Clinical analysis of 32 cases of temporal lobe epilepsy treated by microsurgery under intraoperative cortical EEG monitoring / 中国综合临床

Objective:To investigate the effect of microsurgery by modified pterional approach in the treatment of temporal lobe epilepsy under intraoperative cortical encephalon electricity graph (EEG) monitoring.Methods:The clinical data of 32 patients with temporal lobe epilepsy who were admitted to the Department of Neurosurgery of Shangqiu First People's Hospital from January 2012 to June 2021 were retrospectively analyzed, all patients underwent microsurgical resection of epileptogenic foci by modified pterional approach under cortical EEG monitoring.Results:The postoperative follow-up was from half a year to 6 years. According to the Tan's classification, 25 cases (78.1%(25/32)) of seizures disappeared completely, 3 cases (9.4%(3/32)) of seizures decreased by more than 75%, and 4 cases (12.5%(4/32)) of seizures decreased by more than 50%. Isotropic hemianopia occurred in 1 case (3.1%) after operation, and there was no operative death.Conclusion:Microsurgical resection of epileptogenic foci through modified pterional approach under intraoperative cortical EEG monitoring was a safe and effective method for the treatment of temporal lobe epilepsy.

Clinical implications in orbital and pterional flap surgeries as well as radioimaging studies to determine topographical prevalence and characterization of meningo-orbital foramen in orbits of the Indian population / Implicaciones clínicas en cirugías de colgajo orbitario y pterional, así como estudios de radioimagen para determinar la prevalencia topográfica y la caracterización del foramen meningoorbitario en órbitas de la población india

SUMMARY: The pear-shaped bony orbit connects with intracranial cavity via foramina's and fissures. The Meningo-orbital Foramen (MOF) is usually present in greater wing of sphenoid close to lateral edge of Superior orbital fissure. It provides a route for an anastomosis between the orbital branch of the middle meningeal artery (MMA) and recurrent meningeal branch of Ophthalmic Artery (OA) and hence, risk of damage during surgeries can occur. To verify occurrence and location, with morphology of MOF in dry orbits and the impending clinical hazards in surgeries pertaining to the orbit, document and analysis it to determine a standardized guideline. The presence for MOF was studied in 446 dry orbits with its location from the supra orbital margin (SOM), front zygomatic suture (FZS), the lateral tubercle of Whitnall (WT)and the lateral end of superior orbital fissure (SOF) along with its patency, laterality and number of foramina's present. Nylon probes, long divider/pins, compass and Vernier callipers was used to check the patency and various parameters. The study noted the percentage prevalence of MOF as 69 % with communication with middle cranial fossa (MCF) being 76 % of 69 % and the average distance from SOM, FZS, WT and lateral end of SOF being 35.58 mm, 24.9 mm, 26.6 mm and 0.92 mm. On comparison with various population studies, certain similarities and differences with regards to different parameters were noted. Prevalence of MOF was mostly unilateral and showed multiple foramina, that can act as channels for arteries, a variant of MMA or OA, that supply orbital structures or tumour growths. Thus, awareness of this variation is of prime importance to ophthalmologists and neurosurgeons as well as interventional radiologists, in preventing haemorrhagic condition which could further raise the difficulties in operative procedures and surgical outcomes.

