Keyhole Approach Research Articles

Surgical clipping of a non-ruptured ophthalmic aneurysm through an extradural micropterional keyhole approach.

Clipping continues to be one of the treatment strategies for ophthalmic artery aneurysms not amenable for stenting or coiling, or when long-term treatment durability is a concern. However, crescent development of endovascular techniques demands minimal invasiveness in the transcranial approaches while ensuring satisfactory results. We describe an extradural micropterional keyhole approach (eMKA) to the paraclinoid region and highlight the key anatomical elements of this surgical approach. The eMKA is a minimally invasive approach that provides access to the paraclinoid region using an extradural corridor. Therefore, it is suitable for clipping of ophthalmic artery aneurysms and other paraclinoid aneurysms.

Full Endoscopic Technique for High-Grade Up-Migrated Lumbar Disk Herniation via a Translaminar Keyhole Approach: Preliminary Series and Technical Note.

Technically and anatomically, accessing a high-grade migrated lumbar disk herniation (LDH) using traditional full endoscopic lumbar diskectomy (FELD) approaches (either transforaminal or interlaminar) is challenging. The objective of this study was to present an effective and safe surgical approach for high-grade up-migrated LDH by translaminar FELD. Thirteen patients with soft high-grade up-migrated LDH treated with a translaminar FELD between May 2015 and July 2018 were reviewed in this study. Five of these patients had very high-grade up-migration. Clinical outcomes were assessed including preoperative and postoperative visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and MacNab criteria. Overall, 7 of the 13 patients had disk-fragment migration at L4-L5: three at L5-S1, two at L3-L4, and the remaining one at L2-L3. In all cases, the highly up-migrated LDH was removed successfully through the translaminar approach, as confirmed by postoperative magnetic resonance imaging. The improvements of VAS for back and leg pain were 4.5 ± 0.9 to 1.3 ± 1.3 and 7.1 ± 1.0 to 1.6 ± 0.7, respectively (both p < 0.05). The ODI decreased from preoperative 41.9 ± 6.0 to postoperative 13.0 ± 4.1 (p < 0.05). According to the MacNab criteria, the satisfaction rate was 92.3% (excellent or good outcomes). None of the patients experienced any perioperative complications or recurrence during the follow-up period. Although full endoscopic technique via the translaminar keyhole route may not be used as a routine surgical approach, it could serve as a feasible alternative method for patients with highly up-migrated disk herniation.

Factors determining the side of approach for clipping ruptured anterior communicating artery aneurysm via supraorbital eyebrow keyhole approach

PurposeThe purpose of this study was to review the microsurgical anatomy and clipping of ruptured anterior communicating artery (AComA) aneurysms and to plan and avoid complications before operation. MethodsA total of 523 cases of cerebral aneurysms admitted to the neurosurgery department of the Third Affiliated Hospital of Sun Yat-Sen University from September 2010 to October 2018 were analyzed retrospectively. Among them, 85 patients had ruptured AComA aneurysms. This study was limited to 85 of these cases, whose satisfactory preoperative angiographic diagnostic films can be retrieved from the hospital database system because of the need for detailed review. ResultsWe performed supraorbital eyebrow keyhole approach (SOEK) craniotomy in 85 patients to clip 85 AComA aneurysms, in the setting of subarachnoid hemorrhage (SAH). Patients’ mean age was (52.69 ± 9.94) years (range, 28–78 years). The proportions of small, medium and large aneurysms were 83.5%, 15.3%, and 1.2%, respectively. The average size of the aneurysms was (5.07 ± 2.36) mm. There were 77.8% of patients with inferior aneurysms and 81.3% of patients with superior aneurysms achieved good results. There was a significant correlation between A1 dominance and operation method (p < 0.001). There was no significant relationship between surgical approach and aneurysm projection or A2 plane (p = 0.157 &p = 0.318). ConclusionRegardless of whether the A2 plane is open or closed, the A1 dominant side is still a better choice for accessing AComA aneurysms to avoid dangerous premature bleeding.

