Cuerpo extraño intraorbitario extraído mediante abordaje pterional extradural / Intraorbial foreign body removed by extradural pterional approach

RESUMEN Paciente femenina de 9 años de edad, remitida al Hospital Pediátrico Universitario de Holguín "Octavio de la Concepción de la Pedraja", con el diagnóstico presuntivo de celulitis orbitaria izquierda. Se recoge el antecedente de trauma ocular ipsilateral con objeto de madera hacía un año, por lo que presentó como secuela disminución de la agudeza visual del ojo izquierdo. Al examen oftalmológico presentaba edema y secreciones purulentas a través de trayecto fistuloso en el párpado inferior. Se le realiza ecografía, tomografía computarizada e imagen por resonancia magnética de cráneo y órbitas, con sospecha de cuerpo extraño vegetal. Se decide realizar abordaje pterional extradural, y se logra la extracción de fragmento de madera. Cursa con tratamiento antibiótico con desaparición de las secreciones a las 48 horas del posoperatorio. La evolución ha sido favorable. Los traumas oculares son frecuentes, pero la presencia de cuerpos extraños intraorbitarios son eventos raros que desencadenan un proceso inflamatorio local, cuya magnitud estará en relación con la naturaleza de este. Los estudios imagenológicos son un elemento indispensable para el diagnóstico y la planificación quirúrgica(AU)

ABSTRACT A 9-year-old female patient is referred to Octavio de la Concepción de la Pedraja Children's University Hospital in Holguín with a presumptive diagnosis of left orbital cellulitis. The patient has an antecedent of ipsilateral ocular trauma by a wooden object one year before, which resulted in visual acuity reduction in the left eye. Ophthalmological examination revealed edema and purulent secretion along a fistulous tract in the lower eyelid. Suspicion of the presence of a plant foreign body leads to performance of echography, computed tomography and magnetic resonance imaging of the brain and orbits. It is decided to apply an extradural pterional approach and a wooden fragment is extracted. Antibiotic therapy is indicated and secretion disappears 48 hours after surgery. The patient's evolution has been favorable. Eye trauma is common, but the presence of intraorbital foreign bodies is a rare event that triggers a local inflammatory process whose magnitude will depend on its nature. Imaging studies are indispensable for diagnosis and surgical planning(AU)

Supraorbital Keyhole Approach for Anterior Circulation Aneurysms: An Institutional Experience

Background: Pterional approach is most accepted and most common approach for clipping of intracranial anterior circulationaneurysms. This approach imparts good exposure of anterior and middle skull base. However the Pterional approach haspotential adverse effects, such as long operative time, excessive blood loss, long hospital stay, and temporal muscle atrophy.Supraorbital keyhole via eyebrow incision is a minimal invasive approach for anterior circulation aneurysm surgery. This approachhas advantages of less operative time, less blood loss, less brain retraction, short hospital stay and no temporal muscle atrophy.Objective: Objective of this study to emphasize the advantages and limitations of supra orbital key hole approach for anteriorcirculation aneurysm surgery based on our institutional experience.Material and Methods: Between September 2017 and February 2020, total 16 patients with anterior circulation aneurysmswere operated by suprorbital keyhole craniotomy approach. All patients included were ≥18 years of age with Subarachnoidhemorrhage grade 1, grade 2, grade 3 on modified fischer scale. Intra operative and postoperative parameter noted andanalyzed over a period of 3 months follow up.Results: There were good cosmetic results with less approach related complications. We achieved good recovery (4/5) onGlasgow outcome scale score 4 or 5 were achieved in 87.5% of the patients in follow period of 3 months.Conclusion: Supra orbital key hole approach is not a standard approach for all kind of anterior circulation aneurysms, it can beapplied for small sized aneurysms with SAH grade up to 3 on modified fischer scale. An thorough pre-op work up, experience,skilled hand are prerequisites for supra orbital keyhole approach in aneurysm surgery. Selection of this approach should bebased on aneurysms morphology, size of aneurysm, grade of SAH, brain edema, and the surgeon’s experience.

Retrospective Analysis of Prognosis of Superiorly Projecting Anterior Communicating Artery Aneurysm with Respect to Position of A2 Anterior Cerebral Artery

Introduction: Decision making regarding the surgicalapproach for ACOM artery is based on A1 dominancy,projection and how is the plane of the both A2 vessels. Thepresent study was conducted with the aim to analyze theprognosis of superiorly projecting anterior communicatingartery aneurysm with respect to position of A2 anteriorcerebral artery.Material and methods: The present retrospective analysisconsisted of 543 cases of all cerebral aneurysms operatedfrom Jan 2012 to December 2015 at Sree Chitra TirunalInstitute for Medical Sciences and Technology (SCTIMST),Trivandrum. The open A2 plane was defined as when the A2of the pterional approach side was present more posteriorlythan the contralateral A2. All patients were evaluated throughGlasgow outcome scale at the time of discharge. All the dataobtained was arranged in a tabulated form and analyzed usingSPSS software.Results: The mean age of the subjects was 54.2 years.There were 63 males and 32 females. Among 95 patients,A1dominant was present in 83 patients and co-dominance waspresent in 12 cases. Out of 54 superiorly projecting aneurysms.Intraoperative rupture was present in the 18 patients (33.3%),Gyrus rectus aspiration was done in the 35 patients (64.9%), 1patient had the perforator injury.Conclusion: Surgical approach from the A2 posteriordisplacement side (the open A2 plane) in patients with superiorprojecting aneurysms allows neurosurgeon to secure aneurysmnecks safely and prevent postoperative complications.

