Prospective randomized study comparing clinical, functional, and aesthetic results of minipterional and classic pterional craniotomies

The Endoscopic Transorbital Approach for Vascular Surgery: An Anterior Circulation Anatomic Study, 2-Dimensional Operative Video

BACKGROUND AND OBJECTIVES

Minimally invasive endoscopic approaches in cranial base surgery have been developing in the past decades. The transorbital (TO) route is one promising alternative, yet its adequacy for intracranial vascular lesions remains unclear. The present anatomic work aimed to test the feasibility and to provide a qualitative description of the endoscopic TO approach for the anterior circulation, namely the internal carotid artery and the middle cerebral artery.

METHODS

Seven embalmed adult cadaveric specimens (12 sides) were used in the study. Each side was approached in 3 successive steps: (1) Superior-eyelid TO approach, with great and lesser sphenoid wing removal. (2) Removal of anterior clinoid process (ACP). (3) Removal of the lateral orbital rim. All the procedures were performed under endoscopic view.

RESULTS

The TO approach without removing the ACP allowed to dissect the sphenoidal and lateral segments of the Sylvian fissure with an adequate identification of the middle cerebral artery bifurcation in all specimens. The removal of the ACP allowed further dissection toward the opticocarotid cistern, with the identification of the ophthalmic, posterior communicating, and the anterior choroidal arteries. The internal carotid artery bifurcation and A1 segment were also readily identified. Finally, removal of the lateral orbital rim provided a wider and more comfortable access to the above-mentioned vascular structures.

CONCLUSION

According to our anatomic data, the TO approach can be used to reach the main vascular components of the anterior circulation. This opens the field for exploring its application in the treatment of vascular pathology, particularly aneurysms.

A Prospective Comparison Between Soft Tissue Dissection Techniques in Pterional Craniotomy: Functional, Radiological, and Aesthetic Outcomes

BACKGROUND AND OBJECTIVES

Given the complex anatomy of the operative region and individual surgeon preferences, some techniques for soft tissue dissection before pterional craniotomy have gained more popularity than others. This prospective study used subjective and objective measurements to compare the functional, radiological, and aesthetic outcomes of 3 such dissection techniques.

METHODS

This multicenter prospective cohort study included all patients who underwent elective pterional craniotomy between 2018 and 2020 at 3 centers in Riyadh, Saudi Arabia. All patients underwent 1 of 3 soft tissue dissection techniques: myocutaneous flap, interfascial, and subfascial dissection techniques. Clinical and radiological assessments were performed upon discharge and at the 3- and 6-month follow-ups.

RESULTS

We included 78 patients, with a mean age of 44.9 ± 16.3 years. Myocutaneous flap, interfascial, and subfascial dissections were performed in 34 (43%), 24 (30%), and 20 patients (25%), respectively. The myocutaneous flap method had the shortest opening ( P = .001) and closure ( P = .005) times; tenderness was more evident in this group than in the others ( P = .05). The frontalis muscle was most affected in the interfascial dissection group ( P = .05). The frontalis nerve function was similar in all groups after 6 months ( P = .54). The incidence of temporomandibular joint dysfunction was highest in the myocutaneous flap group (29%). Decreased temporalis muscle thickness at the 6-month postoperative follow-up was most severe in the subfascial dissection group (12.6%), followed by the myocutaneous flap (11.9%) and interfascial dissection (9.9%) groups, with no significant difference ( P = .85). Temporal hollowing was more prominent in the myocutaneous flap group ( P = .03). Cosmetic satisfaction was highest in the interfascial dissection group, with no significant difference ( P = .4).

CONCLUSION

This study provides important information for neurosurgeons in weighing the benefits and risks of each technique for their patients.

Effectiveness of Keyhole Clipping of Unruptured Intracranial Aneurysms Detected by "Brain Dock" in Healthy Japanese Adults

In Japan, brain docking has enhanced the detection of unruptured intracranial aneurysms in healthy adults. At our institution, surgical clipping is the first-line treatment for unruptured intracranial aneurysms (UIA). In this study, the differences in neurological and radiological outcomes, as well as cognitive and psychological results, between standard clipping and keyhole clipping for these aneurysms detected via brain docking were evaluated. The study included 131 aneurysms detected via "brain dock." Of these, 65 were treated with keyhole clipping surgery (keyhole clipping group), and 66 were treated with standard clipping surgery (standard clipping group). Evaluations at 3 months included the National Institutes of Health Stroke Scale, modified Rankin Scale, Mini-Mental State Examination, Hasegawa's Dementia Scale-revised, Beck Depression Inventory, Hamilton Rating Scale for Depression, and radiological abnormalities. The mean operative time and postoperative hospitalization period were significantly shorter in the keyhole clipping group than in the standard clipping group (p < 0.001). Between the groups, no significant differences in postoperative neurological complications or radiological abnormalities were found. The keyhole clipping group demonstrated slightly but significantly better Beck Depression Inventory and Hamilton Rating Scale for Depression scores than the standard clipping group (Beck Depression Inventory, p = 0.046; Hamilton Rating Scale for Depression, p < 0.01). Both the Beck Depression Inventory and Hamilton Rating Scale for Depression scores at 3 months were significantly enhanced (p < 0.001) in the keyhole clipping group. These findings propose that keyhole clipping could be considered a new therapeutic option for small UIA detected via brain docking.

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.

