Original ArticleNeurosurgical “Squeeze Play”: Single Incision with Dual Ipsilateral Craniotomies Versus 2 Separate Approaches for Intracranial Aneurysm Treatment
Introduction
Multiple intracranial aneurysms have a reported incidence of 14% to 34% and pose a neurosurgical challenge that often requires multiple treatments.1, 2, 3 Multiple intracranial aneurysms have been shown to lead to an increased risk of poor outcomes in the setting of subarachnoid hemorrhage (SAH).4 The neurosurgical treatment of patients with multiple intracranial aneurysms is complex because of the variability in the anatomic distribution of these lesions, the potential difficulty in identifying the site of rupture in SAH, and the significant anxiety experienced by patients.5, 6 For supratentorial multiple intracranial aneurysms, treatment with a single operation using a lateral craniotomy has been recommended.3, 7 However, for the 20% of multiple, bilateral intracranial aneurysms, a single-stage approach is challenging, and complete treatment may require 2 stages. However, some bilateral intracranial aneurysms may be amenable to a single-stage approach.7, 8, 9 The presence of a pericallosal artery aneurysm (PcaA) or a complex distal anterior cerebral artery (ACA) aneurysm complicates the surgical strategy because an interhemispheric approach through a bifrontal craniotomy typically requires a separate procedure. In this study, we investigated whether a single incision with dual ipsilateral craniotomies would be safe with PcaA or complex ACA aneurysms, and we compared the results from this approach with those from 2 separate staged craniotomies for multiple aneurysms.
Section snippets
Inclusion Criteria
This study was approved by the University of California San Francisco Institutional Review Board and performed in compliance with Health Insurance Probability Portability and Accountability Act regulations. Patients operated on with a single incision and dual ipsilateral craniotomies (1 lateral and 1 medial craniotomy, squeeze play) and patients operated on with 2 separate approaches (1 lateral and 1 medial craniotomy, control group) by the senior author (M.T.L.) were identified in a
Results
Overall, 28 patients with 106 aneurysms were analyzed in this study, including 12 patients who underwent squeeze play operations with dual ipsilateral craniotomies and 16 patients in the control group who were treated in separate staged surgeries. All aneurysms were successfully clipped (n = 104) or trapped with a bypass procedure (n = 2) as confirmed by postoperative angiography or computed tomographic angiography. Both bypass patients were in the squeeze play group, and the bifrontal
Discussion
Currently, there are no guidelines for the neurosurgical treatment of multiple intracranial aneurysms or the choice of the specific approach.6 A single-stage approach via a lateral craniotomy is commonly performed for multiple unilateral supratentorial unruptured intracranial aneurysms.3 For bilateral multiple intracranial aneurysms, a single-stage approach is also possible if the anatomy enables access across the midline, as for internal carotid artery terminus, ophthalmic artery, and some
Conclusion
Single-staged surgery via a single incision with dual ipsilateral craniotomies (squeeze play) is safe for the treatment of multiple unruptured intracranial aneurysms that include pericallosal and distal ACA aneurysms. The squeeze play results in clinical and radiologic outcomes comparable with those of a 2-staged control group. In the setting of SAH, 2-stage surgery is preferred to prevent bilateral manipulation of the acutely injured brain parenchyma.
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Cited by (0)
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.