RESUMEN: La órbita ósea en forma de pera se conecta con la cavidad intracraneal a través de forámenes y fisuras. El foramen meningoorbitario (MOF) suele estar presente en el ala mayor del esfenoides cerca del margen lateral de la fisura orbitaria superior. Proporciona una ruta para una anastomosis entre la rama orbitaria de la arteria meníngea media (MMA) y la rama meníngea recurrente de la arteria oftálmica (OA) y, por lo tanto, puede ocurrir riesgo de daño durante las cirugías. Para verificar la ocurrencia y ubicación, con la morfología de MOF en órbitas secas y los peligros clínicos inminentes en cirugías de la órbita, documentarlo y analizarlo para determinar una pauta estandarizada. Se estudió la presencia de MOF en 446 órbitas secas desde el margen supraorbitario (MOS), sutura cigomática frontal (FZS), el tubér- culo lateral de Whitnall (WT) y el extremo lateral de la fisura orbitaria superior (SOF) junto con su permeabilidad, lateralidad y número de forámenes presentes. Se utilizaron sondas de nailon, divisores / pasadores largos, brújula y calibradores Vernier para comprobar la permeabilidad. En el estudio se pudo observar que la prevalencia porcentual de MOF era del 69 %, siendo la comunica- ción con la fosa craneal media (MCF) del 76 % del 69 % y la distancia promedio desde SOM, FZS, WT y el extremo lateral de SOF era de 35,58 mm, 24,9 mm, 26,6 mm y 0,92 mm. En comparación con varios estudios de población, se observaron ciertas similitudes y diferencias con respecto a diferentes parámetros. La prevalencia de MOF fue mayoritariamente unilateral y mostró múltiples forámenes, que pueden actuar como canales para las arterias, una variante de MMA u OA, que irrigan estructuras orbitarias o crecimientos tumorales. Por lo tanto, la conciencia de esta variación es de primordial importancia para los oftalmólogos y neurocirujanos, así como para los radiólogos intervencionistas, en la prevención de una enfermedad hemorrágica que podría aumentar aún más las dificultades en los procedimientos y los resultados quirúrgicos.

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.

Value of three-dimensional DSA simulation for the side selection of pterional approach to clip anterior communicating artery aneurysms / 中国脑血管病杂志

Objective To evaluate the safety and efficiency of the treatment strategy based on three-dimensional digital subtraction angioplasty (3 D-DSA) for the side selection of pterional approach to clip anterior communicating artery aneurysm. Methods All 75 continuous patients with single anterior communicating artery aneurysm(Hunt-Hess 0-III grade) treated by microsurgical clipping via the pterional approach were analyzed retrospectively. The side selection of approach was based on 3D-DSA. All patients' gender, age, Hunt-Hess grade, aneurysm size, the side of approach, complications, the length of postoperative stay, the ratio of complete occlusion, and the Glasgow outcome scale (GOS) score at discharge were collected. The ratio of complete occlusion and clinical outcome were analyzed according to the group of left or right approach and different Al dominant approach. Results (1) Fifty-six patients (74. 7%) were left Al dominants, with 30 of those treated via the left-side approach and 26 of those treated via the right-side approach. Nineteen patients (25.3%) were right Al dominants, with 15 of those treated via the right-side approach and 4 of those treated via the left-side approach. (2) Surgical exposure of all aneurysms was satisfactory during operation, which was consistent with the 3D-DSA image simulation before the operation. The median length of postoperative stay was 9(8, 11) days. Six patients(8. 0%) suffered symptomatic cerebral infarction, and 1 patient (1.3%) had an intracranial infection. Sixty-five cases performed DSA or CT antigraphy after the operation. Sixty-two aneurysms (95.4%) were completely clipped and 3 aneurysms (4.6%) existed residual segments in the neck of the aneurysm. Sixty-nine patients (92.0%) reached 5 grade of GOS, 3 patients (4.0%) reached 4 grade of GOS, 3 patients (4.0%) reached 3 grade of GOS, and no patient was below 3 grade of GOS at discharge. (3) The surgical-related complications, clipping results, hospital-stay time after operation, and GOS at discharge were insignificantly different between left and right side approach, also insignificantly different between the dominant Al side and contralateral side approach. Conclusion The treatment strategy, based on preoperative 3D-DSA imaging simulation for the side selection of pterional approach to clip anterior communicating artery aneurysms, was safe and effective.

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 pterional transilviano con apoyo neuroendoscópico en colesteatoma cerebral, a propósito de un caso interesante / Transsilvian pterional approach with neuroendoscopic support in cholesteatoma of the brain. A propos of an interesting case

RESUMEN Los quistes epidermoides constituyen el 1 % de los tumores intracraneales y el 7 % de los del ángulo pontocerebeloso. Los colesteatomas son lesiones benignas que se originan de restos de tejidos epitelial ectodérmicos que quedan en el sistema nervioso central, al cerrarse el tubo neural entre la tercera y quinta semana de gestación. Se trata de un paciente remitido de la Consulta de Neurooftalmología con crisis de cefalea y toma de los pares craneales III, IV, V, rama oftálmica desde hace 2 semanas. Se le realizaron estudios imagenológicos donde se constató un tumor hipodenso en región silviana frontotemporal izquierdo. Se interpretó como un quiste arcnoideo. Se le aplicó un bordaje pterional transilviano con apoyo neuroendoscópico y para sorpresa del equipo quirúrgico se abordó un tumor perlado solido identificado macroscópicamente como un colesteatoma silviano. Se resecó la totalidad del tumor cerebral.

