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Candy NG, Van Der Veken J, Van Velthoven V. 'What's in a name', a systematic review of the pterional craniotomy for aneurysm surgery and its many modifications with a proposal for simplified nomenclature. Acta Neurochir (Wien) 2024; 166:11. [PMID: 38227061 DOI: 10.1007/s00701-024-05888-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/17/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND The pterional or frontosphenotemporal craniotomy has stood the test of time and continues to be a commonly used method of managing a variety of neurosurgical pathology. Already described in the beginning of the twentieth century and perfected by Yasargil in the 1970s, it has seen many modifications. These modifications have been a normal evolution for most neurosurgeons, tailoring the craniotomy to the patients' specific anatomy and pathology. Nonetheless, an abundance of variations have appeared in the literature. METHODS A search strategy was devised according to the 2020 Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) statement. To identify articles investigating the variations in the pterional approach, the following search terms were applied: (pterional OR minipterional OR supraorbital) AND (approach OR craniotomy OR technique). RESULTS In total, 3552 articles were screened with 74 articles being read in full with 47 articles being included for review. Each article was examined according the name of the technique, temporalis dissection technique, craniotomy technique and approach. CONCLUSION This systematic review gives an overview of the different techniques and modifications to the pterional craniotomy since it was initially described. We advocate for the use of a more standardised nomenclature that focuses on the target zone to simplify the management approach to supratentorial aneurysms.
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Affiliation(s)
- Nicholas G Candy
- Department of Surgery - Otolaryngology, Head and Neck Surgery, The University of Adelaide, Basil Hetzel Institute for Translational Research, Woodville South, Adelaide, Australia.
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia.
| | - Jorn Van Der Veken
- Department of Neurosurgery, Aalsters Stedelijk Ziekenhuis, Merestraat 80, 9300, Aalst, Belgium
| | - Vera Van Velthoven
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Jette, Belgium
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Robinow ZM, Peterson C, Riestenberg R, Waldau B, Yu N, Shahlaie K. Cosmetic Outcomes of Supraorbital Keyhole Craniotomy Via Eyebrow Incision: A Systematic Review and Meta-Analysis. J Neurol Surg B Skull Base 2023; 84:470-498. [PMID: 37671300 PMCID: PMC10477017 DOI: 10.1055/s-0042-1755575] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/08/2022] [Indexed: 10/14/2022] Open
Abstract
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.
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Affiliation(s)
- Zoe M. Robinow
- California Northstate University College of Medicine, Elk Grove, California, United States
| | - Catherine Peterson
- Department of Neurological Surgery, University of California Davis, Sacramento, California, United States
| | - Robert Riestenberg
- Department of Neurological Surgery, University of California Davis, Sacramento, California, United States
| | - Ben Waldau
- Department of Neurological Surgery, University of California Davis, Sacramento, California, United States
| | - Nina Yu
- Department of Neurological Surgery, University of California Davis, Sacramento, California, United States
| | - Kiarash Shahlaie
- Department of Neurological Surgery, University of California Davis, Sacramento, California, United States
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Supraorbital Keyhole Craniotomy via Eyebrow Incision: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 158:e509-e542. [PMID: 34775096 DOI: 10.1016/j.wneu.2021.11.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 12/15/2022]
Abstract
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.
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Di Somma A, Andaluz N, Cavallo LM, Keller JT, Solari D, Zimmer LA, de Notaris M, Zuccarello M, Cappabianca P. Supraorbital vs Endo-Orbital Routes to the Lateral Skull Base: A Quantitative and Qualitative Anatomic Study. Oper Neurosurg (Hagerstown) 2018; 15:567-576. [DOI: 10.1093/ons/opx256] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 02/02/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Various extensions of the supraorbital approach reach the lateral and parasellar middle cranial fossa regions by removing the orbital rim and greater/lesser sphenoid wings. Recent proposals of a purely endoscopic ventral transorbital pathway to these regions heighten the need to compare these surgical windows.
OBJECTIVE
To detail the lateral and parasellar middle cranial fossa regions and quantify exposures by 2 surgical windows (transcranial and transorbital) through anatomic study.