Anatomical Justification of Extradural Resection of the Anterior Clinoid Process

Objective  The study aimed to provide neuroanatomical justification of the extradural resection of the anterior clinoid process (ACP). Material and Method  Using a cross-sectional study design, 47 cranial computed tomography (CT) scans were examined. There were 31 (65.96%) females aged 28 to 79 years. The measured dimensions were ACP length and width, and optic strut (OS) width. Index (i acp ) was measured as the ratio of ACP width to ACP length. The ACP volume and working operating field (WOF) volume were measured using Syngo.via Siemens program. The percentage expansion of WOF after removal of the ACP was estimated on 5 fixed human cadaver heads with the exoscope VITOM 3D. The possibilities of the combined approach were demonstrated in a clinical case. Results  The mean ACP lengths were 11.31 ± 2.76 and 11.54 ± 2.86 mm, on the right and left, respectively. The mean ACP widths were 7.70 ± 1.66 and 7.64 ± 1.67 mm, on the right and left, respectively. Average i acp was 0.67 (minimum 0.45; maximum 0.90). The width of the OS varied in the range from 1.37 to 4.75 mm. The average volume of right ACP was 0.71 ± 0.16 cm 3 , right WOF was 3.26 ± 0.74 cm 3 , left ACP was 0.71 ± 0.15 cm 3 , left and WOF was 3.20 ± 0.76 cm 3 . Removal of the right ACP expanded the right WOF by 22.21 ± 3.88%, and left ACP by 22.78 ± 5.50%. There was an approximately 25% increase in the WOF from the cadaveric dissections. Taking into account the variability of the ACP and OS, we proposed our own surgical classification of complicated (i acp ≥ 0.67; medium OS 2.5 mm ≤ 4.0 mm; wide OS ≥ 4.0 mm; ACP with pneumatization) and uncomplicated ACP (i acp 0.45 ≤ 0.67 mm; i acp ≤ 0.45; narrow OS ≤ 2.5 mm; ACP without pneumatization). Using this classification, we developed an algorithm for ACP dissection and removal. This was piloted in a clinical case of microsurgical clipping of a left internal carotid artery-posterior communicating artery aneurysm via the left minipterional approach. Conclusion  Extradural removal of ACP expands the WOF by approximately 25%, it helps neurosurgeons to improve proximal vascular control and avoid complications, and expands the range of indications for neurosurgical interventions in the skull base area.

Transpalpebral Eyelid Approach for Supraorbital Frontal Craniotomy and Access to the Anterior Cranial Fossa

SUMMARY

The transpalpebral eyelid approach is an innovative alternative to traditional incisions for exposure of the anterior cranial fossa for neurosurgery. However, there is a paucity of data on this surgical technique in the plastic surgery literature for accessing the anterior cranial fossa. A retrospective review was performed of patients who underwent supraorbital frontal craniotomy using an anterior skull base approach with transpalpebral exposure over 8 years by a single plastic surgeon. Surgical techniques, medical comorbidities, intraoperative complications, and long-term complications were assessed. Twenty patients (mean age 52 ± 12 years, 55% male, 45% female) underwent supraorbital frontal craniotomy using an anterior skull base approach with upper transpalpebral exposure. Operative indications included the following: 75% had anterior communicating aneurysms, with a mean aneurysm size of 5.36 ± 1.91 mm; 10% had meningiomas; 10% had dural fistulas; and 5% had an orbital hemangioma. A total of 60% of patients had a smoking history. No intraoperative complications were encountered, and no cases required conversion to a traditional open approach. Mean length of hospital stay was 3.2 ± 1.5 days. Postoperative imaging revealed no residual or recurrent pathology. Mean follow-up time was 62.2 ± 30.6 months. No long-term neurologic or ophthalmologic complications or infections occurred. No forehead paresthesias, brow ptosis, or brow paralysis were noted. The transpalpebral technique is a safe, minimally invasive method to approach lesions of the anterior cranial fossa. Successful application may require appropriate management of the frontal sinus and supraorbital nerve. This approach does not limit neurosurgical access or results and led to no neurosurgical complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Minipterional Approach for Middle Fossa Skull Base Lesions: Technical Note

Surgical access to the middle fossa can be technically challenging. As neurosurgery evolves to minimally invasive approaches, the objective of this study is to demonstrate the extension of the Minipterional approach to access the middle fossa. We present a new surgical approach to the middle fossa for the treatment of secondary trigeminal neuralgia. Three cases are reported to illustrate the following techniques: a patient with petrotentorial meningioma and trigeminal neuralgia, a patient with an arachnoid cyst compressing the fifth nerve, and a patient with a middle cerebral artery aneurysm and a long history of TN (trigeminal neuralgia) refractory to medical and surgical treatments. All three experienced full symptom controls with no permanent neurological deficits. Therefore, the Minipterional technique might represent a feasible, effective, and safe option to treat refractory secondary TN. It also allows approaching these lesions when the posterior fossa approach is compromised by anatomical distortion and enables the simultaneous treatment of secondary trigeminal neuralgia and other lesions, such as aneurysms and meningiomas.

The sylvian keyhole approach for surgical clipping of middle cerebral artery aneurysms: Technical nuance to the minipterional craniotomy

Background

The minipterional (MPT) craniotomy is a workhorse approach for clipping of middle cerebral artery (MCA) aneurysms. Because it aims to reach the skull base, traction on the temporal muscle is required. As a result, patients may suffer from transient postoperative temporal muscle discomfort. The sylvian keyhole approach (SKA) represents an alternative craniotomy for the clipping of MCA aneurysms. The aims of this study are to describe the operative technique of the SKA and to discuss the benefits and disadvantages compared to the MPT craniotomy.

Methods

In this technical note, we report the experience gained with the SKA. This experience was acquired with virtual reality, 3D-printed models, and anatomical dissections. We also present two clinical cases.

Results

The SKA is centered on the distal sylvian fissure and tailored toward the specific MCA aneurysm. Traction to the temporal muscle is not necessary because access to the skull base is not sought. With the SKA, dissection of the MCA is performed from distal to proximal, aiming for a proximal control at the level of the M1-segment. The limen insulae was identified as a key anatomical landmark for approach selection. The SKA offers good surgical maneuverability when the aneurysm is located at the level or distal to the limen. The MPT craniotomy, however, remains the most appropriate approach when the aneurysm is located proximal to the limen.

Conclusion

The SKA represents a feasible and innovative alternative approach to the MPT craniotomy for surgical clipping of unruptured MCA aneurysms located at the level or distal to the limen insulae.

Mastication after craniotomy: pilot assessment of postoperative oral health-related quality of life

BACKGROUND

Neurosurgical approaches to the brain often require the mobilization of the temporal muscle. Many patients complain of postoperative pain, atrophy, reduced mouth opening, and masticatory problems. Although the pterional, frontolateral-extended-pterional, and temporal craniotomies are the most frequently used approaches in neurosurgery, a systematic assessment of the postoperative oral health-related quality of life has never been performed so far. This study evaluates the oral health-related quality of life of patients after pterional, frontolateral-extended-pterional, or temporal craniotomy using a validated and standardized dental questionnaire, compares the results with the normal values of the general population, and investigates whether this questionnaire is sensitive to changes caused by surgical manipulation of the temporal muscle.

METHODS

The "Oral Health Impact Profile" (OHIP14) is a validated questionnaire to assess the oral health-related quality of life. It asks the patients to assess their oral health situation within the past 7 days in 14 questions. Possible answers range from 0 (never) to 4 (very often). Sixty patients with benign intracranial processes operated through a lateral cranial approach were included. The questionnaire was answered before surgery (baseline) and 3 months and 15 months after surgery.

