Pterion Research Articles

Therapeutic strategy and effect of different approaches for microsurgical treatment of basilar artery bifurcation aneurysms

Objective To investigate the strategy and effect of microsurgical treatment of basilar artery bifurcation aneurysms with different surgical approaches. Methods We retrospectively reviewed the clinical data of 43 patients with basilar artery bifurcation aneurysms who underwent microsurgical clipping at Department of Neurosurgery, the Second Xiangya Hospital, Central South University from April 2011 to April 2018. Of all 43 cases, 32 cases had ruptured basilar aneurysms and 11 cases had unruptured basilar aneurysms. According to the different morphological and anatomical locations of aneurysms, 17 cases underwent infraorbital approach, 26 cases underwent transsyvian approach (including the transorbirozygomatic approach, the 'half-half’ approach which combined the subtemporal approach with pterion approach and the simple pterion approach) to conduct microsurgical clipping. Intraoperative monitoring was performed using the combination of multiple technologies. Clinical and imaging follow-up was conducted over 6 months post surgery. Results Of all 43 cases with basilar artery bifurcation aneurysms, 38 cases were completely clipped, 4 cases were partially clipped, and 1 case was wrapped. There were 2 cases (4.7%) of hemiplegia after operation, 1 case (2.3%) of coma, 14 cases (32.6%) of oculomotor nerve palsy and no death during perioperative period. Thirty-seven patients (86.4%) were followed up for 25.0±10.1 months (range: 6 months to 4 years). Among them, 35 patients underwent radiographic review without aneurysm residual and 1 patient with partial clipping was treated with second-stage interventional embolization. In 1 case with wrapped aneurysm, the significantly enlargement of aneurysm was not observed in the follow-up image. Of 14 cases with oculomotor nerve palsy after operations, 11 were followed up and 8 of them improved significantly afterwards. Glasgow′s outcome scale(GOS) showed that grade V was reported in 34, grade IV in 1 case, grade III in 1 case, grade II in 0 and grade I in 1 case who died from severe pulmonary infection at 42 days post operation. Conclusions The superior treatment of the basilar artery bifurcation aneurysm could be achieved through subtemporal and transsyvian approach. Preoperative evaluation of anatomical and morphological characteristics of aneurysm seems important for the choice of surgical approach. The application of various assistive techniques during surgery is an important part of ensuring the safety of surgery. Key words: Intracranial aneurysm; Basilar artery; Microsurgery; Treatment outcome

Influence of improved pterion approach on nerve function and prognosis of craniocerebral trauma patients

Objective To explore the effects of improved pterion approach on neurological function and prognosis of patients with craniocerebral trauma. Methods From July 2014 to July 2016, 100 patients with craniocerebral trauma admitted to Hangzhou Dajiang East Hospital were selected in this study, and they were divided into two groups according to different surgical methods, with 50 cases in each group.The control group was given traditional surgical approach, and the observation group was given improved pterion approach surgery.The neurological function, safety and prognosis of the two groups were observed. Results The NDS scores and GCS scores had no statistically significant differences between the two groups before treatment(t=1.03, 0.98, all P>0.05). After treatment, the NDS scores of the two groups were significantly reduced(t=5.62, 7.23, all P<0.05), the GCS scores of the two groups were significantly improved(t=3.46, 4.75, all P<0.05). The NDS score of the observation group was (13.72±5.42)points, which was significantly lower than that of the control group[(20.72±6.51)points](t=4.32, P<0.05). The GCS score of the observation group was (11.25±2.63)points, which was significantly higher than that of the control group[(8.42±1.35)points](t=3.27, P<0.05). The incidence rate of complications of the control group was significantly higher than that of the observation group[48%(24/50) vs.18%(9/50), χ2=7.36, P<0.05]. The mortality rate of the control group was significantly higher than that of the observation group[32%(15/50) vs.16%(8/50), χ2=3.17, P<0.05], and the recovery rate of the control group was significantly lower than that of the observation group[14%(7/50) vs.28%(14/50), χ2=6.35, P<0.05]. Before treatment, there were no statistically significant differences in the Spitzer index between the two groups(t=1.01, 0.98, 0.92, 0.98, 0.87, all P<0.05). After treatment, the Spitzer index of the two groups were significantly higher than those before treatment(t=2.72, 3.64, 2.83, 3.45, 3.52, 3.67, 3.84, 4.61, 4.53, 5.27, all P<0.05), which of the observation group were significantly higher than those of the control group(t=2.56, 2.73, 4.26, 4.43, 3.95, all P<0.05). Conclusion The improved pterion approach in the treatment of patients with craniocerebral trauma has better neural functional recovery than traditional surgery, and it has lower mortality rate and complication rate, better security, and can encourage patients to improve the quality of life, and it has better prognosis. Key words: Craniocerebral trauma; Surgical procedures, operativ; Glasgow coma scale; Postoperative complications; Prognosis; Comparative effectivehess research

