Lateral Supraorbital Approach Research Articles

Keyhole Alternatives to Pterional Craniotomy for the Microsurgical Clipping of Anterior Circulation Aneurysms: Technical Pearls, Surgical Results, and a Case Selection Algorithm.

Despite a recent surge in keyhole approaches to aneurysm clipping, only few studies have compared these approaches, and none have laid any foundation or roadmap for surgeons newly venturing into these procedures. To report a single surgeon's experience of multiple keyhole approaches to these aneurysms, and to highlight the case selection algorithm, technical nuances, and surgical results. Twenty-four patients (25 aneurysms) underwent aneurysm clipping using either a mini-pterional approach (MPA), lateral supraorbital approach (LSO), or a supraorbital keyhole approach (SOKHA). Intraoperative premature rupture, adequacy of clipping, and immediate postoperative and long-term functional outcomes were recorded. All but five patients presented with ruptured aneurysms (Hunt and Hess grade 1 in 12 patients, grade 2 in 5 patients, and grade 3 in 2 patients). The anterior communicating artery (A-Comm; n = 14, 56%) was most frequently involved with aneurysms. The MPA was most frequently employed (n = 11, 45.8%), followed by the LSO (n = 9, 37.5%) and the SOKHA (n = 4, 16.7%). An intraoperative rupture (total n = 5, 20.8%) was most frequently seen in the SOKHA group (50%) and the only case of inadequate aneurysm clipping resulted from inadequate clipping ergonomics during the SOKHA for A-Comm aneurysm. Major complications occurred in the supraorbital approaches (one each in the LSO and SOKHA). Irrespective of the approach used, the long-term outcomes were excellent. In properly selected patients, keyhole approaches-particularly the MPA and the LSO-can provide excellent surgical outcomes. The learning curve in the SOKHA is steeper. A pragmatic case selection algorithm is proposed.

Pterional vs. lateral supraorbital approach in the management of middle cerebral artery aneurysms: insights from a phantom model study

The pterional approach has traditionally been employed for managing middle cerebral artery (MCA) aneurysms. With potential benefits like reduced surgical morbidity and improved postoperative recovery, the lateral supraorbital approach (LSO) should be considered individually based on aneurysm morphology, location and patient-specific variations of the MCA anatomy, which requires considerable technical expertise traditionally acquired through years of experience. The goal of this study was the development and evaluation of a novel phantom simulator in the context of clinical decision-making in the managmement of MCA aneurysms. For this purpose, high-fidelity simulators inclusive of MCA models with identical M1- and bifurcation aneurysms were manufactured employing 3D reconstruction techniques, additive manufacturing and rheological testings. Medical students, neurosurgical residents, and seasoned neurosurgeons (n = 22) tested and evaluated both approaches. Participants’ performances and progress over time were assessed based on objective metrics. The simulator received positive ratings in face and content validity, with mean scores of 4.9 out of 5, respectively. Objective evaluation demonstrated the model’s efficacy as a practical training tool, particularly among inexperienced participants. While requiring more technical expertise, results of the comparative analysis suggest that the LSO approach can improve clipping precision and outcome particularly in patients with shorter than average M1-segments. In conclusion, the employed methodology allowed a direct comparison of the pterional and LSO approaches, revealing comparable success rates via the LSO approach while reducing operation time and complication rate. Future research should aim to establish simulators in the context of clinical decision making.

Lateral Supraorbital Approach for Microsurgical Clipping of Recurrent Ruptured Fetal Posterior Communicating Artery Aneurysm Initially Treated With Woven Endobridge Embolization and Flow Diversion: 2-Dimensional Operative Video

Fetal posterior communicating artery (PComA) is a variant of the cerebral vasculature. 1 Woven endobridge (WEB) embolization carries a good safety profile as treatment for ruptured wide neck PComA aneurysms, without the need for antiplatelet therapy. However, the reported occlusion rates are not optimal. 2 Flow diversion is suboptimal in treating aneurysms originating from fetal PComA. 3 Here we present a case of a 78-year-old female patient with a history of ruptured right fetal PComA aneurysm with wide base. It was initially treated with WEB embolization at an outside hospital. After WEB implantation, the initial follow-up of cerebral angiogram (6 months later) demonstrated a neck recurrence measuring 6 × 3 mm. Approximately 1 year after the initial treatment, pipeline embolization was performed and patient was placed on antiplatelet therapy since. Follow-up images demonstrated a 6 mm × 4 mm persistent neck remnant. Her care was transferred to our institution. Cerebral angiogram obtained 36 months post-WEB implantation showed growth of the neck remnant measuring 9 × 8.5 mm. The WEB device was found to be folded in the aneurysmal fundus. Given this was a growing recurrent previously ruptured fetal PComA aneurysm with a pipeline stent in the internal carotid artery the decision was made to retreat with microsurgical clipping; carotid access at the neck was required for proximal control. We achieved complete aneurysm obliteration through a minimal invasive approach. The patient gave informed consent for surgery and video recording. Institutional Review Board approval was deemed unnecessary.

