Elsevier

World Neurosurgery

Volume 107, November 2017, Pages 554-558
World Neurosurgery

Original Article
Neurosurgical “Squeeze Play”: Single Incision with Dual Ipsilateral Craniotomies Versus 2 Separate Approaches for Intracranial Aneurysm Treatment

https://doi.org/10.1016/j.wneu.2017.08.032Get rights and content

Objective

Patients with bilateral, multiple intracranial aneurysms (IA) can be safely treated using 1 lateral craniotomy. However, in patients with an additional pericallosal artery (PcaA) or distal anterior cerebral artery (ACA) aneurysm, an interhemispheric approach through a bifrontal craniotomy is needed. We investigated the safety of a single incision with dual ipsilateral craniotomies (“squeeze play”) and compared results with 2 separate staged surgeries.

Methods

Retrospective data collection and analysis was performed of all cases of multiple IAs including a PcaA or complex ACA aneurysm between 1997 and 2016. Univariate statistical analysis was performed to compare radiologic and clinical outcomes.

Results

Both the squeeze play group (n = 12) and the control group (n = 16) showed similar female gender and mean age distribution, with a higher mean aneurysm number in the squeeze play group. Indication for surgery was mainly subarachnoid hemorrhage (SAH) for the control group (12/16). Mean aneurysm diameter of the largest aneurysm treated with the lateral craniotomy was higher in the squeeze play group (15.8 vs. 4.7 mm, P = 0.005), with comparable craniotomy types between both groups. Cumulative estimated blood loss was higher in the control group, with a comparable cumulative operating room time, reoperation rate, and favorable clinical outcome in both groups.

Conclusions

Single-staged surgery with a single incision and dual ipsilateral craniotomies is a safe treatment for multiple unruptured aneurysms that include PcaA and distal ACA aneurysms. The squeeze play results in clinical and radiologic outcomes comparable with those in a 2-staged control group. In the setting of SAH, 2-staged surgery with a recovery interval is preferred to prevent bilateral manipulation of the acutely injured brain.

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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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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