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Massimi L, Menna G, Frassanito P, Olivieri G, Bianchi F, Tamburrini G. Do Minimally Invasive Approaches to Pediatric Orbital Tumors Provide an Advantage on Outcome and Efficiency? World Neurosurg 2024; 186:e243-e250. [PMID: 38552790 DOI: 10.1016/j.wneu.2024.03.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/21/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE The present study evaluated whether minimally invasive approaches to orbital lesions could improve surgical, clinical, and aesthetic outcomes compared with more invasive ones. This is the first study specifically addressing this topic in children. METHODS Children consecutively operated on from January 2010 to January 2020 were analyzed. Thirty patients matched the inclusion criteria and were divided into group A: 14 cases treated with traditional surgical approaches; and group B: 16 cases managed by minimally invasive approaches. RESULTS There were no significant differences between the 2 groups in terms of demographic data and extent of tumor resection. Mean surgical time for the approach (40 minutes vs. 70 minutes, P < 0.0001), surgical complication such as periorbital edema (37% vs. 78%, P = 0.02) and dural tear (0 vs. 21%, P = 0.05), and procedures cost (P < 0.0001) were significantly reduced in group B. Regarding clinical outcomes, group B showed a significant reduction both in terms of postoperative pain (mean score based on visual pain scale was 2.9 vs. 4.1 P = 0.003) and mean hospitalization time (4.5 days vs. 5.5 days, P = 0.0004). The cosmetic outcome according to the Sloan classification was significantly better in group B as well (81% vs. 36% class I patients, P = 0.005). CONCLUSIONS The use of mini-invasive approaches to orbital tumor has clear advantages in terms of surgical, clinical, and cosmetic outcomes in comparable patients; therefore, they should be preferred whenever feasible. Craniotomic approaches remain necessary for very large tumors.
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Affiliation(s)
- Luca Massimi
- Pediatric Neurosurgery-Department of Neuroscience, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Grazia Menna
- Pediatric Neurosurgery-Department of Neuroscience, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Paolo Frassanito
- Pediatric Neurosurgery-Department of Neuroscience, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gabriele Olivieri
- Pediatric Unit, Mother-Infant Department, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Federico Bianchi
- Pediatric Neurosurgery-Department of Neuroscience, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gianpiero Tamburrini
- Pediatric Neurosurgery-Department of Neuroscience, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
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Westarp E, Thieringer FM, Roethlisberger M. Virtual Surgical Planning and Customized CAD/CAM Cranial Implants: Preoperative and Intraoperative Strategies for Temporal Intraosseous Meningioma Resection. J Craniofac Surg 2024:00001665-990000000-01414. [PMID: 38526121 DOI: 10.1097/scs.0000000000010095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/18/2024] [Indexed: 03/26/2024] Open
Abstract
Primary intraosseous meningioma (PIM) is a rare subtype of extradural meningiomas, with the indication for surgical resection in most cases. With an increasing demand for efficient workflows with optimal functional and cosmetical results, techniques for bone reconstruction after resection are developing rapidly. The authors present 2 cases with one-stage cranioplasty after resection of PIM, using 3D technology for preplanned patient-specific implants. In the first case, a premanufactured patient-specific PEEK implant was used for reconstruction; in the second case, a 3-dimensional (3D)-based premanufactured silicon mold was used to produce a customized PMMA implant intraoperatively. Both techniques enabled the surgeons to achieve optimal intraoperative fit of the implant after craniectomy, leading to satisfying functional and cosmetic results. The use of 3D technology, such as Computer-Aided Design and Computer-Aided Manufacturing (CAD/CAM) for the production of patient-specific implants can optimize 1-stage cranioplasty after PIM resection.
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Affiliation(s)
- Emilia Westarp
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Florian M Thieringer
- Department of Oral and Cranio-Maxillo-Facial Surgery and 3D Print Lab, University Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Michel Roethlisberger
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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Westarp E, Thieringer FM, Roethlisberger M. Precision Surgery for Orbital Cavernous Hemangiomas: The Role of Three-Dimensional Printing in Individualized Resection-An Educational Experience. J Craniofac Surg 2024; 35:220-222. [PMID: 37603898 DOI: 10.1097/scs.0000000000009640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 08/23/2023] Open
Abstract
Orbital cavernous hemangiomas are the most common primary orbital tumors in adults, providing challenges for optimal surgical approach planning within an anatomically complex area with close proximity to vital neurovascular structures. The authors present an individualized lateral mini-orbitozygomatic approach for the resection of an orbital cavernous haemangioma based on a preoperative 3-dimensional-printed model. This individualized approach enabled the surgeons to achieve optimal exposure while maintaining safety during the resection of the lesion, but also to respect the patient's physiognomy and hairline. In addition, the model was used for patient informed consent, helping the patient understand the procedure. Although adding additional effort to preoperative planning, 3-dimensional model-based approaches can offer great benefits when it comes to customizing surgical approaches, especially for anatomically challenging resections.
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Affiliation(s)
- Emilia Westarp
- Department of Neurosurgery, University Hospital of Basel
| | - Florian M Thieringer
- Department of Oral and Cranio-Maxillo-Facial Surgery and 3D Print Lab, University Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Michel Roethlisberger
- Department of Neurosurgery, University Hospital of Basel
- Faculty of Medicine, University of Basel, Basel, Switzerland
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Sanada Y, Tsuji K, Hamada Y, Fujishima K, Furukawa K, Fukawa N, Kubota H, Satow T, Takahashi JC. Rigid but nonmetallic cranioplasty after pterional craniotomy: Technical note. Surg Neurol Int 2023; 14:337. [PMID: 37810322 PMCID: PMC10559571 DOI: 10.25259/sni_577_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 08/25/2023] [Indexed: 10/10/2023] Open
Abstract
Background Given the popularity of pterional craniotomy, numerous modifications have been made to prevent postoperative deformities. With the advent of titanium plates, fixation has become both simple and excellent. However, titanium plates can cause skin problems, infection, or cause skull growth to fail. Methods To develop a simple, cost-effective, and esthetically satisfactory fixation method, without the use of non-metallic materials, six young and older patients underwent pterional craniotomy. CranioFix Absorbable clamps were used to fix the bone flap in the frontal and temporal regions such that the frontal part was in close contact with the skull. After fixation, the bone chips and bone dust were placed in the bone gap and fixed with fibrin glue. We measured the computed tomography values of the reconstructed area and thickness of the temporal profiles postoperatively over time. Results Bone fusion was achieved in all patients by 1 year after surgery. Both the thickness of the temporalis muscle and the thickness of the temporal profile had changed within 2 mm as compared with the preoperative state. Conclusion Our simple craniotomy technique, gentle tissue handling, and osteoplastic cranioplasty yielded satisfactory esthetic results and rigidness in pterional craniotomy.
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Affiliation(s)
- Yasuhiro Sanada
- Department of Neurosurgery, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Kiyoshi Tsuji
- Department of Neurosurgery, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Yuumi Hamada
- Department of Neurosurgery, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Kazuhiro Fujishima
- Department of Neurosurgery, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Kentaro Furukawa
- Department of Neurosurgery, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Norihito Fukawa
- Department of Neurosurgery, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Hisashi Kubota
- Department of Neurosurgery, Kubota Clinic Neurosurgery, Osaka, Japan
| | - Tetsu Satow
- Department of Neurosurgery, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Jun C. Takahashi
- Department of Neurosurgery, Faculty of Medicine, Kindai University, Osaka, Japan
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Pichugin A, Danilov G, Pashaev B, Shayakhmetov N, Danilov V, Alekseev А. Supraorbital eyebrow approach and pterional approach in surgical treatment of ruptured and unruptured aneurysms: a propensity score-matched analysis. Neurosurg Rev 2023; 46:179. [PMID: 37468681 DOI: 10.1007/s10143-023-02093-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/11/2023] [Accepted: 07/15/2023] [Indexed: 07/21/2023]
Abstract
The aim of this study is to reveal efficacy and efficiency of the supraorbital eyebrow approach (SEA) in clipping ruptured and unruptured aneurysms where both SEA and pterional approach (PA) are considered feasible by comparing SEA and PA using propensity score matching. A total of 229 patients who underwent surgical clipping of an aneurysm from 2013 to 2022 and met inclusion criteria were recruited in the study. A study group of 67 patients treated via the SEA and a comparison group of 162 patients treated via the PA were formed. Then, the subgroups of 66 patients each, with balanced incoming factors, were analyzed using the propensity score technique. The safety and efficacy endpoints were compared. Successful clipping was achieved in all cases of both groups. There were no patients in the SEA group who required conversion to the standard craniotomy. There were no procedure-related deaths in this series. No patient experienced early or late rebleeding in either group. Mean blood loss volume in the SEA group was lower than in the PA group by approximately 77.5 ml (p < 0.001). There were favorable differences in the SEA group regarding postoperative neurological deficit (p = 0.016), postoperative epileptic seizure rate (p = 0.013), ischemic and hemorrhagic complications (p = 0.028 and 0.0009, respectively), and outcomes (p < 0.001). Patients' satisfaction with cosmetic results measured by the visual analog scale was rated highly in both groups (p = 0.081). For patients where SEA provides adequate exposure, it results in safety and cosmetic outcomes not inferior to the PA.