METHODS
In 5 cadaveric specimens (10 sides), dissections consisted of 3 stages: stage 1 began with the supraorbital approach via the eyebrow; stage 2, endo-orbital approach via the superior eyelid, continued with removal of lesser and greater sphenoid wings; and stage 3, extended supraorbital, re-evaluated the gains of stage 2 from the perspective of stage 1. Operative working areas were quantified in Sylvian, anterolateral temporal, and parasellar regions; bone removal volumes were measured at each stage (nonpaired Student t-test).
RESULTS
Visualization into the anterolateral temporal and Sylvian areas, though varied in perspective, were comparable with either eyelid or transcranial routes. Compared with transcranial views through a supraorbital window, the eyelid approach significantly increased exposure in the parasellar region with wider angle of attack (P < .01) and achieved comparable bone removal volumes.
CONCLUSION
Stage 2’s unique anatomic view of the lateral and parasellar middle cranial fossa regions paves the way for possible surgical application to select pathologies typically treated via transcranial approaches. Disadvantages may be the surgeon's unfamiliarity with the anatomy of this purely endoscopic, ventral route and difficulties of dural and orbital repair.
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Affiliation(s)
- Alberto Di Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odon-tostomatological Sciences, Univers-itá degli Studi di Napoli Federico II, Naples, Italy
| | - Norberto Andaluz
- Department of Neuro-surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio
- Comprehensive Stroke Center at UC Neuroscience Institute, Cincinnati, Ohio
- Mayfield Clinic, Cincinnati, Ohio
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odon-tostomatological Sciences, Univers-itá degli Studi di Napoli Federico II, Naples, Italy
| | - Jeffrey T Keller
- Department of Neuro-surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio
- Comprehensive Stroke Center at UC Neuroscience Institute, Cincinnati, Ohio
- Mayfield Clinic, Cincinnati, Ohio
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odon-tostomatological Sciences, Univers-itá degli Studi di Napoli Federico II, Naples, Italy
| | - Lee A Zimmer
- Department of Neuro-surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio
- Comprehensive Stroke Center at UC Neuroscience Institute, Cincinnati, Ohio
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio
| | - Matteo de Notaris
- Department of Neuroscience, G. Rummo Hospital, Neurosurgery Operative Unit, Benevento, Italy
| | - Mario Zuccarello
- Department of Neuro-surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio
- Comprehensive Stroke Center at UC Neuroscience Institute, Cincinnati, Ohio
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odon-tostomatological Sciences, Univers-itá degli Studi di Napoli Federico II, Naples, Italy
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Mathias RN, Lieber S, de Aguiar PHP, Maldaun MVC, Gardner P, Fernandez-Miranda JC. Interfascial Dissection for Protection of the Nerve Branches to the Frontalis Muscles during Supraorbital Trans-Eyebrow Approach: An Anatomical Study and Technical Note. J Neurol Surg B Skull Base 2015; 77:265-70. [PMID: 27175323 DOI: 10.1055/s-0035-1568872] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 10/14/2015] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Roger Neves Mathias
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States; Department of Neurosurgery, State University of Campinas, Campinas, Brazil
| | - Stefan Lieber
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | | | | | - Paul Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
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Kurbanov A, Sanders-Taylor C, Keller JT, Andaluz N, Zuccarello M. The extended transorbital craniotomy: an anatomic study. Neurosurgery 2015; 11 Suppl 2:338-44; discussion 344. [PMID: 25867616 DOI: 10.1227/neu.0000000000000762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Supra-/transorbital approaches are mostly limited to suprasellar and anterior fossa pathologies, whereas lateral supraorbital approaches provide less retrosellar exposure and less overall operative volume, especially in the temporal region. OBJECTIVE Our cadaveric study proposes removal of the lesser and greater wings of the sphenoid bone to increase both the lateral angle typically achieved with pterional approaches and exposure to the temporal lobe and perisellar region. METHODS In 5 cadaveric specimens, our 3 steps to expand transorbital exposures included the following: step 1, standard transorbital craniotomy via a 3-cm supra-eyebrow incision; step 2, removal of the lesser sphenoid wing completed extradurally; and step 3, partial removal of the greater sphenoid wing. Operative extension in sylvian, parasellar, and anterolateral temporal exposures were quantified for each step (t test). RESULTS Step 2 provided the greatest increased exposure in the sylvian and parasellar regions compared with step 3, whereas step 3 provided a significant proportion of the exposure in the lateral temporal region. Finally, the lateral view progressively increased with each subsequent step. CONCLUSION Our 3-step removal of the lesser and greater wings of the sphenoid bone quantified increased sylvian, anterior temporal, and parasellar exposures for this minimally invasive approach with excellent cosmesis. Its increases the anterolateral view (similar to a subfrontal pterional approach) and offers potential applications to vascular and neoplastic (ie, sphenoid meningiomas) pathologies classically treated via a pterional or frontotemporal orbitozygomatic approach.
