Supraorbital Eyebrow Craniotomy for Removal of Intraaxial Frontal Brain Tumors: A Technical Note

doi:10.1016/j.wneu.2012.11.051

World Neurosurgery

Volume 81, Issue 2, February 2014, Pages 348-356

https://doi.org/10.1016/j.wneu.2012.11.051 Get rights and content

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.

Introduction

The supraorbital (SO) keyhole approach to the anterior cranial fossa, suprasellar, and parasellar regions has been well described 4, 6, 7, 8, 9, 11, 13, 15, 16, 20, 26, 27, 28, 29. Its role in the treatment of extraaxial lesions, including meningiomas, craniopharyngiomas, and optic apparatus neoplasms, has also been well established by Reisch and Perneczky 19, 20, our group 5, 13, and others 10, 18. However, few articles have addressed the utility of this approach in the treatment of intraaxial lesions, such as metastatic brain tumors and gliomas 10, 18, 19. Although Reisch and Perneczky (19) included nine frontal gliomas and seven metastatic brain tumors in their extensive report on the utility of the SO approach in 450 cases, its use for intraaxial frontal lesions was not specifically discussed. Jallo et al. (10) also presented their experience with this technique in pediatric patients, but the cases included predominantly extraaxial lesions.

In this study, we describe the use of the SO “eyebrow” craniotomy for intraaxial frontal brain tumors, discuss key technical aspects of the approach, and consider selection criteria for its use versus a traditional frontal craniotomy. In this regard, there are three guiding principles. First, an approach that minimizes brain exposure and transgression of normal brain parenchyma yet allows maximal and safe tumor removal should be chosen. Second, the amount of scalp, muscle, and bone dissection should be minimized. Third, incisions in non–hair-bearing scalp (i.e., the forehead) should be avoided. In a significant portion of intraaxial frontal lesions, particularly lesions of the frontal pole and orbitofrontal regions, the SO approach achieves all these principles, while promoting a relatively rapid recovery with a short hospital stay and minimal pain.

Section snippets

Patient Population and Data Collection

All patients who had a SO approach performed for removal of an intraaxial brain lesion by the senior author (D.F.K.) between September 2008 and January 2011 at Saint John’s Health Center were included for analysis. Patients’ medical records, clinical visits, and imaging studies were reviewed until last available follow-up. Tumor pathology, postoperative complications, and clinical outcomes including operative times and estimated blood loss were collected. Hospital length of stay beginning from

Patient Cohort

Data are summarized in Table 1, Table 2, Table 3. Over 28 months, 10 patients (mean age, 65 years ± 8) underwent 11 SO craniotomies for removal of symptomatic intraaxial lesions. There were seven patients with metastatic carcinoma (mean maximal tumor diameter, 37 mm ± 15) and two patients with gliomas (mean tumor diameter, 16 mm ± 5), including a patient with a pilocytic astrocytoma of the hypothalamus and gyrus rectus region and a patient with a multifocal glioblastoma previously treated for

Discussion

Surgical resection is generally considered first-line therapy for patients with large symptomatic brain metastases and gliomas followed by radiotherapy, radiosurgery, and/or chemotherapy. In these patients, minimizing brain exposure and facilitating a rapid recovery so as not to delay needed adjuvant therapy is an important goal. SO craniotomy appears to offer an excellent approach for many such frontal lobe tumors. Despite the small area of dural exposure, the SO route provides a relatively

Conclusions

In this small series, SO craniotomy is shown to provide a safe, effective, and direct route for intraaxial tumors of the frontal pole and orbitofrontal regions with little or no need for brain retraction. It facilitates a relatively rapid recovery and is associated with a short hospital stay. This approach is ideal for metastases and appropriate for some select gliomas of this region, provided that they are not too superficial with cortical extension beyond the small window of the craniotomy.

Acknowledgments

We would like to acknowledge support of this study from the following individuals: Carole Zumbro and George Adler Family; Carole and Jeff Schwartz; Ruth K. March and Family.

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To reach this area, both standard uni- or bifrontal craniotomy (through a bicoronal skin incision) and pterional approach have been described as the preferred approaches. In some highly selected cases of HGG, supraorbital transciliary approach [1–4] should be discussed with 5-Aminolevulinic Acid use which facilitates the extend of resection, especially when differentiating normal brain from tumor periphery is challenging [5,6]. In this pandemic Covid19 related time, all surgeries permitting a short hospital stay must be considered.
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The microscopic transciliary SupraOrbital keyhole (mtSO) approach has been added to the surgical armamentarium since its first description1-3 to treat pathologies such as suprasellar and third-ventricle craniopharyngiomas,4 suprasellar recurrent pituitary adenomas,5,6 anterior-circulation aneurysms,5-10 anterior cranial fossa midline meningiomas,11,12 frontal brain tumors,13 and many others.14
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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.
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: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Peer-Review ReportSupraorbital Eyebrow Craniotomy for Removal of Intraaxial Frontal Brain Tumors: A Technical Note

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Patient Population and Data Collection

Patient Cohort

Discussion

Conclusions

Acknowledgments

Surg Neurol

Surgical resection of brain metastases from lung cancer

Acta Neurochir (Wien)

The transorbital keyhole approach: early and long-term outcome analysis of approach-related morbidity and cosmetic results

J Neurosurg

The two-point method: evaluating brain stem lesions

BNI Quarterly

Quantitative anatomic study of the transciliary supraorbital approach: benefits of additional orbital osteotomy?

Neurosurgery

Endonasal versus supraorbital keyhole removal of craniopharyngiomas and tuberculum sellae meningiomas

Neurosurgery

Supraorbital minicraniotomy

Skull Base Surg

Supraorbital eyebrow approach to skull base lesions

Arq Neuropsiquiatr

An anatomical evaluation of the mini-supraorbital approach and comparison with standard craniotomies

Neurosurgery

The keyhole concept in aneurysm surgery: results of the past 20 years

Neurosurgery

A superciliary approach for anterior cranial fossa lesions in children. Technical note

J Neurosurg

Orbital roof craniotomy via an eyebrow incision: a simplified anterior skull base approach

Minim Invasive Neurosurg

Tumor bed radiosurgery after resection of cerebral metastases

Neurosurgery

The supraorbital approach for recurrent or residual suprasellar tumors

Minim Invasive Neurosurg

Peer-Review Report
Supraorbital Eyebrow Craniotomy for Removal of Intraaxial Frontal Brain Tumors: A Technical Note