J Cerebrovasc Endovasc Neurosurg.  2013 Mar;15(1):5-12. 10.7461/jcen.2013.15.1.5.

Comparative Analysis of the Mini-pterional and Supraorbital Keyhole Craniotomies for Unruptured Aneurysms with Numeric Measurements of Their Geometric Configurations

• Kang HJ
• Lee YS
• Suh SJ
• Lee JH
• Ryu KY
• Kang DG

• KMID: 2172024
• DOI: http://doi.org/10.7461/jcen.2013.15.1.5

Abstract

OBJECTIVE
Keyhole craniotomy is a modification of pterional craniotomy that allows for use of a minimally invasive approach toward cerebral aneurysms. Currently, mini-pterional (MPKC) and supraorbital keyhole craniotomies (SOKC) are commonly used. In this study, we measured and compared the geometric configurations of surgical exposure provided by MPKC and SOKC.
METHODS
Nine patients underwent MPKC and four underwent SOKC. Their postoperative contrast-enhanced brain computed tomographic scans were evaluated. The transverse and longitudinal diameters and areas of exposure were measured. The locations of the anterior communicating artery, bifurcation of the middle cerebral artery (MCAB), and the internal carotid artery (ICA) terminal were identified, and the working angles and depths for these targets were measured.
RESULTS
No significant differences in the transverse diameters of exposure were observed between MPKC and SOKC. However, the longitudinal diameters and the areas were significantly larger, by 1.5 times in MPKC. MPKC provided larger operable working angles for the targets. The angles by MPKC, particularly for the MCAB, reached up to 1.9-fold of those by SOKC. Greater working depths were required in order to reach the targets by SOKC, and the differences were the greatest in the MCAB by 1.6-fold.
CONCLUSION
MPKC provides larger exposure than SOKC with a similar length of skin incision. MPKC allows for use of a direct transsylvian approach, and exposes the target in a wide working angle within a short distance. Despite some limitations in exposure, SOKC is suitable for a direct subfrontal approach, and provides a more anteromedial and basal view. MCAB and posteriorly directing ICA terminal aneurysms can be good candidates for MPKC.

Keyword

Cerebral aneurysm; Craniotomy; Minimally invasive; Mini-pterional; Supraorbital; Surgical exposure

MeSH Terms

Aneurysm
Arteries
Brain
Carotid Artery, Internal
Craniotomy
Humans
Intracranial Aneurysm
Middle Cerebral Artery
Skin

Figure

• 

  Fig. 1 The illustration depicts the microscopically operable working angles for the anterior communicating artery, the terminal of the internal carotid artery, and the bifurcation of the middle cerebral artery when approached by the mini-pterional keyhole craniotomy (A) and the supraorbital keyhole craniotomy (B). The simplified diagram (C) describes the working angle (black arrow) and the trajectory line (asterisk). The working depth refers to the length of the trajectory line. The black arrow head indicates a half angle of the working angle.

• 

  Fig. 2 The illustration (A) shows the different locations of the skin incision (red dotted line), size and shape of the bone flap (blue dotted line and area), and direction of skin retraction (red arrows) for the supraorbital keyhole craniotomy (SOKC) and the mini-pterional keyhole craniotomy (MPKC). The courses of the supraorbital nerve and artery (black arrow head) and the frontal branches of the facial nerve (white arrow head) are shown. Intraoperative photographs show the area of surgical exposure created by the SOKC (B) and MPKC (C). Note that the basal frontal lobe is exposed by the semilunar SOKC using only upward skin retraction, whereas the sylvian fissure is directly exposed by the MPKC using bilateral skin retraction.

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