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Affiliation(s)
- Almaz Kurbanov
- Department of Neurosurgery, University of Cincinnati (UC) College of Medicine, Comprehensive Stroke Center at UC Neuroscience Institute, Mayfield Clinic, Cincinnati, Ohio
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Ditzel Filho LFS, McLaughlin N, Bresson D, Solari D, Kassam AB, Kelly DF. Supraorbital eyebrow craniotomy for removal of intraaxial frontal brain tumors: a technical note. World Neurosurg 2013; 81:348-56. [PMID: 23352966 DOI: 10.1016/j.wneu.2012.11.051] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 09/09/2012] [Accepted: 11/16/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To present the utility and selection criteria for the supraorbital (SO) craniotomy, an approach commonly used to remove extraaxial tumors such as meningiomas and craniopharyngiomas, to resect intraaxial frontal brain lesions. METHODS All consecutive patients who underwent a SO craniotomy for an intraaxial lesion were retrospectively analyzed for lesion location, pathology, extent of resection, operative times, length of stay, and complications. RESULTS During 28 months, 10 patients (mean age, 67.6 years; 7 women) underwent 11 SO procedures to resect intraaxial brain lesions. Pathologies included metastatic carcinoma (n = 7), glioma (n = 2), and radiation necrosis (n = 1). The mean distance of the shortest trajectory to the lesion was 2.4 mm. Gross total or near-total removal was achieved in 80% of the cases. Median length of hospital stay was 3 days (range, 2-6 days); it was 2 days for patients admitted electively for SO craniotomy. There were no new neurologic deficits, postoperative hematomas, or cerebrospinal fluid leaks. CONCLUSIONS The SO "eyebrow" craniotomy is a safe and effective keyhole method to remove intraaxial frontal lobe lesions, particularly lesions of the frontal pole and orbitofrontal region, allowing for minimal disruption of normal brain parenchyma and promoting a rapid recovery and short hospital stay. Metastatic tumors and select gliomas in this area are most amenable to this approach. Deeper intraaxial tumors can also be effectively accessed via this route with excellent clinical outcomes.
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Affiliation(s)
- Leo F S Ditzel Filho
- Brain Tumor Center, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California, USA
| | - Nancy McLaughlin
- Brain Tumor Center, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California, USA
| | - Damien Bresson
- Brain Tumor Center, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California, USA
| | - Domenico Solari
- Brain Tumor Center, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California, USA
| | - Amin B Kassam
- Brain Tumor Center, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California, USA
| | - Daniel F Kelly
- Brain Tumor Center, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California, USA.
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Owusu Boahene KD, Lim M, Chu E, Quinones-Hinojosa A. Transpalpebral orbitofrontal craniotomy: a minimally invasive approach to anterior cranial vault lesions. Skull Base 2011; 20:237-44. [PMID: 21311616 DOI: 10.1055/s-0030-1249247] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
UNLABELLED To describe a minimally invasive approach to anterior cranial vault pathology using a transpalpebral exposure with a miniorbitofrontal craniotomy. DESIGN Case series. SETTING Tertiary referral hospital with multidisciplinary skull base program. Participants include patients with intra-axial and extra-axial anterior skull base lesions who underwent the transpalpebral minicraniotomy approach. MAIN OUTCOME MEASURES Feasibility of the approach to permit adequate exposure of targeted lesion. We applied this approach in seven patients for the repair of persistent cerebrospinal fluid leaks, pneumocephalus, and the biopsy or resection of midline brain tumors along the anterior cranial base. The approach allowed bimanual instrumentation working with either endoscopic or microscopic visualization for tumor resection and repair of dural and cranial base defects. We measured an average working distance of 4 cm to the sella. The transpalpebral miniorbitofrontal craniotomy approach to the anterior cranial base is quick, adequate, and safe and should be considered as an alternative to extended bifrontal approaches and/or pterional craniotomies for select anterior cranial vault pathology.