RESULTS

Overall, postoperative OHIP scores increase significantly after 3 months and decrease after 15 months, but not to preoperative values. No factors can be identified which show a considerable relationship with the postoperative OHIP score.

CONCLUSIONS

Postoperative impairment of mouth opening and pain during mastication can be observed 3 to 15 months after surgery and sometimes cause feedback from patients and their dentists. However, in line with existing literature, these complaints decrease with time. The study shows that the OHIP questionnaire is sensitive to changes caused by surgical manipulation of the temporal muscle and can therefore be used to investigate the influence of surgical techniques on postoperative complaints. Postoperatively, patients show worse OHIP scores than the general population, demonstrating that neurosurgical cranial approaches negatively influence the patient's oral health-related wellbeing. Larger studies using the OHIP questionnaire should evaluate if postoperative physical therapy, speech therapy, or specialized rehabilitation devices can improve the masticatory impairment after craniotomy.

TRIAL REGISTRATION

Clinical trial register: DRKS00011096.

Reconstruction clipping of ruptured anterior circulation aneurysms via supraorbital lateral keyhole approach

Background

Intracranial aneurysm (IA) is a serious disease. Analyze and review the cases of anterior circulation ruptured IA by supraorbital lateral keyhole approach, and summarize the experiences of this approach.

Methods

Retrospective analysis of 16 cases of ruptured anterior circulation IA in our department from January 2019 to June 2020, CT angiography (CTA) was performed before operation. Analyzing the IA’s parameters by 3D-CT reconstruction. The IA was clipped by supraorbital lateral keyhole approach combined with the 3D-skull reconstruction. Extraventricular drainage was performed before craniotomy. Intraoperative neurophysiological monitoring was performed during the operation. After operation, fluorescein angiography and vascular ultrasound were performed to check the clipping effect. Intracranial pressure monitor was performed postoperatively. CTA was reexamined one week after operation. The modified Rankin Scale (MRS) was performed 6 months after operation.

Results

There were 7 males (43.8%) and 9 females (56.2%), and the average age is 52.31 ± 11.12 years old. Among them, 11 patients (68.8%) were anterior communicating artery aneurysms and 5 (31.2%) were middle cerebral artery aneurysms. All patients were out of hospital within 10 days without any death, without cerebral infarction, cerebrospinal fluid leakage and neurological impairments. About mRS score, after 6 months follow-up, 8 cases (50%) had 0 point, 4 cases (25%) had 1 point, and 4 cases (25%) had 2 points.

Conclusions

For ruptured anterior circulation IA, the supraorbital lateral keyhole approach combined with ventricular drainage, intraoperative electrophysiological monitoring, and intraoperative vascular ultrasound is a safe and minimally invasive treatment. The application of reconstruction clipping can reconstruct the diameter of parent vessel and reduce the recurrence rate of IA.

Late Deformity Following Fronto-Orbital Reconstructive Surgery for Metopic Synostosis: The Role of Temporalis Muscle

ABSTRACT

Theories for late-developing deformity (LDD) following fronto-orbital reconstructive surgery (FOR) for metopic synostosis (MS) must explain both its delayed onset and its physical characteristics. This study examined whether FOR-related interference with the normal childhood expansion of temporalis is responsible for its soft tissue component.Three-dimensional reformats of preoperative and postoperative computed tomography scans of MS patients were reviewed. Measurements of vertical and horizontal reach of temporalis against those of the underlying skull (to allow for normal skull growth) were compared with normal subjects. The thickness of temporalis and the development of the temporal crests were also assessed.Mean age at FOR was 17.1 months; interval between surgery and first report of LDD 4.7 years; mean age at computed tomography scan for post-FOR LDD patients 8.8 years. There was a significant difference between vertical and horizontal reach of temporalis in pre-FOR MS patients compared to normal subjects (P < 0.0017 and P < 0.05, respectively). The vertical age-related reach of temporalis in post-FOR patients after allowing for underlying skull growth was significantly reduced (P = 0.0045) compared to normal subjects but not its horizontal reach (P = 0.25). Temporal crests in LDD patients were absent or aberrantly formed while muscle thickness was similar to normal subjects at the 2 levels measured.This study supports the theory that failure of the normal childhood expansion of temporalis is responsible for the soft tissue element of LDD, accounting for both its delayed onset and physical characteristics. Aberrant temporal crest development suggests FOR-related damage as the probable cause.

Questionnaire-Based Assessment of the Masticatory Function and Facial Nerve Recovery Post Pterional Approach in Brain Tumors Surgery

Background: The pterional approach for craniotomy, one of the most used surgical intervention in neurosurgery, results in a series of postoperative changes that, if they persist, affect the patient’s life, social reintegration, and his/her physical and mental recovery. The aim of the present study was to develop and validate a questionnaire for indicating directly affected masticatory muscles groups and facial nerve branches, in patients undergoing the pterional approach in neurosurgery, so that the recovery therapy can be monitored and personalized. Methods: A self-reporting questionnaire consisting of 18 items (12 for postoperative masticatory status and 6 for facial nerve branches involvement), validated on fifteen patients, following three steps: items development, scale development, and scale evaluation, was prospectively applied twice, at a one-year interval (T0 and T1), with thirty-two patients suffering from vascular or tumoral pathology and surgically treated through a pterional approach. Results: No statistically significant correlation could be found between postoperative outcomes and age or gender. Facial nerve branch involvement could not be correlated with any of the assessed variables. Pathology and time elapsed from surgery were statistically significantly correlated to preauricular pain on the non-operated side (p = 0.008 and p = 0.034, respectively). Time elapsed from surgery was statistically significantly correlated to the ability to chew hard food, pain while yawning, and preauricular pain during back and forward jaw movements and gradual mouth opening. Conclusions: We created and validated a valuable patient-centered questionnaire that can be employed as a tool for postoperative assessment of directly affected masticatory muscles and groups of facial nerve branches.

