Efficacy and safety of the pterional keyhole approach for the treatment of anterior circulation aneurysms

Abstract

Keyhole surgery is partly replacing the standard pterional approach in patients undergoing surgery to treat aneurysms of the anterior circulation. We describe the pterional keyhole approach for the clipping of anterior circulation aneurysms and discuss the efficacy and safety of our keyhole craniotomy procedure. We treated 103 patients with 111 intracranial aneurysms by surgical clipping via the pterional keyhole approach and retrospectively compared the characteristics and clinical outcomes of the keyhole procedure and the standard pterional approach. We also compared the surgical results of the keyhole approach when the operator was an experienced neurosurgeon or a less experienced neurosurgeon guided by an experienced colleague. All keyhole operations were carried out successfully without enlargement of the craniotomy or a change to a different approach. The outcomes of the keyhole and the standard pterional approach in patients with subarachnoid hemorrhage were not significantly different. Favorable outcomes were obtained in patients with unruptured aneurysms treated by either experienced or less experienced surgeons. The pterional keyhole approach offers the same surgical possibilities as conventional pterional approaches for the treatment of anterior circulation aneurysms. It is safe and simple and yields favorable outcomes even if the operators are less experienced neurosurgeons. Careful patient selection and sufficient opening of the sylvian fissure are the key points for good outcomes and the prevention of intraoperative complications.

Superficial Temporal Artery-Sparing Mini-Pterional Approach for Cerebral Aneurysm Surgery

“…This includes the supraorbital keyhole approach using eyebrow incision4,17). The second is the “trans-sylvian approach”14) that includes the pterional keyhole approach1,18). These so-called “keyhole” surgeries have the advantage of a small wound.…”

“…The aim of this approach is to reduce the surgical wound size while maintaining a surgical field that is as wide as possible. However, atrophy of the temporalis muscle can not be resolved6,10,13,18).…”

Use of Three-Dimensional Curved-Multiplanar Reconstruction Images for Sylvian Dissection in Microsurgery of Middle Cerebral Artery Aneurysms

“…Perneczky, et al5 introduced the keyhole concept in neurosurgery. Since the keyhole technique is less-invasive and requires small skin incisions and craniotomies and leads to minimal brain exposure, many neurosurgeons have reported the usefulness of modified pterional keyhole approaches 67891011. Hernesniemi, et al7 suggested the use of focused sylvian opening, which is a less-invasive alternative to the classical wide sylvian opening, which is used for the microsurgical management of most MCA aneurysms.…”

Retractorless Surgery for Anterior Circulation Aneurysms via a Pterional Keyhole Approach

“…After drilling off the sphenoid wing, the visual angle of microscope will increase by 0-15º, which will maximize the working space without the use of fixed retractors. Second, in order to avoid the use of fixed retractors, widely opening the sylvian fissure to the basal cisterns and adequately releasing CSF should be performed (18,19). Cranial cavity was composed of brain, CSF, and blood supply.…”