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Affiliation(s)
- Arseniy Pichugin
- Department of Neurology and Neurosurgery, Kazan State Medical University, Kazan, Russia.
- Department of Neurosurgery, Interregional Clinical and Diagnostic Center, Kazan, Russia.
| | - Gleb Danilov
- Scientific Secretary, Federal State Autonomous Institution "N. N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Bakhtiyar Pashaev
- Department of Neurology and Neurosurgery, Kazan State Medical University, Kazan, Russia
- Department of Neurosurgery, Interregional Clinical and Diagnostic Center, Kazan, Russia
| | - Nail Shayakhmetov
- Department of Neurology and Neurosurgery, Kazan State Medical University, Kazan, Russia
| | - Valeriy Danilov
- Department of Neurology and Neurosurgery, Kazan State Medical University, Kazan, Russia
- Department of Neurosurgery, Interregional Clinical and Diagnostic Center, Kazan, Russia
| | - Аndrey Alekseev
- Department of Neurology and Neurosurgery, Kazan State Medical University, Kazan, Russia
- Department of Neurosurgery, Interregional Clinical and Diagnostic Center, Kazan, Russia
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Kweon GY, Park J, Son W. Acceptable durability of split inner table graft for the reconstruction of a bone defect in pterional craniotomies: a case series. Front Surg 2023; 10:1213648. [PMID: 37520153 PMCID: PMC10375404 DOI: 10.3389/fsurg.2023.1213648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Objective During a pterional craniotomy, the bone defect was reconstructed by a surgical technique using an autogenous bone graft instead of commercially available alloplastic materials. The technical feasibility, durability of the grafted bone, and cosmetic outcome were all evaluated. Methods After a pterional craniotomy was performed, the bone defect at the frontobasal burr hole and drilled sphenoid wing was reconstructed using an autogenous split inner table graft (1 cm × 2 cm) harvested from the craniotomy bone flap. Results The bone reconstruction technique was successfully performed on nine patients with intracranial aneurysms. After 12-19 months from the surgery, a volumetry study using three-dimensional skull images reconstructed from computed tomography angiography showed a minimal decrease in the area of the split inner table graft due to bone resorption in six patients, which ranged from 5.7% to 14.8%. In the other three patients, the bone resorption was more substantial, ranging from 21.2% to 27.5%. However, in the three latter cases, the resorption was mainly limited to the posterior part of the split inner table graft covered by the temporalis muscle and did not affect the cosmetic outcomes. The resultant cosmetic outcomes for the nine patients were all favorable, with only a slight or no anterior temporal hollow. Conclusion The proposed surgical technique using a split inner table graft harvested from the craniotomy bone flap seems viable for reconstructing the bone defect at the frontobasal burr hole and drilled sphenoid wing after a pterional craniotomy.
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Transpalpebral Eyelid Approach for Supraorbital Frontal Craniotomy and Access to the Anterior Cranial Fossa. Plast Reconstr Surg 2023; 151:463e-468e. [PMID: 36730475 DOI: 10.1097/prs.0000000000009928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
SUMMARY The transpalpebral eyelid approach is an innovative alternative to traditional incisions for exposure of the anterior cranial fossa for neurosurgery. However, there is a paucity of data on this surgical technique in the plastic surgery literature for accessing the anterior cranial fossa. A retrospective review was performed of patients who underwent supraorbital frontal craniotomy using an anterior skull base approach with transpalpebral exposure over 8 years by a single plastic surgeon. Surgical techniques, medical comorbidities, intraoperative complications, and long-term complications were assessed. Twenty patients (mean age 52 ± 12 years, 55% male, 45% female) underwent supraorbital frontal craniotomy using an anterior skull base approach with upper transpalpebral exposure. Operative indications included the following: 75% had anterior communicating aneurysms, with a mean aneurysm size of 5.36 ± 1.91 mm; 10% had meningiomas; 10% had dural fistulas; and 5% had an orbital hemangioma. A total of 60% of patients had a smoking history. No intraoperative complications were encountered, and no cases required conversion to a traditional open approach. Mean length of hospital stay was 3.2 ± 1.5 days. Postoperative imaging revealed no residual or recurrent pathology. Mean follow-up time was 62.2 ± 30.6 months. No long-term neurologic or ophthalmologic complications or infections occurred. No forehead paresthesias, brow ptosis, or brow paralysis were noted. The transpalpebral technique is a safe, minimally invasive method to approach lesions of the anterior cranial fossa. Successful application may require appropriate management of the frontal sinus and supraorbital nerve. This approach does not limit neurosurgical access or results and led to no neurosurgical complications. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Signoretti S, Pescatori L, Nardacci B, Delitala A, Zauner A, Visocchi M. Supraorbital Keyhole Versus Pterional Approach: A Morphometric Anatomical Study. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:119-123. [PMID: 38153459 DOI: 10.1007/978-3-031-36084-8_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
OBJECTIVE Although the supraorbital (SO) keyhole approach has a wide range of indications, its routine usefulness with the advance of current technology has not been fully evaluated. In an attempt to address this issue, a cadaveric morphometric analysis to the supra- and parasellar regions was performed, comparing the standard Pterional craniotomy (PT) with the SO keyhole. METHODS ETOH-fixed and silicone-injected human cadaveric heads were used. SO (n = 8) and PT craniotomies (n = 8) were performed. Pre- and post-dissection CT, along with pre-dissection MRI scans were also completed for neuro-navigation purposes, aimed to verify predetermined anatomical landmarks selected for morphometric analysis. RESULTS Notwithstanding the smaller craniotomy, the SO approach allowed optimal anatomical exposure when compared to the PT approach. With 30° of head rotation, the SO keyhole showed a wider surgical field of the suprasellar region. CONCLUSIONS Using detailed preoperative image-guided surgical planning, the SO keyhole approach offered an appropriate alternative route to the supra- and parasellar regions, compared to the PT craniotomy.
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Affiliation(s)
- Stefano Signoretti
- Division of Neurosurgery, Department of Emergency and Urgency, S. Eugenio/CTO Hospital, A.S.L. Roma2, Rome, Italy.
| | - Lorenzo Pescatori
- Division of Neurosurgery, Department of Emergency and Urgency, S. Eugenio/CTO Hospital, A.S.L. Roma2, Rome, Italy
| | - Barbara Nardacci
- Division of Neurosurgery, Department of Emergency and Urgency, S. Eugenio/CTO Hospital, A.S.L. Roma2, Rome, Italy
| | - Alberto Delitala
- Division of Neurosurgery, San Carlo di Nancy Hospital, Rome, Italy
| | - Alois Zauner
- Department of Neurosurgery, Stroke and Neurovascular Center of Central California, Santa Barbara, CA, USA
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Jean WC, Sack KD. Utilization of Navigation-Integrated, Mixed Reality Templates for Minimizing Invasiveness of Neurosurgical Procedures: A Case Series. NEUROSURGERY OPEN 2022. [DOI: 10.1227/neuopn.0000000000000017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Guizzardi G, Mosteiro A, Hoyos J, Ferres A, Topczewski T, Reyes L, Alobid I, Matas J, Cavallo LM, Cappabianca P, Enseñat J, Prats-Galino A, Di Somma A. Endoscopic Transorbital Approach to the Middle Fossa: Qualitative and Quantitative Anatomic Study. Oper Neurosurg (Hagerstown) 2022; 23:e267-e275. [PMID: 36106937 DOI: 10.1227/ons.0000000000000308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 04/03/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The endoscopic superior eyelid transorbital route to the skull base is gaining progressive popularity in the neurosurgical community. OBJECTIVE To evaluate the anatomy of the middle cranial fossa from this novel ventral perspective to reach the skull base through the transorbital route and to show limits for possible safe middle fossa drilling from the transorbital route. METHODS Anatomic study was performed; 5 cadaveric specimens (ie, 10 sides) and 2 dry skulls (ie, 4 sides) were dissected. RESULTS To obtain a functional result, there are boundaries that correspond to neurovascular structures that traverse, enter, or leave the middle fossa that must be respected: inferiorly, the lateral pterygoid muscle; medially, the Gasserian ganglion and the lateral border of the foramen rotundum; laterally, the foramen spinosum with the middle meningeal artery; superiorly, the lesser sphenoid wing; posteriorly, the anterior border of the foramen ovale. Average bone resected was 6.49 ± 0.80 cm3 which is the 63% of total middle fossa floor. The mean axial surgical length calculated was 3.85 cm (3.18-5.19 cm) while the mean sagittal surgical length was 5.23 cm (4.87-6.55 cm). The mean horizontal angle of approach was 38.14° (32.87°-45.63°), while the mean vertical angle of approach was 18.56° (10.81°-26.76°). CONCLUSION Detailed anatomy of the middle cranial fossa is presented, and herewith we demonstrated that from the endoscopic superior eyelid transorbital approach removal of middle cranial fossa floor is possible when anatomic landmarks are respected.