ABSTRACT Epidermal inclusion cysts constitute 1% of the intracranial tumors and 7% of the cerebellopontine angle ones.Cholesteatoma are benign lesions originated from the remains of ectodermic epithelial tissues remaining in the central nervous system when the neural tube closes between the third and fifth week of pregnancy. The case deals with a patient remitted from the Neurophthalmologic Consultation with migraine crisis and lesion on the III, IV, V cranial nerves, ophthalmologic branch, for two weeks. Image studies were carried out, showing a hypo dense tumor in the left silvian frontotemporal region. It was taken as an arachnoid cyst. A pterional trans-silvian approach with neuroendoscopic support was applied, and the surgical team was surprised when they found a solid pearly tumor that was macroscopically identified as a silvian cholesteatoma. The cerebral tumor was totally resected.

Aneurismas paraclinoideos: experiencia personal de 1 año en el Hospital Regional de Temuco / Paraclinoid aneurysm: 1 year personal experience at Hospital Regional de Temuco

Se presenta la experiencia personal en el tratamiento de 5 pacientes con 7 aneurismas paraclinoideos tratados quirúrgicamente en el Hospital Regional Temuco durante junio de 2015 y julio de 2016 (13 meses). Todos los pacientes fueron previamente discutidos con neurorradiologo Intervencional local y considerados no favorables para terapia endovascular. En todos ellos se realizó una craneotomía mini pterional con clinoidectomía extradural y exposición de la arteria carótida interna cervical. Cuatro pacientes consultaron con hemorragia subaracnoidea y requirieron cirugía cerebral de urgencia. En 6 aneurismas se realizó clipaje y en 1 trapping. Cuatro pacientes no tuvieron deterioro neurológico y evolucionaron favorablemente mientras que 1 paciente falleció por hipoperfusión secundario al trapping de la carótida supraclinoidea. Se enfatiza el manejo interdisciplinario, el plan preoperatorio y el conocimiento de la neuroanatomía en el tratamiento de esta patología.

A personal experience is presented in treating 5 patients with 7 paraclinoid aneurysm who underwent surgery at Hospital Regional Temuco between june 2015 and july 2016 (13 months). All patients were previously discussed with local interventional neuroradiologist considering them not favorable to endovascular therapy. Mini pterional craniotomy with extradural clinoidectomy and internal cervical carotid artery exposure was performed in all of them. 4 patients presented with subarachnoid hemorrhage and required urgent brain surgery. Direct clipping was optimal in 6 aneurysm and 1 was treated with trapping. 4 patients had no neurological deteriotation with excellent outcome and 1 patient died because of hypoperfusion secondary to the supraclinoid carotid trapping. Interdisciplinary management, preoperative planning and neuroanatomy knowledge are emphasized in order to treat this pathology.

Analysis of the curative effect of extensive pterional approach combined with cutting of the zygomatic arch for the resection of large sphenoid ridge meningioma / 中国肿瘤临床

Objective: To explore the application of extensive pterional approach combined with cutting of the zygomatic arch for the resection of large sphenoid ridge meningioma. Methods: Thirty-three patients with large sphenoid ridge meningioma underwent operation using the extensive pterional approach combined with cutting of the zygomatic arch. Twenty patients with large sphenoid ridge meningioma received operation with the traditional pterional approach as the control. The resection rate, operative time, intraoperative blood loss, and postoperative complications were compared between the groups. Results: Two groups of patients underwent craniotomy under microscope. The Simpon grade I resection and grade Ⅱ resection rate was 93.9％ in the cutting of the zygomatic arch approach group and 60.0％ in the control group (P<0.01). The operative time was (325.2±121.3) min in the cutting of the zygomatic arch approach group, which was significantly shorter than that in the control group with (406.4±182.9) min (P<0.05). The intraoperative blood loss was (502.5±101.8) mL and (697.7±115.4) mL in the two groups (P<0.05). In addition, postoperative complication rate was 15.2％ and 45.0％ in the cutting the zygomatic arch approach group and the control group, respectively (P<0.05). No death was reported in both groups. Conclusion: Extensive pterional approach combined with cutting of the zygomatic arch can fully expose the anatomical structures of the skull base and the sellar region to eliminate the influence of temporal muscle in the exposure of the surgical area. The operative field is exposed to reduce the stretch injury to only the frontotemporal brain tissue, which might be helpful for the complete resection of large sphenoid ridge meningioma, and is more conducive to neurovascular anatomy and relevant functional protection.