The Supraorbital Approach via an Eyebrow Incision: Analysis of Cosmetic Outcomes Using the Scar Cosmesis Assessment Rating Scale

ABSTRACT

The supraorbital craniotomy through an eyebrow incision, referred to as the suprabrow approach, may be used to access intracranial lesions. Though offering good surgical exposure for anterior base cranial lesions, the suprabrow approach has a paucity of studies on its cosmetic outcomes. In this study, we aimed to assess the cosmetic outcomes of suprabrow approach using validated Scar Cosmesis Assessment Rating (SCAR) scale for the first time. Three patients underwent a suprabrow approach for resection of a suprasellar or frontal mass. Their postoperative courses were followed, with specific attention to the cosmetic outcome of their procedures. The SCAR scale was used to determine the cosmetic success of the approach. We found that all 3 patients scored ≤ 5 on the SCAR scale. All 3 resections were successful with no major postoperative complications. The only minor complication was transient hypoesthesia of the ipsilateral forehead that was noted in all 3 patients.This study quantified the positive cosmetic outcomes of a minimally invasive suprabrow approach. The suprabrow approach provides acceptable surgical exposure and access in an appropriately selected patient with anterior cranial base lesions and results in favorable cosmesis. Although transient hypoesthesia in the distribution of the ophthalmic branch of the trigeminal nerve occurs, the overall benefits of the approach and desirable cosmetic outcomes make the suprabrow approach a good technique to access intracranial lesions in appropriate cases.

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.

Comparison of postoperative temporalis muscle atrophy between the muscle-preserving pterional approach and the mini-pterional approach in the treatment of unruptured intracranial aneurysms

This study aimed to compare the muscle-preserving pterional approach (modified classic pterional approach, mCP) and the mini-pterional approach (mPA) with respect to postoperative temporalis muscle atrophy.From November 2013 to April 2020, 78 patients with unruptured intracranial aneurysm of the anterior circulation underwent surgery using mCP or mPA in our institution. Patients' background characteristics, postoperative complications, and temporalis muscle volume (MV) rates (operative side/healthy side) were retrospectively investigated. In 64 patients (n = 31, mCP group; n = 33, mPA group), excluding 14 patients with missing imaging data from 6 to 24 months after surgery, associations between the MV rate and clinical variables were assessed. A multiple regression model was used to examine the association between the MV rate and the surgical method, which is a predictor of postoperative atrophy.The mCP group had a significantly higher mean MV rate than the mPA group (0.955 ± 0.040 and 0.915 ± 0.070, respectively; p = 0.008). Based on the results of the univariate analysis, a multiple regression model was established using sex, age, follow-up period, and the presence of diabetes in addition to the surgical method. Patients who underwent mCP had a higher MV rate than those who underwent mPA (t value = 2.33, p = 0.023).The present result suggested that mCP has a preventive effect on postoperative temporalis muscle atrophy. However, further studies are needed in order to prove that mCP is also effective in terms of postoperative aesthetic and functional outcomes.

Comparative anatomical analysis between the minipterional and supraorbital approaches

OBJECTIVE

Keyhole approaches, namely the minipterional approach (MPTa) and the supraorbital approach (SOa), are alternatives to the standard pterional approach to treat lesions located in the anterior and middle cranial fossae. Despite their increasing popularity and acceptance, the indications and limitations of these approaches require further assessment. The purpose of the present study was to determine the differences in the area of surgical exposure and surgical maneuverability provided by the MPTa and SOa.

METHODS

The areas of surgical exposure afforded by the MPTa and SOa were analyzed in 12 sides of cadaver heads by using a microscope and a neuronavigation system. The area of exposure of the region of interest and surgical freedom (maneuverability) of each approach were calculated.

RESULTS

The area of exposure was significantly larger in the MPTa than in the SOa (1250 ± 223 mm2 vs 939 ± 139 mm2, p = 0.002). The MPTa provided larger areas of exposure in the ipsilateral and midline compartments, whereas there was no significant difference in the area of exposure in the contralateral compartment. All targets in the anterior circulation had significantly larger areas of surgical freedom when treated via the MPTa versus the SOa.

CONCLUSIONS

The MPTa provides greater surgical exposure and better maneuverability than that offered by the SOa. The SOa may be advantageous as a direct corridor for treating lesions located in the contralateral side or in the anterior cranial fossa, but the surgical exposure provided in the midline region is inferior to that exposed by the MPTa.

The transsylvian corridor through minimally invasive transcranial approaches: a comparative anatomical study

Minimally invasive transcranial approaches (MITAs) continue to expand in popularity in neurosurgery. Only few MITAs allow sufficient sylvian exposure to enable wide use of the transsylvian corridor. In this study, we aim to compare the transsylvian corridor in two MITAs: the minipterional (MPTa) and the extended supraorbital eyebrow approaches (XSEa). Eight cadaver heads were used to quantify the surgical exposure and maneuverability along the sylvian fissure and the insular lobe provided by the MPTa and the XSEa. Surgical exposure was calculated by means of the exposed length of the sylvian fissure and by the area framed within three extreme points in the insular lobe. Maneuverability was assessed by means of the surgical freedom along the sylvian cistern. XSEa provides twice the frontal exposure and half of the temporal exposure in comparison to the MPTa (p < 0.001 and p = 0.02, respectively). No significant differences were found between the two craniotomies in the length of the exposure of the sylvian fissure, area of insular exposure, or surgical freedom. Both the MPTa and the XSEa afford sufficient grades of exposure along the sylvian fissure and the insular lobe, although the viewing angle is significantly different between the two approaches. Such properties allow either to be used for microsurgery deep within the sylvian cistern. The use of additional corridors, such as the subfrontal route (XSEa) and pretemporal route (MPTa), may influence selection of either the minipterional or the extended supraorbital approaches according to the origin of the surgical pathology addressed.

Microsurgical clipping of multiple cerebral aneurysms in the acute phase of aneurysmal subarachnoid hemorrhage through a minipterional approach: The Chilean experience

OBJECTIVE

The minipterional craniotomy (MPTc) has been widely accepted as a minimally invasive alternative to the pterional approach for the treatment of certain small non-ruptured anterior circulation aneurysms. The aim of this study was to determine the effectiveness and safety of the MPTc in the context of a complex and potentially harmful scenario: acute onset of subarachnoid hemorrhage (SAH) in patients harboring multiple intracranial aneurysms (MIA).

METHODS

Patients harboring MIA clipped through a unilateral MPTc were selected from four retrospective databases of four high-volume neurosurgical centers. Patients with a Hunt & Hess score 4 or 5 were not considered candidates for clipping through a MPTc. Medical records and radiological images were retrospectively reviewed. Epidemiological, clinical and radiological data, as well as short-term outcome (modified Rankin scale at 6 month-follow-up) were analyzed.

RESULTS

16 patients harboring 33 aneurysms (16 ruptured, 17 non ruptured) met the inclusion criteria. Each aneurysm size was 5.7 ± 2.1 mm (range 3-11). 12 out of 33 aneurysms were located in the middle cerebral artery (MCA). Anterior communicating (ACom) and MCA aneurysms were the aneurysm locations most commonly ruptured (5 each, 62 %). Complete occlusion was achieved in 32 aneurysms (97 %) and near-complete occlusion in 1 (3%). 13 patients (93 %) were independent at 6 month-follow-up. Mortality rate was 0%. Complications included 1 cerebrospinal-fluid leakage.

