Abstract
Background:The sylvian fissure (SF) is the anatomical pathway used in a pterional approach, which leads to most aneurysms. There are four different anatomical variants of the SF described. In the present retrospective study the four different categories of the SF were studied in order to evaluate any correlation of these variants to surgical outcome.Methods:Patients treated for intracranial aneurysms by a pterional transsylvian approach during 2003-2012 (N = 237) were included in the study. The SF category was determined by analysis of preoperative computed tomography (CT) scanning. Patients were grouped into unruptured intracranial aneurysms (UIA) and ruptured intracranial aneurysms with subarachnoid hemorrhage (SAH) according to the Hunt and Hess grades. Brain edema, vasospasms, ischemic lesion rate, and outcome were evaluated for possible correlation with SF anatomical variants.Results:Postsurgically brain edema formation correlated significantly with more complex anatomical variants of the SF in patients with UIAs and in patients with Hunt and Hess 1 and 2. Ischemia rate, vasospasms, or clinical outcome was not negatively affected though.Conclusion:The classification of the SF as proposed by Yasargil is more than a pure anatomical observation. In this retrospective study, we show that the anatomical variants of the SF can be associated to postoperative complications like formation of brain edema or ischemic lesions Preoperative knowledge of the SF anatomy and possibly consecutive adapted extend of the surgical approach can decrease procedure-related morbidity.
Highlights
The pterional approach to aneurysms of the circle of Willis is one of the most common approaches in vascular neurosurgery.[1,2,3] There are different variants of the pterional approach described, such as the orbito‐cranial approach as an extended and the sphenoid ridge keyhole approach as a less invasive approach.[11,12] The aim of the pterional approach is to use a naturally occurring plane, through the sylvian fissure (SF), to approach an aneurysm without extensive brain retraction.[12]
We considered the question of whether a complex SF anatomy affect postsurgical outcome and should play a role in the planning of the extend of the pterional approach to intracranial aneurysms
delayed cerebral ischemia (DCI) has a huge number of factors that can be responsible for its occurrence, but the SF anatomy seems to be excluded of list of triggers.[18,19]
Summary
The pterional approach to aneurysms of the circle of Willis is one of the most common approaches in vascular neurosurgery.[1,2,3] There are different variants of the pterional approach described, such as the orbito‐cranial approach as an extended and the sphenoid ridge keyhole approach as a less invasive approach.[11,12] The aim of the pterional approach is to use a naturally occurring plane, through the sylvian fissure (SF), to approach an aneurysm without extensive brain retraction.[12]. A more complex SF anatomy could affect the surgical outcome by a pterional approach. We aimed to analyze systematically the role of the anatomical variants of the SF and its influence on procedure‐related complications like edema, ischemic lesions, and cerebral vasospasm and outcome. We considered the question of whether a complex SF anatomy affect postsurgical outcome and should play a role in the planning of the extend of the pterional approach to intracranial aneurysms. The sylvian fissure (SF) is the anatomical pathway used in a pterional approach, which leads to most aneurysms. In the present retrospective study the four different categories of the SF were studied in order to evaluate any correlation of these variants to surgical outcome
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