Clinical application of external ventricular drainage for ruptured anterior communicating artery aneurysms / 局解手术学杂志

Objective To investigate the clinical effect of external ventricular drainage on the prognosis of anterior communicating artery aneurysms.Methods Retrospectively collected and analyzed 96 patients of anterior communicating artery aneurysms who were treated in our hospital from June 2013 to October 2015,and they were divided into the observation group which was given external ventricular drainage treatment and the control group which was not given external ventricular drainage treatment.These patients were followed up for 6 months to 2 years,and the results of the 2 groups were graded according to the analysis of postoperative complications and the Glasgow prognostic score (GOS).Meanwhile,evaluated the general function of the patients according to the KPS score.Results The the incidence rate of complications after treatment in observation group was 54.17％,which was lower than 86.96％ in the control group,and the difference was statistically significant(P ＜ 0.05).The cure rate of observation group was 79.16％,which was higher than 50％ in the control group,and the difference was statistically significant (P ＜ 0.05).The postoperative KPS score in the observation group was (79.68 ± 13.24) points,which was higher than (62.57 ± 12.72) points in the control group,and the differences were statistically significant (P ＜ 0.05).Conclusion External ventricular drainage can reduce the compression injury of the brain tissue to a minimum degree,reduce intracranial pressure,relieve cerebral edema caused by intracranial pressure,reduce complications,and improve the prognosis of patients and the cure rate.

Pterional or Subfrontal Access for Proximal Vascular Control in Anterior Interhemispheric Approach for Ruptured Pericallosal Artery Aneurysms at Risk of Premature Rupture

OBJECTIVE: Cases of a ruptured pericallosal artery aneurysm with a high risk of intraoperative premature rupture and technical difficulties for proximal vascular control require a technique for the early and safe establishment of proximal vascular control. METHODS: A combined pterional or subfrontal approach exposes the bilateral A1 segments or the origin of the ipsilateral A2 segment of the anterior cerebral artery (ACA) for proximal vascular control. Proximal control far from the ruptured aneurysm facilitates tentative clipping of the rupture point of the aneurysm without a catastrophic premature rupture. The proximal control is then switched to the pericallosal artery just proximal to the aneurysm and its intermittent clipping facilitates complete aneurysm dissection and neck clipping. RESULTS: Three such cases are reported: a ruptured pericallosal artery aneurysm with a contained leak of the contrast from the proximal side of the aneurysm, a low-lying ruptured pericallosal artery aneurysm with irregularities on its proximal wall, and a multilobulated ruptured pericallosal artery aneurysm with the parasagittal bridging veins hindering surgical access to the proximal parent artery. In each case, the proposed combined pterional-interhemispheric or subfrontal-interhemispheric approach was successfully performed to establish proximal vascular control far from the ruptured aneurysm and facilitated aneurysm clipping via the interhemispheric approach. CONCLUSION: When using an anterior interhemispheric approach for a ruptured pericallosal artery aneurysm with a high risk of premature rupture, a pterional or subfrontal approach can be combined to establish early proximal vascular control at the bilateral A1 segments or the origin of the A2 segment.