Abordaje único para aneurismas del círculo arterial cerebral / Unique craniotomy for aneurysms of the cerebral arterial circle

El objetivo del trabajo fue escribir la técnica quirúrgica y reportar la experiencia de nuestro hospital en el uso del abordaje pterional modificado como primera elección para el clipaje de aneurismas del círculo arterial cerebral en cualquier ubicación e incluso múltiples. Realizamos un estudio retrospectivo y reportamos una serie de 37 pacientes (25 mujeres y 12 hombres) con diagnóstico de aneurismas derivados del círculo arterial cerebral de distintas ubicaciones, desde enero del 2012 hasta marzo del 2015. Se presenta la experiencia de 51 aneurismas incluidos 8 casos de aneurismas múltiples y 9 aneurismas gigantes.Todos los aneurismas fueron clipados mediante un abordaje pterional modificado. Se describieron yesquematizaron los pasos del procedimiento quirúrgico secuencialmente. Mediante este análisis se estableceque el abordaje frontotemporoesfenoidal modificado (pterional) permite el acceso quirúrgico para el clipajede estas lesiones vasculares provenientes del círculo arterial cerebral lo cual correlaciona con la evidencia previa. La descripción detallada de la técnica quirúrgica favorece una adecuada comprensión de la anatomía quirúrgica y permite la reproducción de esta técnica.

The objective of the study was to describe our surgical and technical experience by reporting a series of 51 aneurysms treated by a pterional craniotomy as a unique approach foraneurismatic lesions of the cerebral arterial circle (Willis polygon). Retrospective study that reportsa series of 37 patients (25 females and 12 males) with diagnosis of aneurismatic lesions from different localization in the Willis polygon from January 2012 to March 2015. Fifty one (51)aneurismatic lesions were treated by a unique pterional craniotomy, including 8 cases of multiple aneurismatic disease and 9 giant aneurysms. Every lesion was clipped by the same pterional modified approach. Every step of this procedure was described and illustrated sequentally. This analysis establishes that the modified fronto temporoesfenoidal (pterional) craniotomy allows surgical access to the clipping of these vascular lesions, from the circle of Willis which correlates with previous evidence. The detailed description of the surgical technique promotes a proper understanding of surgical anatomy and allows playback of this technique.

The Usefulness of the Frontolateral Approach as a Minimally Invasive Corridor for Clipping of Anterior Circulation Aneurysm

OBJECTIVE: Several studies have reported on the effectiveness of fronto-lateral craniotomy in reducing the operating time and post-operative complications. However, no study has practically evaluated this method from the cosmetic point of view. MATERIALS AND METHODS: We designed this study for comparison of the clinical differences and cosmetic outcomes between the frontolateral craniotomy and the conventional pterional craniotomy for clipping of unruptured intracranial aneurysms. We performed a retrospective analysis of the two groups based on their medical records and radiologic findings juxtaposed with their length of hospital stay, intensive care unit day and operation time, and the emergence of postoperative complication, mean size of aneurysm, and temporal depression. RESULTS: After careful comparison of the thickness of temporalis muscle between the craniotomy side and the contralateral side, the results clearly showed that the conventional pterional craniotomy group was asymmetric by a p value of 0.152 and the frontolateral craniotomy group was symmetric by a p value of 0.002. CONCLUSION: Frontolateral craniotomy could be a practical alternative for patients with an unruptured intracranial aneurysm in the anterior circulation including the posterior communicating artery, particularly those who are in a medically poor state or who highly demand minimal aesthetic mutilation.

The Pterional Approach and Extradural Anterior Clinoidectomy to Clip Paraclinoid Aneurysms

OBJECTIVE: The surgical clipping of paraclinoid segment internal carotid artery aneurysms is considered difficult because of the complex anatomical location and important neighboring structures. Our experiences of pterional craniotomy and extradural anterior clinoidectomy (EAC) to clip paraclinoid aneurysms are reported herein. METHODS: We present two patients with paraclinoid aneurysms who underwent surgical clipping using pterional craniotomy and EAC. The clinical results and operative techniques were reviewed from the patients' medical records. RESULTS: EAC improves the surgical field in the suprasellar and periclinoid regions. Clinically, a good outcome was obtained in both cases. No surgical complications directly resulting from the EAC were observed. CONCLUSION: Favorable surgical results can be obtained with pterional craniotomy and EAC for the clipping of paraclinoid aneurysms. EAC is advocated for the clipping of paraclinoid aneurysms.

