Microsurgical principles for anterior circulation aneurysms

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.

Clipping Versus Coiling in Anterior Circulation Ruptured Intracranial Aneurysms: A Meta-Analysis

OBJECTIVE

To evaluate open surgical versus endovascular repair of anterior circulation ruptured intracranial aneurysms based on operative mortality, permanent neurologic deficit, late mortality, and need for reintervention.

METHODS

This meta-analysis included articles published since December 6, 2016, that compared outcomes of the 2 methods. Extracted data were organized in a standard table format, including first author, country, covered study period, publication year, number of patients and patients at follow-up, operative mortality rate (with 30 days from treatment), permanent neurologic deficit (appearing after surgery), late mortality (after 1 month), and reintervention (surgery or coiling) for both groups of patients. Follow-up was at least 1 year.

RESULTS

There were 8 articles that matched our study criteria. The study population was 628 patients; 374 were treated with surgical clipping, and 254 were treated with endovascular coiling. Pooled results showed no statistically significant difference between the 2 groups in terms of operative mortality, permanent neurologic deficit, late mortality, and need for reintervention.

CONCLUSIONS

Selection of the appropriate procedure must be made on the basis of the special characteristics of each case.

Feasibility and Efficacy of Olfactory Protection Using Gelfoam and Fibrin Glue during Anterior Communicating Artery Aneurysm Surgery

Objective

Patients treated with surgical clipping for anterior communicating artery (A-com) aneurysm often complain of anosmia, which can markedly impede their quality of life. We introduce a simple and useful technique to reduce postoperative olfactory dysfunction in A-com aneurysm surgery.

Methods

We retrospectively reviewed the medical records of patients who underwent surgical clipping for unruptured aneurysm from 2011-2013 by the same senior attending physician. Since March 2012, olfactory protection using gelfoam and fibrin glue was applied in A-com aneurysm surgery. Therefore we categorized patients in two groups from this time-protected group and unprotected group.

Results

Of the 63 enrolled patients, 16 patients showed postoperative olfactory dysfunction-including 8 anosmia patients (protected group : unprotected group=1 : 7) and 8 hyposmia patients (protected group : unprotected group=2 : 6). Thirty five patients who received olfactory protection during surgery showed a lower rate of anosmia (p=0.037, OR 10.516, 95% CI 1.159-95.449) and olfactory dysfunction (p=0.003, OR 8.693, 95% CI 2.138-35.356). Superior direction of the aneurysm was also associated with a risk of olfactory dysfunction (p=0.015, OR 5.535, 95% CI 1.390-22.039).

Conclusion

Superior direction of aneurysm appears associated with postoperative olfactory dysfunction. Olfactory protection using gelfoam and fibrin glue could be a simple, safe, and useful method to preserve olfactory function during A-com aneurysm surgery.

Anatomical configuration of the Sylvian fissure and its influence on outcome after pterional approach for microsurgical aneurysm clipping

Background:

The sylvian fissure (SF) is the anatomical pathway used in a pterional approach, which leads to most aneurysms. There are four different anatomical variants of the SF described. In the present retrospective study the four different categories of the SF were studied in order to evaluate any correlation of these variants to surgical outcome.

Methods:

Patients treated for intracranial aneurysms by a pterional transsylvian approach during 2003-2012 (N = 237) were included in the study. The SF category was determined by analysis of preoperative computed tomography (CT) scanning. Patients were grouped into unruptured intracranial aneurysms (UIA) and ruptured intracranial aneurysms with subarachnoid hemorrhage (SAH) according to the Hunt and Hess grades. Brain edema, vasospasms, ischemic lesion rate, and outcome were evaluated for possible correlation with SF anatomical variants.

Results:

Postsurgically brain edema formation correlated significantly with more complex anatomical variants of the SF in patients with UIAs and in patients with Hunt and Hess 1 and 2. Ischemia rate, vasospasms, or clinical outcome was not negatively affected though.

Conclusion:

The classification of the SF as proposed by Yasargil is more than a pure anatomical observation. In this retrospective study, we show that the anatomical variants of the SF can be associated to postoperative complications like formation of brain edema or ischemic lesions Preoperative knowledge of the SF anatomy and possibly consecutive adapted extend of the surgical approach can decrease procedure-related morbidity.

Benefits of early aneurysm surgery: Southern Iran experience

Background:

Neurovascular surgery has been practiced in Shiraz, the main referral center of the Southern Iran, for over 30 years; however, the trend has accelerated tremendously in recent years following subspecialization of neurovascular surgery in Shiraz, Department of Neurosurgery. Over 100 patients are operated each year, and nearly all are addressed during the first 72 hours after presentation.

Methods:

In this paper, we focus on the description of techniques we apply for early clipping of ruptured intracranial aneurysms in the anterior circulation. Improvements in outcome, mortality, and rebleeding rates are also discussed.

Results:

Mortality and rebleeding rates have declined significantly since the institution of new techniques.

Conclusion:

The establishment of early surgery for ruptured anterior circulation aneurysms through the lateral supraorbital approach along with specific anesthetic protocol has resulted in significant improvement of morbidity, mortality, and rebleeding rates at our department.

Lateral supraorbital approach applied to tuberculum sellae meningiomas: experience with 52 consecutive patients

BACKGROUND

Various surgical approaches for the removal of tuberculum sellae meningiomas (TSMs) have previously been described.

OBJECTIVE

To assess the reliability and safety of the lateral supraorbital (LSO) approach to remove TSMs.

METHODS

We identified all TSM patients operated on at the Department of Neurosurgery at Helsinki University Central Hospital, Finland, by the senior author (J.H.) using the LSO approach between September 1997 and August 2010. We retrospectively analyzed the clinical data, radiological findings, surgical treatment, histology, and outcome of patients and discuss the operative technique.

RESULTS

Apparent complete tumor removal was achieved in 45 patients (87%). Of 42 patients, preexisting visual deficit improved in 22, remained the same in 13, and worsened in 7, and de novo visual deficit occurred in 1 patient. At 3 months post-discharge, 47 patients (90%) had a good recovery, 4 (8%) were moderately disabled, and 1 (2%) died 40 days after surgery of unexplained cardiac arrest. Seven patients (13%) had minimal residual tumors, 2 of which required reoperation. During the median follow-up of 59 months (range, 1-133 months), tumor recurred in 1 of the patients who had undergone a second operation.

CONCLUSION

TSMs of all sizes can be removed via the LSO approach with minimal morbidity and mortality. Low-power or no coagulation is recommended near the optic nerves and the optic chiasm to preserve their vascular support from the internal carotid artery perforators. Our results are comparable to those obtained using more extensive and time-consuming approaches. We recommend the LSO approach to remove TSMs.