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 Extended Pterional Approach and Microsurgery Resection for Craniopharyngiomas, Operative Nuances and Results: A Series of 29 Patients

Objective The aim of this paper is to observe if the extended pterional approach for the removal of craniopharyngiomas is safe and effective. The mortality, morbidity, and recurrence rates are presented and discussed. Method This is a retrospective analysis of 29 craniopharyngioma patients who underwent surgery between January 1988 and December 2014 at the Department of Neurosurgery of the Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil. The charts, operative reports and imaging studies were reviewed. Results We identified 17 males (58.6%) and 12 females (41.3%) ranging in age from 0.6 to 84 years (mean 57.4 years). Thirteen (44.8%) patients were infants or adolescents. Surgical mortality occurred in one patient (3.4%). Gross total tumor removal was achieved in 15 (51.7%) patients. The median follow-up time was 7.1 years. Conclusion The extended pterional approach provides adequate access to craniopharyngiomas, and the majority of lesions could be totally removed, with a low mortality rate, but the best treatment for craniopharyngiomas remains controversial.

Objetivo Observar se a craniotomia pterional estendida é uma técnica segura e efetiva. Método É um estudo retrospectivo de 29 pacientes com craniofaringiomas que foram submetidos a craniotomia pterional estendida entre 1988 e 2014. As imagens e os prontuários foram analisados. Resultados Esse grupo é composto por 17 homens (58,6%) e 12 mulheres (41,3%), e a idade variou de 0,6 a 84 anos (media 57,4 anos). Treze (44,8%) pacientes eram crianças ou adolescentes. A remoção total da lesão ocorreu em 15 (51,7%) indivíduos. A mortalidade cirúrgica: um paciente (3,4%). O follow-up médio é de 7,1 anos. Conclusão A craniotomia pterional estendida permitiu a remoção total da lesão na maioria dos pacientes, com baixa mortalidade, porém o melhor tratamento para o craniofaringioma ainda gera muita controvérsia.

The Clinical Analysis of Microsurgical Treatment for Anterior Communicating Artery Aneurysm Via Pterional Approach / 昆明医科大学学报

Objective To summarize treatment experiences of microsurgical clipping for anterior communicating artery aneurysm via pterional approach.Methods Clinical data of 82 cases undergoing microsurgical clipping for anterior communicating artery aneurysm via pterional approach in the first affiliated hospital of Kunming Medical University from October 2008 to December 2014 were collected and retrospectively analyzed.The patients were divided into different groups by Hunt-Hess illness grading scale,with 11 cases for level 0,7 cases for level Ⅰ,30 cases for level Ⅱ,25 cases for level Ⅲ,8 cases for level Ⅳ,and 1 cases for level Ⅴ.Twenty-one patients underwent operation at early stage of SAH (＜3d),15 at late stage of SAH (4d～2W),and 35 at prolonged stage of SAH (＞2W).The prognosis of patients was evaluated according to GOS classification criteria at discharge.Results A total of 85 ACoAA were found in 82 patients and all of them were clipped and,at the same time,3 aneurysms were resected and 11 thrombuses were punctured,cut and removed.In the operation,15 (17.6％) aneurysms ruptured again and temporary blocking happened for 73 times,with the shortest blocking time of 2 rmin,the longest of 40 rmin,and the average of 9.26min.According to GOS score,good recovery rate was 79.3％ (65/82),moderate disability rate was 12.2％ (10/82),severe disability rate was 3.7％ (3/82),vegetative state rate was 0％,and death rate was 4.9％ (4/82).Good recovery rates for the operations at early,late and prolonged stage of SAH were 85.7％,73.3％ and 82.3％ respectively and for level 0 to level Ⅴ were 90.9％,85.6％,86.7％ and 84.0％,25.0％ and 0.0％ respectively.Results of DSA or CTA re-examination upon 55 patients followed-up at discharge or three months after discharge showed that tumor pedicle were clipped and aneurysm disappeared.Fifty cases were followed up from four months to seven years after the operation,with one case of aneurysm recurrence.Another thirty-two cases were lost to follow-up.ConclusiornS Microsurgical techniques and microdissection are keys to successful operation.Pterional approach can guarantee successful clipping of aneurysms with different directions,locations and sizes.It is also an easy,effective and reliable approach with less postoperative complications.Operation for anterior communicating artery aneurysm should be performed as early as possible.