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9
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Cavalcanti DD, García-González U, Agrawal A, Crawford NR, Tavares PLMS, Spetzler RF, Preul MC. Quantitative anatomic study of the transciliary supraorbital approach: benefits of additional orbital osteotomy? Neurosurgery 2010; 66:205-10. [PMID: 20489507 DOI: 10.1227/01.neu.0000369948.37233.70] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The transciliary supraorbital approach (TCSO) provides an anterior view for visualizing sellar, parasellar, and suprasellar structures. Whether an orbital osteotomy adds to this exposure has not been quantified. OBJECTIVE We quantitatively evaluated the TCSO and benefits of an additional orbital osteotomy for exposing common sites of anterior circulation aneurysms. METHODS Under image guidance, TCSO and orbital osteotomy were performed on 10 sides of 5 cadaver heads to quantify exposures of 4 surgical targets: (1) the junction of the anterior cerebral and anterior communicating arteries (ACoA); (2) the internal carotid artery (ICA) at the level of the posterior communicating artery (PCoA); (3) the bifurcation of the ICA; and (4) the middle cerebral artery (MCA) bifurcation. Horizontal and vertical angles of attack and surgical freedom for instrument manipulation were measured before and after the orbital rim and roof were removed. RESULTS An orbital osteotomy significantly increased surgical freedom to the ACoA (from 471.15 +/- 182.14 mm2 to 683.35 +/- 283.78 mm2, P = .021); PCoA (from 746.58 +/- 242.78 mm2 to 966.23 +/- 360.22 mm2, P = .007); ICA bifurcation (from 616.08 +/- 310.95 mm2 to 922.38 +/- 374.88 mm2, P = .002); and MCA bifurcation (from 1160.77 +/- 412.03 mm2 to 1597.71 +/- 733.18 mm2, P = .004). There were no significant differences in horizontal angles of attack. The vertical angles of attack were significantly greater after orbital osteotomy, principally with the ACoA and ICA bifurcation as targets. CONCLUSION TCSO combined with orbital osteotomy improves exposure. Removing the orbital rim and roof increases the area for instrument use and improves the vertical angle of attack to common sites in the anterior circulation involving aneurysms.
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Affiliation(s)
- Daniel D Cavalcanti
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Beretta F, Andaluz N, Chalaala C, Bernucci C, Salud L, Zuccarello M. Image-guided anatomical and morphometric study of supraorbital and transorbital minicraniotomies to the sellar and perisellar regions: comparison with standard techniques. J Neurosurg 2009; 113:975-81. [PMID: 19895194 DOI: 10.3171/2009.10.jns09435] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Minimally invasive approaches have been proposed for the treatment of anterior cranial base pathology. Whereas earlier studies have quantified surgical exposure by referring to the opening on the surface, this cadaveric morphometric study redefines the concept of working area by examining the deep exposures afforded by several different approaches. Specifically, the authors systematically quantify and compare the operative exposure afforded by the pterional, supraorbital, and transorbital keyhole approaches to the sellar, suprasellar, and perisellar regions, including the anterior communicating artery complex. METHODS Pterional, supraorbital, and transorbital approaches were sequentially performed in 5 embalmed cadaveric heads on both sides. Preoperative and postoperative CT scans were obtained for frameless stereotactic navigation and measurements. Using reproducible anatomical landmarks, 6 triangles were defined to systematically measure the working area, depth of the surgical window, and angle of observation for each approach. Areas of the triangles were calculated using the Heron mathematical formula based on stereotactic navigation measurements. Ten sets of data were analyzed. RESULTS The pterional, supraorbital, and transorbital keyhole approaches provided progressively increasing working areas. The transorbital approach was associated with significantly increased exposure when compared with the pterional approach (p < 0.01). The transorbital approach was associated with a shallower depth of the surgical window when compared with either the supraorbital (p < 0.05) or pterional (p < 0.01) approach. The angle of basal view increased 56.6% with the transorbital approach (p < 0.001) when compared with the supraorbital approach. The transorbital route provided greater exposure on deeply located midline and contralateral structures. CONCLUSIONS In refining the concept of working area as deep rather than superficial in the surgical field, the authors quantified the 6 triangles whose boundaries were relative to the target structures to be exposed in the approach. The authors' morphometric findings support the use of the supraorbital and transorbital approaches as a valid alternative to the pterional approach for the treatment of sellar and perisellar pathology. The transorbital approach combines the advantages of minimal invasiveness with those of cranial base techniques.
