Outcomes After Pterional and Supraorbital Eyebrow Approach for Cranio-Orbital Lesions Communicated via the Supraorbital Fissure—A Retrospective Comparison

A novel classification for guiding the surgical approach for cranio-orbital lesions: a single institution case series of 45 cases and a literature review

We aim to share our experience of the removal of cranio-orbital lesions (COLs) and propose a novel classification to guide the tailored approach selection. We retrospectively reviewed 45 consecutive patients with COLs who underwent surgery performed by the same neurosurgeon between November 2010 and November 2022. The surgical approach was selected according to the anatomical region classification of the COLs. For lesions limited to space A (lateral superior orbital fissure, SOF), the pterion or extended pterion approach (PA or EPA) was used. For lesions limited to space B (extraconal compartment medial SOF, and cavernous sinus CS) and C (intraconal compartment, medial SOF, and CS), the pretemporal transcavernous approach (PTCA) was used. For lesions limited to space D (intraconal compartment and optic canals), the subfrontal approach (SA) was used. For lesions extending into the infratemporal fossa (ITF), the cranio-orbito-zygomatic approach (COZA) was used. For lesions involving pterygopalatine fossa (PPF), the endoscopic transnasal approach (ETNA) was used. We analyzed the clinical manifestations, imaging data, surgical approaches, surgical outcomes, neurological outcomes, and follow-up data. Gross total resection was performed in 35 patients (35/45, 77.8%). SA, PA, EPA, PTCA, COZA, and ETNA were performed in 9, 9, 10, 10, 6, and 1 case(s), respectively. Progression of the residual tumor was observed in 6 cases (1 adenoid cystic carcinoma and 5 meningiomas). Surgical approach selection plays a vital role in patient prognosis. This novel classification based on the involvement of anatomic space could help surgeons select an appropriate approach to remove the COLs.

Prechiasmatic Transection of the Unilateral Dodge Class Ⅰ Optic Pathway Glioma without Neurofibromatosis Type 1: Technical Description and Clinical Prognosis

OBJECTIVE

For unilateral Dodge Class Ⅰ optic pathway glioma (OPG-uDCⅠ) without neurofibromatosis type 1, unilateral isolated optic nerve gliomas before the optic chiasm have been confirmed to possibly cause visual deterioration and poor prognosis. For this type of highly selective localized tumor, we explored surgery as the only treatment method. This article retrospectively analyzed and summarized the clinical data of this case series, with the aim of exploring the main technical details and clinical prognosis.

METHODS

Included were patients with OPG-uDCⅠ without neurofibromatosis type 1 and experiencing vision loss on the affected side. The fronto-orbital approach was used, which was mainly divided into 3 parts: intraorbital, optic canal, and intracranial. All patients underwent prechiasmatic resection without any adjuvant treatments. The follow-up period was 3 months after surgery, and magnetic resonance imaging and contralateral visual acuity were reviewed annually after surgery.

RESULTS

All OPG-uDCⅠ cases were completely removed without any adjuvant treatments, and there was no recurrence during the follow-up period. Pathological results showed that, except for 1 adult patient with pilomyxoid astrocytoma (World Health Organization grade Ⅱ), the others all had pilocytic astrocytoma (World Health Organization grade Ⅰ). Five patients experienced transient ptosis, and all recovered 3 months after surgery.

CONCLUSIONS

For OPG-uDCⅠ without neurofibromatosis type 1, radical prechiasmatic resection of the tumor is possible, without the need for postoperative radiotherapy and chemotherapy.

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.

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.

Esthetics outcomes in patients submitted to pterional craniotomy and its variants: A scoping review

Background:

Highly performed nowadays, the pterional craniotomy (PC) has several widespread variants. However, these procedures are associated with complications such as temporalis muscle atrophy, facial nerve frontal branch damage, and masticatory difficulties. The postoperative cranial aesthetic is, nonetheless, the main setback according to patients. This review aims to map different pterional approaches focusing on final aesthetics.

Methods:

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Studies were classified through the Oxford method. We searched PubMed/MEDLINE, EMBASE, and Cochrane Library from January 1969 to February 2021 for cohorts and randomized clinical trials that met our inclusion criteria.

Results:

1484 articles were initially retrieved from the databases. 1328 articles did not fit the inclusion criteria. 118 duplicates were found. 38 studies were found eligible for the established criteria. 27 (71.05%) were retrospective cohorts, with low evidence level. Only 5 (13.15%) clinical trials were found eligible to the criteria. The majority of the studies (36/38) had the 2B OXFORD evidence level. A limited number of studies addressed cosmetic outcomes and patient satisfaction. The temporal muscle atrophy or temporal hollowing seems to be the patient’s main complaint. Only 17 (44.73%) studies addressed patient satisfaction regarding the aesthetics, and only 10 (26.31%) of the studies reported the cosmetic outcome as a primary outcome. Nevertheless, minimally invasive approaches appear to overcome most cosmetic complaints and should be performed whenever possible.

Conclusion:

There are several variants of the classic PC. The esthetic outcomes are poorly evaluated. The majority of the studies were low evidence articles.

The Treatment Strategy for Skull Base Reconstruction for Anterior Cranial Fossa Intra- and Extracranial Tumors

ABSTRACT

Anterior cranial fossa intra- and extracranial tumors arise from the anterior cranial fossa and invade the orbit and nose. Anterior cranial fossa tumor resection and skull base reconstruction are challenging for neurosurgeons due to the complex anatomy, leakage of cerebrospinal fluid, and critical neurovasculature involvement. The authors report a case series of cranio-orbital communicating tumors and cranionasal-orbital communicating tumors. All patients underwent a modified Derome approach or transfrontal basal approach, and all tumor resections were satisfactory. Skull base reconstruction for small defects (<1.5 cm) can be performed with autogenous fascia, muscle, and fat. Large defects (≥1.5 cm) require autogenous fascia, muscle, and fat combined with osseous reconstruction (autogenous bone, titanium mesh, and polyetheretherketone). The techniques and treatments were successful, and only 1 patient experienced mild cerebrospinal fluid leak but no intracranial infection, pneumocrania or intracranial hemorrhage. Additionally, long-term follow-up demonstrated that the outcomes remain favorable. According to a literature review, this technique might be an alternative strategy for treating anterior cranial fossa intra- and extracranial tumors, and better skull base reconstruction can prevent many postoperative complications.

The extradural extended eyebrow approach: A cadaveric feasibility study

INTRODUCTION

Extradural anterior clinoidectomy (eAC) is key to expose the paraclinoid region. Several authors have pointed limitations of performing an eAC through a supraorbital craniotomy. In this article, we aim to provide educational material and discuss the technical nuances to successfully perform an eAC throughout a modification of the supraorbital approach, the extradural extended eyebrow approach (xEBA+eAC).

METHODS

Four embalmed heads were used for anatomic dissection and perform the xEBA+eAC. Additionally, one head was used for a video demonstration of the surgical approach.

RESULTS

The anterior clinoid process was successfully removed, and the ophthalmic artery and paraclinoid region were exposed in all specimens. Drilling the sphenoid wing until exposing the meningo-orbital band and further interdural dissection are vital steps to expose the anterior clinoid process. Removal of the anterior clinoid process can be simplified in 3 osteotomies, including the optic canal unroofing, detachment from the lateral pillar, and drilling of the optic strut. Sectioning of the distal dural ring facilitates the mobilization of the internal carotid artery and the surgical exposure of the ophthalmic artery.

CONCLUSIONS

xEBA+eAC is a technically feasible approach that provides exposure to the paraclinoid region, along with anterior and middle cranial fossa.