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Affiliation(s)
- Giulia Guizzardi
- Division of Neurosurgery, Department of Neuroscience, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Alejandra Mosteiro
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jhon Hoyos
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Abel Ferres
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Thomaz Topczewski
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Luis Reyes
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Isam Alobid
- Rhinology Unit and Smell Clinic, ENT Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jessica Matas
- Clinic Institute of Ophthalmology (ICOF), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neuroscience, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neuroscience, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Joaquim Enseñat
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Alberto Di Somma
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain.,Rhinology Unit and Smell Clinic, ENT Department, Hospital Clínic de Barcelona, Barcelona, Spain.,Clinic Institute of Ophthalmology (ICOF), Hospital Clínic de Barcelona, Barcelona, Spain.,Laboratory of Surgical Neuroanatomy, Universitat de Barcelona, Barcelona, Spain
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Kudulaiti N, Liu F, Hameed NUF, Wang P, Zhang J, Feng R, Wu J. Mini-temporal approach as an alternative to the classical pterional approach for resective temporal region surgeries. Chin Neurosurg J 2022; 8:30. [PMID: 36138449 PMCID: PMC9494766 DOI: 10.1186/s41016-022-00280-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 04/25/2022] [Indexed: 11/29/2022] Open
Abstract
Background Classical pterional appoach for temporal surgeries may cause atrophy and dysfunction of temporalis, injury to the facial nerve, and unnecessary cortical exposure. As an alternative to the classical pterional approach for such surgeries, we hereby describe an mini-temporal approach which reduces these risks and proven to be practical in neurological surgeries. Material and methods In the mini-temporal incision design, the frontal end of the incision never surpassed the hairline at the level of temporal line, and a one-layer skin-galea-muscle flap was detached from the cranium, effectively avoiding the injuries of facial nerve. The surgical bone window was completely located underneath the temporalis muscle, allowing it to be completely repositioned postoperatively. Results We demonstrated the application of mini-temporal approach in a variety of temporal region tumors, which can be applied to complete successful resective surgeries while effectively reducing injuries to extra-temporal cortex, temporalis, and facial nerve. There were no postoperative complications related to extra-temporal cortical damage, atrophy of temporalis, or injury to the facial nerve. Conclusion The mini-temporal approach can effectively shorten the time of craniotomy and closure, decrease the size of bony removal, increase the restoration of temporalis during closure, and lower the chance of facial nerve injury. Therefore, it improves cosmetic outcomes and reduces the risk of unintentional extra-temporal cortical injury, which fully embodies the minimally invasive principle in neurosurgery.
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Karadimas S, Shakil H, Almeida JP, Tymianski M, Radovanovic I. Minimally Invasive and Outpatient Aneurysm Surgery. Neurosurg Clin N Am 2022; 33:371-382. [DOI: 10.1016/j.nec.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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13
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Babacan S, Deniz M. Estimating the Person-Specific Location of Pterion Based on Cranial Morphometry. J Craniofac Surg 2022; 33:1599-1602. [DOI: 10.1097/scs.0000000000008229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 09/07/2021] [Indexed: 11/25/2022] Open
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Serrano Sponton L, Oehlschlaegel F, Nimer A, Schwandt E, Glaser M, Archavlis E, Conrad J, Kantelhardt S, Ayyad A. The Endoscopic-Assisted Supraorbital Approach for Resection of Anterior Skull Base Meningiomas: A Large Single-Center Retrospective Surgical Study. J Neurol Surg B Skull Base 2022. [DOI: 10.1055/s-0042-1751000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Abstract
Objective The endoscopic-assisted supraorbital approach (eSOA) constitutes a minimally invasive strategy for removing anterior skull base meningiomas (ASBM). We present the largest retrospective single-institution and long-term follow-up study of eSOA for ASBM resection, providing further insight regarding indication, surgical considerations, complications, and outcome.
Methods We evaluated data of 176 patients operated on ASBM via the eSOA over 22 years.
Results Sixty-five tuberculum sellae (TS), 36 anterior clinoid (AC), 28 olfactory groove (OG), 27 planum sphenoidale, 11 lesser sphenoid wing, seven optic sheath, and two lateral orbitary roof meningiomas were assessed. Median surgery duration was 3.35 ± 1.42 hours, being significantly longer for OG and AC meningiomas (p <0.05). Complete resection was achieved in 91%. Complications included hyposmia (7.4%), supraorbital hypoesthesia (5.1%), cerebrospinal fluid fistula (5%), orbicularis oculi paresis (2.8%), visual disturbances (2.2%), meningitis (1.7%) and hematoma and wound infection (1.1%). One patient died due to intraoperative carotid injury, other due to pulmonary embolism. Median follow-up was 4.8 years with a tumor recurrence rate of 10.8%. Second surgery was chosen in 12 cases (10 via the previous SOA and two via pterional approach), whereas two patients received radiotherapy and in five patients a wait-and-see strategy was adopted.
Conclusion The eSOA represents an effective option for ASBM resection, enabling high complete resection rates and long-term disease control. Neuroendoscopy is fundamental for improving tumor resection while reducing brain and optic nerve retraction. Potential limitations and prolonged surgical duration may arise from the small craniotomy and reduced maneuverability, especially for large or strongly adherent lesions.
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Affiliation(s)
- Lucas Serrano Sponton
- Department of Neurosurgery, Sana Klinikum Offenbach, Offenbach am Main, Germany
- Department of Neurosurgery, Mainz University Medical Centre, Mainz, Germany
| | - Florian Oehlschlaegel
- Department of Neurosurgery, Mainz University Medical Centre, Mainz, Germany
- Department of Neurosurgery, Helios Amper Clinic, Dachau, Germany, Germany
| | - Amr Nimer
- Department of Neurosurgery, Mainz University Medical Centre, Mainz, Germany
- Department of Neurosurgery, Charing Cross Hospital, Imperial College Healthcare, London, United Kingdom
| | - Eike Schwandt
- Department of Neurosurgery, Mainz University Medical Centre, Mainz, Germany
| | - Martin Glaser
- Department of Neurosurgery, Mainz University Medical Centre, Mainz, Germany
| | | | - Jens Conrad
- Department of Neurosurgery, Mainz University Medical Centre, Mainz, Germany
| | - Sven Kantelhardt
- Department of Neurosurgery, Mainz University Medical Centre, Mainz, Germany
| | - Ali Ayyad
- Department of Neurosurgery, Mainz University Medical Centre, Mainz, Germany
- Department of Neurosurgery, Hamad General Hospital, Doha, QATAR
- Department of Neurosurgery, Saarland University Medical Centre, Homburg, Germany
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Avery MB, Mallari RJ, Barkhoudarian G, Kelly DF. Supraorbital and mini-pterional keyhole craniotomies for brain tumors: a clinical and anatomical comparison of indications and outcomes in 204 cases. J Neurosurg 2022; 136:1314-1324. [PMID: 34715664 DOI: 10.3171/2021.6.jns21759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors' objective was to compare the indications, outcomes, and anatomical limits of supraorbital (SO) and mini-pterional (MP) craniotomies in patients with intra- and extraaxial brain tumors, and to assess approach selection, utility of endoscopy, and surgical field overlap. METHODS A retrospective analysis was conducted of all brain tumor patients who underwent an SO or MP approach. The analyzed characteristics included pathology, endoscopy use, extent of resection, length of stay (LOS), and complications. On the basis of preoperative MRI data, tumor heatmaps were constructed to compare surgical access provided by both routes, including coronal projection heatmaps for parasellar tumors. RESULTS From 2007 to 2020, 158 patients underwent 173 (84.8%) SO craniotomies and 30 patients underwent 31 (15.2%) MP craniotomies; 71 (34.8%) procedures were reoperations. Of these 204 operations, 110 (63.6%) SO and 21 (67.7%) MP approaches were for extraaxial tumors (meningiomas in 65% and 76.2%, respectively). Gliomas and metastases together represented 84.1% and 70% of intraaxial tumors accessed with SO and MP approaches, respectively. Overall, 56.1% of tumors accessed with the SO approach and 41.9% of those accessed with the MP approach were in the parasellar region. Axial projection heatmaps showed that SO access extended along the entire ipsilateral and medial contralateral anterior cranial fossa, parasellar region, ipsilateral sylvian fissure, medial middle cranial fossa, and anterior midbrain, whereas MP access was limited to the ipsilateral middle cranial fossa, sylvian fissure, lateral parasellar region, and posterior aspect of anterior cranial fossa. Coronal projection heatmaps showed that parasellar access extended further superiorly with the SO approach compared with that of the MP approach. Endoscopy was utilized in 98 (56.6%) SO craniotomies and 7 (22.6%) MP craniotomies, with further tumor resection in 48 (49%) and 5 (71.4%) cases, respectively. Endoscope-assisted tumor removal was clustered in areas that were generally at farther distances from the craniotomy or in angled locations such as the cribriform plate region where microscopic visualization is limited. Gross-total or near-total resection was achieved in 120/173 (69%) SO approaches and 21/31 (68%) MP approaches. Major complications occurred in 11 (6.4%) SO approaches and 1 (3.2%) MP approach (p = 0.49). The median LOS decreased to 2 days in the last 2 years of the study. CONCLUSIONS This clinical experience suggests the SO and MP craniotomies are versatile, safe, and complementary approaches for tumors located in the anterior and middle cranial fossae and perisylvian and parasellar regions. The SO route, used in 85% of cases, achieved greater overall reach than the MP route. Both approaches may benefit from expanded visualization with endoscopy.