Minimally invasive keyhole temporal lobectomy approach for supramaximal glioma resection: A safety and feasibility study

With a recent trend towards supra-maximal resection for gliomas and minimally invasive techniques, keyhole temporal lobectomies may serve an important role in neurosurgical oncology. Due to their location and proximity to eloquent brain, temporal lobe gliomas offer unique challenges that may limit the extent of resection. Here we describe a modified technique using mini-craniotomies through a keyhole approach for temporal lobectomies in glioma patients. We retrospectively reviewed data from consecutive patients who underwent temporal lobectomies for resection of gliomas from 2012 to 2018. Demographic data, extent of tumor resection, pre and post-op KPS, short term and long term complications, as well as other relevant data were collected. We identified 57 patients who underwent keyhole-mini craniotomy for temporal lobectomies for glioma. Surgical procedures were performed in 12 patients for low-grade glioma (LGG) and 45 patients for high-grade glioma (HGG). Awake craniotomies were performed in 15 of the cases, and 13 cases were for tumor recurrence. Supra-maximal resection (SMR) was achieved in 15 patients, while gross total resection (GTR) and near total resection (NTR) achieved in 32 patients and 10 patients, respectively. Average pre- and post-op KPS were equivalent, and post-operative complications requiring surgical intervention were experienced in 4 patients. Here we show that our modified keyhole craniotomy is both safe and effective in achieving SMR or GTR in glioma patients, with minimal morbidity. This minimally-invasive temporal lobectomy may be an instrumental tool for neurosurgical oncologists transitioning to less invasive techniques.

Fronto-Orbital Variant of Supraorbital Keyhole Approach for Clipping Ruptured Anterior Circulation Aneurysms (f-Sokha).

The following paper describes the technique and outcomes of fronto-orbital variant of supraorbital key hole approach (f-SOKHA) to clip anterior circulation aneurysms and compares the same with a similar cohort operated through pterional craniotomy (PT). Ambispective study (2012-2019); Technique applied for anterior circulation aneurysms. Contraindications included: Large hematomas, tense brain, avoided in poor grade (Hunt and Hess grade III and IV). Large frontal sinus: Relative contraindication. Procedure included a trans-ciliary skin incision, burr hole over key point, cutting of orbital roof via the burr hole, and removal of a single small fronto-orbital flap (1). This was followed by drilling of the inner table of the frontal bone (2). Both 1 and 2 resulted in expansion of the operative space by 60%. Results compared with a similar cohort of PT. n = 75 cases; most commonly used for ACom (anterior communicating: 43) followed by middle cerebral (16), internal cerebral (13), Posterior communicating (6), anterior cerebral (2), and anterior choroidal (1). Mean age: 47.9 ± 14 years; mean Hunt and Hess grade: 1.96 ± 1.35; duration of surgery: 203 ± 45 minutes, mean size of aneurysm: 6.96 ± 3.65 mm. Both blood loss and surgery duration was less (P: 0.099 and <0.001) when compared with a similar cohort with PT. It also demonstrated better cosmetic results and patient satisfaction. f-SOKHA provided a larger operating corridor (60% more) as compared with the standard supra-orbital key-hole approaches while preserving the same degree of minimally invasive nature and cosmetic results.

Supraorbital Keyhole Approach for Clipping Ruptured Anterior Circulation Aneurysms.

Supraorbital Keyhole Approach for Clipping Ruptured Anterior Circulation Aneurysms.

Facial Nerve Preservation for Supraorbital Approaches: Anatomical Mapping Based on Consistent Landmarks.

The supraorbital keyhole approach (SOKA) provides a safe and advantageous access to the anterior cranial fossa. The implemented skin incision varies depending on surgeon's preferences and requirements. Facial nerve (FN) injury might appear in up to 5.6% of patients. There is a lack of validated tenets for avoiding FN injury. To define a safety area for FN preservation during a SOKA. Ten dried skulls and 5 injected cadaveric heads (10 sides) were used. A Cartesian frame was created with its horizontal axis at the level of the supraorbital notch and the vertical axis just lateral to the frontozygomatic junction (FZj). FNs were dissected and points along their course were registered and transferred to the Cartesian frame. Ten microscopic dissections of the FN were performed preserving all branches. A safety area could be defined 8 mm superior and 10 mm inferior to the FZj extending medially to the supraorbital notch and beyond. A 20 mm2 area superior and lateral to the FZj provided low probability (≤10%) of injuring the FN. Similarly, starting 4 mm inferior to the FZj, a lateral safety area was also found. A probabilistic colored heat map was built to represent the results. We provide a "safety zone" for a SOKA incision in which the probability to encounter the FN is low. Clinical studies following our method may validate our findings and add evidence to the tenets for minimizing morbidity related to the SOKA incision.

