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.

Analysis of predictable factors of intra-operative aneurysm rupture of anterior circulation aneurysm treated by clipping / 中国综合临床

Objective To discuss the predictable factors for the occurrence of intra-operative aneurysm rupture(IAR).Methods A total of 84 patients with 101 aneurysms treated by neurosurgical clipping from September 2009 to September 2014 were retrospectively analyzed.The statistic analysis was performed for the risk factors of IAR such as aneurysm location,aneurysm sac,dome/neck ratio,direction,pre-operative Hunt-Hess Scale,history of hypertension and operation time.Results Eighteen cases (21.4％) occurred LAR (18 (17.8％) of aneurysms) during the operations,2 patients (2.4％) died.Statistic analysis revealed that preoperative Hunt-Hess scale (P =0.042),history of hypertension (P =0.038),aneurysm sac (P =0.012),dome/neck ratio(P=0.027),direction (P =0.010) and operation time (P =0.002) were the predictable factors for the occurrence of IAR,while the location of aneurysm was not included (P =0.199).Conclusion The IAR may be the result of the synthesis of various factors in the occurrence of intracranial aneurysms clipping.Hypertension history,Hunt-Hess scale,direction,aneurysm sac,operation time and dome/neck ratio 1.78-2.89 are the predictable factors for the occurrence of IAR and the combination of various factors leads to the occurrence of IAR.

The Quality of Life of Patients with Good Outcomes after Anterior Circulation Aneurysm Surgery Assessed by the World Health Organization Quality of Life Instrument-Korean Version

OBJECTIVE: Even in the patients with neurologically good outcome after intracranial aneurysm surgery, their perception of health is an important outcome issue. This study aimed to investigate the quality of life (QOL) and its predictors of patients who had a good outcome following anterior circulation aneurysm surgery as using the World Health Organization Quality of Life instrument-Korean version. METHODS: We treated 280 patients with 290 intracranial aneurysms for 2 years. This questionnaire was taken and validated by 99 patients whose Glasgow Outcome Scale score was 4 and more and Global deterioration scale 3 and less at 6 months after the operation, and 85 normal persons. Each domain and facet was compared between the two groups, and a subgroup analysis was performed on the QOL values and hospital expenses of the aneurysm patients according to the type of craniotomy, approach, bleeding of the aneurysm and brain injury. RESULTS: Aneurysm patients showed a lower quality of life compared with control patients in level of independence, psychological, environmental, and spiritual domains. In the environmental domain, there were significant intergroup differences according to the type of craniotomy and the surgical approach used on the patients (p<0.05). The hospital charges were also significantly different according to the type of craniotomy (p<0.05). CONCLUSION: Despite good neurological status, patients surgically treated for anterior circulation aneurysm have a low quality of life. The craniotomy size may affect the QOL of patients who underwent an anterior circulation aneurysm surgery and exhibited a good outcome.

Minimally Invasive and Tailored Surgical Approach to the Anterior Circulation Aneurysms / 대한뇌혈관외과학회지

OBJECTIVES: Supraorbital route through eyebrow incision, mini-pterional craniotomy, and midline interhemispheric route are most generally used methods for key hole surgery on anterior circulation aneurysm. Surgical route is determined according to aneurysm architecture and patient status. The approaching route can be selected according to the findings of 3-dimensional computed tomography (CT) angiography simulation. Prospective decision-making protocol, surgical technique of key hole surgery, and the results are presented in this paper. METHODS: 173 patients with anterior circulation aneurysms were treated by direct surgical neck clipping during last two years. Twenty patients of poor grade (Hunt-Hess grade IV,V) were treated by craniectomy with clipping. Decision making protocol was applied to 153 unruptured and good grade ruptured aneurysm patients. Simulation of key hole surgery was conducted by CT work station using conventional software InSpace (Siemens, Germany), and direction and shape of aneurysm was observed from the perspective of microsurgery. RESULTS: 113 ruptured and 40 unruptured aneurysms were secured through one of the three approaching routes. Supraorbital approach had been performed in 82 cases (unruptured 24, ruptured 58) while 64 cases were treated by mini-pterional craniotomy. Midline key hole surgery were carried out in seven distal anterior circulation aneurysms (DACA) using brain navigation system. After locating the aneurysm, supraorbital approach was applied to 46 cases involving anterior cerebral artery (ACA), 16 in internal carotid artery (ICA) and 20 in middle cerebral artery (MCA). Mini-pterional craniotomy was carried out in aneurysms located in ACA (9), ICA (18), and MCA (37). In most cases, the results of clipping were good. The average follow-up time was 16.7months (ranging 2 to 32months) and the results were cosmetically excellent. CONCLUSION: Simulating surgical approaches with 3-D CT angiography is a highly useful method for determining various surgical routes in anterior circulation aneurysm treatment. Therefore, minimally invasive and tailored surgical approaches are recommended since optimal route can be found through simulation. Thus, minimal invasive and tailored surgical approach is available through this method. These procedures have clear advantages; shorter surgical time and hospital stay, less operative trauma, reduced costs and less pain, and better cosmetic outcomes compared to standard craniotomy. Optimal surgical results are expected from minimally invasive and tailored surgical craniotomy.