Surgical treatment of intracranial aneurysms via the pterional keyhole approach

Modify the pterional approach for intracranial aneurysms clipping with minimally invasive concept to reduce the risk of iatrogenic surgical trauma. A 4.0 cm skin incision was made along the temporal hairline and centered on the pterion, temporal muscle was incised along the sylvian fissure.A bone flap with 2.0 to 2.5 cm in diameter was milled after a bone hole was drilled just on the sphenoid ridge, which was drilled off as needed then.Aneurysms were exposed after dissection of sylvian fissure and cistern, as well as cerebrospinal fluid releasing.A total of 123 cases with 140 intracranial aneurysms were treated surgically via the pterional keyhole approach, including 6 large aneurysms, 4 giant aneurysms, and 17 cases with multiple aneurysms (34 aneurysms). Of 3 cases with bilateral aneurysms, 2 were treated via bilateral approach as well as 1 via unilateral approach. Contralateral approach was used in 1 case with ophthalmic artery aneurysm, which pointed medial. Concomitant intracranial tumors were removed simultaneously in 2 cases, and one of them was diagnosed with middle cerebral artery aneurysm and tuberculum sellae meningioma, the other one with posterior communicating artery aneurysm and middle cranial fossa menigioma. Of the 140 aneurysms, 139 aneurysms were clipped and 1 was trapped.Postoperative image showed 4 cases had residual of aneurysm neck. 3 cases had incomplete dysfunction of oculomotor nerve and 1 had mild hemiplegia after surgery and recovered eventually. 4 cases presented with aggravated disturbance of consciousness, of whom 3 cases were caused by ischemia and 1 by brain edema.Unusual ipsilateral hemiplegia occurred in 1 case in Hunt&Hess grade IV, which caused by contralateral vasospasm. Postoperative courses in other cases were uneventful. As a minimally invasive and effective approach, the pterional keyhole approach is applicable to intracranial aneurysms clipping for patients without any necessary for decompressive craniectomy. Surgical related complications and operative duration can be reduced significantly.

Microsurgical treatment of the insular lobe gliomas

Objective To investigate the preoperative evaluation methods and intraoperative measures of the extent of resection and blood vessel protection in insular glioma resection surgery via transsylvian approach. Methods The clinical data in 46 patients with glioma mainly in insular lobe treated by surgery at the Department of Neurosurgery, Brain Hospital Affiliated to Nanjing Medical University from January 2008 to July 2014 were analyzed retrospectively. M2 was exposed after separating lateral fissure via the pterion or extended pterional approach. After processing the short perforator from M2, the gliomas were resected piecemeal. The outermost artery of internal capsule did not participate in the insular lobe glioma blood supply, and it was the inner side border for glioma resection. Results Under the microscope, the gliomas of 38 patients were resected near totally and were confirmed by the postoperative imaging. The gliomas of 8 patients were resected subtotally, 2 had hemiplegia after procedure, and one had subdural hemorrhage. After procedure, 3 patients had contralateral limb hemiparesis (strength grade IV). One had a transient mixed aphasia. Conclusions Preoperative imaging findings, especially 3D-TOF of the relationship in between the gilomas and vessels, have an important guiding role for intraoperative blood vessel protection. The outermost artery of internal capsule is the medial boundary of giloma resection. Key words: Giloma; Microsurgery; Blood vessels; Insular lobe