Keyhole Approach for Microscopic Excision of Third Ventricular Colloid Cyst: Our Experience

Endoscopic surgery has truly revolutionized the surgical management of colloid cysts. Their central and deep location within the third ventricle has historically demanded a great degree of surgical skill and demand on the patient. Until the last two decades the treatment options for patients with colloid cysts included a traditional craniotomy (opening the skull for removal of the cyst), stereotactic cyst aspiration, or placement of a shunt for hydrocephalus.

The supraorbital keyhole approach for clipping of anterior circulation ruptured aneurysms

Introduction. The supraorbital approach has been demonstrated to be useful, particularly in minimization of brain retraction and exposure to air, decreases blood loss, surgical trauma, operative time and infection rates. While its shortcomings include difficult control of frontal air sinus, narrower surgical view and limited exposure of sylvian fissure.&#x0D; Patients and methods. We retrospectively reviewed the files of patients who underwent clipping of anterior circulation aneurysms through the supraorbital keyhole approach at Neurosurgery Department, Mansoura University between Jan 2014 and May 2016.&#x0D; Results. Twenty-five consecutive patients harbouring aneurysm at anterior circulation underwent clipping through the supraorbital keyhole approach, sixteen A-com artery aneurysms and nine cases of ICA aneurysms Table 1 show the location of aneurysms. Eleven patients were males, and 14 were females. The ages ranged from 44 to 69 with a mean age of 61.9 years. All patients were presented with subarachnoid haemorrhage due to rupture of aneurysms in anterior circulation The Hunt and Hess grade was (1.50 ± 0.65) and Fisher grade was (1.67 ± 0.45). The average operative time was 3.32 ± 1.14 hours. Follow-up ranged from 1 to 16 months with a mean of 7 months&#x0D; Conclusion. Surgical clipping of some selected aneurysms of anterior circulation can be operated through minimally invasive supraorbital approach which minimize the dissection and retraction of the brain, reduce operative time and blood loss with small incision and good cosmetic results.

Private domestic well water as a possible source of lead exposure in three rural illinois counties: a pilot study

Minimally invasive surgery of small skull base meningiomas is technically challenging. We report the role of endoscopic 5-aminolevulinic acid fluorescence guidance (e-5-ALA-FGS) for small and deep-seated anterior skull base meningiomas.We report the cases of 2 patients. The first case was a small olfactory groove meningioma resected via a trans-eyebrow, subfrontal approach. The second case was a clinoid meningioma with invasion of the optic canal resected via a small frontolateral approach. Intraoperative documentation demonstrated the usefulness of 5-ALA endoscopy. In either case, residual fluorescing tumor tissue was detected. No complication was encountered. The clinical and radiological outcomes were good. No regrowth had occurred after 54 and 17 months of follow-up, respectively.Residual meningioma tissue on the far side of a keyhole approach (e.g., in the olfactory groove or at the optic canal) can be difficult to visualize. Visualization can be improved by use of an endoscope. To date, fluorescence guidance with a microscope was limited by insufficient fluorescence signals in deep corridors. With a specially equipped 5-ALA fluorescence endoscope, one can combine the advantages of both endoscopic vision and fluorescence guidance. The results of present report have demonstrated the usefulness of 5-ALA endoscopy for difficult to visualize areas.Endoscopic 5-ALA fluorescence guidance was shown to be feasible when resecting small and deep-seated skull base meningiomas via minimally invasive approaches. Based on this proof of principle, we encourage its evaluation for the middle or posterior fossa (e.g., internal auditory canal) and other difficult areas (e.g., behind neurovascular structures or the brainstem). The sensitivity and specificity of this method should be prospectively and systematically investigated.

