Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
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Unruptured Supraclinoid Internal Carotid Artery Aneurysm Surgery : Superciliary Keyhole Approach versus Pterional Approach

  • Shin, Donguk (Department of Neurosurgery, Cardiocerebrovascular Center, Kyungpook National University) ;
  • Park, Jaechan (Department of Neurosurgery, Cardiocerebrovascular Center, Kyungpook National University)
  • Received : 2012.04.07
  • Accepted : 2012.10.04
  • Published : 2012.10.28
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Abstract

Objective : A superciliary keyhole approach is an attractive, minimally invasive surgical technique, yet the procedure is limited due to a small cranial opening. Nonetheless, an unruptured supraclinoid internal carotid artery (ICA) aneurysm can be an optimal surgical target of a superciliary approach as it is located in the center of the surgical view and field. Therefore, this study evaluated the feasibility and surgical outcomes of a superciliary keyhole approach for unruptured ICA aneurysms. Methods : The authors report on a consecutive series of patients who underwent a superciliary approach for clipping unruptured ICA aneurysms between January 2007 and February 2012. The data were compared with a historical control group who underwent a pterional approach between January 2003 and December 2006. Results : In the superciliary group, a total of 71 aneurysms were successfully clipped without a residual sac in 70 patients with a mean age of 57 years (range, 37-75 years). The maximum diameter of the aneurysms ranged from 4 mm to 14 mm (mean${\pm}$standard deviation, $6.6{\pm}2.3$ mm). No direct mortality or permanent morbidity was related to the surgery. The superciliary approach demonstrated statistically significant advantages over the pterional approach, including a shorter operative duration (mean, 100 min), no intraoperative blood transfusions, and no postoperative epidural hemorrhages. Conclusion : A superciliary keyhole approach provides a sufficient surgical corridor to clip most unruptured supraclinoid ICA aneurysms in a minimally invasive manner.