Intradural Procedural Time to Assess Technical Difficulty of Superciliary Keyhole and Pterional Approaches for Unruptured Middle Cerebral Artery Aneurysms

OBJECTIVE: This study used the intradural procedural time to assess the overall technical difficulty involved in surgically clipping an unruptured middle cerebral artery (MCA) aneurysm via a pterional or superciliary approach. The clinical and radiological variables affecting the intradural procedural time were investigated, and the intradural procedural time compared between a superciliary keyhole approach and a pterional approach. METHODS: During a 5.5-year period, patients with a single MCA aneurysm were enrolled in this retrospective study. The selection criteria for a superciliary keyhole approach included : 1) maximum diameter of the unruptured MCA aneurysm <15 mm, 2) neck diameter of the MCA aneurysm <10 mm, and 3) aneurysm location involving the sphenoidal or horizontal segment of MCA (M1) segment and MCA bifurcation, excluding aneurysms distal to the MCA genu. Meanwhile, the control comparison group included patients with the same selection criteria as for a superciliary approach, yet who preferred a pterional approach to avoid a postoperative facial wound or due to preoperative skin trouble in the supraorbital area. To determine the variables affecting the intradural procedural time, a multiple regression analysis was performed using such data as the patient age and gender, maximum aneurysm diameter, aneurysm neck diameter, and length of the pre-aneurysm M1 segment. In addition, the intradural procedural times were compared between the superciliary and pterional patient groups, along with the other variables. RESULTS: A total of 160 patients underwent a superciliary (n=124) or pterional (n=36) approach for an unruptured MCA aneurysm. In the multiple regression analysis, an increase in the diameter of the aneurysm neck (p<0.001) was identified as a statistically significant factor increasing the intradural procedural time. A Pearson correlation analysis also showed a positive correlation (r=0.340) between the neck diameter and the intradural procedural time. When comparing the superciliary and pterional groups, no statistically significant between-group difference was found in terms of the intradural procedural time reflecting the technical difficulty (mean±standard deviation : 29.8±13.0 min versus 27.7±9.6 min). CONCLUSION: A superciliary keyhole approach can be a useful alternative to a pterional approach for an unruptured MCA aneurysm with a maximum diameter <15 mm and neck diameter <10 mm, representing no more of a technical challenge. For both surgical approaches, the technical difficulty increases along with the neck diameter of the MCA aneurysm.

Abordaje pterional / Pterional approach

Objetivo: describir, paso a paso, la realización de un abordaje pterional (AP). Descripción: Posición: El paciente es colocado en decúbito dorsal, con la cabeza rotada contralateral y deflexionada. Incisión: se extiende desde la línea media hasta el borde inferior del arco cigomático, 1 cm adelante del trago. Disección interfascial: tiene varios referentes anatómicos: la arteria temporal superficial, el reborde orbitario y al arco cigomático en su porción inferior. La incisión se inicia en la línea temporal superior, 2 cm posterior del reborde orbitario, y se extiende en dirección al sector medio del arco cigomático. Desinserción del músculo temporal: se procede a realizar un corte muscular hasta alcanzar el plano óseo, y se realiza una disección subperióstica. Craneotomía: la remoción ósea debe lograr una exposición suficiente de la fisura silviana, con mayor exposición del lóbulo frontal; así, deben exponerse los giros frontales medio e inferior y el giro temporal superior. Apertura dural: en dos colgajos, uno frontal y otro temporal. Conclusión: el AP constituye aún hoy día una técnica actual y vigente, que se resiste a ser olvidada, cuya aplicación juiciosa permite acceso a un gran numero de patologías de la base de cráneo anterior y media.

Objective: the aim of this study is to describe, step by step, the pterional approach. Description: position: the patient is placed supine, and the head rotated and also deflected. Incision: from the midline to de zygomatic arch, 1 cm in front of the tragus. Interfascial dissection: the landmarks: superficial temporal artery, orbital rim and zygomatic arch. The incision started at the level of the superior temporal line, 2 cm posterior to the orbital rim, and is pointed to the middle portion of the zygomatic arch. Temporal muscle displacement: after a transversal section of the upper portion of the muscle, it is detached in a subperiosteal fashion. Craniotomy: the osseous removal should expose the sylvian fissure and the middle and inferior frontal gyrus and also the superior temporal giri. Dural opening: in two flaps (frontal and temporal). Conclusion: the pterional approach is still, nowadays, a valid and current technique. This approach allows treating many lesions located in the anterior and middle cranial fossa.