Meta-Analysis of Pterional Versus Supraorbital Keyhole Approach for Clipping Intracranial Aneurysms: Direct Comparison of Approach-Related Complications

The supraorbital keyhole approach (SKA) and pterional approach (PA) have been recommended for clipping intracranial aneurysms (IAs). We conducted a meta-analysis to systematically and comprehensively compare the clinical outcomes between the 2 approaches. We retrieved potential academic studies that had compared the clinical outcomes of SKA and PA for clipping IAs from the Cochrane Library, Medline, PubMed, and EMBASE databases. The references of the identified studies were carefully reviewed to ensure that all available documents had been included in the present study. The meta-analysis was conducted in accordance with the acknowledged PRISMA (prioritized reported items for systematic review and meta-analysis) guidelines. A total of 8 studies with 1016 participants were included in our study. Of these 1016 patients with IAs, 518 were assigned to the SKA group and 498 to the PA group. Our results showed that the SKA is preferable for clipping IAs compared with the PA because of its shorter operative time (weighted mean difference,-3.163; 95% confidence interval [CI],-5.577 to-0.749; P= 0.01) and length of stay, especially for the patients with unruptured IAs (weighted mean difference,-52.107; 95% CI,-81.597 to-22.618). However, a lower risk of postoperative infection was found in the SKA group (4.6% vs. 8.5%; odds ratio, 0.398; 95% CI, 0.186-0.850; P= 0.017), which seemedto derive from the ruptured IAs (OR, 0.330; 95% CI, 0.136-0.800; P= 0.014). However, no significant difference was found in the incidence of frontal sinus opening, completed occlusion, procedural complications, intraoperative rupture, postoperative hematoma, or cerebral vessel spasm. The SKA was associated with a shorter length of stay and operation time and a lower risk of postoperative infection. Hence, the SKA seems to be equally effective and safe for clipping IAs compared with PA and should be recommended for surgeons who have acquired sufficient experience with this technique owing to its advantages compared with the PA.

Supraorbital keyhole approach: Pure endoscopic and endoscope-assisted perspective

ObjectiveTo assess the assumed advantages of pure endoscopic and endoscope-assisted methods for the supraorbital keyhole approach. The aim is to demonstrate visibility and accessibility of the pure endoscope approach as a possible standard approach for the supraorbital keyhole approach. Patients and MethodsWe performed eight dissections on four cadaver heads using an operating microscope, an endoscope, and neuronavigation. The visibility and accessibility of the anterior and middle cranial fossae regions were compared for each. Special structures were defined to assess their preservation in both approaches. We used pure endoscopy on the eight sides and with a microscope on those same eight sides. Accessibility was quantified for key structures using linear measurements taken with the navigation system. In addition, we present clinical cases in which an endoscope-assisted supraorbital approach was employed. ResultsOur measurements have been reported for each side in the formalin-fixed heads as the mean ± SD (in mm) from the bone margin to selected regions. Moreover, image analysis was performed using ImageJ software to compare selected surface area measurements between the endoscope and microscope images on each side for all cadaveric available specimens. There were no significant statistical differences between visualization of the selected areas. This means that by visual analysis both endoscopic and microscopic images can provide the surgeon nearly the same visibility and accessibility of a selected region. ConclusionA pure endoscopic method can be used to conduct the supraorbital keyhole approach when the endoscope is used as a primary tool. Our recommendation is to use the measurements described in this study for preoperative planning of the keyhole approach. We believe that with advances in neuro-endoscope technology, and instrumentations, the endoscopic approach may replace the microscopic approach in the near future.

Application of 3D-Printed Craniocerebral Model in Simulated Surgery for Complex Intracranial Lesions

To demonstrate the use of 3-dimensional (3D)-printed intracranial lesion models for complex neurosurgery to increase the success rate of clinical surgeries via practice in simulated surgeries. We collected computed tomographic, magnetic resonance (MR), and computed tomographic images from patients with intracranial tumor or aneurysm, conducted multimodal image reconstruction, and then constructed a 3D-printed model with the skull base, cerebral arteries, and brain tumor or aneurysm. Forty-nine simulated surgeries were carried out on the model under a microscope, and actual surgery was carried out after validation and accumulation of experience. The 3D-printed brain tumor models were used to design the surgical route, to simulate piecemeal resection of tumors through keyhole approach, and to verify the extent of tumor resection. A drill was used for bone flap removal and milling of bony structures such as the anterior clinoid process, tuberculum sellae, petrous apex, and internal acoustic meatus. The tumors were removed by laser knife and cavitron ultrasonic aspiration. The 3D-printed aneurysm models were used to assess the feasibility of different keyhole approaches and to select the aneurysm clip. Actual surgery was based on the results of the simulated surgery. Postoperative MR image review showed that 84% (21/25) of patients had total tumor resection and 16% (4/25) subtotal resection. Digital subtraction angiography confirmed complete clipping of all aneurysms (24 cases/39 aneurysms). 3D-printed craniocerebral models provide effective simulated surgery conditions for keyhole surgeries of complex brain tumors or aneurysms and aid in preoperative surgical design, accumulation of surgical experience, and validation of surgical outcomes.