Perioperative blood transfusion management in surgical resection of intracranial meningiomas: A meta-analysis.

Gross total resection (GTR) of intracranial meningiomas is curative in most cases. However, perioperative blood transfusions may be necessary for complex skull bases and/or high-grade meningiomas. Guidelines for blood transfusions during intracranial meningioma surgery remain unclear. This scoping review aims to delineate the main characteristics of patients who underwent intracranial meningioma surgery, the prevalence of the selected patients who required blood transfusions, and common causes for transfusion. A scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews guidelines to include studies reporting eligibility, protocols, and potential complications related to blood transfusion within the perioperative management of intracranial meningiomas. A total of 33 articles encompassing 3009 meningioma patients were included in the study. The most common symptom was headache (18%), and the most frequent type of meningioma was World Health Organization grade-1 meningothelial (50.4%). The lateral supraorbital approach was the most common surgical corridor (59.1%) in skull base meningiomas, and most patients underwent GTR (69%). Blood transfusion was required for 20% of patients, with a mean estimated intraoperative blood loss of 703 mL (ranging from 200 mL to 2000 mL). The main indications for blood transfusion in meningioma surgery were intraoperative blood loss (86%) and preoperative anemia (7.3%). This scoping found that 20% of the included patients required blood transfusion. It also points out that several factors could influence the necessity for a transfusion, encompassing surgical blood loss, pre-existing anemia, and the surgery's length. This scoping review may provide surgeons with a potential guide to inform their decision-making process regarding blood transfusions during meningioma surgeries.

Exoscopic resection of giant olfactory groove meningioma.

Olfactory groove meningiomas represent 8%-13% of all intracranial meningiomas. Gross-total resection for large (4-6 cm) and giant (> 6 cm) cases remains challenging due to their relationship with critical neurovascular structures and extensive frontal lobe edema. A variety of transcranial and endoscopic approaches have been described. This 2D operative video shows the use of a digital 3D exoscope in the removal of a giant olfactory groove meningioma through a lateral supraorbital approach in a 57-year-old woman with visual impairment and apathy. The exoscope provides a very good angulated view of the subfrontal area on both sides of the anterior cranial fossa even through a small craniotomy. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23125.

The Lateral Supraorbital Approach: 2-Dimensional Operative Video.

The lateral supraorbital approach (LSO), a minimally invasive alternative to the pterional approach, can be used for anterior circulation aneurysms (except distal anterior cerebral artery), some posterior circulation aneurysms, and tumors located around the sellar and suprasellar regions. Performing one-layer myocutaneous flap that is retracted anteriorly, exposure of the superior temporal line, and zygomatic process of the frontal bone and the inferior limit of the craniotomy represent the upper edge of the Sylvian fissure, exposing the anterolateral skull base. Skin incision behind the hairline, one-layer myocutaneous flap retracted anteriorly, minimal detachment of the temporalis muscle, burr hole over the superior temporal line, and craniotomy of 4 cm in diameter (inferior limit of the craniotomy represents the Sylvian fissure). Potential risks include opening of the frontal sinus, entering the orbit and exposure of the orbital fat, wrong craniotomy location, and limited exposure. Inadequate craniotomy size limits instruments maneuverability. To avoid complication, identification of anatomic landmarks, sinus closure, preoperative evaluation of computed tomography scans, and use of neuronavigation are necessary. This requires surgical expertise and familiarity of minimal invasive craniotomies. Anatomic limitations of the LSO include temporomesial region, distal Sylvian +/-, posterior communicating artery aneurysms medial projection, retro carotid space, and carotid cave. For pathologies requiring an additional lateral trajectory, we use an extended LSO, drilling the sphenoid wing through the fronto-pterio-orbital window without drilling of the temporal bone. Additional variations include performing an intradural or extradural clinoidectomy. The patient consented to the procedure and to the publication of their image.