CONCLUSION

When indicated (Hunt Hess < 4), performing a MPTc is safe and effective in aSAH cases with multiple aneurysms.

Minipterional craniotomy for surgical clipping of anterior circulation aneurysms: compatibility between the feasibility, safety and efficiency

Objective

The aim of this study was to assess the feasibility, safety and efficiency of minipterional craniotomy (MPT) for surgical clipping of anterior circulation aneurysms.

Methods

A retrospective study was conducted to compare the MPT from Jan 2015 to Dec 2018 and conventional pterional craniotomy (CPT) from Jan 2012 to Dec 2013 in unruptured intracranial aneurysms (UIA) and ruptured intracranial aneurysms (RIA). The feasibility and safety of MPT and CPT were assessed by analyzing medical records, radiologic imaging, and clinical outcomes. The efficiency of MPT and CPT were based on a survey research of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry.

Results

Total 628 patients who underwent 458 MPT (UIA:313, RIA:145) and 170 CPT (UIA: 106, RIA: 64) with anterior circulation aneurysms were included in this study. The baseline characteristics between MPT and CPT had no difference (p>0.05). There was no difference in the incidence of postoperative hemorrhage or ischemic lesions between MPT and CPT (p>0.05). The incidence of surgical wound infection was lower in MPT (0.4%) than CPT (3.5%) (p=0.002). More than 90% of postoperative pain disappeared faster in MPT (14.25±4.83 days) than CPT (27.59±10.35 days), and the feeling of facial asymmetry in surgical side was also lower for MPT (1.7%) than CPT (7.6%) (p<0.001). In the MPT, no patients presented with progress to chronic pain, masticatory disability, discomfort of maximal mouth opening or permanent facial palsy.

Conclusions

We suggest that MPT and CPT had similar clinical outcomes, and MPT showed better functional and cosmetic outcomes than CPT in terms of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry. Therefore, MPT for surgical clipping of anterior circulation aneurysms can be a compatible technique that satisfies the feasibility, safety and efficiency.

Extradural minipterional approach: Evolving indications of the minipterional craniotomy

Background:

In this paper, we report a clinical series of skull base lesions operated on trough the MiniPT, extending its application to skull base lesions, either using the classical minipterional or a variant, we call extradural minipterional approach (MiniPTEx).

Methods:

We describe our surgical technique of operating on complex skull base lesions using a minipterional extradural approach. Anterior clinoidectomy, middle fossa peeling, transcavernous, and Kawase approaches were performed as needed. In total, we carried out 24 surgeries: three skull base tumors, 1 Moyamoya case, and 20 giant/complex intracranial aneurysms. All the patients present good neurological result (mRs < 3). Only two patients had paralysis of any cranial nerve and only one patient had a mild hemiparesis.

Results:

This surgery series there are 24 cases, 10 patients were treated with exclusive MiniPT. MiniPT extradural approach was made in 14 patients. Twelve were treated using pure MiniPTEx approach, 1 patient using transcavernous approach, and in 1 patient, the anterior clinoid was resected with the combination of a MiniPT, a medium fossa peeling, and the Kawase anterior petrosectomy for skull base surgery.

Conclusion:

We further advance the indications of the MiniPT by extending it to operate on the cranial base tumors or complex vascular lesions without additional morbidity. MiniPT approach may be safely associated with skull base techniques, including anterior and posterior clinoidectomies, peeling of the middle fossa, transcavernous approach, and anterior petrosectomy. The versatility of the MiniPT craniotomy and the feasibility of performing skull base surgery through the MiniPT technique have been demonstrated in this paper.

Same viewing angle, minimal craniotomy enlargement, extreme exposure increase: the extended supraorbital eyebrow approach

The supraorbital eyebrow approach (SEa) has been commonly used as a straightforward route to reach lesions located in the anterior cranial fossa. The reduced surgical exposure provided by this approach limits its applicability. A modification of the SEa, the extended supraorbital eyebrow approach (X-SEa), allows use of the transylvian corridor to approach parasellar lesions, while maintaining most of the aesthetic advantages of the SEa. To quantify the surgical exposure and maneuverability provided by the X-SEa using a cadaveric study. Eleven heads were used to obtain all stereotactic measurements. Surgical exposure and maneuverability were measured by means of the area of exposure and the angles of attack along key representative points in the anterior circulation. The horizontal angle of attack at the middle cerebral artery provided by the X-SEa was larger than that provided by the SEa (32.6 vs 18.4°, p = 0.009). The X-SEa afforded broader vertical angles of attack at all targets in the anterior circulation (p < 0.05). The total area of exposure provided by the X-SEa was significantly larger than that provided by the SEa (1272 vs 978 ± 156 mm², p = 0.003). The area of exposure in the ipsilateral trigon and in the midline quadrangle was also significantly larger for the X-SEa (paramedian 195 vs 121 mm², p = 0.01; midline 1310 vs 778 mm², p = 0.002). The X-SEa increases the exposure and surgical maneuverability along the anterior and middle cranial fossa when compared to the standard SEa.

Surgical clipping of a non-ruptured ophthalmic aneurysm through an extradural micropterional keyhole approach

BACKGROUND

Clipping continues to be one of the treatment strategies for ophthalmic artery aneurysms not amenable for stenting or coiling, or when long-term treatment durability is a concern. However, crescent development of endovascular techniques demands minimal invasiveness in the transcranial approaches while ensuring satisfactory results.

METHODS

We describe an extradural micropterional keyhole approach (eMKA) to the paraclinoid region and highlight the key anatomical elements of this surgical approach.

CONCLUSION

The eMKA is a minimally invasive approach that provides access to the paraclinoid region using an extradural corridor. Therefore, it is suitable for clipping of ophthalmic artery aneurysms and other paraclinoid aneurysms.

Extended Pterional Approach for Medial Sphenoid Wing Meningioma: A Series of 47 Patients

Background  To describe our operative strategy and analyze its safety and effectiveness for the removal of medial sphenoid wing meningiomas (MSWMs) through the extended pterional approach. Method  We identified 47 patients with MSWMs who were operated using this approach between 1986 and 2016. Medical charts, operative reports, imaging results, and clinical follow-up evaluations were reviewed and retrospectively analyzed. Results  No surgical mortality was observed in this sample. Gross total resection was achieved in 30 (63.8%) patients. Intradural clinoidectomy was performed in 16 (34%) patients. The median length of follow-up was 8.5 years (range, 1-30 years). Conclusion  The extended pterional approach associated with microsurgery techniques provided excellent results for the removal of MSWMs.