Acceso minipterional interfascial simple y combinado, con peeling de fosa media y clinoidectomia anterior extradural. Serie clínica

Introducción: En las últimas dos décadas al acceso pterional clásico descrito por Yasargil se le han realizado modificacionesimportantes en búsqueda de acceder a la base del cráneo, tales como el acceso transcigomático y orbitocigomático; más recientemente, accesos mínimamente invasivos, abordajes keyhole. Es así como se ha descrito el acceso minipterionalcon disección interfascial, el que ha sido combinado con técnicas de la base del cráneo, clinoidectomía anterior extradural,peeling de fosa media y petrosectomía anterior de Kawase, por el equipo de Neurocirugía Vascular y de la base del Cráneodel Instituto de Neurocirugía (INCA), a cargo del Dr. Jorge Mura, logrando resolver patologías complejas por un acceso keyhole. Este trabajo presenta una serie clínica, multicéntrica, realizada por un mismo neurocirujano, y que tiene como objetivo demostrar que el acceso minipterional simple y combinado es reproducible en otros centros, con buenos resultados clínicos. Materiales y Métodos: El autor presenta una serie clínica, de 56 pacientes, tratados en el hospital San Pablo de Coquimbo y Clínica Elqui de La Serena, entre abril de 2017 y agosto de 2018, con un seguimiento prospectivo de los resultados clínicos, los cuales fueron evaluados con la escala de Rankin modificado. Resultados: En un total de 56 casos, predominó el sexo femenino (71%), la edad media fue de 53 años y la patología aneurismática fue lo más frecuente con 45 casos, de estos el 60% fueron aneurismas rotos; el 7% correspondieron a tumores de la base del cráneo y el 12,5% a hidrocefalias no comunicantes resueltas por la apertura de la lámina terminalis. En 9 casos se combinó el acceso minipterional con clinoidectomía anterior extradural y en 3 casos se hizo un peeling de fosa media. El mayor tiempo quirúrgico estuvo asociado al acceso minipterional combinado, ya sea por patología tumoral o aneurismas paraclinoideos. Se obtuvo un resultado neurológico favorable (ERm &lt; 3) en el 87,5% de los pacientes. Conclusión y Discusión: actualmente la evidencia ha dejado de manifiesto que el acceso minipterional tiene ventajas sobre otros accesos keyhole, principalmente por la posibilidad de poder combinarlo con técnicas de base del cráneo, pudiendo resolver patologías que antes no era posible tratar por accesos mínimamente invasivos. El acceso pterional clásico, sin embargo, sigue teniendo indicación en casos seleccionados. Por otra parte, esta serie clínica confirma que el acceso minipterional simple y combinado, es reproducible y que, utilizándolo con un adecuado manejo microquirúrgico, logra buenos resultados en patologías complejas.

Vasospasm and delayed cerebral ischemia after uneventful clipping of an unruptured intracranial aneurysm \u2013 a case report