Comparative cost analysis of endovascular and open approaches for elective treatment of middle cerebral artery aneurysms

Background Intracranial aneurysms of the middle cerebral artery can be treated using several open surgical and endovascular approaches. Given the growing evidence of clinical equipoise between these various treatment strategies, there is a need to assess the costs associated with each. Methods Cost of aneurysm treatment was divided into two categories for comparison. “Initial cost” comprised the total in-hospital expenses for initial aneurysm treatment and “total cost” comprised initial aneurysm treatment and all expenses relating to readmission due to treatment-related complications, prescribed catheter angiograms for monitoring of treatment stability, and any retreatments needed for a given aneurysm. The open surgical group was subdivided into a pterional approach group and a lateral supraorbital (LSO) approach group for. Results Median initial cost was $37,152 (IQR $31,318–$44,947) for aneurysms treated with the pterional approach, $29,452 (IQR $27,779–$32,826) for aneurysms treated with the LSO approach, and $19,587 (IQR $14,125–$30,521) for aneurysms treated with endovascular approaches. The median total cost was $39,737 (IQR $33,891–$62,259) for aneurysms treated with the pterional approach, $31,785 (IQR $29,513–$41,099) for aneurysms treated with the LSO approach, and $24,578 (IQR $18,977–$34,547) for aneurysms treated with endovascular approaches. Analysis of variance test demonstrated variance across groups for both initial and total cost ( p = 0.004, p = 0.008, respectively). In our subsequent analysis, initial cost and total cost were higher in the pterional group than the endovascular group ( p = 0.003 and p = 0.006, respectively). Conclusions Endovascular treatment of elective aneurysms has a significantly lower cost than open surgical treatment with the pterional approach, but not with the LSO approach. For aneurysms not amenable to endovascular treatment, a minimally invasive LSO approach carries a lower cost burden than a pterional approach.

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Lateral Supraorbital Approach with Expanded Indications

Abstract Objectives The lateral supraorbital (LSO) approach is a less-invasive alternative to the pterional craniotomy that provides rapid transsylvian access. Establishing familiarity with the LSO technique and its features as compared with other anterolateral approaches is an important component of advanced skull base training. We present a step-by-step demonstration of the LSO approach using cadaveric dissection in a manner that is digestible for trainees at various levels. Design This is anatomic step-by-step dissection and representative case series. Setting This study was carried out in the cadaveric dissection laboratory. Participants A formalin-fixed, latex-injected cadaveric head specimen was dissected under microscopic magnification by a neurosurgery resident under faculty supervision. Following dissection, representative case applications were reviewed. Main Outcome Measures Dissection and case illustration were the main outcome measures. Results A single-layer myocutaneous flap is developed, and a single-burr-hole technique is used, followed by extensive drilling of the sphenoid wing. The dura is opened in a C-shaped fashion centered on the Sylvian fissure, exposing the inferior frontal and superior temporal lobes. Labeled photographs of dissections with pertinent anatomical structures are presented. Three case examples illustrating the versatility of the LSO approach, including the resection of a large pituitary adenoma, an inferior frontal melanoma metastasis presenting to the Sylvian surface, and a frontoinsular low-grade glioma, are reviewed. Conclusions As compared with the pterional craniotomy, the LSO approach involves a shorter incision, smaller craniotomy, and faster exposure; it can be conveniently tailored to various indications. Understanding the step-by-step dissection and indications of the LSO approach is of paramount importance to neurosurgery trainees.

Application of protective superficial temporal artery to middle cerebral artery bypass through the lateral supraorbital approach: Technical note

ObjectiveThe lateral supraorbital (LSO) approach is a minimally invasive craniotomy widely used in the surgical treatment of intracranial aneurysms (IAs). A protective bypass is considered a safety measure in high-risk and complex clipping procedures to maintain distal cerebral flow. However, the protective bypass has so far only been applied through a pterional or larger craniotomy. We aimed to describe the characteristics of the superficial temporal artery to middle cerebral artery (STA-MCA) bypass through the LSO craniotomy to treat complex IAs. MethodsWe retrospectively identified six patients with complex IAs who underwent clipping and a protective STA-MCA bypass through the LSO approach between January 2016 and December 2020. The STA donor artery was harvested through the same curvilinear skin incision with a small extension, and it was anastomosed to the opercular segment of the MCA. Subsequently, aneurysm clipping followed standardized steps. ResultsAnastomosis was successful in all patients. Despite requiring temporary occlusion of the parent artery, all aneurysms were successfully clipped without any neurological deterioration. ConclusionsA protective STA-MCA bypass is feasible through the LSO approach with certain technical modifications. This technique helps protect distal cerebral flow for safe clip placement in the treatment of complex IAs with the associated benefits of a less invasive craniotomy.

