The Supraorbital Keyhole Craniotomy through an Eyebrow Incision: Its Origins and Evolution

Anomalous branching of the middle meningeal artery from the basilar artery: a systematic review

Background

Anomalous origin of the middle meningeal artery (MMA) from the basilar artery is a rare congenital neurological variant that has been detected in both children and adults with diagnoses ranging from intracranial haemorrhage to ependymoma. This review aims to investigate the anatomical course of an anomalous basilar-middle meningeal artery and its clinical presentation.

Methods

A systematic search was performed in PubMed using the keywords (middle meningeal artery) and (basilar artery). Ninety-four papers were identified, of which seven were included. One paper was further identified through cross-referencing.

Results

The average age of presentation was 43 years with a male predominance (7/9). In most cases, the MMA arose between the superior cerebellar artery and the anterior inferior cerebellar artery (8/9) (versus 1 case between the anterior inferior cerebellar artery and the posterior inferior cerebellar artery). The anomaly mostly presented on the left side (6/11), but was bilateral in one case. Most of the cases showed a pontine artery branching from the basilar artery arising 5 mm to 10 mm proximal to the superior cerebellar artery, which would then assume the trajectory of the MMA. In three cases, the vessel increased in calibre near the trigeminal ganglion. Foramen spinosum absence in the anomalous side was noted in 3/6 of the patients.

Conclusion

To avoid unexpected complications during neurosurgical and neuroradiointerventional procedures, it is essential to have a clear understanding of the anomalous routes of the MMA. This is especially important when it proves to be the only available route for embolization.

'What's in a name', a systematic review of the pterional craniotomy for aneurysm surgery and its many modifications with a proposal for simplified nomenclature

BACKGROUND

The pterional or frontosphenotemporal craniotomy has stood the test of time and continues to be a commonly used method of managing a variety of neurosurgical pathology. Already described in the beginning of the twentieth century and perfected by Yasargil in the 1970s, it has seen many modifications. These modifications have been a normal evolution for most neurosurgeons, tailoring the craniotomy to the patients' specific anatomy and pathology. Nonetheless, an abundance of variations have appeared in the literature.

METHODS

A search strategy was devised according to the 2020 Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) statement. To identify articles investigating the variations in the pterional approach, the following search terms were applied: (pterional OR minipterional OR supraorbital) AND (approach OR craniotomy OR technique).

RESULTS

In total, 3552 articles were screened with 74 articles being read in full with 47 articles being included for review. Each article was examined according the name of the technique, temporalis dissection technique, craniotomy technique and approach.

CONCLUSION

This systematic review gives an overview of the different techniques and modifications to the pterional craniotomy since it was initially described. We advocate for the use of a more standardised nomenclature that focuses on the target zone to simplify the management approach to supratentorial aneurysms.

Novel use of an image-guided supraorbital craniotomy via an eyebrow approach for the repair of a delayed traumatic orbital encephalocele: illustrative cases

BACKGROUND

Traumatic orbital encephaloceles are rare but severe complications of orbital fractures. These encephaloceles can present months to years after the initial injury.

OBSERVATIONS

The authors present two cases of traumatic orbital encephalocele in young males struck by motor vehicles.

LESSONS

The exact traumatic mechanism of these encephaloceles is unknown, and diagnosis can be confounded by concomitant injuries. The use of a minimally invasive supraorbital keyhole craniotomy has the potential to change how this disease process is managed and has not been previously documented in this setting.

Microsurgical and endoscopic-assisted supraorbital keyhole approach for intra-suprasellar cysticercosis

Background

Treatment for intra/suprasellar cysticercosis can be challenging and may result in visual disturbances if not managed properly. Despite its limited knowledge, an effective surgical option exists to treat this condition. This article presents three cases of sellar cysticercosis, comprising one female and two male patients, managed with microsurgical supraorbital keyhole approach (mSKA) and endoscopic-assisted supraorbital keyhole approach (eaSKA).

Case Description

The first patient is a 35-year-old man with no prior medical history who suffered from memory deficits and visual disturbances due to a sellar cyst pushing the orbitofrontal gyrus treated with mSKA. The second case involved a 52-year-old man who experienced visual deficits caused by a rostral sellar cyst with posterior displacement of the pituitary gland treated with eaSKA. The third case was a 46-year-old woman who experienced decreased visual acuity and memory loss due to multifocal neurocysticercosis (NCC) with sellarsuprasellar cyst extension treated with mSKA. All case diagnoses were confirmed by neuropathology department.

