Modified Supraorbital Keyhole Approach to Anterior Circulation Aneurysms

Abstract

ObjectiveTo select a surgical approach for aneurysm clipping by comparing 2 approaches.Materials and Methods204 patients diagnosed with subarachnoid hemorrhage treated by the same neurosurgeon at a single institution from November 2011 to October 2013, 109 underwent surgical clipping. Among these, 40 patients with Hunt and Hess or Fisher grades 2 or lower were selected. Patients were assigned to Group 1 (supraorbital keyhole approach) or Group 2 (modified supraorbital approach). The prognosis according to the difference between the two surgical approaches was retrospectively compared.ResultsSupraorbital keyhole approach (Group 1) was performed in 20 aneurysms (50%) and modified supraorbital approach (Group 2) was used in 20 aneurysms. Baseline characteristics of patients did not differ significantly between two groups. Total operative time (p = 0.226), early ambulation time (p = 0.755), length of hospital stay (p = 0.784), Glasgow Coma Scale at discharge (p = 0.325), and Glasgow Outcome Scale scores (p = 0.427) did not show statistically significant differences. The amount of intraoperative hemorrhage was significantly lower in the supraorbital keyhole approach (p < 0.05).ConclusionThe present series demonstrates the safety and feasibility of the two minimal invasive surgical techniques for clipping the intracranial aneurysms. The modified supraorbital keyhole approach was associated with more hemorrhage than the previous supraorbital keyhole approach, but did not exhibit differences in clinical results, and provided a better surgical view and convenience for surgeons in patients with Hunt and Hess or Fisher grades 2 or lower.

The supraorbital keyhole approach for clipping of anterior circulation ruptured aneurysms

“…Our results of clipping 96% of aneurysms and 82.3% of patients attained favorable outcome support others conclusions [3,5,7,16] that the supraorbital approach can be performed reliably and safely to clip ruptured anterior circulation aneurysms. However the fact that we spare the approach for certain selected aneurysms doesn't support its use for all anterior circulation aneurysms.…”

“…We routinely used lumbar drain inserted before positioning of patient which opened after opening of dura for CSF drainage which facilitate relaxation of the frontal lobe, we think it is of extremely important step because all of our patients presented by aneurysm rupture and brain swelling is expected and blood in subarachnoid spaces made opening of cisterns and drainage of CSF of limited value However some report operating on ruptured aneurysm as early as 2 days through keyhole approach and found slow CSF drainage from cistern is feasible [20]. Others drain cerebrospinal fluid by intraoperative ventriculostomy at Paine's point [6,14,16]. The small sample size, retrospective design of this study and selection of certain aneurysm size type and location are limitations of this report but we reported our experience of clipping the ruptured anterior circulation aneurys through this approach.…”

“…Narrower surgical view and limited exposure, unfamiliar view of anatomy especially of sylvian fissure which appeared laterally in the operative field. This make this approach not universe for all cases and not standard approach like pterional, but should be served for cases when the size and extent of exposure is enough for safe proximal control of parent vessel, appropriate dissection of the aneurysm neck and secure clip application [14,16] We faced intraoperative early rupture of aneurysm in 2 cases (8%) in one patient we couldn't clip the aneurysm a situation realized later and after doing DSA to be related to planning and selection of the aneurysm. Madhugiri et al [17] in a systematic review of Intraoperative Rupture Rates in suprabrow and pterional approaches, they analyzed a total number of 3039 ruptured aneurysms, 2848 aneurysms in the pterional group and 191 in the suprabrow group and they found the rate of intraoperative rupture is higher in suprabrow patients than pterional group 19.37% and 13.8% respectively.…”

“…They reported no frontal sinus exposure and emphasized the importance of measurement of the frontal sinus on pre-operative images [24]. Kim et al made wider craniotomy (4.5cm) and report one sinus exposure in their 10 approaches [16].…”

“…The supraorbital approach has been demonstrated to be useful, particularly in minimization of brain retraction and exposure to air, decreases blood loss, surgical trauma, operative time and infection rates. While its shortcomings include difficult control of frontal air sinus, narrower surgical view and limited exposure of sylvian fissure [14,16,19,22].…”