BackgroundDue to improvements in both the quality and availability of intracranial imaging as well as the evolution of surgical and endovascular techniques during the last decade, the number of treatments of unruptured intracranial aneurysms (UIA) has increased steadily. However, it is not generally known that vasospasm can arise after an uneventful clipping.Case presentationWe present a case of a 69-year-old woman who suffered from vasospasm and delayed cerebral ischemia that occurred after an uneventful clipping of a UIA.The aneurysm of the right middle cerebral artery was found incidentally via magnetic resonance imaging ordered after the patient complained of a short period of slight gait disturbances. To avoid a subarachnoid hemorrhage and consecutive complications like vasospasms, the patient elected microsurgical treatment. Clipping was managed by keyhole approach. Temporal clipping of the M1 was not necessary. After clip placement, appropriate flow in all distal segments was confirmed by indocyanine green video-angiography and micro-Doppler. The patient was discharged seven days after surgery without neurological deficits.After 12 days, the patient developed at home a sudden drooping on the left side of the face. Upon admission to the emergency room, the patient was alert but slightly confused. Neurological examination revealed a left-sided hemiparesis and motor speech disorder. In contrast to the preoperative transfemoral catheter angiography, the subsequent right internal carotid angiogram showed clear signs of vasospasm along the M1 and M2 segments of the right middle cerebral artery.Antithrombotic treatment with acetylsalicylic acid was begun. In accordance with guidelines for the treatment of subarachnoid hemorrhage and vasospasm, nimodipine was added. After 11 days the patient was discharged with no symptoms.ConclusionCerebral vasospasm as a cause of ischemic stroke after uneventful surgery for a UIA seems to be a rare but possibly underestimated etiology that demands particular attention with respect to providing appropriate treatment. In future, it may be prudent to perform follow-up transcranial ultrasonography testing after the clipping of a UIA, especially considering the availability of potentially neuroprotective medications like nimodipine.

An Anatomic Study of the Keyhole Supra-Tentorium to Infra-Tentorium Endoscope Approach.

To provide anatomic basis for the retrosigmoid supra-tentorium to infra-tentorium keyhole approach and to explore the feasibility, 60 skulls were observed and measured to demonstrate the position relations among related bony landmarks, 12 cadaveric heads were dissected and measured for localization of the keyhole and the incision through tentorium. For giving the angle and depth for endoscopic approach, 40 adult volunteers were performed head MRI scan and the pictures were measured and analyzed. The surface projection of sigmoid and transverse sinus can be positioned by mastoidale, external occipital protuberance, and anterior end of parietomastoid suture (AEPMS) on body. There is a safe trigone of cerebellar tentorium (STCT) among inner edge of upper curve of sigmoid sinus, entrance of tentorial sinus/vein and midpoint of posterior edge of temporal arcuate eminence. 15 mm superior to the midpoint between asterion and AEPMS can be recognized as the central point of the keyhole. Magnetic resonance imaging pictures show there is potential subarachnoid space for endoscopic approach from the indicated keyhole to pontocerebellar trigone. This study demonstrated endoscopy can arrive at pontocerebellar trigone through the STCT and the keyhole supra-tentorium to infra-tentorium endoscope approach is feasible in anatomy and will contribute to excise lesions involving both supra- and infra-tentorial structures.

Minimally Invasive Endoscopic Keyhole Approach for Meningiomas

Abstract INTRODUCTION The advantages of neuroendoscopic surgery are wide viewing angle and freedom of axis of view with minimal surgical trauma. Taking advantage of the features of neuroendoscopy, the authors report the experience of minimally invasive endoscopic keyhole approach (EKA) for various meningiomas. METHODS A total of 28 cases of various type of meningiomas were treated by EKA from 2007 to 2018. A keyhole of about 2.5 cm was created according to the case, and tumor removal was performed using an endoscope and exoscope. The scope was held by a pneumatic holder controlled by the assistant to continue the procedure in a comfortable environment. RESULTS EKAs were performed for anterior skullbase lesions via eyebrow skin incision (n = 12), posterior fossa lesions including tentorial meningiomas, torcular meningiomas (n = 7), falcine lesions (n = 6), subtemporal approach (n = 2), enplaque convexity menigiomas (n = 1). All the tumors were resected as planned with minimum brain retraction and well-illuminated fine vision in deep corner. In the cases of a large tumor in the elderly, maximum internal decompression was performed, and the adhered tumor was left on the surface of the brain to avoid injury. The brain retraction was automatically limited by the small craniotomy, and excellent magnified image in deep corner was obtained by EKA. By eliminating the blind spots, radical resection is achieved. Also, in the aging society, depending on the patient with benign meningioma, it is important to consider what better treatment is, to alleviate symptoms and to coexist with the tumor. The cooperation of the assistant is important for this approach. To avoid the interference between the endoscope and the instrument, it is necessary to have a technique for moving the endoscope as needed in order to keep the fine visual field. CONCLUSION In the treatment of meningioma, the role of endoscopes is important in both the radicality obtained in a wide field of view and the less invasiveness in the aging society.