Conclusion

The authors confidently suggest that the SKA is an effective surgical option and could be considered for removing sellar cystic lesions with suprasellar extension. With endoscopic assistance, it improves adequate neurovascular structure visualization.

Surgical treatment of traumatic frontal hematoma: comparison of the endoscopic supraorbital approach with frontotemporal approach

Background

The objective of this study was to compare the efficacy, safety, and outcomes of the endoscopic supraorbital approach and frontotemporal approach for the treatment of traumatic frontal hematoma, with the aim of demonstrating the feasibility of the endoscopic supraorbital approach.

Methods

A total of 24 cases underwent hematoma evacuation, including 10 cases using the endoscopic supraorbital approach and 14 cases using the frontotemporal approach. Baseline demographic data, hematoma clearance rate, blood loss, postoperative complications, and 6-month outcomes were retrospectively analyzed.

Results

Both approaches effectively evacuated the hematoma, with hematoma clearance rates of 90.97 ± 10.23% in the endoscopic supraorbital group and 85.29 ± 16.15% in the frontotemporal approach group (p > 0.05). The supraorbital approach group demonstrated significantly shorter operation times compared to the frontotemporal approach group (116.50 ± 28.19 min vs. 193.29 ± 72.55 min, p < 0.05), as well as significantly less blood loss (55.00 ± 33.08 mL vs. 685.71 ± 840.20 mL, p < 0.05). There was no significant difference in the rate of postoperative complications between the two groups, and the majority of patients achieved favorable outcomes with a Glasgow Outcome Scale score of 4 or 5 in both groups.

Conclusion

Compared to the frontotemporal approach, the endoscopic supraorbital approach offers advantages such as shorter operation times, reduced blood loss, similar treatment effects, and comparable complication rates. Therefore, the endoscopic supraorbital approach may serve as a viable alternative for the treatment of traumatic frontal hematoma.

Experience and Balance: Long-Term Trends in Preferred Skull Base Approach for a Case Series of Cavernous Malformation Resections

BACKGROUND

Skull base approaches are a foundation of modern cerebrovascular surgery; however, their application over time has varied.

OBJECTIVE

To assess trends in skull base approach selection for cavernous malformation (CM) resection.

METHODS

This is a retrospective case series of all first-time CM resections by a single surgeon from 1997 to 2021. Cases were classified by craniotomy and approach. Four sets of common comparator skull base approaches were identified by coauthor consensus: pterional and orbitozygomatic; retrosigmoid, extended retrosigmoid (xRS), and far-lateral; suboccipital and torcular; and trans-cerebellar peduncle (MCP) and transcerebellopontine angle. Counts were binned by 5-year or 10-year clusters for descriptive statistical assessment of temporal trends.

RESULTS

In total, 372 primary CM resections met the study criteria and were included. Orbitozygomatic approach use increased during the second 5-year period, after which the pterional approach rapidly became and remained the preferred approach. During the first two 5-year periods, the far-lateral approach was preferred to the retrosigmoid and xRS approaches, but the xRS approach grew in popularity and accounted for >50% of operations in this comparator group. Trans-MCP use compared with the transcerebellopontine angle approach closely mirrored the change in xRS use. The midline suboccipital approach accounted for a larger proportion (range, 62%-88%) of cases than the torcular approach (range, 12%-38%) across all periods.

CONCLUSION

The xRS and trans-MCP approaches have been increasingly used over time, while the orbitozygomatic and far-lateral approaches have become less common. These trends seem to reflect versatility, efficiency, and safety of these techniques.

Minimally invasive craniotomies for lesions of the anterior and middle fossa

Minimally invasive craniotomies are the subject of increasing attention over the last two decades in neurosurgery, following the current trend of attempting to increase patient safety by providing surgeries with less tissue disruption, blood loss, and decreased operative time. However, a significant information overlap exists among the various keyhole approaches regarding their indications and differences with more invasive techniques. Therefore, the present study aims to comprehensively review, illustrate, and describe the potential benefits and disadvantages of minimally invasive techniques to access the anterior and middle fossa, including the mini-pterional, mini orbito-zygomatic, supraorbital, lateral supraorbital, and extended lateral supraorbital approaches while comparing them to classic, more invasive approaches.