Lateral supraorbital approach for resection of large and giant olfactory groove meningiomas: a single center experience

Background The lateral supraorbital approach (LSO) provides an optimal access corridor for various skull bases lesions, including olfactory groove meningiomas (OGMs). The aim of this study is to describe the authors’ experience with the management of large and giant OGMs utilizing the LSO approach and describe the technical nuances of the procedure. Methods A retrospective review of seven patients with large and giant OGMs managed with the LSO approach between 2013 and 2019 was performed. Radiographic and clinical data were recorded and analyzed. Results Seven patients with large and giant OGMs underwent surgical resection via the LSO approach. Six patients were female, with a median age of 56 years. Patients commonly presented with altered mentation, anosmia, and headaches. The average tumor volume was 120.6 ± 64.7 cm3 with five cases of vascular encasement. Simpson grade II resection was achieved in four patients while Simpson grade IV resection was achieved in three patients. The median length of stay was 2.0 days. The median preoperative Karnofsky Performance Scale (KPS) score was 70, improving to 100 at last postoperative follow-up visit. Two complications were encountered in the form of postoperative cerebrospinal fluid leak in one patient and a transient diplopia in another patient. Tumor recurrence/progression was identified in two patients during a median follow-up time of 65.5 months. Both cases have been managed with adjuvant radiosurgery. Conclusion The LSO approach is a safe and effective minimally invasive transcranial corridor for the management of OGMs that should be part of the armamentarium of skull base neurosurgeons.

Minimally invasive craniotomies for lesions of the anterior and middle fossa.

Minimally invasive craniotomies are the subject of increasing attention over the last two decades in neurosurgery, following the current trend of attempting to increase patient safety by providing surgeries with less tissue disruption, blood loss, and decreased operative time. However, a significant information overlap exists among the various keyhole approaches regarding their indications and differences with more invasive techniques. Therefore, the present study aims to comprehensively review, illustrate, and describe the potential benefits and disadvantages of minimally invasive techniques to access the anterior and middle fossa, including the mini-pterional, mini orbito-zygomatic, supraorbital, lateral supraorbital, and extended lateral supraorbital approaches while comparing them to classic, more invasive approaches.

Microsurgical Management of Posterior Circulation Aneurysms: A Retrospective Study on Epidemiology, Outcomes, and Surgical Approaches

Posterior circulation aneurysms have been regarded as the most challenging for endovascular coiling and microsurgical occlusion. The role of microsurgical treatment is gradually being overlooked and diminishing in the trend of endovascular treatment. As microsurgical occlusion of posterior circulation aneurysms is decreasing, we present our relevant experience to evaluate treatment options and surgical approaches. A retrospective study was conducted in the Department of Neurosurgery of the First Affiliated Hospital of Soochow University between 2016 and 2021. Patients with posterior circulation aneurysms treated by clipping, bypass, and trapping were enrolled and followed up for at least six months. We included 50 patients carrying 53 posterior circulation aneurysms, 43 of whom had aneurysm ruptures. The posterior cerebral artery and posterior inferior cerebellar artery were the most common aneurysm locations. Direct clipping was performed in 43 patients, while bypass and trapping was performed in six patients. The retrosigmoid, far-lateral, and midline or paramedian suboccipital approaches were performed for those aneurysms in the middle and lower thirds. Aneurysms in the upper third required the lateral supraorbital approach, pterional approach, subtemporal approach, and occipital craniotomy. The lateral supraorbital approach was utilized in seven patients for aneurysms above the posterior clinoid process. Thirty-four patients recovered well with modified Rankin score 0–3 at discharge. No patient experienced aneurysm recurrence during the mean follow-up period of 3.57 years. Microsurgery clipping and bypass should be considered in conjunction with endovascular treatment as a treatment option in posterior circulation aneurysms. The lateral supraorbital approach is a feasible, safe, and simple surgical approach for aneurysms above the posterior clinoid process.