Pterion Formation in North Indian Population: An Anatomico-Clinical Study

El pterion es un punto correspondiente con el extremo posterior de la sutura donde se ubican los huesos frontal, parietal, temporal y esfenoides. Este punto metrico del craneo se relaciona con diversas estructuras en la cavidad craneal como la arteria meningea media y polo anterior de la insula en el area de Broca. Este estudio se realizo para determinar la variacion mas comun de la forma y presencia de huesos epiptericos y comparar estos con otros grupos raciales. Cincuenta craneos humanos adultos de sexo desconocido obtenidos en el departamento de anatomia, Sri Guru Ram Das Instituto de Ciencias Medicas e Investigaciones, Vallah (Amritsar, India) fueron examinados en ambos lados para el tipo y posicion del pterion. Se observaron cuatro tipos de formacion. Esfenoparietal en el 89% de las muestras, fronto temporal en el 7% de las muestras, estrelladas en 4% y epipterico en el 12% de los casos. Desde la sutura frontocigomatica el pterion se encontraba a 3,1±0,44 cm en el lado derecho, 3,4±0,40 cm en el lado izquierdo y desde el centro del hueso cigomatico a 4,1±0,45 cm en el lado derecho y 4,4±0,32 cm en el lado izquierdo. Estas variaciones en la morfologia de la sutura son comparables a otras poblaciones. Su posicion es de interes para los antropologos, patologos forenses y cirujanos, y merece una mayor investigacion en poblaciones de diferentes regiones.

Puncture decompression technique used in clipping intracranial large and giant aneurysms

Objective To explore the role of puncturing the aneurysm to decompress in clipping intracranial large and giant aneurysms.Methods Different methods were used according to the different location of 25 cases of large and giant aneurysms.Cervical carotid internal artery was exposed and the pterional craniotomy was used for carotid-ophthalmic aneurysm,and direct pterion craniotomy used in the carotid-post communicating artery aneurysm.Temporary occluded the exposed the cervical internal carotid artery or the intracranial proximal segment of parent artery and distal segment of parent artery and its branches,then punctured aneurysm body and suck gushing blood with suction.When aneurysm body collapsed,remodel the parent artery and clipped aneurysm.As a thrombotic giant aneurysm which was incised then removed thrombus and clipped aneurysm after parent artery and its branches have been occluded provisionally.Microvascular doppler (MVD) was used to monitor before and after clipped aneurysms.Results The time of temporary occlusion vessels was 9-15 minutes.,the average time was 11 minutes.MVD monitor showed vortex flow disappearance of aneurysm and the bloodstream amplitude of the parent artery and its branches were not changed before and after clip.Postoperative DSA or CTA showed aneurysms disappeared and the bloodstream of the parent artery and its branches were normal after operation.Conclusions The temporary occlusion of the parent artery and its branches and the direct puncture of aneurysm body (or incise aneurysm and remove thrombus) to decompress are indicated for the most large and giant aneurysms (including thrombotic aneurysm).MVD is of benefit in providing operative safe and improving treatment effects in aneurysm surgery. Key words: Large and giant aneurysm; Puncture; Incision; Decompression; Clip

Microsurgical resection of anterior clinoid meningiomas-- 46 cases report

To investigate the microsurgical tchniques and effects for the resection of anterior clinoid meningioma (ACM). Between January 2003 and March 2013, a total of 46 ACM patients were operated on via the pterion approach or lateral subfrontal approach. There were 16 male patients and 30 female patients, their mean age was 48.5 (16-69) years. Symptoms lasted from 1 month to 9 years(average 24.7 months). Preoperative CT and MRI examination showed that the tumors were located in the anterior clinoid process (25 cases on the right side, 21 cases on the left side). The average maximal tumor diameter was 4.4 cm (1.9-7.4 cm). The patients were peroidly followed-up on outpatient on 3 months to 6 months, then every year postoperativelly. The clinical data, radiological findings, surgical records and outcome of patients were retrospectively analyzed, and the prognostic factors were ananlyzed by using of the unpaired data χ(2) test with continuity correction. Of fourty-six patients operated on, apparently complete removal was achieved in 36 patients (78.3%), 10 patients (21.7%) had minimal residual tumors, 5 of which had gamma knife radiosurgery. Preexisting visual deficit improved in 21 of 41 patients (51.2%), unchanged in 16(35.6%), and worsened in 9(20.0%). At 3-6 months after discharge, 37(80.4%) patients had a good recovery, 7(15.6%) patients were moderately disabled, 1(2.2%) presented with severe disability, and 1 (2.2%) patient died of surgery-related causes. The tumor wrapping blood vessels (χ(2) = 4.676, P = 0.031) and violating cavernous sinus(χ(2) = 4.973, P = 0.026) were causes of unfavorable prognosis. During the mean follow-up of 35.1 months (range, 4-107 months) for 40 patients, the average Karnofsky score was 83.2. Tumor recurred in 4 cases: 2 of which required reoperation, and 2 had gamma knife radiosurgery. Tumor wrapped vessels and invasion of the cavernous sinus are important unfavorable prognostic factors for ACM resection. By using appropriate surgical strategies and techniques, ACM can be removed safely via the pterion approach or lateral subfrontal approach with relatively low morbidity and mortality.