Supraorbital Keyhole Craniotomy via Eyebrow Incision: A Systematic Review and Meta-Analysis

BACKGROUND

Supraorbital eyebrow keyhole craniotomy is a minimally invasive alternative to a frontotemporal craniotomy and is often used for tumor resection and aneurysm clipping. The purpose of this study is to provide a contemporary review on the outcomes related to this approach and to determine whether they vary with the type of pathology and the addition of an endoscope.

METHODS

PubMed, Embase, and Scopus databases were systematically searched, and results were reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. For the meta-analysis portion, the DerSimonian-Laird random effects model was used.

RESULTS

A total of 2629 manuscripts were identified. of those, 124 studies (8241 surgical cases) met the inclusion criteria. Mean total complication rate was 26.7 ± 25.7% and the mean approach-related mortality rate was 1.3 ± 2.8%. Technical success, defined as gross total tumor resection or complete aneurysm clipping, was achieved in 83.6 ± 21.5% of the cases. Vascular pathologies were associated with greater technical success, lower total complications, and longer length of hospital stay compared with tumor cases (P < 0.05 for all). For vascular cases, addition of the endoscope yielded lower technical success (P = 0.001) and lower complication rate (P = 0.041). The use of the endoscope for tumor pathologies did not affect technical success, complications, mortality, length of hospital stay, operative time, or reoperation rate (P > 0.05).

CONCLUSIONS

The supraorbital craniotomy via an eyebrow incision is a feasible minimally invasive approach with an overall high technical success rate for both vascular and tumor pathologies.

Anatomical Predictors of Transcranial Surgical Access to the Suprasellar Space

Objective  The suprasellar space is a common location for intracranial lesions. The position of the optic chiasm (prefixed vs. postfixed) results in variable sizes of operative corridors and is thus important to identify when choosing a surgical approach to this region. In this study, we aim to identify relationships between suprasellar anatomy and external cranial metrics to guide in preoperative planning. Methods  T2-weighted magnetic resonance images (MRIs) from 50 patients (25 males and 25 females) were analyzed. Various intracranial and extracranial metrics were measured. Statistical analysis was performed to determine any associations between metrics. Results  Interoptic space (IOS) size correlated with interpupillary distance (IPD; a  = 7.3, 95% confidence interval [CI] = 4.5-10.0, R ²  = 0.3708, p  = 0.0009). IOS size also correlated with fixation of the optic chiasm, for prefixed chiasms ( n  = 7), the mean IOS is 205.14 mm ² , for normal chiasm position ( n  = 33) the mean IOS is 216.94 mm ² and for postfixed chiasms ( n  = 10) the mean IOS is 236.20 mm ² ( p  = 0.002). IPD correlates with optic nerve distance (OND; p  = 0.1534). Cranial index does not predict OND, IPD, or IOS. Conclusion  This study provides insight into relationships between intracranial structures and extracranial metrics. This is the first study to describe a statistically significant correlation between IPD and IOS. Surgical approach can be guided in part by the size of the IOS and its correlates. Particularly small intraoptic space may guide the surgeon away from a subfrontal approach.

The evolution of intracranial aneurysm treatment techniques and future directions

Treatment techniques and management guidelines for intracranial aneurysms (IAs) have been continually developing and this rapid development has altered treatment decision-making for clinicians. IAs are treated in one of two ways: surgical treatments such as microsurgical clipping with or without bypass techniques, and endovascular methods such as coiling, balloon- or stent-assisted coiling, or intravascular flow diversion and intrasaccular flow disruption. In certain cases, a single approach may be inadequate in completely resolving the IA and successful treatment requires a combination of microsurgical and endovascular techniques, such as in complex aneurysms. The treatment option should be considered based on factors such as age; past medical history; comorbidities; patient preference; aneurysm characteristics such as location, morphology, and size; and finally the operator’s experience. The purpose of this review is to provide practicing neurosurgeons with a summary of the techniques available, and to aid decision-making by highlighting ideal or less ideal cases for a given technique. Next, we illustrate the evolution of techniques to overcome the shortfalls of preceding techniques. At the outset, we emphasize that this decision-making process is dynamic and will be directed by current best scientific evidence, and future technological advances.

