Monolateral Pterional Keyhole Approaches to Bilateral Cerebral Aneurysms: Anatomy and Clinical Application

Yu, Long; Shang-Guan, Huang-Cheng; Chen, Guorong; Zheng, Shi; Lin, Yuanxiang; Zhang, Lin; Yao, Pei-Sen; Kang, Dezhi

doi:10.1016/j.wneu.2017.09.048

Cited by 7 publications

(7 citation statements)

References 17 publications

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“…The versatility of the pterional approach is such that it can be used even for aneurysms of the contralateral side, as demonstrated by many authors (46)(47)(48)(49)(50), and also confirmed by the reported illustrative case. Our long-lasting experience in the surgical management of intracranial aneurysms allowed us to identify some variables at the basis of the tailoring of the pterional approach route to the basilar tip, the so-called "half-and-half approach" (57,58).…”

Section: Tailoring the Pterional Approachsupporting

confidence: 67%

Pterional Approach: Technical Variations, Functional, and Cosmetic Outcome in a Series of 1000 Patients

et al. 2022

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INTRODUCTION Most of the versatility of the pterional approach depends on a series of variations progressively reported by several groups, but little emphasized over the years. The present study condenses the technical notes which the authors adopted in their practice to maximize the surgical freedom of the pterional approach, at once lessening the approach-related complication rate. METHODS Data of a series of patients who underwent a pterional approach between January 2011 and May 2021 were retrospectively reviewed focusing on the technical variations compared to the original Yaşargil’s description. The anatomical rationale, technique, and advantages were outlined and validated through the appraisal of functional and cosmetic complications. RESULTS 994 patients were reviewed. Head extension was avoided in the case of anterior clinoidectomy. A single double-layered galea-pericranium flap was used for duraplasty. The submuscular technique, with compulsive preservation of deep temporal fascia and deep temporal arteries, was preferred for temporalis muscle dissection. McCarty keyhole was never used, thus avoiding exposing the orbit if unnecessary. Widening of the superior orbital fissure and thinning of the orbital roof allowed to significantly increase the working area. The average follow-up was 7.2 years. The overall rate of functional and cosmetic complications was 2.1. DISCUSSION In the authors' experience, the gradual adoption of technical variations related to the patient's positioning, soft tissue dissection, bony work, dura opening, and reconstruction allowed to enhance the versatility of the pterional approach concurrently decreasing the risk of functional and cosmetic complications.

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Section: Tailoring the Pterional Approachsupporting

confidence: 67%

Pterional Approach: Technical Variations, Functional, and Cosmetic Outcome in a Series of 1000 Patients

et al. 2022

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“…Incising the contralateral falciform ligament was reported to increase exposure to the paraclinoid ICA by 2 mm in the proximal direction. 5 In addition to freeing the falciform ligament, drilling the contralateral portion of the tuberculum sellae and planum sphenoidale increases exposure of the paraclinoid ICA from 6.6 to 9 mm. 4 These maneuvers increase the interoptic space in a stepwise fashion.…”

Section: Methods To Increase Mobilization Of the Contralateral Optic Nervementioning

confidence: 99%

“…The IOT can be identified after the frontal lobe is sufficiently separated from the optic apparatus. 9 In the literature, contralateral falciform ligament disconnection 5 (Fig. 1B) and tuberculum sellae drilling 10 are the two methods that have been reported to significantly expand the size of the IOT and the exposure of the contralateral paraclinoid ICA.…”

Section: Surgical Approachmentioning

confidence: 99%

“…The olfactory nerve, which connects the basal frontal lobe and anterior skull base, is at risk of damage during the frontal lobe elevation. 5,16,17 Andrade-Barazarte et al 16 reported that the risk of olfactory dysfunction is minimized when the olfactory tract can be fully mobilized after it is dissected free from the surrounding arachnoid adhesions.…”

Section: Advantages Of the Contralateral Interoptic Approachmentioning

confidence: 99%

“…The anatomical relationships between the neurovascular structures, the accessibility of this trajectory, and other related factors have been thoroughly investigated in the literature. [3][4][5][6] However, to our knowledge, no preoperative algorithm has been developed for approach selection, which could help in deciding whether this challenging but effective approach should be selected for the treatment of certain aneurysms. We conducted a quantitative anatomical study to develop a pre-ABBREVIATIONS DDR = distal dural ring; ICA = internal carotid artery; IOT = interoptic triangle.…”

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confidence: 99%

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Contralateral interoptic approach to paraclinoid aneurysms: a patient-selection algorithm based on anatomical investigation and clinical validation

Zhao¹,

Meybodi²,

Labib³

et al. 2021

Journal of Neurosurgery

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OBJECTIVEAneurysms that arise on the medial surface of the paraclinoid segment of the internal carotid artery (ICA) are surgically challenging. The contralateral interoptic trajectory, which uses the space between the optic nerves, can partially expose the medial surface of the paraclinoid ICA. In this study, the authors quantitatively measure the area of the medial ICA accessible through the interoptic triangle and propose a potential patient-selection algorithm that is based on preoperative measurements on angiographic imaging.METHODSThe contralateral interoptic trajectory was studied on 10 sides of 5 cadaveric heads, through which the medial paraclinoid ICA was identified. The falciform ligament medial to the contralateral optic canal was incised, the contralateral optic nerve was gently elevated, and the medial surface of the paraclinoid ICA was inspected via different viewing angles to obtain maximal exposure. The accessible area on the carotid artery was outlined. The distance from the distal dural ring (DDR) to the proximal and distal borders of this accessible area was measured. The superior and inferior borders were measured using the clockface method relative to a vertical line on the coronal plane. To validate these parameters, preoperative measurements and intraoperative findings were reviewed in 8 clinical cases.RESULTSIn the sagittal plane, the mean (SD) distances from the DDR to the proximal and distal ends of the accessible area on the paraclinoid ICA were 2.5 (1.52) mm and 8.4 (2.32) mm, respectively. In the coronal plane, the mean (SD) angles of the superior and inferior ends of the accessible area relative to a vertical line were 21.7° (14.84°) and 130.9° (12.75°), respectively. Six (75%) of 8 clinical cases were consistent with the proposed patient-selection algorithm.CONCLUSIONSThe contralateral interoptic approach is a feasible route to access aneurysms that arise from the medial paraclinoid ICA. An aneurysm can be safely clipped via the contralateral interoptic trajectory if 1) both proximal and distal borders of the aneurysm neck are 2.5–8.4 mm distal to the DDR, and 2) at least one border of the aneurysm neck on the coronal clockface is 21.7°–130.9° medial to the vertical line.

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A literature review concerning contralateral approaches to paraclinoid internal carotid artery aneurysms

Serrano¹,

Ayyad²,

Archavlis³

et al. 2018

Neurosurg Rev

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Monolateral Pterional Keyhole Approaches to Bilateral Cerebral Aneurysms: Anatomy and Clinical Application

Cited by 7 publications

References 17 publications

Pterional Approach: Technical Variations, Functional, and Cosmetic Outcome in a Series of 1000 Patients

Pterional Approach: Technical Variations, Functional, and Cosmetic Outcome in a Series of 1000 Patients

Contralateral interoptic approach to paraclinoid aneurysms: a patient-selection algorithm based on anatomical investigation and clinical validation

A literature review concerning contralateral approaches to paraclinoid internal carotid artery aneurysms

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