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Affiliation(s)
- Federica Beretta
- Department of Neurosurgery, University of Cincinnati Neuroscience Institute and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Andaluz N, Romano A, Reddy LV, Zuccarello M. Eyelid approach to the anterior cranial base. J Neurosurg 2008; 109:341-6. [DOI: 10.3171/jns/2008/109/8/0341] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Skull base approaches play a fundamental role in modern neurosurgery by reducing surgical morbidity. Increasing experience has allowed surgeons to perform minimally invasive approaches without straying from the premises of skull base surgery. The eyelid approach has evolved from the orbitopterional osteotomy into a more effective and targeted approach to disease of the anterior cranial fossa. In this technique, after an incision is made on the supratarsal fold, the orbicularis oculi muscle is incised, and a myocutaneous flap composed of the elements of the anterior lamella is elevated. Subperiosteal dissection is used to expose the superior and lateral walls of the orbit, the superior and lateral orbital rim, and the frontosphenoidal suture. A MacCarty bur hole is drilled, and a frontal osteotomy is fashioned medial to the supraorbital notch and extending through the orbital roof back toward the orbital half of the MacCarty bur hole, exposing the frontobasal brain. A conventional microsurgical technique is used to treat tumors and aneurysms of the anterior cranial fossa under the operative microscope.
Five patients were treated for unruptured aneurysms of the anterior circulation (3 anterior communicating artery aneurysms, 1 ophthalmic artery aneurysm, and 1 posterior communicating artery aneurysm) using the eyelid approach. The mean aneurysm size was 5 mm, and all aneurysms were approached from the right side. Three tumors in the anterior fossa (2 suprasellar pituitary adenomas and 1 craniopharyngioma) were also excised using this approach. There was no surgical morbidity. Three months after surgery all patients presented excellent cosmetic results. The eyelid approach may be considered as an effective, cosmetically beneficial, and minimally invasive skull base approach to selected aneurysms and tumors of the anterior circulation.
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Affiliation(s)
- Norberto Andaluz
- 1Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Alberto Romano
- 2Neurosurgical Unit, Instituto Ortopedico Villa Salus, Augusta, Italy
| | - Likith V. Reddy
- 3Division of Oral and Maxillofacial Surgery, Department of Surgery; and
| | - Mario Zuccarello
- 4Department of Neurosurgery and
- 5The Neuroscience Institute, Mayfield Clinic, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Pondé JM, Prandini MN. Minicraniotomia supraorbital para abordagem da região selar e parasselar. ARQUIVOS DE NEURO-PSIQUIATRIA 2002. [DOI: 10.1590/s0004-282x2002000400029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Relatamos nossa experiência com a minicraniotomia supraorbital em uma série de 36 pacientes operados, com resultados satisfatórios. Foram operados 31 aneurismas 4 adenomas hipofisários, um astrocitoma anaplásico e um cisto aracnóide. Houve um óbito na série. A técnica foi descrita em detalhes. Concluimos que a minicraniotomia é um método seguro para o tratamento de várias patologias parasselares, devendo ser avaliada a sua eficácia em estudos comparativos com as técnicas tradicionais.
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Fernandes YB, Maitrot D, Kehrli P, Tella OID, Ramina R, Borges G. Supraorbital eyebrow approach to skull base lesions. ARQUIVOS DE NEURO-PSIQUIATRIA 2002; 60:246-50. [PMID: 12068354 DOI: 10.1590/s0004-282x2002000200012] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We report our experience with a supraorbital eyebrow minicraniotomy. This technique is suitable to lesions situated in the region of the anterior fossa, suprasellar cisterns, parasellar region and Sylvian fissure. A 50 mm incision in the eyebrow and a supraorbital minicraniotomy is performed. Sixteem patients harboring different lesions were operated on with good postoperative and cosmetic results. We conclude that this approach is safe and useful in selected cases.
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Affiliation(s)
- Yvens Barbosa Fernandes
- Disciplina de Neurocirurgia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brasil
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