Comparative study between minimally invasive supraorbital craniotomy and pterional craniotomy for treating anterior circulation cerebral aneurysms in a low-resource setting

The challenges encountered in performing minimally invasive approaches, such as supraorbital minicraniotomy (SOMC), in services without adequate equipment are rarely reported in the literature. This study analyzes the viability of SOMC in the treatment of cerebral aneurysms, using exactly the same resources as pterional craniotomy (PC). The results of these two techniques are compared. 35 patients underwent SOMC, compared to 50 patients underwent CP (100 aneurysms in total), using the same microsurgical instruments. The following variables were compared: operative time, angiographic cure, length of intensive care unit stay during the post-operative period, surgical complications, length of hospital stay after surgery until hospital discharge, intraoperative aneurysm rupture, aesthetic satisfaction with the scar, and neurological status at discharge. SOMC had a significantly shorter operative time in relation to PC (213.9 ± 11.09 min and 268.6 ± 15.44 min, respectively) (p = 0.0081).With respect to the cosmetic parameters assessed by the Visual Analog Scale, the average for SOMC was 94.12 ± 1.92 points, and the average for PC was 83.57 ± 4.75 points (p = 0.036). SOMC was as effective as PC in relation to successful aneurysm clipping (p = 0.77). The SOMC technique did not show advantages over PC in any other variable. Even in a general neurosurgery service lacking a specific structure for minimally invasive surgeries, SOMC was feasible and effective for treating intracranial aneurysms, using the same set of microsurgical instruments used for PC, obtaining better results in operating time and cosmetic satisfaction.

The Keyhole Approach in Anterior Circulation Aneurysm - Current Indication and Limitation with Review of Literature

Introduction:

The keyhole approach has been an emerging technique for cerebral aneurysm surgery in the past two decades. The preoperative simulation and tailored-made approach for each patient make feasible to clip many cerebral aneurysms via keyhole approach. In our study, we reviewed the previous experiences of the keyhole approach, related specifically for anterior circulation aneurysm.

Material and Methods:

The comprehensive literature review was performed on PubMed, Google Scholar, ScienceDirect, and various neurosurgery and neurology journals. Then, each manuscript's reference list was reviewed for the potential relevant article. The data of total 17 articles, which met our inclusion criteria included for the final review.

Results:

It was found that the anterior communicating artery, middle cerebral artery, and internal carotid- posterior communicating aneurysms were the most common locations treated by keyhole approach. The size of an aneurysm was <10 mm in most of the studies. Many studies treated multiple aneurysms by single keyhole approach.

Conclusion:

The keyhole approach has shown benefit in term of satisfactory aneurysmal occlusion rate, short operative time, less blood loss, short hospital stay, and good overall surgical outcome.

Comparison of Minimally Invasive and Pterional Craniotomies for Ruptured Anterior Circulation Aneurysms: A Propensity Score Matched Analysis

BACKGROUND

Minimally invasive craniotomy (MIC) for ruptured aneurysm remains a debatable issue because of unclear information regarding its safety and efficacy compared with standard approaches. Here, we compared the outcomes between MIC and pterional craniotomy (PTC) for the treatment of ruptured anterior circulation aneurysms.

METHODS

A database of patients with ruptured anterior circulation aneurysm who were treated with surgical clipping was reviewed. With the use of propensity score matching to balance the baseline characteristics of MIC and PTC groups, outcomes of the 2 groups were compared. Clinical predictors of favorable outcomes (modified Rankin scale score 0-2) were evaluated by using uni- and multivariate analyses.

RESULTS

A total of 102 matched pairs were identified. MIC resulted in a significantly shorter operative time (2.8 ± 0.9 vs. 4.2 ± 0.7 hours; P = 0.004) and hospital stay (14.2 ± 5.9 vs. 19.2 ± 9.1 days; P < 0.001), respectively. Both MIC and PTC had similar mortality and complication rates except for the incidences of intracranial hemorrhage (2% vs. 9.8%; P = 0.039) and brain injury (9.8% vs. 27.5%; P = 0.036), respectively. Use of MIC instead of standard surgery and lower World Federation of Neurosurgical Societies (WFNS) grade and absence of hydrocephalus were significant predictors of favorable outcome at 1 month, whereas higher WFNS grade and higher Fisher grade were significantly associated with a poor outcome at 6 months.

CONCLUSIONS

For the treatment of ruptured anterior circulation aneurysms, MIC was comparable with PTC and presented additional advantage in terms of earlier recovery. Therefore, MIC can be considered an alternative surgical treatment in this setting.