Transpalpebral Approach for Microsurgical Removal of Tuberculum Sellae Meningiomas

BACKGROUND

The evolution of skull base approaches associated with individualization of surgical corridor and minimizing the collateral damage. Achieving the radical removal of tumor and preserving the neurological status of the patient is possible, both with the traditional approaches and keyhole approaches. Our work presents experience using the transpalpebral approach (TPA) for microsurgical removal of tuberculum sellae meningioma (TSM).

MATERIALS AND METHODS

A total of 15 patients with meningiomas underwent microsurgical removal of TSM through TPA. Ten patients were women and five were men. The standard preoperative diagnostic protocol includes magnetic resonance imaging with contrast enhancement, brain computed tomography for neuronavigation. We assess surgical complications, functional and cosmetic outcomes, and surgical parameters, including the time of surgery and intraoperative blood loss.

RESULTS

Visual impairment was finding in 100% patients, including slight decrease of vision (46,7%, seven patients), partial vision field loss (six patients, 40%), and serious visual impairment (two patients 13.3%). Visual improvement was noted in ten cases (66.7%), there was no improvement in four cases (26.7%), and one case (6.6%) had transient visual worsening for 4 days and slow improvement in 1 month. Headache disappeared in three patients (50%). There were no cases of cerebrospinal fluid leak. Transient frontal hypoesthesia was noted in all patients (100%) without permanent deficit. Transient palsy of the frontal muscle was noted in four patients for 4-6 months. Histological examination revealed WHO Grade I meningioma in 14 cases and in 1 case WHO Grade II meningioma. No deaths were identified in follow-up at 12 months. The average value of the Modified Rankin Scale was 1.4. The mean length of stay in hospital was 5.

CONCLUSION

TPA is technically difficult and requires some experience to work in deep structures in a small surgical corridor. This technique can be good alternative to traditional fronto-lateral, supraorbital keyhole craniotomies, and endoscopic endonasal approaches.

The extradural minipterional approach for the treatment of paraclinoid aneurysms: a cadaver stepwise dissection and clinical case series

Minipterional (MPT) craniotomy has recently been added to the neurosurgical armamentarium as a less invasive alternative to the pterional craniotomy for the treatment of parasellar lesions. However, its clinical applicability in the treatment of certain complex aneurysms, such as those arising in the paraclinoid region, remains unclear. To illustrate the microsurgical anatomy of a modified extradural MPT approach, which combines a classic MPT craniotomy with an extradural anterior clinoidectomy, and to demonstrate its clinical applicability in the treatment of complex paraclinoid aneurysms. A stepwise extradural MPT approach is illustrated in a cadaver study. Clinical outcome data from a series of 19 patients with 20 paraclinoid aneurysms treated surgically using the extradural MPT approach between 2016 and 2018 were retrospectively collected. In 95% of the cases, complete aneurysm occlusion was achieved. No aneurysm recurrences were seen during follow-up with a median length of 21 months. The outcome, according to the modified Rankin Scale, was 0 points in 12 patients (63%), 1 point in 6 patients (32%), and 2 points in 1 patient (5%). Four out of 6 patients (67%) with initial visual symptoms showed improvement following treatment, whereas in two (11%), vision became worse. The extradural MPT approach ensures a sufficiently large exposure of the paraclinoid region that is comparable with conventional approaches with the advantage of being minimally invasive. Our case series demonstrates the feasibility of this approach for the treatment of complex paraclinoid aneurysms.

Surgical Treatment of Ruptured Anterior Circulation Aneurysms: Comparative Analysis of Modified Mini-Pterional and Standard Pterional Craniotomies

Background

Minimally invasive surgical techniques for cerebral aneurysms have been developed.

Aims

To compare the efficacy and safety of modified mini-pterional (mMPT) and standard pterional (PT) craniotomies for ruptured anterior circulation aneurysms.

Materials and Methods

A total of 45 patients with ruptured anterior circulation aneurysms underwent surgical clipping; for 21 patients PT was used and for 24 patients mMPT was used. Initial clinical demographics and outcomes were retrospectively compared. A systemic inflammatory response syndrome (SIRS) score was derived by summing the number of variables meeting standard criteria for SIRS.

Results

The two groups were comparable with initial clinical demographics. Total operative time was significantly shorter in the mMPT (166.6 minutes, P = 0.001) compared with the PT (235 minutes). The rate of permanent operative morbidity were similar in both groups (P = 0.92). The mean SIRS score at 24 hours after the completion of the operation was significantly lower for patients in the mMPT group (0.96, P = 0.01) as compared to the patients in the PT group (1.81). The rate of postoperative symptomatic vasospasm was significantly lower in patients operated through the mMPT (8.3%, P = 0.03) than the PT (38.1%). Good outcome at discharge was more frequently seen in the mMPT (91.7%) than in the PT (70%), but this difference was not statistically significant (P = 0.11).

Conclusion

The mMPT craniotomy is a safe and less invasive approach for ruptured anterior circulation aneurysms, leading to a significant lower rate of postoperative symptomatic vasospasm and a marginally significant improvement in clinical outcomes.

Lateral supraorbital versus pterional approach for parachiasmal meningiomas: surgical indications and esthetic benefits

The lateral supraorbital (LSO) approach is a minimally invasive modification of the pterional approach. The authors assess the surgical indications and esthetic benefits of the LSO approach in comparison with the pterional approach for parachiasmal meningiomas. From April 2013 to May 2017, a total of 64 patients underwent surgery for parachiasmal meningiomas. Among them, tumor resection was performed with the LSO approach for 34 patients and pterional approach for 30 patients. A retrospective analysis was done on tumor characteristics, surgical outcome, approach-related morbidity, and esthetic outcome between the two approaches. Gross total resection was achieved in 33 of 34 patients (97.1%) with the LSO approach. There were no differences in tumor size, origin, consistency, internal carotid artery encasement, cranial nerve adhesion, and optic canal invasion between the two approaches. The most common tumor origin was the tuberculum sellae for both the LSO and pterional approaches. For tumors with preoperative visual compromise, immediate visual outcome improved or remained stable in 76% and 80.9% with the LSO and pterional approaches, respectively. Surgery time, surgical bleeding, hospital length of stay, and esthetic outcome were significantly shorter and superior with the LSO approach. There were no differences in surgical morbidity and brain retraction injury between the two approaches. The LSO approach can provide a safe, rapid, and minimally invasive exposure for parachiasmal meningiomas compared with the pterional approach. Surgeons must consider tumor size, origin, and extent in determining the resectability of the tumor rather than the extent of exposure.

