Elsevier

World Neurosurgery

Volume 109, January 2018, Pages 36-39
World Neurosurgery

Doing More with Less
Minipterional and Supraorbital Keyhole Craniotomies for Ruptured Anterior Circulation Aneurysms: Experience at Single Center

https://doi.org/10.1016/j.wneu.2017.09.058Get rights and content

Background

Keyhole craniotomy is a type of pterional craniotomy that involves a minimally invasive approach for the treatment of cerebral aneurysms. Currently, the minipterional keyhole craniotomy and supraorbital keyhole craniotomy procedures are frequently performed.

Methods

We evaluated the feasibility and safety of supraorbital keyhole craniotomies and minipterional keyhole craniotomy for the clipping of ruptured intracranial aneurysms in the anterior cerebral circulation as an alternative to the pterional approach in a consecutive series of 25 patients.

Results

The rate of intraoperative aneurysmal rupture was 8% (2/25), and all ruptures were safely controlled.

Conclusion

The success solely depends on careful selection of patients and the experience of the surgical team.

Introduction

Minimally invasive surgery has become a standard of care in neurosurgery. Keyhole approaches for treating intracerebral aneurysms are effective and advantageous. Their smaller incisions result in less muscle dissection, minimal craniotomy, and less brain retraction, with a similar microsurgical field and full access to the lesions. These approaches can expose critical anatomic structures that aid in successfully clipping an aneurysm.1 The minipterional keyhole craniotomy (MPKC) and supraorbital keyhole craniotomy (SOKC) procedures have been developed as alternative modalities for the treatment of unruptured anterior circulation aneurysms.1, 2, 3 However, these approaches have some safety issues, especially when an intraoperative rupture occurs. The small corridor poses a challenge for the neurosurgeon for bleeding control.

Keyhole surgery is not a novel topic for the global neurosurgical community, especially in advanced medical countries. However, in Vietnam, the application of the minimally invasive keyhole approach to intracranial injuries is only beginning in most medical centers. For cases treated with the keyhole approach, complicated injuries such as ruptured aneurysms that require a minimally invasive approach are even more rare. Thus we started this case series to compare its treatment efficacy with that of the traditional approach applied in previous patients. Our objective is to apply the minimally invasive approach to alleviate complications resulting from the conventional approach.

In this article, we describe our experiences treating 25 cases of ruptured aneurysms using MPKC and SOKC approaches and discuss how to avoid and manage intraoperative aneurysm rupture.

Section snippets

Methods

Approval for the study was issued by the Scientific Research & Medical Ethics Committee at our hospital. Written consent and authorization were obtained before the surgeries and submission of this article.

From June 2015 to January 2017, we conducted a prospective case series of 25 patients with ruptured anterior circulation aneurysms. All were treated with clipping using SOKC or MPKC approaches by a single neurosurgical team. All cases presented to the emergency department with subarachnoid,

Supraorbital Keyhole Approach

The patient was placed in a supine position, with his or her head elevated 15°, retroflexed, and rotated 20–30° to the contralateral side. A 3.5- to 5-cm skin incision was made within the eyebrow or frontal skin fold, starting from the lateral supraorbital foramen, following the orbital rim, and extending to the end of the scheduled craniotomy. The temporal fascia was incised about 10–15 mm and retracted from the superior temporal line using fish hooks and rubber bands. A single burr hole was

Results

Twenty-eight aneurysms were clipped in 25 patients. The median age was 55 (range: 32–75) years, with a female-to-male ratio of 14/11. One case had 2 aneurysms that were treated with a single SOKC, and 1 had 3 aneurysms that were clipped by an MPKC. We selected patients with good preoperative conditions (H-H I–III): 21/25 (84%) were H-H I–II cases, and 4 were H-H III (16%) cases. The majority (96%, 24/25) of the cases were evaluated, and the surgical plan was based on the CT angiography results.

Discussion

Perneczky first advocated for the use of minimal craniotomy to treat various intracranial pathologies.4, 7, 9 The primary goal of this concept is to safely access the pathologies at the end of a “reverse funnel-shaped corridor” with minimal exposure of the anatomic structures, thereby reducing soft tissue and approach-related brain injuries. The objective is to avoid scarring to achieve safety and effectiveness that are comparable with using conventional approaches.

At Da Nang hospital, the

Conclusion

We believe that SOKC and MPKC are feasible and safe options in certain patients with ruptured aneurysms. Success solely depends on careful selection and the experience of the surgical team. Moreover, these approaches have advantages, such as less soft tissue damage, quicker recovery, and better cosmetic results.

Acknowledgments

Special thanks to Quoc-Anh Thai, M.D., FAANS, FACS, for his valuable opinions on this article. We thank Elsevier Editing Service for strengthening the English in this paper.

References (14)

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  • A meta-analysis of Lateral supraorbital vs mini Pterional approach in the outcome of rupture and unruptured noncomplex aneurysms’ surgery

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    After the initial searching, 19 articles were found to be eligible for further analysis. After applying all exclusion and inclusion criteria, there were six articles left into the final article pool (Fig. 1).17–22 The detailed meta-analysis results on these articles are presented in Table 2b.

  • Supraorbital Keyhole Craniotomy in Pediatric Neurosurgery: A Systematic Review of Clinical Outcomes and Cosmetic Outcomes

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    As with other small cranial openings, the supraorbital keyhole (relative to larger craniotomies) approach involves a smaller operative space15,16 with decreased lighting17,18 and requires more advanced planning with a higher degree of technical skills to achieve surgical goals while avoiding complications such as facial nerve injury.19 Adult studies have reported the use of supraorbital keyhole craniotomy for treatment of craniopharyngioma,2,19,20 meningioma,19-24 and anterior circulation aneurysms with good outcomes.2,17,25-30 When considering pediatric patients, however, the supraorbital keyhole approach has not been used as extensively.

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Conflict of interest statement: The authors have no potential conflicts of interest.

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