[A comparative study of the efficacy and safety of the eyebrow supraorbital approach in cerebral aneurysm surgery]

OBJECTIVE

The study objective was to compare the efficacy and safety of supraorbital eyebrow (SEA) and pterional (PA) approaches in surgery of anterior circle of Willis (ACW) aneurysms and to determine the advantages and disadvantages of SEA in aneurysm clipping.

MATERIAL AND METHODS

The analysis included 166 patients with ACW aneurysms aged 18 to 70 years who were treated in the Neurosurgery Department of the Interregional Clinical Diagnostic Center (Kazan) in the period from 2013 to 2016. At the first stage of the study, factors affecting surgical outcomes were compared (by using the Glasgow outcome scale (GOS)) in subpopulations of patients operated on using SEA (n=49) and PA (n=117). At the second stage, we compared the efficacy and safety of approaches using a case-control subanalysis in appropriate subgroups of the SEA (n=37) and PA (n=37) groups. The subgroups were comparable in the following factors: gender, age, severity of subarachnoid hemorrhage (SAH) on (Fisher scale), severity of the patient's condition (Hunt-Hess scale), size and location of the aneurysm, surgery duration, intraoperative aneurysm rupture (IOAR), amount of blood loss, rate of frontal sinus surgery, rate of nasal CSF leak, rate of intraoperative and postoperative complications, hemorrhagic and ischemic complications according to postoperative CT, patient's satisfaction with the cosmetic result of surgery (visual analogue scale - VAS), and treatment outcomes (GOS). Treatment outcomes (GOS) and patient's satisfaction with the cosmetic result of surgery (VAS) were considered as the efficacy parameters. The safety parameters included the amount of blood loss, rate of frontal sinus surgery, rate of nasal CSF leak, and rate of intraoperative and postoperative (hemorrhagic and ischemic) complications.

RESULTS

At the first stage of the study, we found that the amount of intraoperative blood loss in the subpopulation of patients with ACW aneurysms who were operated on using SEA was statistically significantly less than that in the PA group (p=0.0000002). In the postoperative period, patients who underwent surgery using SEA less frequently experienced neurological deficit (p=0.003), less frequently developed first epileptic seizures (p=0.035), and had a lower rate of hemorrhagic complications (p=0.003) and better treatment outcomes (GOS) (p=0.01). Comparison of appropriate subgroups in the SEA and PA groups, which were selected according to the case-control methodology and were comparable in the main factors affecting treatment outcomes, confirmed statistically significantly lower blood loss for SEA (p=0.0000002) than for PA. Compared to the SEA group, the PA group was characterized by more frequent, but not statistically significantly different, IOAR (p=1), postoperative worsening of neurological deficit (p=0.115), newly developed epileptic seizures (p=0.493), and hemorrhagic complications (p=0.0557). There were no deaths in both groups. In the SEA group, the treatment outcome was scored 4 and 5 (GOS, favorable outcome); in the PA group, the treatment outcome was scored 3 (GOS) in 2 (5.4%) patients and 4 or 5 in 35 (94.6%) patients (p=0.063). The mean subjective score of satisfaction with the treatment result (VAS) in the SEA group was significantly higher (9.4±1) than in the PA group (8.8±1; p=0.01).

CONCLUSION

SEA is an adequate approach for clipping ACW aneurysms, in particular ACA-AComA and MCA aneurysms, which is as effective and safe as the pterional approach.

Tumors of the Orbit: Case Report and Review of Surgical Corridors and Current Options

Tumors that involve the orbit can be classified into two major groups: primary tumors of the orbit and tumors that extend into the orbit from other sites. The most frequent primary orbital lesions in adults include cavernous hemangiomas, lymphoid tumors, and meningiomas. The most common tumors that extend into the orbit are meningiomas, followed by sinonasal carcinomas. In this article, we report a case of intraconal orbital lesion operated at our center and a review of the surgical approaches to the orbit.

Supraorbital Craniotomy for Large Anterior Skull Base Meningiomas: A Technical Note

Background:

Supraorbital craniotomy (SOC) has brought a paradigm shift in approaching anterior skull base lesions. With better understanding of relevant anatomy, the indications are being stretched from highly selected, small-to-moderate-sized tumors to large and complex anterior skull base lesions.

Objective:

We share our experience and discuss the nuances of surgery for large anterior skull base meningiomas using the SOC.

Methods:

This is a single institute study using prospectively collected retrospective data from seven cases of large anterior skull base meningiomas (>3 cm) using the SOC. We reviewed the indications, safety, and procedural complications in these cases.