Keywords

References

  1. Birknes JK, Hwang SK, Pandey AS, Cockroft K, Dyer AM, Benitez RP, et al. : Feasibility and limitations of endovascular coil embolization of anterior communicating artery aneurysms : morphological considerations. Neurosurgery 59 : 43-52; discussion 43-52, 2006 https://doi.org/10.1227/01.NEU.0000219220.25721.B9
  2. Brydon HL, Akil H, Ushewokunze S, Dhir JS, Taha A, Ahmed A : Supraorbital microcraniotomy for acute aneurysmal subarachnoid haemorrhage : results of first 50 cases. Br J Neurosurg 22 : 40-45, 2008 https://doi.org/10.1080/02688690701601521
  3. Chen L, Tian X, Zhang J, Huang Y, Chen E, Lan Q : Is eyebrow approach suitable for ruptured anterior circulation aneurysms on early stage : a prospective study at a single institute. Acta Neurochir (Wien) 151 : 781-784; discussion 784, 2009 https://doi.org/10.1007/s00701-009-0205-9
  4. Czirjak S, Szeifert GT : Surgical experience with frontolateral keyhole craniotomy through a superciliary skin incision. Neurosurgery 48 : 145-149; discussion 149-150, 2001
  5. Fukamachi A, Koizumi H, Nagaseki Y, Nukui H : Postoperative extradural hematomas : computed tomographic survey of 1105 intracranial operations. Neurosurgery 19 : 589-593, 1986 https://doi.org/10.1227/00006123-198610000-00013
  6. Goh DH, Kim GJ, Park J : Medpor craniotomy gap wedge designed to fill small bone defects along cranial bone flap. J Korean Neurosurg Soc 46 : 195-198, 2009 https://doi.org/10.3340/jkns.2009.46.3.195
  7. Hendler BH, Kreger TM, Goldman HW : Fibrous ankylosis of the mandible following frontotemporal craniotomy. Case report. J Neurosurg 55 : 836-837, 1981 https://doi.org/10.3171/jns.1981.55.5.0836
  8. Ioannidis I, Lalloo S, Corkill R, Kuker W, Byrne JV : Endovascular treatment of very small intracranial aneurysms. J Neurosurg 112 : 551-556, 2010 https://doi.org/10.3171/2008.8.17657
  9. Kang DH, Park JC, Kim SO, Hamm IS : Intubation difficulty in patients with pseudoankylosis of temporo-mandibular joint after pterional craniotomy. J Korean Neurosurg Soc 36 : 166-167, 2004
  10. Kawaguchi M, Sakamoto T, Furuya H, Ohnishi H, Karasawa J : Pseudoankylosis of the mandible after supratentorial craniotomy. Anesth Analg 83 : 731-734, 1996
  11. Kim BM, Park SI, Kim DJ, Kim DI, Suh SH, Kwon TH, et al. : Endovascular coil embolization of aneurysms with a branch incorporated into the sac. AJNR Am J Neuroradiol 31 : 145-151, 2010 https://doi.org/10.3174/ajnr.A1785
  12. Koebbe CJ, Veznedaroglu E, Jabbour P, Rosenwasser RH : Endovascular management of intracranial aneurysms : current experience and future advances. Neurosurgery 59 : S93-S102; discussion S3-S13, 2006
  13. Lan Q, Gong Z, Kang D, Zhang H, Qian Z, Chen J, et al. : Microsurgical experience with keyhole operations on intracranial aneurysms. Surg Neurol 66 Suppl 1 : S2-S9, 2006
  14. Le Roux PD, Elliott JP, Winn HR : Blood transfusion during aneurysm surgery. Neurosurgery 49 : 1068-1074; discussion 1074-1075, 2001
  15. Lubicz B, Lefranc F, Levivier M, Dewitte O, Pirotte B, Brotchi J, et al. : Endovascular treatment of intracranial aneurysms with a branch arising from the sac. AJNR Am J Neuroradiol 27 : 142-147, 2006
  16. Mitchell P, Vindlacheruvu RR, Mahmood K, Ashpole RD, Grivas A, Mendelow AD : Supraorbital eyebrow minicraniotomy for anterior circulation aneurysms. Surg Neurol 63 : 47-51; discussion 51, 2005 https://doi.org/10.1016/j.surneu.2004.02.030
  17. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, et al. : International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms : a randomised trial. Lancet 360 : 1267-1274, 2002 https://doi.org/10.1016/S0140-6736(02)11314-6
  18. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. : International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms : a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 366 : 809-817, 2005 https://doi.org/10.1016/S0140-6736(05)67214-5
  19. Moret J, Pierot L, Boulin A, Castaings L, Rey A : Endovascular treatment of anterior communicating artery aneurysms using Guglielmi detachable coils. Neuroradiology 38 : 800-805, 1996 https://doi.org/10.1007/s002340050352
  20. Murayama Y, Nien YL, Duckwiler G, Gobin YP, Jahan R, Frazee J, et al. : Guglielmi detachable coil embolization of cerebral aneurysms : 11 years' experience. J Neurosurg 98 : 959-966, 2003 https://doi.org/10.3171/jns.2003.98.5.0959
  21. Nelson PK, Sahlein D, Shapiro M, Becske T, Fitzsimmons BF, Huang P, et al. : Recent steps toward a reconstructive endovascular solution for the orphaned, complex-neck aneurysm. Neurosurgery 59 : S77-S92;discussion S3-S13, 2006 https://doi.org/10.1227/01.NEU.0000219217.14930.14
  22. Nitzan DW, Azaz B, Constantini S : Severe limitation in mouth opening following transtemporal neurosurgical procedures : diagnosis, treatment, and prevention. J Neurosurg 76 : 623-625, 1992 https://doi.org/10.3171/jns.1992.76.4.0623
  23. Paladino J, Mrak G, Miklic P, Jednacak H, Mihaljevic D : The keyhole concept in aneurysm surgery--a comparative study : keyhole versus standard craniotomy. Minim Invasive Neurosurg 48 : 251-258, 2005 https://doi.org/10.1055/s-2005-915599
  24. Paladino J, Pirker N, Stimac D, Stern-Padovan R : Eyebrow keyhole approach in vascular neurosurgery. Minim Invas Neurosurg 41 : 200-203, 1998 https://doi.org/10.1055/s-2008-1052042
  25. Park J : Self-drilling anchor screws for dural tenting sutures : technical note. Surg Neurol 72 : 175-176, 2009 https://doi.org/10.1016/j.surneu.2008.05.004
  26. Park J, Kang DH, Chun BY : Superciliary keyhole surgery for unruptured posterior communicating artery aneurysms with oculomotor nerve palsy : maximizing symptomatic resolution and minimizing surgical invasiveness. J Neurosurg 115 : 700-706, 2011 https://doi.org/10.3171/2011.5.JNS102087
  27. Park J, Woo H, Kang DH, Sung JK, Kim Y : Superciliary keyhole approach for small unruptured aneurysms in anterior cerebral circulation.Neurosurgery 68 : 300-309; discussion 309, 2011
  28. Raaymakers TW, Rinkel GJ, Limburg M, Algra A : Mortality and morbidity of surgery for unruptured intracranial aneurysms : a meta-analysis. Stroke 29 : 1531-1538, 1998 https://doi.org/10.1161/01.STR.29.8.1531
  29. Ramos-Zuniga R, Velazquez H, Barajas MA, López R, Sanchez E, Trejo S : Trans-supraorbital approach to supratentorial aneurysms. Neurosurgery 51 : 125-130; discussion 130-131, 2002 https://doi.org/10.1097/00006123-200207000-00019
  30. Reisch R, Perneczky A : Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery 57 : 242-255; discussion 242-255, 2005 https://doi.org/10.1227/01.NEU.0000178353.42777.2C
  31. Sanai N, Caldwell N, Englot DJ, Lawton MT : Advanced technical skills are required for microsurgical clipping of posterior communicating artery aneurysms in the endovascular era. Neurosurgery 71 : 285-294; discussion 294-295, 2012 https://doi.org/10.1227/NEU.0b013e318256c3eb
  32. van Lindert E, Perneczky A, Fries G, Pierangeli E : The supraorbital keyhole approach to supratentorial aneurysms : concept and technique. Surg Neurol 49 : 481-489; discussion 489-490, 1998 https://doi.org/10.1016/S0090-3019(96)00539-3

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