Microsurgical treatment of ruptured anterior communicating artery aneurysms

Objective To explore the microsurgical treatment strategy of ruptured anterior communicating artery aneurysms.Methods From September 2009 to February 2013,thirty-three patients with ruptured anterior communicating artery aneurysms were treated with microsurgical clipping via modified pterion approach.The clinical and follow-up data were analyzed retrospectively.Results At 3 to 44 months period followed-up after microsurgical clipping of ruptured anterior communicating artery aneurysms were obtained in 32 patients.According to Glasgow Outcome Score,the curative effects score were 5 in 28 cases,four in 2 cases,three in 1 case and death in 1 case.Conclusion Microsurgical clipping of ruptured anterior communicating artery aneurysms via modified pterional approach was an effective method with sufficient exposure.It has less invasiveness to the brain tissue,reliable neck clipping and satisfactory results.Safety and effectiveness of this procedure are based on preoperative radiological evaluation of three-dimensional morphological specificity of aneurysms,identification of the parental arteries and its branches,as well as temporary proximal occlusion. Key words: Anterior communicating artery; Intracranial aneurysms; Modified pterional approach; Microneurosurgery

The clinical analysis of cranio-orbital communicating tumors

To investigate the clinical manifestations, imageological features, surgical approaches and prognosis of cranio-orbital communicating tumors. The retrospective analysis was performed in the 22 patients of cranio-orbital communicating tumors in the past three years. CT and MRI examinations were applied in all cases. Of 16 patients were treated by surgical approaches, Of 6 patients were for radiation therapy. Of 22 cases, 2 cases were osteoid osteoma, 3 cases were meningioma, 1 case was aneurysmal bone cyst, 2 cases were mucous cyst, 2 cases were schwannoma, 2 cases were adenoid cystic carcinoma of lacrimal gland, 2 cases were metastatic carcinoma, and 2 cases were rhabdomyosarcoma. Other 6 cases were treated by radiotherapy without pathological diagnosis. 8 cases for orbital operation including excision of orbital contents 1/8, anterior orbitotomy 3/8, and lateral orbitotomy 4/8, and 8 cases for transcranial operation including frontotemporal orbital roof approach 3/8 and pterion approach 5/8. After operation, the vision acuity of 3 cases was improved, of 10 cases was unchanged and of 3 cases was decreased. Two patients died of metastasis. Among 8 cases of transcranial operation, the complaints such as eye movement disorder, proptosis and conjunctival edema emerged in 1 case. However, among 8 cases of orbital operation, such above complaints were respectively found in 7, 5 and 6 cases. CT and MRI have the great value for diagnosis of cranio-orbital communicating tumors, especially combined with enhanced contrast MRI. Resection of cranio-orbital communicating tumors via the transcranial surgical approach is the effective surgical approach for cranio-orbital communicating tumors.