Results:

Simpson's Grade 2 excision was achieved in all these seven cases, with faster postoperative recovery. Follow-up clinical outcome and cosmesis were satisfactory.

Conclusion:

SOC is a safe alternative for the standard skull base approaches in treating large anterior skull base meningiomas. The SOC can be effectively used to treat selected large anterior skull base meningiomas.

Supraorbital keyhole versus pterional craniotomies for ruptured anterior communicating artery aneurysms: a propensity score-matched analysis

The safety and efficacy of the supraorbital keyhole approach for aneurysm surgery have not been well researched through a high-quality controlled study. The objective of the study was to compare the safety and efficacy of the supraorbital and pterional approaches for ruptured anterior communicating aneurysm (AComAn). A total of 140 patients, with 70 patients in each group, were enrolled after 1:1 propensity score matching. Clinical variables, postoperative complications, and long-term outcomes were retrospectively compared. Baseline characteristics were equivalent between the two groups. Significantly shorter operative time and less intraoperative blood loss were observed in the supraorbital group compared to the pterional group (141.9 min vs. 184.5 min, P < 0.001; 160.4 ml vs. 250.7 ml, P = 0.008). The incidence of intraoperative aneurysm rupture was similar between the groups (20% vs. 18.6%, P = 0.830). The rate of procedural complications involving subdural hematoma and intracranial infection was lower in patients treated through the supraorbital (10.0%) vs. the pterional approach (32.9%, P < 0.001), but no significant difference was observed for the incidence of ischemic events (15.7% vs. 18.6%, P = 0.654). Within a median 33.4-month (range, 11-67 months) follow-up, a similar proportion of patients achieved a favorable outcome (Glasgow Outcome Scale IV or V) across the two groups (83.6% vs. 80.0%, P = 0.285), while better cosmetic results were observed in the supraorbital group (94.0%) vs. the pterional group (86.2%, P = 0.129). According to our results, we recommend the keyhole approach for AComAn surgery for neurosurgeons who have gained sufficient experience with this technique due to its advantages over the pterional approach.

[The use of platelet gel for repair of a cerebrospinal fluid fistula of the skull base (a case report and literature review)]

Nasal liquorrhea is a serious problem in surgery of skull base tumors, which is associated with a high risk of purulent-septic complications. This paper presents a case of successful repair of a cerebrospinal fluid fistula with an autologous platelet gel in the postoperative period after removal of meningioma of the anterior cranial fossa base, which was accompanied by a purulent-inflammatory complication in the surgical wound area.

[The trans-eyebrow supraorbital approach for removal of anterior cranial fossa and suprasellar meningiomas]

Over the past two decades, improvements in surgical tools, navigation systems, and endoscopic techniques have resulted in the widespread use of keyhole surgery for a wide range of skull base tumors. Currently, the trans-eyebrow supraorbital approach is being increasingly used in surgery for anterior cranial fossa and parasellar tumors.

MATERIAL AND METHODS

The study included 7 patients who underwent surgery for meningioma using the trans-eyebrow supraorbital approach at the Burdenko Neurosurgical Institute in the period between 2013 and 2017. The age of patients ranged from 51 to 75 years (median, 60 years); there were 5 females and 2 males. The maximum diameter of resected tumors ranged from 20 to 60 mm (median 40 mm).

RESULTS

Total resection of the tumor was achieved in all 7 cases, which was confirmed by postoperative MRI control. All 7 patients had a good cosmetic result. In 1 case, there was postoperative cerebrospinal fluid rhinorrhea due to incomplete closure of the frontal sinus, which required the patient to be re-operated. None of 7 cases was associated with injury to the main vessels or cavernous sinus.

CONCLUSION

Supraorbital trans-eyebrow craniotomy provides a minimally invasive approach for removing most anterior cranial fossa base and suprasellar tumors. The advantages of keyhole surgery, in comparison with traditional craniotomies, are minimal complications associated with the approach.

[A supraorbital trans-eyebrow approach in surgery of chiasmatic-sellar and anterior cranial fossa tumors]

OBJECTIVE

to analyze 31 resections of chiasmatic-sellar region (CSR) and anterior cranial fossa (ACF) tumors using the supraorbital trans-eyebrow approach (STA).

