Doing More with LessMinipterional and Supraorbital Keyhole Craniotomies for Ruptured Anterior Circulation Aneurysms: Experience at Single Center
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.
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Conflict of interest statement: The authors have no potential conflicts of interest.