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Affiliation(s)
- Michael B Avery
- 1Pacific Neuroscience Institute, Santa Monica, California; and
- 2Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | | | - Garni Barkhoudarian
- 1Pacific Neuroscience Institute, Santa Monica, California; and
- 2Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Daniel F Kelly
- 1Pacific Neuroscience Institute, Santa Monica, California; and
- 2Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
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16
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Zaimoglu M, Can Alpergin B, Mert Ozpiskin O, Cihan Can K, Ozcelik Eroglu E, Eroglu U. As Concepts That Should Not Be Thrown Out of Focus, Aesthetic And Social Appearance Anxiety In Neurosurgery. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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17
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The Supraorbital Approach via an Eyebrow Incision: Analysis of Cosmetic Outcomes Using the Scar Cosmesis Assessment Rating Scale. J Craniofac Surg 2021; 33:307-311. [PMID: 34690317 DOI: 10.1097/scs.0000000000008071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
ABSTRACT The supraorbital craniotomy through an eyebrow incision, referred to as the suprabrow approach, may be used to access intracranial lesions. Though offering good surgical exposure for anterior base cranial lesions, the suprabrow approach has a paucity of studies on its cosmetic outcomes. In this study, we aimed to assess the cosmetic outcomes of suprabrow approach using validated Scar Cosmesis Assessment Rating (SCAR) scale for the first time. Three patients underwent a suprabrow approach for resection of a suprasellar or frontal mass. Their postoperative courses were followed, with specific attention to the cosmetic outcome of their procedures. The SCAR scale was used to determine the cosmetic success of the approach. We found that all 3 patients scored ≤ 5 on the SCAR scale. All 3 resections were successful with no major postoperative complications. The only minor complication was transient hypoesthesia of the ipsilateral forehead that was noted in all 3 patients.This study quantified the positive cosmetic outcomes of a minimally invasive suprabrow approach. The suprabrow approach provides acceptable surgical exposure and access in an appropriately selected patient with anterior cranial base lesions and results in favorable cosmesis. Although transient hypoesthesia in the distribution of the ophthalmic branch of the trigeminal nerve occurs, the overall benefits of the approach and desirable cosmetic outcomes make the suprabrow approach a good technique to access intracranial lesions in appropriate cases.
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18
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Dallan I, Cristofani-Mencacci L, Fiacchini G, Caniglia M, Sellari-Franceschini S, Berrettini S. When multidisciplinary surgical trans-orbital approaches should be considered to reach the skull base. ACTA ACUST UNITED AC 2021; 41:S59-S66. [PMID: 34060521 PMCID: PMC8172113 DOI: 10.14639/0392-100x-suppl.1-41-2021-06] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 01/16/2021] [Indexed: 11/29/2022]
Abstract
The transorbital approaches are a group of surgical procedures performed passing through the orbital spaces and aimed to reach deeper areas. This kind of surgery has been proved to be safe and effective in the management of selected lesions of the anterior, middle and infratemporal fossa. The aim of the present study is to perform a review of the literature, in order to draw the reader’s attention on the main features of this kind of surgery, focusing on the anatomical background and the surgical setting; we will also summary the current indications and contraindications to this approach and find out the related complications and the possible alternatives. Even if we consider the transorbital approach as a promising route to the skull base, we underline that there is no better approach over another and the choice must always consider several elements. Furthermore, as for every skull base procedure, a multidisciplinary management is strongly advisable.
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Affiliation(s)
- Iacopo Dallan
- Otolaryngology Unit, Department of Surgical, Medical, Molecular Pathology and Emergency Medicine, University Hospital of Pisa, Italy
| | - Lodovica Cristofani-Mencacci
- Otolaryngology Unit, Department of Surgical, Medical, Molecular Pathology and Emergency Medicine, University Hospital of Pisa, Italy
| | - Giacomo Fiacchini
- Otolaryngology Unit, Department of Surgical, Medical, Molecular Pathology and Emergency Medicine, University Hospital of Pisa, Italy
| | | | - Stefano Sellari-Franceschini
- Otolaryngology Unit, Department of Surgical, Medical, Molecular Pathology and Emergency Medicine, University Hospital of Pisa, Italy
| | - Stefano Berrettini
- Otolaryngology Unit, Department of Surgical, Medical, Molecular Pathology and Emergency Medicine, University Hospital of Pisa, Italy
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19
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Mattogno PP, Guerrini F, Nicolosi F, Panciani P, Olivi A, Fontanella M, Spena G. Minimally Invasive Subfrontal Approach: How to Make it Safe and Effective from the Olfactory Groove to the Mesial Temporal Lobe. J Neurol Surg A Cent Eur Neurosurg 2021; 82:585-593. [PMID: 34384130 DOI: 10.1055/s-0040-1722697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Different surgical approaches have been developed to manage lesions of the anterior and middle skull base areas. Frontal, pterional, bifrontal, and fronto-orbito-zygomatic approaches are traditionally used to reach these regions. With advancements in the neurosurgical field, skull opening should be simple and as minimally invasive as possible, tailored on the surgical corridor to the target. The supraorbital approach and the "keyhole" concept have been introduced and popularized by Axel Perneczky starting from 1998 and are now considered a part of everyday practice. The extended possibilities of this surgical route, considering the reachable targets and surgical limits, are described and systematically analyzed, including a description of the salient surgical anatomy, presenting different illustrative cases. METHODS AND RESULTS Different illustrative cases are presented and discussed to underline the potentials and limits of the minimally invasive subfrontal approach (MISFA) and the possibilities to tailoring the craniotomy on the basis of the targets: extra-axial lesions with different localizations (anterior roof of the orbit, olfactory groove, tuberculum sellae, medial third of the sphenoid wing, anterior and posterior clinoid process), deeper intra-axial lesions (gyrus rectus, medial temporal lobe-uncus-amygdala-anterior hippocampus), and vascular lesions (anterior communicating aneurysm). Each case has been preoperatively planned considering the anatomical and radiologic features and using virtual simulation software to tailor the best possible corridor to reach the surgical target. CONCLUSIONS The MISFA is a safe multicorridor approach that can be used efficiently to manage lesions of the anterior and middle skull base areas with extremely low approach-related morbidity.
