Keyhole approach in anterior circulation aneurysm: Current indication, advantages, technical limitations, complications and their avoidance

Abstract

Keyhole surgery recently evolved as a minimal invasive surgical approach for treatment of anterior circulation aneurysm. This review was done to evaluate the keyhole approach for anterior circulation aneurysms, their indications, advantages, technical limitations, complications and their avoidance. The literature review was performed with the phrase "keyhole approach for anterior circulation aneurysm" as a search term in PubMed central, Medline, Google scholar and Embase data base to identify all the articles published till December 2020. Out of 113 articles searched, 22 were included in this review after screening for eligibility. On analyzing these articles, there was total 2058 aneurysm in 1871 patients. Out of 2058 aneurysm, 988 were ruptured and 547 unruptured. In 5 studies, which include 344 aneurysms in 344 cases, aneurysm ruptured or unruptured status was not specified. The most frequent aneurysm site was anterior communicating artery (n=573). The size of the aneurysm mentioned in most of the study was <15 mm. The rate of complete occlusion was ranged from 93.6-100%. The range of intra operative rupture (IOR) was 0-28.6%. The mean operative time was ranged from 70 min-5.34 hours as reported in 13 studies. Good outcome [Glasgow outcome scale (GOS): 4-5] were seen in 75-100% cases. The frontalis muscle weakness has been reported in 3 studies and ranged from 0-1.99%. Keyhole surgery can be a safe and effective treatment modality for treatment of a selected anterior circulation aneurysm. In the experienced hand it has certain advantages over standard pterional craniotomy.

Keyhole Microsurgery for Cerebral Aneurysms

“…It is important that minimally invasive approaches make it possible to minimize iatrogenic trauma by creating an individual surgical corridor. The principle of "individual" access to cerebral aneurysms is reduced to the use of several minimally invasive approaches depending on the specific neuroimaging pattern in comparison with the previously used algorithm and the choice of pterional craniotomy for all aneurysms of the anterior cerebral arterial circle [2][3][4][5][6][7].…”

“…The main goal of individualization is to create the shortest efficient route to the target with minimal collateral damage, ensuring the safety of the intervention. Individualized minimally invasive approach in the microsurgical treatment of cerebral aneurysms improves surgical and clinical outcomes, reduces the time of surgery, length of stay in the hospital, and the cost of treatment and provides excellent cosmetic results [4,6,7].…”