Supraorbital Keyhole Approach for Intracranial Aneurysms : Transitioning from Concerns to Confidence.

For surgical minimalism to reduce iatrogenic traumatization, a supraorbital keyhole approach has already been successfully applied to treat many unruptured anterior circulation aneurysms. However, using this minimal approach also raises several technical concerns due to the small cranial opening and cosmetic impact of a facial incision. Yet, such technical limitations can be overcome by using favorable surgical indications, slender surgical instruments, and optimized surgical techniques, while excellent cosmetic outcomes can be achieved using a short skin incision located <1 cm from the supraorbital margin, reconstruction of any bone defects around the bone flap, and meticulous wound closure. Thus, given such reassuring surgical results, in terms of the clipping status, neurological effects, and cosmetic outcomes, any concerns can be transitioned into confidence.

Comparison of the Surgical Approaches for Frontal Traumatic Intracerebral Hemorrhage

Purpose: Recent developments in minimally invasive techniques have the potential to reduce surgical morbidity, promote patient recovery, accelerate surgical procedures, and thus improve cost-effectiveness in case management. In this study, we compared the treatment efficacy and results of supraorbital keyhole approach (SOKA) with those of conventional unilateral frontal craniotomy (CUFC) for traumatic intracerebral hemorrhage (TICH) in the frontal lobe. Methods: We analyzed the data of 38 patients who underwent CUFC (n=30) and SOKA (n=8) and retrospectively reviewed their medical records and radiological findings. Furthermore, we tried to identify the best surgical method for such lesions by including patients who underwent burr hole aspiration and drainage (BHAD) (n=9) under local anesthesia due to various circumstances. Results: The difference in the initial Glasgow coma scale score, operative time, and length of hospitalization between the CUFC and SOKA were statistically significant. All radiological features between the two groups including associated skull fracture, amount of pre- and postoperative hematoma, percentage of complete hematoma removal, pre- and postoperative midline shifting of the hematoma, and development of postoperative delayed hematoma were not statistically significant. Our experience of 46 patients with TICH in the frontal lobe with any of the three different surgical methods including BHAD enabled us to obtain valuable findings. Conclusions: Although it is difficult to insist that one particular approach is more useful than the other, we are confident that SOKA will have more advantages over CUFC in carefully selected patients with frontal TICH depending on the surgical experience of a neurosurgeon.

Comparative study of supraorbital keyhole approach and pterional approach in treatment of ruptured anterior communicating artery aneurysms

Objective To compare the clinical effects of aneurysm ligation of ruptured anterior communicating artery through supraorbital keyhole approach and pterional approach. Methods We performed a retrospective study of 45 cases with anterior communicating artery aneurysms admitted to Department of Neurosurgery, Peace Hospital Affiliated to Changzhi Medical College and 29 cases with anterior communicating artery aneurysms admitted to Department of Neurosurgery, Shanxi Dayi Hospital from January 2013 to June 2018. Among them, 40 cases underwent clipping of aneurysms through pterional approach (pterional approach group) and 34 cases underwent aneurysm clipping via supraorbital keyhole approach (keyhole approach group). Clinical follow-up was performed at 6 months post surgery. The Glasgow Outcome Scale (GOS) was used for outcome assessment: grades Ⅳ-Ⅴ for good outcome, grade Ⅱ-Ⅲ for poor outcome and grade Ⅰ for death. Based on the patient's self-cosmetic satisfaction scores (1-5 points), 1 represented very dissatisfied and 5 meant very satisfied . The clinical efficacy in the 2 groups of patients was compared. Results There was no significant difference in age, gender, Hunt-Hess grade or aneurysm diameter between the 2 groups (all P>0.05). Compared with the pterional approach group, the operation time in the keyhole approach group was shorter (215.0±46.7 min vs. 272.4±50.6 min, P 0.05). However, the cosmetic satisfaction scores of patients in the keyhole approach group was higher than those in the pterional approach group (4.8±0.6 vs. 3.9±1.1, P<0.01). Conclusions The keyhole approach is a safe and reliable surgical approach, ruptured anterior communicating artery aneurysm, the supraorbital approach can be partly used to replace the pterional approach. Key words: Intracranial aneurysm; Treatment outcome; Anterior artery; Supraorbital keyhole approach; Pterional approach