Anatomic changes in operation through pterion to opticocarotid space

Objective To comprehend the anatomic changes of opticocarotid space during neuro⁃surgical procedure to increase the success rate of operation at sellar region. Methods Tumors at sellar region were operated through Yasargil pterion to opticocarotid space. Digital imaging was used to collect the picture of anatomic changes at preoperation and during operation. The ratio of the length of opticocarotid space and the diameter of internal carotid artery (ICA), and the ratio of the width of opticocarotid space and the diameter of ICA were measured in each picture. These ratios of each patient at preoperation stage and operation stage were compared. Results Opticocarotid space was classified into 3 types: triangle type, fusiform type and fissure type. The ratio of each type may be changed after operation due to the release of tumor. During operation, the ratio of the length of opticocarotid space and the diameter of ICA was 2.58 ± 0.86, and the ratio of the width of opticocarotid space and the diameter of ICA was 1.28 ± 0.52. At preoperation stage, the ratio of the length of opticocarotid space and the diameter of ICA was 1.08 ± 0.87, and the ratio of the width of opticocarotid space and the diameter of ICA was 0.49 ± 0.48. The ratios at operation stage were significantly higher than those at preoperation stage (t = 6.164, P = 0.000; t = 7.030, P = 0.000). Conclusion Comprehending these anatomic changes of opticocarotid space is useful in directing the operation at sellar region. DOI：10.3969/j.issn.1672-6731.2010.05.014

The microsurgical treatment patient with 21 cases of anterior circulation aneurysms by pterional approach

Objective To investigate the related issues on surgical treatment of anterior circulation aneurysms by pterion approach. Methods 21 patients were diagnosed with intracranial anterior circulation aneurysms by CTA or DSA, and were treated by micro-surgery of pterion approach, the clinical data on 21 patientswas analysed retrospectively, and surgical timing and short-term effect was evaluated. Results The results of preoperative Hunt-Hess grade respectively is grade Ⅰ in 7 patients, grade Ⅱ 9 cases, grade Ⅲ 4 cases, grade Ⅳ 1 cases. The 21 patients were taken operations successfully ,4 aneurysms ruptured and bleeded during operations.Followed-up for 2 ～ 12 months, 16 cases were in good ,3 cases was light residual, 1 case was severe disability and 1 case was dead. According to Short-term effect on this group ,the good rate was 85.8% (20/21), the mortality was 6. 6% ( 1/21 ), the intraoperative rupture rate was 19. 05 % (4/21 ). Conclusion The patient with anterior circulation aneurysm in Hunt-Hess grade Ⅰ～Ⅲ should be taken an operation as soon as possible, the pterional approach is the classical approach in the treatment of anterior circulation intracranial aneurysms, the controlled hypotension can increase the safety of operation, the skillful microsurgical technique involves guarantee of successful surgery. Key words: Intracranial aneurysms; Micro-surgery; Pterional approach

Microsurgical removal of suprasellar craniopharyngioma via pterional approach

Objective To explore the microsurgical techniques for total removal of the suprasellar cranio pharyngiomas via the pterional approach.Methods The clinical data of 28 patients with suprasellar craniopharyngio mas resected by the microsurgery was analyzed retrospectively.Results The tumors were total removed in 24 cases (86%)and subtotal resected in 4 cases(14%).The frequent postoperative complications are diabetes insipidus,hy perthermy,imbalance of water and electrolyte and lower level of hormone.Conclusion It is the key to get fine operation effect that removal sclerotin of base of skull as far as possible and releasing cerebrospinal fluid sufficiently,paying attention to protect the perforating branch and nourishing artery in each operative spaces. Key words: Craniopharyngiomas; Pterion approach; Microsurgery

The clinical research in enlarging pterion approach operation to treat severe patients with frontal lobe and temple lobe injury

Objective To explore the clinical significance of treating severe patients with frontal lobe and temple lobe with enlarging pterion approach operation. Methods All the severe patients with frontal lobe and temple lobe injury were divided into two groups at random. One group adopted the standard large trauma craniotomy, the other group adopted enlarging pterion approach operation. Under the same conditions, score of GCS, patients ages in two groups were analyzed. And we compare their operation results. Results Compared the standard large trauma cranioto-my,the good recover rates rise 9.2% (P < 0.05) and the death rate reduce 10.2% (P < 0.05) by using the enlarging pterion approach operation. Conclusion The enlarging pterion approach operation could improve existing quality and decrease mortality and disabled rate in patients with severe brain injury in frontal lobe and temple lobe. Key words: Craniocerebral tramna; frontal lobe and temple lobe; Craniotom