Feasibility and Efficacy of Olfactory Protection Using Gelfoam and Fibrin Glue during Anterior Communicating Artery Aneurysm Surgery

OBJECTIVE: Patients treated with surgical clipping for anterior communicating artery (A-com) aneurysm often complain of anosmia, which can markedly impede their quality of life. We introduce a simple and useful technique to reduce postoperative olfactory dysfunction in A-com aneurysm surgery. METHODS: We retrospectively reviewed the medical records of patients who underwent surgical clipping for unruptured aneurysm from 2011-2013 by the same senior attending physician. Since March 2012, olfactory protection using gelfoam and fibrin glue was applied in A-com aneurysm surgery. Therefore we categorized patients in two groups from this time-protected group and unprotected group. RESULTS: Of the 63 enrolled patients, 16 patients showed postoperative olfactory dysfunction-including 8 anosmia patients (protected group : unprotected group=1 : 7) and 8 hyposmia patients (protected group : unprotected group=2 : 6). Thirty five patients who received olfactory protection during surgery showed a lower rate of anosmia (p=0.037, OR 10.516, 95% CI 1.159-95.449) and olfactory dysfunction (p=0.003, OR 8.693, 95% CI 2.138-35.356). Superior direction of the aneurysm was also associated with a risk of olfactory dysfunction (p=0.015, OR 5.535, 95% CI 1.390-22.039). CONCLUSION: Superior direction of aneurysm appears associated with postoperative olfactory dysfunction. Olfactory protection using gelfoam and fibrin glue could be a simple, safe, and useful method to preserve olfactory function during A-com aneurysm surgery.

A Simple Method for Reconstruction of the Temporalis Muscle Using Contourable Strut Plate after Pterional Craniotomy: Introduction of the Surgical Techniques and Analysis of Its Efficacy

OBJECTIVE: Pterional craniotomy (PC) using myocutaneous (MC) flap is a simple and efficient technique; however, due to subsequent inferior displacement (ID) of the temporalis muscle, it can cause postoperative deformities of the muscle such as depression along the inferior margin of the temporal line of the frontal bone (DTL) and muscular protrusion at the inferior portion of the temporal fossa (PITF). Herein, we introduce a simple method for reconstruction of the temporalis muscle using a contourable strut plate (CSP) and evaluate its efficacy. MATERIALS AND METHODS: Patients at follow-ups between January 2014 and October 2014 after PCs were enrolled in this study. Their postoperative deformities of the temporalis muscle including ID, DTL, and PITF were evaluated. These PC cases using MC flap were classified according to two groups; one with conventional technique without CSP (MC Only) and another with reconstruction of the temporalis muscle using CSP (MC + CSP). Statistical analyses were performed for comparison between the two groups. RESULTS: Lower incidences of ID of the muscle (p < 0.001), DTL (p < 0.001), and PITF (p = 0.001) were observed in the MC + CSP than in the MC Only group. The incidence of acceptable outcome was markedly higher in the MC + CSP group (p < 0.001). ID was regarded as a causative factor for DTL and PITF (p < 0.001 in both). CONCLUSION: Reconstruction of the temporalis muscle using CSP after MC flap is a simple and efficient technique, which provides an outstanding outcome in terms of anatomical restoration of the temporalis muscle.

Selección del lado de abordaje a los aneurismas de la arteria comunicante anterior / Selection of the approach side to the aneurysms of the anterior communicating artery