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Affiliation(s)
- Pier Paolo Mattogno
- Department of Neurosurgery, Institute of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Guerrini
- Department of Neurosurgery, Neurosurgery Unit, Ospedale Alessandro Manzoni, Lecco, Italy
| | - Federico Nicolosi
- Department of Neurosurgery, Humanitas Research Hospital, Milan, Italy
| | - Pierpaolo Panciani
- Neurosurgery Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University of Brescia, Brescia, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Institute of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Marco Fontanella
- Neurosurgery Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University of Brescia, Brescia, Italy
| | - Giannantonio Spena
- Department of Neurosurgery, Neurosurgery Unit, Ospedale Alessandro Manzoni, Lecco, Italy
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20
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Dhandapani S, Wankhede LS. Orbital Rim Sparing Single-piece Fronto-orbital Keyhole Craniotomy Through Eyebrow Incision: A Technical Report and Comparative Review. Neurol India 2021; 69:441-445. [PMID: 33904472 DOI: 10.4103/0028-3886.314520] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background The classical eyebrow supraorbital keyhole craniotomy has limited working volume due to the thick incurving of the frontal bone necessitating generous drilling of the frontal base. However, the basal variant with sectioning of the orbital rim results in increased periorbital edema. Objective We describe a novel orbital rim sparing single-piece fronto-orbital keyhole approach, probably the first such report with a comparative review of relevant literature. Methods Following eyebrow incision, bidirectional drilling with a ball tip behind the fronto-zygomatic suture exposes the periorbita and frontal dura, with orbital roof in-between. The craniotomy is fashioned with an angled fronto-orbital cut parallel to and sparing the orbital rim with dura-guard over the periorbita, a frontal cut over the dura, and an optional cut along the lateral orbital roof from within the burr hole. A comparative review of this technique with traditional methods is also carried out. Results Compared to the classical supraorbital keyhole, this minimally invasive approach yields a wider basal exposure with greater working volume for intracranial and orbital lesions. Compared to the basal variant of keyhole fronto-orbital approach, this technique results in the least disturbance to periorbita's attachment with the orbital margin, maintenance of orbital contour, better cosmesis with use of simple tools and self-fitting flap. Conclusion The orbital rim sparing single-piece fronto-orbital keyhole craniotomy is an easy and novel minimally invasive approach with greater working volume without the disadvantages of sectioning the orbital rim.
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Affiliation(s)
- Sivashanmugam Dhandapani
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Lomesh S Wankhede
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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21
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Martinez-Perez R, Beer-Furlan A, Albonette-Felicio T, Hardesty DA, Mohyeldin A, Hara T, Carrau RL, Prevedello DM. The transsylvian corridor through minimally invasive transcranial approaches: a comparative anatomical study. Neurosurg Rev 2020; 44:2619-2627. [PMID: 33210182 DOI: 10.1007/s10143-020-01439-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/17/2020] [Accepted: 11/11/2020] [Indexed: 11/29/2022]
Abstract
Minimally invasive transcranial approaches (MITAs) continue to expand in popularity in neurosurgery. Only few MITAs allow sufficient sylvian exposure to enable wide use of the transsylvian corridor. In this study, we aim to compare the transsylvian corridor in two MITAs: the minipterional (MPTa) and the extended supraorbital eyebrow approaches (XSEa). Eight cadaver heads were used to quantify the surgical exposure and maneuverability along the sylvian fissure and the insular lobe provided by the MPTa and the XSEa. Surgical exposure was calculated by means of the exposed length of the sylvian fissure and by the area framed within three extreme points in the insular lobe. Maneuverability was assessed by means of the surgical freedom along the sylvian cistern. XSEa provides twice the frontal exposure and half of the temporal exposure in comparison to the MPTa (p < 0.001 and p = 0.02, respectively). No significant differences were found between the two craniotomies in the length of the exposure of the sylvian fissure, area of insular exposure, or surgical freedom. Both the MPTa and the XSEa afford sufficient grades of exposure along the sylvian fissure and the insular lobe, although the viewing angle is significantly different between the two approaches. Such properties allow either to be used for microsurgery deep within the sylvian cistern. The use of additional corridors, such as the subfrontal route (XSEa) and pretemporal route (MPTa), may influence selection of either the minipterional or the extended supraorbital approaches according to the origin of the surgical pathology addressed.
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Affiliation(s)
- Rafael Martinez-Perez
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 W 10th Ave, Columbus, OH, 43210, USA.
| | | | - Thiago Albonette-Felicio
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Douglas A Hardesty
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 W 10th Ave, Columbus, OH, 43210, USA.,Department of Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Ahmed Mohyeldin
- Department of Neurosurgery, Stanford University, Palo Alto, CA, USA
| | - Takuma Hara
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Ricardo L Carrau
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 W 10th Ave, Columbus, OH, 43210, USA.,Department of Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 W 10th Ave, Columbus, OH, 43210, USA. .,Department of Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
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22
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Martinez-Perez R, Tsimpas A, Cuevas JL, Perales I, Jimenez O, Poblete T, Rubino PA, Mura J. Microsurgical clipping of multiple cerebral aneurysms in the acute phase of aneurysmal subarachnoid hemorrhage through a minipterional approach: The Chilean experience. Clin Neurol Neurosurg 2020; 198:106243. [PMID: 32980797 DOI: 10.1016/j.clineuro.2020.106243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/16/2020] [Accepted: 09/16/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The minipterional craniotomy (MPTc) has been widely accepted as a minimally invasive alternative to the pterional approach for the treatment of certain small non-ruptured anterior circulation aneurysms. The aim of this study was to determine the effectiveness and safety of the MPTc in the context of a complex and potentially harmful scenario: acute onset of subarachnoid hemorrhage (SAH) in patients harboring multiple intracranial aneurysms (MIA). METHODS Patients harboring MIA clipped through a unilateral MPTc were selected from four retrospective databases of four high-volume neurosurgical centers. Patients with a Hunt & Hess score 4 or 5 were not considered candidates for clipping through a MPTc. Medical records and radiological images were retrospectively reviewed. Epidemiological, clinical and radiological data, as well as short-term outcome (modified Rankin scale at 6 month-follow-up) were analyzed. RESULTS 16 patients harboring 33 aneurysms (16 ruptured, 17 non ruptured) met the inclusion criteria. Each aneurysm size was 5.7 ± 2.1 mm (range 3-11). 12 out of 33 aneurysms were located in the middle cerebral artery (MCA). Anterior communicating (ACom) and MCA aneurysms were the aneurysm locations most commonly ruptured (5 each, 62 %). Complete occlusion was achieved in 32 aneurysms (97 %) and near-complete occlusion in 1 (3%). 13 patients (93 %) were independent at 6 month-follow-up. Mortality rate was 0%. Complications included 1 cerebrospinal-fluid leakage. CONCLUSION When indicated (Hunt Hess < 4), performing a MPTc is safe and effective in aSAH cases with multiple aneurysms.
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Affiliation(s)
- Rafael Martinez-Perez
- Division of Neurological Surgery, University of Colorado, Denver, CO, United States; Division of Neurosurgery, Institute of Neurosciences, Universidad Austral de Chile, Valdivia, Chile.
| | - Asterios Tsimpas
- Department of Surgery, Division of Neurosurgery, Advocate Health Masonic Illinois Center, Chicago, IL, USA
| | - Jose Luis Cuevas
- Deparment of Neurosurgery, Hospital de Puerto Montt, Puerto Montt, Chile
| | - Ivan Perales
- Department of Neurosurgery, San Pablo's Hospital Coquimbo, Coquimbo, Chile
| | - Oscar Jimenez
- Department of Neurosurgery, Universidad La Frontera, Temuco, Chile
| | - Tomas Poblete
- Department of Anatomy and Legal Medicine, Universidad de Chile, Santiago, Chile
| | | | - Jorge Mura
- Department of Skull Base and Vascular Neurosurgery, Institute of Neurosurgery Dr Asenjo, Santiago, Chile; Department of Neurosciences, Universidad de Chile, Santiago, Chile; Department of Neurosurgery, Clinica Las Condes, Santiago, Chile
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23
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Ansari SF, Eisenberg A, Rodriguez A, Barkhoudarian G, Kelly DF. The Supraorbital Eyebrow Craniotomy for Intra- and Extra-Axial Brain Tumors: A Single-Center Series and Technique Modification. Oper Neurosurg (Hagerstown) 2020; 19:667-677. [PMID: 32745195 DOI: 10.1093/ons/opaa217] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 05/03/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The supraorbital (SO) eyebrow craniotomy provides minimally invasive access to the anterior and middle fossae and parasellar region. OBJECTIVE To present a series of patients treated with the SO approach to assess outcomes, the impact of endoscopy, and describe a modified pericranial flap aimed at reducing postoperative frontalis paresis and hypesthesia. METHODS A retrospective analysis was undertaken of our prospective database of patients who underwent SO craniotomy for tumor/cyst removal. Patients were evaluated based on pathology, utility of endoscopy, extent of resection, complications, and functional/esthetic recovery. RESULTS From 2007 to 2018, 129 operations were performed in 117 patients (54% women; mean age 60 ± 16.5 yr). The most common lesions were meningiomas (43%), gliomas (15%), and metastases (15%). Prior surgery and/or radiation had been performed in 37% and 26% of patients, respectively. Endoscopy was used in 76 (61%) operations and allowed more complete tumor removal in 38 (50%). For first-time operations, gross-total removal was achieved in 78%. Major complications included stroke (3%), cranial nerve deficit (3%), acute hematoma (1%), and cerebrospinal fluid leak (1%). The modified pericranial flap technique used in 18 recent patients resulted in a shorter duration of transient frontalis paresis and forehead hypesthesia with complete functional recovery in all 18. CONCLUSION The SO craniotomy is an effective keyhole approach for intra- and extra-axial tumors. Endoscopic assistance may allow additional tumor removal in almost 30% of the cases. The modified pericranial flap appears to accelerate functional recovery, although additional patients and follow-up are required to better assess this technique.