Therapeutic strategies of multiple intracranial aneurysms

Objective To explore the incidence,principles of treatment and prognosis of multiple intracranial aneurysms.Method The clinical and imaging data of 36 patients with 76 aneurysms were analyzed retrospectively.Results 28 aneurysms were clipped and 2 were wrapped through single pterion approach in 14 patients.40 aneurysms were treated with endovascular therapy in 20 patients.4 aneurysms were clippled and 2 were coiled with surgical treatment combined with endovascular therapy in 2 patients.The clinical outcomes of these patients evaluated by Glasgow Outcome Scale grades were:28 persons without deficit,4 persons with minor deficit,2 persons with major deficit,1 person was vegetative state and 1 person was dead.Conclusions At first days based on the sites of aneurysms and patient's conditions,all multiple intracranial aneurysms should be treated selectively by microsurgery or endovascular therapy in one stage whenever possible,and the prognosis is good. Key words: Intracranial aneurysm; Microsurgery; Endovascular embolization

Microsurgical strategies of glioma located in lateral fissure area

To investigate the microsurgical strategies of glioma located in lateral fissure area. The clinical data of 123 patients with glioma located in lateral fissure area confirmed by pathology, 76 males and 47 females, aged 46.2 (4-75), were retrospectively analyzed. The optimal surgical approach and comprehensive therapeutic strategies were selected according to the imaging features and pathological properties of tumors. Resections were performed by the pterion approach in all cases to remove the tumors, navigational orientation was used in 17 cases, and supervision by B mode ultrasonography was used in 12 cases. The branches of middle cerebral artery and fissure vein were protected carefully. The patients with tumors above grade U, confirmed pathologically after resection, underwent chemotherapy ( teniposide + semustine or temozolomide) and radiotherapy that was designated individually according to the pathological grade and distribution of the tumors. Follow-up was conducted by telephone, mail or outpatient department visit on 102 of the 133 patients (82.9%). 82 patients (66.7%) underwent total resection, 18 (14.6%) underwent subtotal resection, 16 (13.0%) underwent major resection, and 7 (5.7%) underwent partial resection. Postoperatively cerebral vasospasm in 8 cases, brief aphasia and reaction clumsily in 4 cases, muscle strength decline in 3 cases, and epilepsy in 1 case, these patients were submitted to symptomatic treatment with progressive improvement of the above-mentioned signs and symptoms. One patient died of malignant intracranial hypertension. The follow-up showed that 97 patients survived over 1 year, the 5-year survival rate was 25.6%, and the average survival time was 21.7 months. The lateral fissure area glioma can be treated through proficient microsurgical technique after the anatomic training. It is the key in the surgery on the lateral fissure glioma to protect the main branches of middle cerebral artery, trunk of middle cerebral vein, and important brain functional areas.

Anatomic Position of the Pterion among Kenyans for Lateral Skull Approaches

La pterion es un punto de confluencia sutural visto en la norma lateral del craneo, donde se unen los huesos frontal, parietal, temporal y esfenoides. La posicion del pterion exhibe variaciones en la poblacion. La ubicacion de este punto es importante en abordajes quirurgicos a las fosas craneales anterior y la media. Mediciones especificas se han realizado en ambos lados de 90 craneos humanos Kenyanos (51 varones, 39 mujeres). Las distancias desde el centro de pterion a la sutura frontocigomatica fue de 38,88+3,49 mm en el lado derecho y 38,24+3,47 mm en el lado izquierdo. El pterion fue ubicado 30,35+3,40 mm y 30,34+4,34 mm por encima del punto medio del arco cigomatico en los lados derecho e izquierdo, respectivamente. Los hombres presentaron un pterion estadisticamente significativo superior en comparacion con las mujeres, siendo de 39,31+3,28 mm y 37,35+2,97 mm por encima del punto medio del cigoma, respectivamente. La sutura frontocigomatica y el punto medio del cigoma pueden ser utilizados como referencia fiables para localizar a el pterion. Esta informacion puede ser util en la planificacion previa a la cirugia, sobre todo cuando los equipos dispositivos de neuronavegacion son escasos.