Objetivo: analizar el lado de abordaje pterional elegido teniendo en cuenta la disposición del segmento postcomunicante de las arterias cerebrales anteriores (A2) en el plano coronal y sus implicancias quirúrgicas. Material y Método: Estudio observacional descriptivo retrospectivo. Se analizaron 24 pacientes con aneurismas de la arteria comunicante anterior de variedad superior y antero-superior, operados en el período 2009-2014. Se operaron 22 pacientes con Hemorragia Subaracnoidea (91.67%) y 2 pacientes con aneurismas incidentales (8.33%). Se estudió la dominancia del segmento precomunicante (A1), la variedad de A2 (abierta o cerrada) y sus consecuencias quirúrgicas: necesidad de aspiración del girus recto (AGR), utilización de clip fenestrados, presencia de contusión debido a retracción cerebral, isquemia en territorio de perforantes (ITP) y cuello remanente. Resultados: De los 24 pacientes estudiados, 12 (50%) presentaban una variedad A2 abierta. Tan solo 1 requirió AGR, 1 sufrió ITP y 2 contusiones, sin necesidad de utilizar clips fenestrados ni tampoco registrarse algún cuello remanente. Los 12 pacientes restantes (50%) presentaron una variedad A2 cerrada. En este grupo fue necesario AGR en 8 casos, utilización de clip fenestrados en 3 casos, se registraron 3 ITP, 3 contusiones y 1 con cuello remanente (p=0.01). Conclusión: Creemos que abordar a los aneurismas de variedad superior y antero-superior del lado en el que las A2 representan una variedad abierta, permite lograr una correcta exposición anatómica con el consiguiente clipado aneurismático adecuado y reducción de las complicaciones quirúrgicas.

Objective: to analyze the chosen side in a pterional approach based on the position of the postcommunicating segment of anterior cerebral artery (A2) in a coronal plane, and its surgical requirements and complications. Material and Method: A descriptive observational retrospective study has been designed. We analyzed 24 patients with anterior communicating artery aneurysms projecting superior and supero-anterior, who underwent microsurgical clipping between 2009-2014. This study includes 22 subarachnoid hemorrhages (91.67%) and 2 incidental aneurysms (8.33%). We studied the dominancy of the precommunicating segment (A1), A2 plane (open or closed) and the surgical requirements: gyrus rectus aspiration (GRA) or the need of fenestrated clips, and complications: cerebral contusion due to brain retraction, perforators' ischemia (PI) and residual neck. Results: Out of the 24 patients, 12 (50%) were A2 open plane. Only 1 required GRA, 1 suffered perforators' ischemia and 2 had cerebral contusion. No fenestrated clip was used, and there was no residual neck. The remaining 12 patients (50%) had an A2 close plane. In this group, GRA was necessary in 8 cases and the use of fenestrated clip in 3. Perforators' ischemia was present in 3 cases, whereas another 3 patients suffered cerebral contusion and 1 had a residual neck (p=0.01). Conclusion: We suggest that approaching anterior cerebral arteries aneurysms projecting superior and supero-anterior from an A2 open plane, allows an optimal anatomical exposure view with an adequate aneurysm clipping and reducing surgical complications.

Abordaje pterional: alcances y revisión de la técnica quirúrgica / Pterional approach: scope and revision of the surgical technique

Objetivo: exponer nuestra experiencia quirúrgica en el abordaje pterional resaltando los alcances y detalles técnicos de dicho procedimiento. Material y método: Se realizó un estudio descriptivo retrospectivo, analizando las historias clínicas de 145 pacientes intervenidos quirúrgicamente a través de un abordaje pterional clásico o alguna de sus variantes, entre octubre de 2009 y octubre de 2012, en nuestro servicio. Se recabaron datos epidemiológicos y los relacionados a las diferentes patologías alcanzadas mediante esta vía. Para una mejor interpretación, las imágenes fueron adquiridas en 3D. Resultados: Durante dicho período se realizaron 149 craneotomías pterionales sobre un total de 145 pacientes, 4 de los cuales debieron ser sometidos a abordaje pterional bilateral. Fueron intervenidos 95 pacientes con aneurismas cerebrales, 9 de ellos con enfermedad aneurismática múltiple...

Objective: to report our surgical experience in the pterional approach, highlighting the extent and technical details of that procedure. Material and Method: we performed a retrospective study analyzing the medical records of 142 patients who went under surgery through a classic pterional approach or one of its variants, between October 2009 and October 2012. Epidemiological data was collected and also that related to the different pathologies achieved by this route. For a better interpretation, the images were taken in 3D. Results: during that period we performed 149 pterional craniotomies over a total of 145 patients, 4 of them underwent bilateral pterional approach. There were 95 patients with cerebral aneurysms, 9 of them with multiple aneurysmal disease...