Clinical Experience of the Brushite Calcium Phosphate Cement for the Repair and Augmentation of Surgically Induced Cranial Defects Following the Pterional Craniotomy

OBJECTIVE: To prevent temporal depression after the pterional craniotomy, this study was designed to examine the safety and aesthetic efficacy of the brushite calcium phosphate cement (CPC) in the repair and augmentation of bone defects following the pterional craniotomy. METHODS: The brushite CPC was used for the repair of surgically induced cranial defects, with or without augmentation, in 17 cases of pterional approach between March, 2005 and December, 2006. The average follow-up month was 20 with range of 12-36 months. In the first 5 cases, bone defects were repaired with only brushite CPC following the contour of the original bone. In the next 12 cases, bone defects were augmented with the brushite CPC rather than original bone contour. For a stability monitoring of the implanted brushite CPC, post-implantation evaluations including serial X-ray, repeated physical examination for aesthetic efficacy, and three-dimensional computed tomography (3D-CT) were taken 1 year after the implantation. RESULTS: The brushite CPC paste provided precise and easy contouring in restoration of the bony defect site. No adverse effects such as infection or inflammation were noticed during the follow-up periods from all patients. 3D-CT was taken 1 year subsequent to implantation showed good preservation of the brushite CPC restoration material. In the cases of the augmentation group, aesthetic outcomes were superior compared to the simple repair group. CONCLUSION: The results of this clinical study indicate that the brushite CPC is a biocompatible alloplastic material, which is useful for prevention of temporal depression after pterional craniotomy. Additional study is required to determine the long-term stability and effectiveness of the brushite calcium phosphate cement for the replacement of bone.

Difficult Intubation during Induction of a Patient with Pseudoankylosis of the Temporo-mandibular Joint after Pterional Craniotomy: A case report / 대한마취과학회지

We describe here a case of difficult intubation due to pseudoankylosis of the temporo-mandibular joint after a pterional craniotomy. A 50-year-old female was admitted to our hospital presenting with severe headache. According to her angiogram, a ruptured aneurysm in left posterior communicating artery (PCoA) and an unruptured right PCoA aneurysm were detected. We the operation in two-steps; the first operation for the left PCoA proceeded without any problem, and the tracheal intubation also was not difficult. Four weeks later, while inducing the general anesthesia for her second operation, severe trismus was detected after the infusion of propofol 120 mg. While ventilating the patient with a well-fitted mask, we performed several attempts of conventional tracheal intubation, and the patient was finally managed using a ProSealTM laryngeal mask airway with controlled ventilation. According to patient's history, trismus has also occurred after her first operation. We think that the reason for her trismus was a result of contracture of the temporalis muscle after her first pterional craniotomy.

Intubation Difficulty in Patient with Pseudoankylosis of Temporo-mandibular Joint after Pterional Craniotomy

The authors report on a severe case of pseudoankylosis of the temporo-mandibular(TM) joint following a pterional craniotomy and the intubation difficulty encountered in the second surgery. Preventive and therapeutic aspects in addition to the clinical pitfalls of the case are discussed.

The Usefulness of Subfascial Temporalis Dissection Method in Pterional Craniotomy

The pterional craniotomy is the one of the most frequently used surgical procedures in the field of neurosurgery. Two main methods(muscle-splitting and interfascial technique) of the temporalis dissection and its modifications have been described in detail in the neurosurgical literature. But the muscle splitting technique may limit the exposure of the skull base and the interfascial dissection carries a significant risk of frontalis nerve palsy. The authors have used the subfascial dissection method and compared it with other two techniques in the aspects of functional and cosmetic outcomes. A total of 253 consecutive patients who underwent pterional craniotomies between January 1990 and June 1995 were selected. Among these, interfascial technique was used in 92 patients, muscle-splitting method in 93 patients, and subfascial temporalis dissection in 68 patients . The patients were examined to compare the incidence of facial nerve palsy, the presence of chewing difficulty, temporal asymmetry and the degree of maximal mouth opening. The interfascial approach showed the worst outcome in preserving frontalis nerve and maintaining temporal symmetry(p<0.05). There were no significant differences among these three techniques in maximal mouth opening and chewing difficulties. In conclusion, the subfascial temporalis dissection technique enable many surgeons to perform pterional craniotomies without fear of frontalis nerve injury while obtainig satisfactory operative exposure. We believe this is the choice of dissection method when performing pterional craniotomy.

Subfascial Osteoplastic Bone Flap in Pterional Approach: Technical Note

The authors describe a technique consisting of subfascial temporalis dissection and performing a pedicled bone flap in pterional craniotomy. This technique provides reliable preservation of the frontalis nerve, does not necessitate the reconstruction of the temporalis muscle at the end of the surgery, and does not compromise the operative exposure.