The Lateral Supraorbital Craniotomy Approach for Anterior Circulation Aneurysms: A Modern Surgical Case Series in the Endovascular Era

The lateral supraorbital (LSO) approach is a minimally invasive modification of the standard pterional approach to anterior circulation aneurysms. This study aimed to describe a dual-trained cerebrovascular neurosurgeon's first 18-month experience with the LSO approach, including decision-making criteria and lessons learned. This retrospective case series analyzed 50 consecutive patients treated with LSO craniotomy for aneurysm clipping by a single surgeon. Aneurysms were separated into 3 categories by location: internal carotid artery, anterior communicating artery, and middle cerebral artery. Surgical characteristics were evaluated for differences by location and rupture status. Aneurysm clipping via LSO was performed on 57 aneurysms in 50 patients. Fixed retraction was employed less often in patients with internal carotid artery aneurysms than in patients with anterior communicating artery, middle cerebral artery, or multiple aneurysms (10% vs. 68.2%, 45.5%, and 42.9, P= 0.02). Of patients, 26 (52%) presented with subarachnoid hemorrhage; the majority of patients (92.3%) had Hunt and Hess grade I-III. No differences were noted in intraoperative rupture rates, fixed retractor use, operative duration, or estimated blood loss by rupture status. Adverse events included permanent frontalis nerve palsy in 1 patient (2%), temporalis atrophy in 1 patient, and transient aphasia in 1 patient. No postoperative hematomas or strokes were observed. The LSO approach can safely and effectively treat anterior circulation aneurysms and should be considered a viable minimally invasive option for aneurysm clipping. Further studies comparing the LSO approach with other cranial approaches are needed.

Surgical Strategy for Ethmoidal Dural Arteriovenous Fistula

Ethmoidal dural arteriovenous fistula (DAVF) is a rare type of intracranial DAVF. The aim of this study was to report our experience with a unilateral approach and discuss its effectiveness for ethmoidal DAVF treatment. The study included 19 patients who underwent surgical treatment for ethmoidal DAVF between January 1999 and May2021. Median age of patients was 59.7 years; 16 (84%) patients were male. Three patients had a ruptured ethmoidal DAVF. Preoperative digital subtraction angiography showed that all ethmoidal DAVFs were supplied by the bilateral external carotid artery branches. In 18 (95%) patients, cortical draining veins were located on the unilateral side. Bilateral lesions were identified in only 1 (5%) patient. The frontobasal approach was performed in 5 patients (26%), the pterional approach was performed in 5 (26%) patients, and the lateral supraorbital approach was performed in 9 (47%) patients; median procedural times were 198 minutes, 172 minutes, and 111 minutes, respectively. Cortical draining vein was successfully disconnected in all 19 patients with 20 ethmoidal DAVFs. Complete obliteration of ethmoidal DAVF was confirmed in all patients, with no postoperative complications. No recurrence or related clinical events were reported in 13 (68%) patients over 12 months of clinical and radiological follow-up. We reconfirmed excellent outcomes of surgical treatment for ethmoidal DAVFs. Three different surgical strategies were attempted, and each had pros and cons. The lateral supraorbital approach is an efficient surgical option for unilateral ethmoidal DAVFs. Careful preoperative examination for the presence of bilateral drainage is essential.

Influencing Factors for Complication with Aneurysm Rupture of the Fetal Posterior Communicating Artery After Clipping Through the Lateral Supraorbital Approach and Prognosis

BackgroundTo explore the influencing factors for complication with aneurysm rupture of the fetal posterior communicating artery after clipping through the lateral supraorbital (LSO) approach and prognosis.MethodsA total of 119 patients with posterior communicating artery aneurysm (PCoAA) accompanied by fetal posterior cerebral artery (fPCA), who underwent clipping through the LSO approach from January 2014 to December 2019, were selected. They were aged 50–70 years old, (60.5 ± 13.7) on average. The treatment outcome, incidence of complications and follow-up results were analyzed. Based on the follow-up results, univariate comparative analysis was conducted for the clinical data of patients with good or poor prognosis. The statistically significant factors were incorporated into multivariate Cox regression analysis, and the nomogram prediction model for prognosis was established. The accuracy of the model was assessed using the Hosmer–Lemeshow goodness-of-fit test.ResultsClipping through the LSO approach was successful in all cases. Perioperative complications occurred in 41 patients. According to the follow-up results, 89 patients had good prognosis, while 30 had poor prognosis. Age of > 65 years old, history of hypertension, high Hunt–Hess grade and high modified Fisher grade were independent risk factors for the poor prognosis of patients with PCoAA accompanied by fPCA after clipping through the LSO approach. The results obtained by the established model were consistent with the actual ones.ConclusionAge, history of hypertension, Hunt–Hess grade and modified Fisher grade are independent risk factors for the prognosis of patients with PCoAA accompanied by fPCA after clipping through the LSO approach.