Evaluation of temporal muscle trophism in relation to the manipulation time and infiltration of 0.5% isobaric bupivacaine through a pterional approach

INTRODUCTION

There are different techniques for the reconstruction of the temporal muscle (TM) in the pterional approach (PA) in order to avoid and reduce atrophy, it has not been able to avoid it in its entirety. The administration of bupivacaine generates regeneration of muscle fibres. There are no studies in the medical literature that evaluate the time of TM manipulation and the use of bupivacaine for the treatment of atrophy after pterional approach, the present investigation aim is to describe the effects of these variables.

PATIENT AND METHODS

Longitudinal study, including patients from 18-80 years old with pterional approach at 2016-2017. We evaluated the effects of the TM manipulation times and the administration of 0.5% bupivacaine on the trophism and function of TM.

RESULTS

Twenty-nine patients underwent a PA; 16(55.17%) count with criteria for 0.5% bupivacain infiltration. We found a negative correlation between manipulation times and trophism, with no statistically significance (p>.05). We evaluated presurgical and postsurgical index of Helkimo and Fonseca's index, finding an increase of disfunction with statistically significance (p<.05). In patients who were infiltrated with 0.5% bupivacaine we observed a mean difference in the TM's trophism of 0.275±1.18mm, in contrast with no infiltrated which was 2.39±1.30mm (t[27] = -5.118, p=.0001).

CONCLUSIONS

The manipulation of the TM during a pterional approach conditioned an impact on the quality of life according to the disfunction indexes, due to atrophy. This investigation exhibits that de administration of 0.5% bupivacaine during surgery offers a decrease in the TM atrophy.

Keyhole strategy aiming at minimizing hospital stay for surgical clipping of unruptured middle cerebral artery aneurysms

OBJECTIVE

Aneurysms of the middle cerebral artery (MCA) are still most often treated by clipping through standard craniotomy, but a longer hospital stay is one of the main drawbacks of this treatment. The authors developed a pterional keyhole clipping strategy for unruptured MCA aneurysms with the intention of minimizing hospital stay. In this paper, they report on their experience with this approach and analyze the long-term neurological and radiological outcomes.

METHODS

A total of 160 relatively small unruptured MCA aneurysms (mean 6.4 mm) were clipped through the pterional keyhole approach (19-30 mm, mean 24.6 mm) in 149 patients (aged 34-79 years, mean 62 years). Neurological and cognitive function were examined by several scales, including the modified Rankin Scale (mRS) and Mini-Mental State Examination (MMSE). Patients' level of depression was assessed using the Beck Depression Inventory and Hamilton Depression Scale. The state of clipping was assessed at 1 year and then every few years after the operation.

RESULTS

The mean duration of postoperative hospitalization was 2.3 ± 3.4 days; in 31.3% of the cases, the patients were discharged on the day after the operation (overnight hospital stay) and in 93.2% within 3 days. Of the patients younger than 60 years, 40.4% required only an overnight stay. Complete aneurysm neck clipping was confirmed in 157 cases (98.1%). None of the completely clipped aneurysms showed any recurrence during the mean follow-up period of 5.0 years. The mean length of clinical follow-up was 5.4 years. After 2 (1.3%) of the surgical procedures, the patients showed persistent neurological deficits, defined as mRS score 1, but the overall operative morbidity based on the International Study of Unruptured Intracranial Aneurysms (ISUIA) definition (mRS score ≥ 2 or MMSE score < 24) was 0% at the last examination. Depression scores were significantly improved after surgery, and in 85.6% of the cases the patients were satisfied with their cosmetic results.

CONCLUSIONS

Pterional keyhole clipping is less invasive than clipping via standard craniotomy, minimizes hospital stay, and achieves durable treatment for relatively small unruptured MCA aneurysms.

Comparative Analysis of the Exposure and Surgical Freedom of the Endoscopic Extended Minipterional Craniotomy and the Transorbital Endoscopic Approach to the Anterior and Middle Cranial Fossae

BACKGROUND

Numerous minimally invasive approaches to the skull base have been successively developed. Knowledge of the surgical nuances of a specific approach may facilitate approach selection. This study sought to compare the nuances of an extended version of the minipterional craniotomy (EMPT) with those of the transorbital endoscopic approach (TOEA) to the anterior and middle cranial fossae (ACF and MCF, respectively).

OBJECTIVE

To quantitatively analyze and compare the area of exposure and surgical freedom between EMPT and TOEA to the ACF and MCF.

METHODS

EMPT and TOEA were carried out in 5 latex-injected cadaveric heads, bilaterally (10 sides). For each approach, the area of exposure, surgical freedom, and angle of attack were obtained with neuronavigation and statistically compared.

RESULTS

No significant difference was found between the mean area of exposure of EMPT and TOEA at the ACF and MCF (P = .709 and .317, respectively). The mean exposure area at the ACF was of 13.4 ± 2.6 cm2 (mean ± standard deviation) and 13.0 ± 1.9 cm2 for EMPT and TOEA, respectively. Except for the crista galli, EMPT afforded a larger area of surgical freedom at all targets. EMPT also achieved significantly greater attack angles in vertical axis except to the crista galli. The horizontal attack angles to all targets were similar between approaches.

CONCLUSION

EMPT and TOEA offer a comparable area of exposure at the ACF and MCF in the cadaver; however, the instrument maneuverability afforded by EMPT is superior. Further studies are necessary to better define their precise surgical application.

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.

