J Cerebrovasc Endovasc Neurosurg.  2016 Mar;18(1):5-11. 10.7461/jcen.2016.18.1.5.

Modified Supraorbital Keyhole Approach to Anterior Circulation Aneurysms

• Kim Y
• Yoo CJ
• Park CW
• Kim MJ
• Choi DH
• Kim YJ
• Park K

• KMID: 2161696
• DOI: http://doi.org/10.7461/jcen.2016.18.1.5

Abstract

OBJECTIVE
To select a surgical approach for aneurysm clipping by comparing 2 approaches.
MATERIALS AND METHODS
204 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.
RESULTS
Supraorbital 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).
CONCLUSION
The 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.

Keyword

Minimally invasive surgical procedures; Craniotomy; Intracranial aneurysm

MeSH Terms

Aneurysm*
Craniotomy
Early Ambulation
Glasgow Coma Scale
Glasgow Outcome Scale
Hemorrhage
Humans
Intracranial Aneurysm
Length of Stay
Operative Time
Prognosis
Retrospective Studies
Subarachnoid Hemorrhage
Surgical Instruments
Surgical Procedures, Minimally Invasive

Figure

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  Fig. 1 Surgical methods to the anterior circulation aneurysm clipping. (A) Group 1 (Supraorbital keyhole approach), (B) Group 2 (Modified supraorbital keyhole approach). Tm = temporalis muscle; F = frontal lobe; K = key hole.

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  Fig. 2 Microscope view (A) Group 1 (Supraorbital keyhole approach). Clipping of ruptured aneurysm of Rt. MCA bifurcation. Operative view under craniotomy and durotomy. The sylvian vein is not well exposed as it is hidden under the lateral side of the craniotomy site (A-1). Approaching the Sylvian vein using a subfrontal approach (A-2). The retractor is placed under the frontal base. The angle of the retractor is nearly perpendicular to the skull base (A-3). (B) Group 2 (Modified supraorbital keyhole approach). Clipping of ruptured aneurysm of Lt. MCA bifurcation. The path of the Sylvian vein is well exposed after durotomy (B-1). The frontal lobe and temporal lobe is retracted to the side and allows for a more accessible Sylvian dissection (B-2). The retractor angle is less steep and the angle between retractors is wider (B-3). MCA = middle cerebral artery.

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