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Affiliation(s)
- Shaheryar F Ansari
- Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, California.,John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Amy Eisenberg
- Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, California.,John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Amanda Rodriguez
- Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, California.,John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, California.,John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Daniel F Kelly
- Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, California.,John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
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24
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Park JS, Kwon MY, Lee CY. Minipterional craniotomy for surgical clipping of anterior circulation aneurysms: compatibility between the feasibility, safety and efficiency. J Cerebrovasc Endovasc Neurosurg 2020; 22:65-77. [PMID: 32665913 PMCID: PMC7329563 DOI: 10.7461/jcen.2020.22.2.65] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of this study was to assess the feasibility, safety and efficiency of minipterional craniotomy (MPT) for surgical clipping of anterior circulation aneurysms. Methods A retrospective study was conducted to compare the MPT from Jan 2015 to Dec 2018 and conventional pterional craniotomy (CPT) from Jan 2012 to Dec 2013 in unruptured intracranial aneurysms (UIA) and ruptured intracranial aneurysms (RIA). The feasibility and safety of MPT and CPT were assessed by analyzing medical records, radiologic imaging, and clinical outcomes. The efficiency of MPT and CPT were based on a survey research of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry. Results Total 628 patients who underwent 458 MPT (UIA:313, RIA:145) and 170 CPT (UIA: 106, RIA: 64) with anterior circulation aneurysms were included in this study. The baseline characteristics between MPT and CPT had no difference (p>0.05). There was no difference in the incidence of postoperative hemorrhage or ischemic lesions between MPT and CPT (p>0.05). The incidence of surgical wound infection was lower in MPT (0.4%) than CPT (3.5%) (p=0.002). More than 90% of postoperative pain disappeared faster in MPT (14.25±4.83 days) than CPT (27.59±10.35 days), and the feeling of facial asymmetry in surgical side was also lower for MPT (1.7%) than CPT (7.6%) (p<0.001). In the MPT, no patients presented with progress to chronic pain, masticatory disability, discomfort of maximal mouth opening or permanent facial palsy. Conclusions We suggest that MPT and CPT had similar clinical outcomes, and MPT showed better functional and cosmetic outcomes than CPT in terms of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry. Therefore, MPT for surgical clipping of anterior circulation aneurysms can be a compatible technique that satisfies the feasibility, safety and efficiency.
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Affiliation(s)
- Jung-Sik Park
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Min-Yong Kwon
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Chang-Young Lee
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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25
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Rychen J, Zumofen DW, Riina HA, Mariani L, Guzman R. The Transpalpebral Versus the Transciliary Variant of the Supraorbital Keyhole Approach: Anatomic Concepts for Aneurysm Surgery. Oper Neurosurg (Hagerstown) 2020; 19:E24-E31. [PMID: 31828349 DOI: 10.1093/ons/opz358] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 09/10/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The supraorbital craniotomy (SOC) is classically performed through a skin incision in the patient's eyebrow. A variant with a skin incision in the patient's eyelid has become increasingly popular in recent years. OBJECTIVE To compare the transpalpebral and the transciliary variants of the SOC with regard to their potential role in aneurysm surgery. METHODS We carried out cadaveric dissections and virtual craniotomies on computerized tomography datasets. The skin incision, the craniotomy location and size, the working angles, and the achievable exposure of neurovascular structures were assessed and compared for both variants of the SOC. RESULTS The skin incision measured 4 cm for the transpalpebral and 3 cm for the transciliary variant. The skin could be retracted 1.5 cm upward from the lower edge of the orbital rim with the transpalpebral and 2.5 cm upward with the transciliary variant. The craniotomy size was 2.5 × 1.5 cm for both variants, given that the transpalpebral variant included an orbital osteotomy. The bony opening in the transpalpebral variant was 1 cm more caudal; this restricted the craniocaudal working angles and, thereby, limited the achievable exposure of neurovascular structures in the paraclinoid area and along the sphenoid ridge. CONCLUSION If the orbital rim and the anterior aspect of the orbital roof are removed, then the transpalpebral variant of the SOC enables a bony opening that is just as large as that of the transciliary variant. Nonetheless, the more caudal location of the bony opening alters the available working angles and may impede exposure of key structures during aneurysm surgery.
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Affiliation(s)
- Jonathan Rychen
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Daniel W Zumofen
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland.,Division of Neurosurgery, Department of Surgery, Maimonides Medical Center, New York, New York
| | - Howard A Riina
- Department of Neurological Surgery, New York University School of Medicine, New York, New York
| | - Luigi Mariani
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland
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26
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Martinez-Perez R, Hardesty DA, Li R, Carrau RL, Prevedello DM. Sylvian and Insular Exposure in the Extended Minipterional Approach: Landmarks, Benefits, and Quantitative Analysis Using a Cadaveric Study. World Neurosurg 2020; 138:e859-e866. [DOI: 10.1016/j.wneu.2020.03.126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 12/13/2022]
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27
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Martínez-Pérez R, Albonette-Felicio T, Hardesty DA, Prevedello DM. Comparative anatomical analysis between the minipterional and supraorbital approaches. J Neurosurg 2020; 134:1276-1284. [DOI: 10.3171/2019.12.jns193196] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 12/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEKeyhole approaches, namely the minipterional approach (MPTa) and the supraorbital approach (SOa), are alternatives to the standard pterional approach to treat lesions located in the anterior and middle cranial fossae. Despite their increasing popularity and acceptance, the indications and limitations of these approaches require further assessment. The purpose of the present study was to determine the differences in the area of surgical exposure and surgical maneuverability provided by the MPTa and SOa.METHODSThe areas of surgical exposure afforded by the MPTa and SOa were analyzed in 12 sides of cadaver heads by using a microscope and a neuronavigation system. The area of exposure of the region of interest and surgical freedom (maneuverability) of each approach were calculated.RESULTSThe area of exposure was significantly larger in the MPTa than in the SOa (1250 ± 223 mm2 vs 939 ± 139 mm2, p = 0.002). The MPTa provided larger areas of exposure in the ipsilateral and midline compartments, whereas there was no significant difference in the area of exposure in the contralateral compartment. All targets in the anterior circulation had significantly larger areas of surgical freedom when treated via the MPTa versus the SOa.CONCLUSIONSThe MPTa provides greater surgical exposure and better maneuverability than that offered by the SOa. The SOa may be advantageous as a direct corridor for treating lesions located in the contralateral side or in the anterior cranial fossa, but the surgical exposure provided in the midline region is inferior to that exposed by the MPTa.
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Affiliation(s)
| | | | - Douglas A. Hardesty
- Departments of 1Neurosurgery and
- 2Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Daniel M. Prevedello
- Departments of 1Neurosurgery and
- 2Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
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Mao G, Gigliotti M, Aziz K, Aziz K. Transpalpebral Approach "Eyelid Incision" for Surgical Treatment of Intracerebral Aneurysms: Lessons Learned During a 10-Year Experience. Oper Neurosurg (Hagerstown) 2020; 18:309-315. [PMID: 31414139 DOI: 10.1093/ons/opz217] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 03/15/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The classic pterional, pretemporal, and orbitozygomatic approaches achieve large areas of exposure with easy maneuverability. In select cases (eg, some anterior circulation aneurysms), the minimally invasive fronto-orbital craniotomy can yield adequate exposure that must be balanced with its risk of frontalis injury. OBJECTIVE To detail a 10-yr experience using the transpalpebral approach, characterized by an incision whose camouflage is the natural eyelid crease, notably the effectiveness and outcomes of this exposure for anterior circulation aneurysms. METHODS In this retrospective review, 82 patients with 88 aneurysms underwent a supraorbital frontal minicraniotomy via the eyelid incision performed by a single neurosurgeon and closure by an oculoplastic surgeon (2007-2016). Incision of the orbiculi oculi developed a plane between the muscle and orbital septum superiorly. Outcomes recorded included aneurysm occlusion or residual, treatment modality (clipping/wrapping), postoperative hemorrhage or stroke, postoperative wound healing, and overall cosmesis. RESULTS Of 85 (97%) aneurysms treated by clipping, postoperative and follow-up imaging showed complete obliteration in 81 (95%) aneurysms and residuals in 4 (5%). Cosmetic outcomes for the eyelid incision were excellent: 81 (99%) patients noted excellent wound healing at follow-up and no scarring; 1 patient developed significant temporalis wasting and upper eyelid scarring after posterior communicating artery aneurysm clipping. Overall, 13 minor and 8 major complications affected 19 patients. CONCLUSION Our findings confirm the versatility of the eyelid supraorbital frontal minicraniotomy for common anterior circulation aneurysms. This large series found that postoperative complication risks were similar to traditional techniques and cosmetic results were excellent.
