The results of treatment of anterior circulation aneurysms with keyhole approaches / Монголын Анагаах Ухаан

ABSTRACT

IntroductionA cerebral aneurysm has been surgically treated since the early twentieth century. Since then, numerous new surgical methods and technologies have been developed in neurosurgical practice to improve outcome of the neurosurgical treatments. In fall of 1980, the very first aneurysm surgery was successfully performed in Mongolia. Until 2011, the bitemporal and pterional approaches had been used as the main treatment option for anterior circulation aneurysms in Mongolian neurosurgicalpractice. The keyhole approach, cultivated by German neurosurgeon A.Perneczky, was introduced to Mongolian neurosurgical practice in 2011 as another threatment option for the anterior circulation aneurysmGoalThis study aimed to design new key hole surgical techniques with four small burr holes, based on the method of German neurosurgeon A. Perneczky for treatment of anterior circulation aneurysms and decrease the rate of surgically related complications.Materials and MethodsBetween January 2011 and March 2012, in the neurosurgical department of Third State Central Hospital 259 patients were treated with anterior circulation aneurysms. 103 of them treated with key hole approaches (as the study groupe), while 55 were treated with pterional approaches. We choose 103 patients reports (as the control groupe), who were treated with traditional approaches and studied the results retrospectively, which were compared with the results of the new techniquesof surgical treatment. We compared the outcomes of the new keyhole surgical approach with the outcomes of traditional approaches based on the severity of after surgery complications, focal neurological deficits, postoperative mental changes and functional impairments, and duration of hospital stay (recovery period). The skin incision begins laterally from the supraorbital incisura and is made within the eyebrow. Posterior to the temporal line at the level just above the zygomatic arch we drilled two small (0.5 cm) burr holes, and two more burr holes above the orbital rim. Quadrangle shaped bone flap is cut with the angle 45o, and removed, after which drill of the inner edge of the bone above the orbital rim. Inner edge of the other side is not drilled off. After intradural procedure, we fixed bone flap using the inner edge, which was not drilled off.ResultsFrom Jan, 2011 to Dec, 2012, 235 patients received surgical treatment (78 women and 79 men, median age, 46.3±2.3 yo). The lesions included 9 anterior cerebral artery aneurysms, 6 in posterior communicating artery, 35 in middle cerebral artery, 34 in anterior communicating artery, 1 in ophthalmic artery, and 18 in internal carotid artery aneurysms. The ratio of men and women with aneurysmal SAH was 11, which demonstrated different results comparing with the countries such as Japan, Austria and Canada. Two patients died after operation due to cerebral vasospasm, who were admitted to our hospital with the WFNS grade III-IV after SAH. The postoperative hemiparesis accounts 4.8% (5 cases). After short-term observations (3 months) 4 of these patients showed a good recovery of paralyzed extremities. One patient missed out of follow up. Surgically related complications like mental change, temporal muscle atrophy were about 4%-8%. (The difference between two methods is P<0,009). The average duration of hospital stay was 8.2 ±2. ConclusionsSubtemporal, subfrontal, and paranasal key hole with pterional approaches have several advantages over the traditional craniotomies, including minor tissue damage, less brain retraction, a superior cosmetic results, and shorter duration of surgery and hospital stay. The operative field becomes wider in the deep area, providing sufficient space for microscope-assisted surgeries without need of highly specialized instruments.