human cadaver heads.

SUBJECTS

Fifteen latex-injected adult cadaver heads.

MAIN OUTCOME MEASURES

The anatomic boundaries of the operative field and the dimensions of exposure of the anterior communicating artery (ACoA) complex were measured and clip placement feasibility was assessed.

RESULTS

Exposure of the ACoA and bilateral A1 and A2 segments was accomplished in all 15 cadaver heads. Average length of the exposed ACoA was 3 ± 1 mm, the left A1 was 5 ± 3 mm and right A1 was 5 ± 1 mm, while the A2 segment was 5 ± 2 mm bilaterally. The average distance from the alar floor to the ACoA was 95 mm, while proximal lateral limit measured between the alar floor margins was 36 mm. The distal lateral limit as defined by the distance between the lateral most exposed margins of the chiasm was 19 mm. Clip placement was accomplished for the ACoA and the A1 and A2 segments bilaterally in all specimens.

CONCLUSION

The endoscopic, endonasal transtuberculum, transplanum approach is an anatomically feasible alternative to treating select aneurysms of the ACoA complex.

Interfascial Dissection for Protection of the Nerve Branches to the Frontalis Muscles during Supraorbital Trans-Eyebrow Approach: An Anatomical Study and Technical Note

Introduction Preservation of the temporal branches of the facial nerve during anterolateral craniotomies is important. Damaging it can inflict undesirable cosmetic defects to the patient. The supraorbital trans-eyebrow approach (SOTE) is a versatile keyhole craniotomy but still has a high rate of frontalis muscle (FM) palsy. Objective Anatomical study to implement the interfascial dissection during the SOTE to preserve the nerves to the FM. Methods Slight modification of the standard technique of the SOTE was performed in 6 cadaveric specimens (12 sides). Results Distal rami to the FM were exposed. The standard "u-shape" incision of the FM can cross over the nerves. Alternatively, an "l-shape" incision was performed until the superior temporal line (STL). An interfascial dissection was performed near to the STL and the interfascial fat pad was used as a protective layer for the nerves. Conclusion Various pathologies can be addressed with the SOTE. In the majority of the cases the cosmetic results are good, but FM palsy remains a drawback of this approach. The interfascial dissection may be used in an attempt to prevent frontalis rami palsy.