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Affiliation(s)
- Gordon Mao
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | | | - Khaled Aziz
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Khaled Aziz
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania.,Drexel University School of Medicine, Philadelphia, Pennsylvania
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29
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Figueiredo EG, Yamaki VN, Spetzler RF. Letter to the Editor Regarding "Resection of Pediatric Trigeminal Schwannoma Using Minimally Invasive Approach: Case Report, Literature Review, and Operative Video". World Neurosurg 2020; 134:682. [PMID: 32059289 DOI: 10.1016/j.wneu.2019.11.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 11/28/2022]
Affiliation(s)
| | - Vitor Nagai Yamaki
- Department of Neurosurgery, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Park HH, Yoo J, Yun IS, Hong CK. Comparative Analysis of Endoscopic Transorbital Approach and Extended Mini-Pterional Approach for Sphenoid Wing Meningiomas with Osseous Involvement: Preliminary Surgical Results. World Neurosurg 2020; 139:e1-e12. [PMID: 32001400 DOI: 10.1016/j.wneu.2020.01.115] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Sphenoid wing meningiomas (SWMs) can be treated with complete surgical resection and the recently introduced endoscopic transorbital approach (ETOA) offers a minimally invasive alternative. In this study, the surgical outcome of ETOA and the extended mini-pterional approach (eMPTA) for SWMs with osseous involvement is compared. METHODS From October 2015 to May 2019, 24 patients underwent surgery for SWMs with osseous involvement. Among them, tumor resection was performed by ETOA for 11 patients (45.8%) and eMPTA for 13 patients (54.2%). The tumor characteristics, surgical outcome and morbidity, and approach-related aesthetic outcome were analyzed and compared retrospectively between ETOA and eMPTA based on SWM classification. RESULTS The location of SWMs was mostly the middle sphenoid ridge (group III) (45.8%), followed by the greater sphenoid wing (group IV) (29.2%). Simpson resection grades I/II were achieved in 9 of 11 patients (81.8%) with ETOA and 11 of 13 patients (84.6%) with eMPTA. There were no differences in tumor characteristics between the 2 approaches. Surgery time, surgical bleeding, and hospital length of stay were significantly shorter with ETOA. Three patients had transient surgical morbidities such as diplopia (n = 1), ptosis (n = 1), and cerebrospinal fluid leak (n = 1) after ETOA. No differences could be seen in surgical morbidities between ETOA and eMPTA. CONCLUSIONS ETOA can provide direct access to the sphenoid bone and resectability with a more rapid and minimally invasive exposure than does eMPTA. Maximal subtotal resection with extensive sphenoid bone decompression for tumors with cavernous sinus infiltration is the key to a good clinical outcome, regardless of the surgical approach.
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Affiliation(s)
- Hun Ho Park
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Jihwan Yoo
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - In-Sik Yun
- Department of Plastic Surgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Chang-Ki Hong
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.
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Martinez-Perez R, Joswig H, Tsimpas A, Poblete T, Albiña P, Perales I, Mura JM. The extradural minipterional approach for the treatment of paraclinoid aneurysms: a cadaver stepwise dissection and clinical case series. Neurosurg Rev 2019; 43:361-370. [PMID: 31820141 DOI: 10.1007/s10143-019-01219-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/14/2019] [Accepted: 11/26/2019] [Indexed: 12/12/2022]
Abstract
Minipterional (MPT) craniotomy has recently been added to the neurosurgical armamentarium as a less invasive alternative to the pterional craniotomy for the treatment of parasellar lesions. However, its clinical applicability in the treatment of certain complex aneurysms, such as those arising in the paraclinoid region, remains unclear. To illustrate the microsurgical anatomy of a modified extradural MPT approach, which combines a classic MPT craniotomy with an extradural anterior clinoidectomy, and to demonstrate its clinical applicability in the treatment of complex paraclinoid aneurysms. A stepwise extradural MPT approach is illustrated in a cadaver study. Clinical outcome data from a series of 19 patients with 20 paraclinoid aneurysms treated surgically using the extradural MPT approach between 2016 and 2018 were retrospectively collected. In 95% of the cases, complete aneurysm occlusion was achieved. No aneurysm recurrences were seen during follow-up with a median length of 21 months. The outcome, according to the modified Rankin Scale, was 0 points in 12 patients (63%), 1 point in 6 patients (32%), and 2 points in 1 patient (5%). Four out of 6 patients (67%) with initial visual symptoms showed improvement following treatment, whereas in two (11%), vision became worse. The extradural MPT approach ensures a sufficiently large exposure of the paraclinoid region that is comparable with conventional approaches with the advantage of being minimally invasive. Our case series demonstrates the feasibility of this approach for the treatment of complex paraclinoid aneurysms.
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Affiliation(s)
- Rafael Martinez-Perez
- Department of Neurological Surgery, Wexner Medical Center, Ohio State University, 410 W 10th Ave, Columbus, OH, 43215, USA. .,Division of Neurosurgery, Institute of Neurosciences, Universidad Austral de Chile, Valdivia, Chile.
| | - Holger Joswig
- Department of Neurosurgery, Ernst von Bergmann Hospital, Potsdam, Germany
| | - Asterios Tsimpas
- Department of Surgery, Division of Neurosurgery, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Tomas Poblete
- Department of Skull Base and Cerebrovascular Neurosurgery. National Institute of Neurosurgery Dr Asenjo, University of Chile, Santiago, Chile
| | - Pablo Albiña
- Department of Skull Base and Cerebrovascular Neurosurgery. National Institute of Neurosurgery Dr Asenjo, University of Chile, Santiago, Chile
| | - Ivan Perales
- Department of Skull Base and Cerebrovascular Neurosurgery. National Institute of Neurosurgery Dr Asenjo, University of Chile, Santiago, Chile
| | - Jorge M Mura
- Department of Skull Base and Cerebrovascular Neurosurgery. National Institute of Neurosurgery Dr Asenjo, University of Chile, Santiago, Chile.,Department of Neurological Sciences, University of Chile, Santiago, Chile.,Department of Neurosurgery, Clínica Las Condes, Santiago, Chile
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32
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Saraceno G, Agosti E, Qiu J, Buffoli B, Ferrari M, Raffetti E, Belotti F, Ravanelli M, Mattavelli D, Schreiber A, Hirtler L, Rodella LF, Maroldi R, Nicolai P, Gentili F, Kucharczyk W, Fontanella MM, Doglietto F. Quantitative Anatomical Comparison of Anterior, Anterolateral and Lateral, Microsurgical and Endoscopic Approaches to the Middle Cranial Fossa. World Neurosurg 2019; 134:e682-e730. [PMID: 31731015 DOI: 10.1016/j.wneu.2019.10.178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 10/27/2019] [Accepted: 10/28/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To quantitatively compare different microsurgical and endoscopic approaches to the middle cranial fossa in a preclinical setting with a novel, computer-based research method. METHODS Different approaches were performed bilaterally in 5 head and neck specimens that underwent high-resolution computed tomography scans: 5 transcranial anterolateral (supraorbital, mini-pterional, pterional, pterional-transzygomatic, fronto-temporal-orbito-zygomatic) without and with anterior clinoidectomy; 2 transcranial lateral (subtemporal and subtemporal-transzygomatic); 2 endoscopic transnasal (transpterygoid, transpterygoid to infratemporal fossa); 2 endoscopic transorbital (superior eyelid and inferolateral), and endoscopic transmaxillary. A dedicated navigation system was used to quantify surgical working volumes and exposure of different areas of the middle cranial fossa (ApproachViewer, part of GTx-Eyes II, University Health Network, Toronto, Canada). Statistical analysis was performed using a mixed linear model with bootstrap resampling. RESULTS Endoscopic transnasal and fronto-temporal-orbito-zygomatic approaches with anterior clinoidectomy showed the largest surgical volumes. Endoscopic approaches allowed a wider exposure of medial anatomical surfaces (e.g., the petrous apex) compared with transcranial ones. Transcranial approaches with larger craniotomies allowed the widest exposure of superomedial anatomical structures (e.g., roof of cavernous sinus). The resection of the zygomatic arch allowed exposure of more medial surfaces with an inferior to superior trajectory. CONCLUSIONS This study implemented a novel neuronavigation-based research method to quantitatively compare different approaches to the middle cranial fossa; its results might guide, after consideration of clinical implications, the choice of the neurosurgical approach to different areas of this complex skull base region.