Microsurgical Management of the Middle Cerebral Artery Bifurcation Aneurysms: An Anatomic Feasibility Study

Background: The proper head positioning decreases the surgical complications by enabling a better surgical maneuverability. Middle cerebral artery (MCA) bifurcation aneurysms have been classified by Dashti et al. [Surg Neurol. 2007 May;67(5):441–56] as the intertruncal, inferior, lateral, insular, and complex types based on dome projection. Our aim was to identify the optimum head positions and to explain the anatomic variables, which may affect the surgical strategy of MCA bifurcation aneurysms. Methods: The lateral supraorbital approach bilaterally was performed in the 4 cadaveric heads. All steps of the dissection were recorded using digital camera. Results: The distal Sylvian fissure (SF) dissection may be preferred for insular type and the proximal SF dissection may be preferred for all other types. Fifteen degrees head rotation was found as the most suitable position for the intertruncal, lateral type and subtype of complex aneurysms related with superior trunk. Thirty degrees head rotation was found the most suitable position for the inferior type, insular type, and subtype of complex aneurysms related with inferior trunk. Conclusions: The head positioning in middle cerebral bifurcation aneurysms surgery is a critical step. It should be tailored according to the projection and its relationship with the parent vessels of the middle cerebral bifurcation.

Case report: Subdural hygroma in an adolescent caused by a soccer ball strike to head

Arachnoid cysts are benign, congenital, non-neoplastic, extra-axial-intra cerebrospinal fluid (CF) collection lesions. They are often diagnosed incidentally during imaging examinations and are usually asymptomatic. We present a case of a subdural hygroma, secondary to an arachnoid cyst which had ruptured following minor head injury. This is a rarely seen complication although it has previously been described in the literature. • Arachnoid cysts are benign congenital, non-neoplastic, extra-axial-intra cerebrospinal fluid (CF) collection lesion. (Established facts). • The majority of AC cases are usually asymptomatic. (Established facts). • Arachnoidcyst are often diagnosed incidentally during imaging examination. (Established facts). • Hygroma secondary to arachnoid cyst is a rarely seen complication, which is often required surgery (Novel insight). • In this case subdural hygroma evacuation and microsurgical fenestration was performed with a left lateral supraorbital approach depend on patient condition and symptoms. (Novel insight).

Efficiency and safety of minimally invasive approaches for microsurgical treatment of brain aneurysms

To assess the effectiveness and safety of minimally invasive approaches in microsurgical treatment of brain aneurysms in comparison with traditional approaches, to clarify the indications and contraindications for minimally invasive approaches. There were 394 patients with cerebral aneurysms for the period 2014-2019. All patients were divided into 2 groups depending on surgical approach: traditional approach (TrA) (n=171, 43.4%) and minimally invasive approach (MiniAp) (n=223, 56.6%). In the TrA group, pterional (n=85), orbitozygomatic (n=23) and lateral supraorbital approaches (n=63) were used. In the MiniAp group, transbrow supraorbital (n=88), mini-pterional (n=62), transbrow transorbital (n=37) and transpalpebral transorbital approaches (n=36) were used. Treatment outcomes were compared in both groups for patients with ruptured and unruptured aneurysms. We evaluated intra- and postoperative complications, surgery time and postoperative hospital-stay. Neurological outcomes were assessed using the Glasgow Outcome Scale (GOS) and the modified Rankin Scale (mRs). Cosmetic outcomes were compared using the visual analogue cosmetic scale. Unilateral hypesthesia and eyebrow movement were assessed separately after 3, 6 and 12 months. In acute period of SAH, surgery time was significantly less in the MiniAp group (p=0.001). There were no significant between-group differences in the incidence of intraoperative rupture, surgical and neurological complications (p>0.05). Postoperative hospital-stay was significantly less in the MiniAp group (p=0.006). In this group, neurological outcomes were slightly better (p<0.001), there was no mortality, adverse outcomes occurred in 5.3% of cases (n=5). In the TrA group, 1 patient died from postoperative hematoma, adverse outcomes were noted in 9 (8.7%) patients. Cosmetic outcomes were significantly better in the MiniAp group (p<0.001). In delayed period of SAH and unruptured aneurysms, surgery time was less in the MiniAp group (p=0.051). Incidence of intra- and postoperative complications was similar in both groups (p>0.05). Hospital-stay was significantly shorter in the MiniAp group (p<0.001). Functional outcomes were comparable in both groups. Cosmetic outcomes were significantly better in the MiniAp group (p<0.05). MiniAp and TrA are characterized by similar efficacy in microsurgical treatment of cerebral aneurysms. MiniAp is recommended only for experienced neurosurgeons in a specialized hospital. Safety and effectiveness of MiniAp are achieved by careful selection of patients, individual neuroimaging and preoperative planning.