A Simplified Skull Base Approaches for Anterior Circulation Aneurysms: Superolateral Orbital Craniotomy and Orbital Roof Craniotomy viaan Eyebrow Incision

OBJECTIVE: Previous standard surgical approaches for aneurysms of anterior circulation are concerned with possible injury to the normal brain by cerebral retraction. Simplified skull base approaches have been introduced to fulfill the ideal goals of skull base surgery, brain protection and technical minimalism. Superolateral orbital craniotomy and orbital roof craniotomy via eyebrow incision offered sufficient working space for aneurysmal neck clipping of anterior circulaton and have advantages of minimal brain retraction and rapid recovery. METHODS: The concept and technique of the superolateral orbital craniotomy and orbital roof craniotomy are presented in detail. We conducted a retrospective study in which we evaluated the technical aspect of the superolateral orbital craniotomy and orbital roof craniotomy considering the indications, limitations, and complications of these approaches. RESULTS: The superolateral orbital craniotomy and orbital roof craniotomy provide an ample space to access the neurovascular structure of the anterior skull base without using brain retractors, enable rapid anatomical reconstruction for closure and acceptable cosmetic results. CONCLUSION: The superolateral orbital craniotomy and orbital roof craniotomy via eyebrow incision offer better surgical possibilities and approach related morbidity than conventional approaches in the treatment of anterior circulation aneurysms.

A Simplified Skull Base Approaches for Anterior Circulation Aneurysms: Superolateral Orbital Craniotomy and Orbital Roof Craniotomy viaan Eyebrow Incision

OBJECTIVE: Previous standard surgical approaches for aneurysms of anterior circulation are concerned with possible injury to the normal brain by cerebral retraction. Simplified skull base approaches have been introduced to fulfill the ideal goals of skull base surgery, brain protection and technical minimalism. Superolateral orbital craniotomy and orbital roof craniotomy via eyebrow incision offered sufficient working space for aneurysmal neck clipping of anterior circulaton and have advantages of minimal brain retraction and rapid recovery. METHODS: The concept and technique of the superolateral orbital craniotomy and orbital roof craniotomy are presented in detail. We conducted a retrospective study in which we evaluated the technical aspect of the superolateral orbital craniotomy and orbital roof craniotomy considering the indications, limitations, and complications of these approaches. RESULTS: The superolateral orbital craniotomy and orbital roof craniotomy provide an ample space to access the neurovascular structure of the anterior skull base without using brain retractors, enable rapid anatomical reconstruction for closure and acceptable cosmetic results. CONCLUSION: The superolateral orbital craniotomy and orbital roof craniotomy via eyebrow incision offer better surgical possibilities and approach related morbidity than conventional approaches in the treatment of anterior circulation aneurysms.

Management Outcome and Clinical Manifestation of Posterior Circulation Aneurysms VS. Anterior Circulation Aneurysm

OBJECT: With the recent variable treatment modalities and the development of microsurgical techniques, outcomes of surgical and medical management of aneurysm have shown much progress in the last 10 years. However, the management of posterior circulation aneurysm is still a debatable due to its difficulty in limited surgical approach, complicated anatomical structure and many small perforators to vital structure. The purpose of this study is to compare the results of clinical manifestation and outcome of surgery with respect to anterior and posterior circulation aneurysms. MATERIAL AND METHODS: We evaluated the 33 patients with PCAs(posterior circulation aneurysm) and 359 patients with ACAs(anterior circulation aneurysm) treated between 1994 and 1999, retrospectively. RESULTS: Posterior circulation aneurysms showed higher tendency(5 cases, 14.7%) to have unusual shapes, such as dissecting or fusiform compared with anterior circulation aneurysm(15 cases, 4.2%). There were more multiple aneurysms in posterior circulation aneurysm(8 cases, 26.5%) than anterior circulation aneurysm(59 cases, 16.2%). The number of patients with Hunt-Hess grade III or IV on admission were 91(25.3%) in anterior circulation aneurysms, and 14(42.4%) in posterior circulation aneurysms. There were higher incidences of vasospasm and acute hydrocephalus in patients with posterior circulation aneurysm. In cases of anterior circulation aneurysm, neck clipping was possible in 97%. But, in posterior circulation aneurysm, neck clipping was possible only in 67.7% of each. Two hundred forty four cases(85.0%) of all anterior circulation aneurysms and 22 cases(78.6%) of all posterior circulation aneurysms showed good recovery(GR) or moderate disability(MD). The postoperative mortality rates of anterior and posterior circulation aneurysms were 4.9% and 10.7%, respectively. CONCLUSION: These results indicate that there exist substantial differences with respect to that there were few difference in the aspect of surgery and management outcome between posterior circulation aneurysms and anterior circulation aneurysms.

Surgical Result for Ruptured Anterior Circulation Aneurysms in Elderly Patients

In order to define the surgical result for ruptured anterior circulation aneurysms in the elderly, 59 patients(from June 1989 to May 1994) whose age was 66 years of age or older were analyzed. The factors which might influence the outcome were statistically compared between those aged 66 years or older(elderly patients group:59 patients:12.5%) and those aged 65 years or younger(younger patients group :413 patients;87.5%);the clinical grading, the location of aneurysms, the multiplicity, the presence of the angiographic vasospasm, the development of the symptomatic vasospasm, the presence of the hypertension. Fisher's grade IV(intracerebral hemorrhage or intraventricular hemorrhage), and the timing of surgery. Overall outcome between two groups was not different significantly, and many factors did not affect the outcome except the location. Surgical outcome in good grade patients(Hunt and Hess Grade I, II) was excellent regardless of age and timing of surgery. "Early surgery in the elderly?" The answer was Yes especially in good grade patients. We conclude that surgical outcome for ruptured anterior circulation aneurysms in the elderly does not seem to be directly affected by age, so elderly patients need not therefore be excluded from the benefits of surgery just because of their chronological age. It is principally the patient's condition during the acute stage that determine the surgical outcome.