Minimally invasive approaches to aneurysms of the anterior circulation: selection criteria and clinical outcomes

Over the last few decades, cerebrovascular surgery has gravitated towards a minimally invasive philosophy without compromising the foundational principles of patient safety and surgical efficacy. Enhanced radiosurveillance modalities and increased average life expectancy have resulted in an increased reported incidence of intracranial aneurysms. Although endovascular therapies have gained popularity in the recent years, microsurgical clipping continues to be of value in the management of these aneurysms owing to its superior occlusion rates, applicability to complex aneurysms and reduced retreatment rates. The concept of keyhole transcranial procedures has advanced the field significantly leading to decreased postoperative neurological morbidity and quicker recovery. The main keyhole neurosurgical approaches include the supraorbital craniotomy (SOC), lateral supraorbital craniotomy (LSOC), mini-pterional craniotomy (MPTC), mini-orbitozygomatic craniotomy and the mini anterior interhemispheric approach (MAIA). As these minimally invasive approaches can have an inherent limitation of a narrow viewing angle and low regional illumination, the use of endoscopic assistance in such procedures is being popularized. Neuroendoscopy can aid in the visualization of hidden neurovascular structures and inspection of the parent arterial segment without undue retraction of the lesion. This review focuses on the historical progression of the surgical management of intracranial aneurysms, the technical details of various minimally invasive approaches, patient selection and clinical outcomes of the anterior circulation aneurysms and useful tenets to avoid complications during these procedures. Meticulous preoperative planning to understand the patient's vascular anatomy, the orientation and relationship of the aneurysm to adjacent structures, use of neuronavigation guidance and endoscopic assistance if needed can lead to an optimal surgical outcome while minimizing neurological morbidity and mortality.

Validation of a Novel Clinical Score: The Rostock Functional and Cosmetic Cranioplasty Score

With a rising number of cranioplasty (CP) procedures and an increasing percentage of patients with a good clinical outcome and prolonged survival after CP, looking at the functional and aesthetic outcome of these patients becomes more and more important. The aim of our study was to evaluate a novel score, combining functional and cosmetics aspects after CP, created at our institution: the Rostock Functional and Cosmetic Cranioplasty (RFCC-) Score. A total of 27 patients were enrolled, representing all indications for a secondary CP after decompressive craniectomy or extended temporal trephination with a complete separation of the temporalis muscle. Besides the clinical evaluation, five different already established clinical rating systems were tested and compared with our score. For reasons of objectivity, the score was also tested against the patient's own rating. Our findings showed that the RFCC-Score, derived from a health professional, is superior to other scoring systems, which only display a facet of the functional state of the patient. Our score is objective and independent of a disposition for a depression of the patient. It can be obtained without the need of a verbal communication, making it applicable for nearly all patients after CP. The score is time-saving, clearly arranged, and reliable, which are inevitable requirements for the comparing and evaluation of different surgical techniques and associated complications of CP.

[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.

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.

Engaging in a Keyhole Concept for the Management of Ruptured and Unruptured Aneurysms

OBJECTIVE

Many new endovascular devices have been used under the guidance of the International Subarachnoid Aneurysm Trial. Clipping still offers higher occlusion rates, and its technique continues to evolve, resulting in smaller exposures and reduced manipulation to brain tissue. We sought to evaluate the routine use of the minisphenoidal approach to manage intracranial aneurysms in a high-volume institution.

METHODS

We retrospectively reviewed our database of patients with aneurysm from October 2013 to May 2016. Data were originally collected prospectively. The minisphenoidal approach has been progressively replacing the pterional approach for managing aneurysms in our department. Occlusion rates for ruptured and unruptured aneurysms were analyzed using late follow-up angiograms. Functional outcome assessment and the impact on quality of life were also measured.

RESULTS

We performed 124 minisphenoidal craniotomies in 117 patients to clip 147 aneurysms. Patient mean age was 53.9 years. Seventy patients (59.8%) presented with subarachnoid hemorrhage. Middle cerebral artery aneurysms represented 48% of the total number of aneurysms; posterior communicating artery aneurysms represented 24%. The minisphenoidal craniotomy was helpful in managing superior cerebellar artery aneurysms and 1 ruptured orbitofrontal artery aneurysm. We achieved an occlusion rate of 97.8%, with a mean follow-up of 13.2 months. Favorable outcomes were achieved for 79% of patients with subarachnoid hemorrhage and for 98% of unruptured patients.

CONCLUSIONS

Evolution of endovascular techniques has paved the way for minimizing surgical exposures. Routine use of the minisphenoidal approach for managing ruptured, unruptured, and previously coiled aneurysms is safe and provides adequate exposure with robust occlusion rates.

Minipterional Craniotomy for Treatment of Unruptured Middle Cerebral Artery Aneurysms. A Single-Center Comparative Analysis with Standard Pterional Approach as Regard to Safety and Efficacy of Aneurysm Clipping and the Advantages of Reconstruction

Pterional craniotomy (PT) has long been the standard approach for the treatment of middle cerebral artery (MCA) aneurysms, even though it may cause temporalis muscle atrophy, facial nerve injury, and masticatory difficulties. Minipterional craniotomy (MPT) is an alternative approach that may provide the same surgical corridor, limiting the risk of postoperative esthetic and functional complications. From January 2011 to December 2014 we consecutively performed 68 craniotomies for surgical treatment of unruptured MCA aneuryms: 37 were standard PT and 31 were MPT. There were no significant differences in mean age, sex, and aneurysm topography between the two groups. The mean skin incision length was 14 cm in the PT group and 6 cm in the MPT group. According to the Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS), there were no significant differences in clinical outcome at discharge or follow-up between the two groups. Also, the rates of complete aneurysm exclusion were comparable. However, the number of patients complaining of masticatory disorders was higher among those treated with PT. Finally, the number of complications observed in the PT group was higher than that in the MPT group, but only the differences in mean hospitalization length and necessity for a dural patch for reconstruction were statistically significant. In conclusion, the MPT approach is a safe and effective alternative to the standard PT for the treatment of unruptured MCA aneurysms.

Drilling of the marginal tubercle to enhance exposure via mini pterional approach: An anatomical study and clinical series of 25 sphenoid wing meningiomas

Background:

The marginal tubercle (MT) of zygomatic bone can be an obstacle in the standard mini pterional (MPT) craniotomy; we aim to evaluate the effect of drilling this MT in enhancing the exposure of MPT craniotomy for resection of sphenoid wing meningiomas (SWMs).

Methods:

The authors utilized 60 dry skulls to perform the anatomical part of the study. The MT size was reflected by the AB distance, wherein point A is the most prominent part of MT and point B is located on the orbital rim in the same axial plane as point A. The authors analyzed the effect of MT size in masking the sphenozygomatic suture (SZS), which is the most anterior part of the MPT craniotomy. One silicon-injected embalmed specimen was used to demonstrate other modifications to the standard MPT approach. The results of the anatomical analysis were translated into the second part of the study, which consisted of the resection of 25 SWMs.

Results:

The MT obscured visualization when the AB distance measured 13 mm or greater. In the clinical series of SWMs, drilling such prominent MT maximized exposure during MPT approach.

Conclusion:

The MPT approach could be used for the resection of SWMs. Drilling of prominent MTs can enhance and optimize exposure to SWMs through standard MPT approaches.

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.