The use of three-dimensional anatomical patient-specific printed models in surgical clipping of intracranial aneurysm: A pilot study.

Background: In the present study, we aim to develop simulation models based on computed tomography angiography images of intracranial aneurysms (IAs) and their parent vessels using three-dimensional (3D) printing technology. The study focuses on the value of these 3D models in presurgical planning and intraoperative navigation and ultimately their impact on patient outcomes. To the best of our knowledge, this is the first report of its kind from a war-torn country, like Iraq.Methods: This is a prospective study of a series of 11, consecutively enrolled, patients suffering from IAs for the period between February and September 2019. The study represents a collaboration between the two major neurosurgical centers in Baghdad/Iraq; Neurosciences Teaching Hospital and Neurosurgery Teaching Hospital. We analyzed the data of eleven patients with IAs treated by microsurgical clipping. These data include patient demographics, clinical, surgical, and outcomes along with the data of the 3D-printed replica used in these surgeries. All cases were operated on by one surgeon.Results: Our study included 11 patients, with a total of 11 aneurysms clipped. The mean age was 44 ± 8, with a median of 42.5 and a range of 35–61 years. About 60% of our patients were female with a female-to-male ratio of 1:5. About 60% of the aneurysms were located at the anterior communicating artery (Acom) while the remaining 40% were equally distributed between the posterior communicating and internal carotid arteries bifurcation. The standard pterional approach was followed in 50% of cases, whereas the other 50% of patients were treated through the lateral supraorbital approach. About 90% (n = 9) of the patients had a Glasgow Outcome Scale (GOS) of 5 and 10% had a GOS of 4. The 3D-printed models successfully replicated the aneurysm size, location, and relation to the parent vessel with 100% accuracy and were used for intraoperative guidance. The average production time was 24–48 h and the production cost was 10–20 US dollars.Conclusion: 3D printing is a promising technology that is rapidly penetrating the field of neurosurgery. In particular, the use of 3D-printed patient-matched, anatomically accurate replicas of the cerebral vascular tree is valuable adjunct to the microsurgical clipping of IAs, and our study conclusions support this concept. However, both the feasibility and clinical utility of 3D printing remain the subject of much, ongoing investigations.

Advantages and Pitfalls of the Lateral Supraorbital Approach as Less Invasive Surgery for Unruptured Anterior Circulation Aneurysms

The lateral supraorbital approach(LSOA)is widely accepted as a less invasive surgical technique compared with the conventional pterional approach(PA). However, only a few studies have reported less invasiveness associated with LSOA. To evaluate this issue, we retrospectively investigated the surgical outcomes in 133 patients who underwent LSOA and 28 patients who underwent PA for unruptured anterior circulation aneurysms. We analyzed operation time, postoperative symptoms and complications, and the length of postoperative hospitalization(in days)for each method. All aneurysms were successfully clipped regardless of the approach. The operation time was significantly shorter, the postoperative headache rate was lower, resumption of oral intake was more rapid, and length of hospitalization was shorter in the LSOA group. Statistical significance was not observed in the postoperative complication rates. Compared with conventional PA, LSOA was associated with less invasiveness and better patient satisfaction. LSOA is a safe and effective alternative to conventional PA, following optimal patient selection.