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Affiliation(s)
- Giorgio Saraceno
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Edoardo Agosti
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Jimmy Qiu
- TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Ferrari
- Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Elena Raffetti
- Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Francesco Belotti
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ravanelli
- Radiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Davide Mattavelli
- Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alberto Schreiber
- Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Luigi F Rodella
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Roberto Maroldi
- Radiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Fred Gentili
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Walter Kucharczyk
- Division of Neuroradiology, Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Marco M Fontanella
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Doglietto
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
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Park J. Supraorbital Keyhole Approach for Intracranial Aneurysms : Transitioning from Concerns to Confidence. J Korean Neurosurg Soc 2019; 63:4-13. [PMID: 31295975 PMCID: PMC6952737 DOI: 10.3340/jkns.2019.0042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/04/2019] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Jaechan Park
- Department of Neurosurgery and Biomedical Research Institute, School of Medicine, Kyungpook National University, Daegu, Korea
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34
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Denadai R, Raposo-Amaral CA, Buzzo CL, Ghizoni E, Cendes F, Raposo-Amaral CE. Anatomical Fat Grafting for Reconstruction of Frontotemporal Contour Deformities After Neurosurgical and Craniofacial Surgical Interventions: A Symmetry Outcome Study. World Neurosurg 2019; 127:e1064-e1082. [PMID: 30980984 DOI: 10.1016/j.wneu.2019.04.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 02/08/2023]
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Toyooka T, Wada K, Otani N, Tomiyama A, Takeuchi S, Tomura S, Nishida S, Ueno H, Nakao Y, Yamamoto T, Mori K. Potential Risks and Limited Indications of the Supraorbital Keyhole Approach for Clipping Internal Carotid Artery Aneurysms. World Neurosurg X 2019; 2:100025. [PMID: 31218296 PMCID: PMC6580886 DOI: 10.1016/j.wnsx.2019.100025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 02/15/2019] [Indexed: 11/17/2022] Open
Abstract
Background Internal carotid artery (ICA) aneurysm may be a good target for supraorbital keyhole clipping. We discuss the surgical indications and risks of keyhole clipping for ICA aneurysms based on long-term clinical and radiologic results. Methods This was a retrospective analysis of 51 patients (aged 35–75 years, mean 62 years) with ICA aneurysms (mean 5.8 ± 1.8 mm) who underwent clipping via the supraorbital keyhole approach between 2005 and 2017. Neurologic and cognitive functions were examined by several methods, including the modified Rankin Scale and Mini-Mental Status Examination. The state of clipping was assessed 1 year and then every few years after the operation. Results Complete clipping was confirmed in 45 patients (88.2%), dog-ear remnants behind the clip persisted in 4 patients, and wrapping was performed in 2 patients. Mean duration of postoperative hospitalization was 3.4 ± 6.9 days. The mean clinical follow-up period was 6.6 ± 3.2 years. The overall mortality was 0, and overall morbidity (modified Rankin Scale score ≥2 or Mini-Mental Status Examination <24) was 3.9%. Completely clipped aneurysms did not show any recurrence during the mean follow-up period of 6.3 ± 3.1 years, but the 2 (3.9%) aneurysms with neck remnants showed regrowth. Conclusions The risk of neck remnant behind the clip blade is a drawback of supraorbital keyhole clipping. The surgical indication requires preoperative simulation and careful checking of the clip blade state is essential.
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Key Words
- 3D, 3-Dimensional
- AcomA, Anterior communicating artery
- AntChoA, Anterior choroidal artery
- BDI, Beck Depression Inventory
- CT, Computed tomography
- CTA, Computed tomography angiography
- Clipping
- DSA, Digital subtraction angiography
- DWI, Diffusion-weighted imaging
- HAM-D, Hamilton Depression Scale
- HDS-R, Revised Hasegawa Dementia Scale
- ICA, Internal carotid artery
- ISUIA, International Study of Unruptured Intracranial Aneurysms
- Internal carotid artery
- Keyhole surgery
- MCA, Middle cerebral artery
- MMSE, Mini-Mental Status Examination
- MRI, Magnetic resonance imaging
- NIHSS, National Institutes of Health Stroke Scale
- PcomA, Posterior communicating artery
- UCA, Unruptured cerebral aneurysm
- Unruptured cerebral aneurysm
- mRS, Modified Rankin Scale
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Affiliation(s)
- Terushige Toyooka
- Department of Neurosurgery, Tokyo General Hospital, Tokyo, Japan.,Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Kojiro Wada
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Naoki Otani
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Arata Tomiyama
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Satoru Takeuchi
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Satoshi Tomura
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Sho Nishida
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Hideaki Ueno
- Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Shizuoka, Japan
| | - Yasuaki Nakao
- Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Shizuoka, Japan
| | - Takuji Yamamoto
- Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Shizuoka, Japan
| | - Kentaro Mori
- Department of Neurosurgery, Tokyo General Hospital, Tokyo, Japan.,Department of Neurosurgery, National Defense Medical College, Saitama, Japan
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Rychen J, Croci D, Roethlisberger M, Nossek E, Potts MB, Radovanovic I, Riina HA, Mariani L, Guzman R, Zumofen DW. Keyhole approaches for surgical treatment of intracranial aneurysms: a short review. Neurol Res 2018; 41:68-76. [PMID: 30311865 DOI: 10.1080/01616412.2018.1531202] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: To clarify the reported experience with keyhole approaches for the treatment of intracranial aneurysms. Methods: The PubMed and Embase databases were searched up to December 2017 for full-text publications that report the treatment of aneurysms with the eyebrow variant of the supraorbital craniotomy (SOC), the minipterional craniotomy, or the eyelid variant of the SOC. The anatomical distribution of aneurysms, the postoperative aneurysm occlusion rate, and the type and rate of complications were examined using univariate analysis. Results: Sixty-seven publications covering treatment of 5770 aneurysms met the eligibility criteria. The reported experience was the largest for the eyebrow variant of the SOC (69.4% of aneurysms), followed by the minipterional approach (28.2%), and the eyelid variant of the SOC (2.4%). The anterior communicating artery (ACoA) was the most frequent aneurysm location for the SOC (eyebrow variant: 33.2%; eyelid variant: 31.2%). The middle cerebral artery (MCA) was the most frequent aneurysm location in the minipterional cohort (55.2%). In the eyelid variant of the SOC cohort, the rate of complete aneurysm occlusion was the lowest (eyelid variant: 90.8%; eyebrow variant: 97.8%, p < 0.001; minipterional approach: 97.9%, p < 0.001), and the postoperative infarction rate was the highest (eyelid variant: 7.2%; eyebrow variant: 3.5%, p = 0.025; minipterional approach: 2.6%, p = 0.003). Conclusion: Each approach has a specific safety and efficacy profile. Surgeons selected the eyebrow variant of the SOC for many aneurysm locations including in particular the ACoA. There is a recent tendency however to opt for the minipterional approach above all for MCA aneurysms. Abbreviations: SOC: Supraorbital Craniotomy; MPT: Minipterional; MCA: Middle Cerebral Artery; ACoA: Anterior Communicating Artery; PCoA: Posterior Communicating Artery; aSAH: Aneurysmal Subarachnoid Hemorrhage; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; MINORS: Methodological Index For Non-Randomized Studies.
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Affiliation(s)
- Jonathan Rychen
- a Department of Neurosurgery , Basel University Hospital, University of Basel , Basel , Switzerland.,b Department of Neurosurgery , Bern University Hospital, University of Bern , Bern , Switzerland
| | - Davide Croci
- a Department of Neurosurgery , Basel University Hospital, University of Basel , Basel , Switzerland
| | - Michel Roethlisberger
- a Department of Neurosurgery , Basel University Hospital, University of Basel , Basel , Switzerland
| | - Erez Nossek
- c Division of Neurosurgery, Department of Surgery , Maimonides Medical Center , Brooklyn , NY , USA.,d Department of Neurosurgery , Donald and Barbara Zucker School of Medicine at Hofstra/Northwell , New York , NY , USA
| | - Matthew B Potts
- e Department of Neurosurgery , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Ivan Radovanovic
- f Division of Neurosurgery, Toronto Western Hospital, University Health Network and Department of Surgery , University of Toronto , Toronto , ON , Canada
| | - Howard A Riina
- g Department of Neurosurgery , New York University School of Medicine , New York , NY , USA
| | - Luigi Mariani
- a Department of Neurosurgery , Basel University Hospital, University of Basel , Basel , Switzerland
| | - Raphael Guzman
- a Department of Neurosurgery , Basel University Hospital, University of Basel , Basel , Switzerland
| | - Daniel W Zumofen
- a Department of Neurosurgery , Basel University Hospital, University of Basel , Basel , Switzerland.,h Division of Diagnostic and Interventional Neuroradiology, Department of Radiology , Basel University Hospital, University of Basel , Basel , Switzerland
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