Transblepharo-Preseptal Modified Orbitozygomatic Craniotomy for Treatment of Ruptured Aneurysm: 3-Dimensional Operative Video

Mini Fronto-Orbital Approach: "Window Opening" Towards the Superomedial Orbit - A Virtual Reality-Planned Anatomic Study

BACKGROUND

Surgical approaches to the orbit are challenging and require combined multispecialist skills. Considering its increasing relevance in neurosurgical practice, keyhole surgery could be also applied to this field. However, mastering a minimally invasive approach necessitates an extended learning curve. For this reason, virtual reality (VR) can be effectively used for planning and training in this demanding surgical technique.

OBJECTIVE

To validate the mini fronto-orbital (mFO) approach to the superomedial orbit, using VR planning and specimen dissections, conjugating the principles of skull base and keyhole neurosurgery.

METHODS

Three-dimensional measurements were performed thanks to Surgical Theater (Surgical Theater© LLC), and then, simulated craniotomies were implemented on cadaver specimens.

RESULTS

The mFO approach affords optimal exposure and operability in the target area and reduced risks of surrounding normal tissue injuries. The eyebrow skin incision, the minimal soft-tissue retraction, the limited temporalis muscle dissection and the single-piece craniotomy, as planned with VR, are the key elements of this minimally invasive approach. Furthermore, the "window-opening" cotton-tip intraorbital dissection technique, based on widening surgical corridors between neuromuscular bundles, provides a safe orientation and a deep access inside the orbit, thereby significantly limiting the risk of jeopardizing neurovascular structures.

CONCLUSION

The mFO approach associated to the window-opening dissection technique can be considered safe, effective, suitable, and convenient for treating lesions located in the superomedial orbital aspect, up to the orbital apex.

The Transpalpebral Versus the Transciliary Variant of the Supraorbital Keyhole Approach: Anatomic Concepts for Aneurysm Surgery

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.

Surgical Versus Endovascular Management of Ruptured and Unruptured Intracranial Aneurysms: Emergent Issues and Future Directions

Ideal management of unruptured intracranial aneurysms (UIAs) and ruptured intracranial aneurysms (RIAs) is a controversial issue. Over the last few decades, a significant paradigm shift has occurred away from open microsurgical clipping toward endovascular coil embolization. Multiple studies have been performed with mixed results. Some studies suggest that endovascular treatment produces better clinical and functional outcomes, but is associated with increased need for retreatment. Other studies report increased durability in aneurysms treated with microsurgical clipping, but that clipping may be associated with worse functional outcomes in some cases. Further complicating the dialogue are variable costs associated with different treatment modalities, including country-dependent cost differences. Here we provide a review of some of the major studies comparing open surgery versus endovascular treatment for both RIAs and UIAs to distill their key findings and corresponding implications for clinical practice. We relate these research results to our institution's experience with RIAs and UIAs and describe our approach to treatment of these conditions. Finally, we discuss implications of the paradigm shift for both open and endovascular surgery, including educational initiatives directed toward preserving important microsurgical tenets in the setting of diminishing surgical volume.