MATERIAL AND METHODS

We analyzed medical histories of 31 patients who underwent tumor resection using STA in the period between October 2013 and April 2017. We analyzed the age and gender of patients, size and location of the tumor, presence of a neurological deficit, vision and olfactory functions before and after surgery, surgery duration, amount of intraoperative blood loss, rate of frontal sinus trephination and nasal liquorrhea, hemorrhagic and ischemic complications after surgery, Simpson grade of tumor resection, patient's condition before and after surgery (Glasgow Outcome Scale and Karnofsky Scale), and degree of patient satisfaction with the cosmetic result of surgery. A total of 26 meningiomas (20 sphenoid plate, tubercle, and diaphragm tumors, 3 lesser sphenoid wing meningiomas, 2 orbital roof tumors, and 1 anterior clinoid process meningioma), 3 frontal lobe gliomas, and 2 pituitary adenomas were resected.

RESULTS

In all 31 operations, the approach was adequate and enabled tumor resection without lethal outcomes. The mean surgery duration was 174.6±64.4 min. The mean blood loss was 190±96.6 mL (50-380 mL). After surgery, none of the patients developed motor deficits and new epileptic seizures. Neurological deficit aggravation in the form of impaired vision and mental disorders occurred in 8 (25.8%) patients. Vision impaired in 4 (12.9%) patients, improved in 6 (19.3%) patients, and remained unchanged in 21 (67.7%) patients. An endocrinological deficit in the form of partial hypopituitarism developed in 3 (9.6%) patients; in 4 (12.9%) patients, there were mental disorders that regressed by the end of the first month of therapy. There were no intracerebral and subarachnoid hemorrhages. In 2 (6.4%) patients, small epidural hematomas were diagnosed, which did not require surgical treatment. There were only good outcomes (a GOS score of 4 or 5). After surgery, the median Karnofsky index in the STA group was 90±7. In all 31 (100%) patients, the postoperative wound healed by primary intention, without infectious complications and wound liquorrhea. One (4%) patient developed eyebrow palsy; 3 (12%) patients had hypoesthesia in the supraorbital region. The mean VAS score of patient satisfaction with the cosmetic result was 9.36 (median 10±1). The mean follow-up period was 16.2±13.5 months (2-38 months).

CONCLUSION

The STA is adequate for removal of CSR and ACF tumors under proper selection of patients. It provides an adequate view of anatomical structures and enables successful tumor resection through a less traumatic access.

Modified Supraorbital Keyhole Approach to Anterior Circulation Aneurysms

Objective

To select a surgical approach for aneurysm clipping by comparing 2 approaches.

Materials and Methods

204 patients diagnosed with subarachnoid hemorrhage treated by the same neurosurgeon at a single institution from November 2011 to October 2013, 109 underwent surgical clipping. Among these, 40 patients with Hunt and Hess or Fisher grades 2 or lower were selected. Patients were assigned to Group 1 (supraorbital keyhole approach) or Group 2 (modified supraorbital approach). The prognosis according to the difference between the two surgical approaches was retrospectively compared.

Results

Supraorbital keyhole approach (Group 1) was performed in 20 aneurysms (50%) and modified supraorbital approach (Group 2) was used in 20 aneurysms. Baseline characteristics of patients did not differ significantly between two groups. Total operative time (p = 0.226), early ambulation time (p = 0.755), length of hospital stay (p = 0.784), Glasgow Coma Scale at discharge (p = 0.325), and Glasgow Outcome Scale scores (p = 0.427) did not show statistically significant differences. The amount of intraoperative hemorrhage was significantly lower in the supraorbital keyhole approach (p < 0.05).

Conclusion

The present series demonstrates the safety and feasibility of the two minimal invasive surgical techniques for clipping the intracranial aneurysms. The modified supraorbital keyhole approach was associated with more hemorrhage than the previous supraorbital keyhole approach, but did not exhibit differences in clinical results, and provided a better surgical view and convenience for surgeons in patients with Hunt and Hess or Fisher grades 2 or lower.

Interfascial Dissection for Protection of the Nerve Branches to the Frontalis Muscles during Supraorbital Trans-Eyebrow Approach: An Anatomical Study and Technical Note

Introduction Preservation of the temporal branches of the facial nerve during anterolateral craniotomies is important. Damaging it can inflict undesirable cosmetic defects to the patient. The supraorbital trans-eyebrow approach (SOTE) is a versatile keyhole craniotomy but still has a high rate of frontalis muscle (FM) palsy. Objective Anatomical study to implement the interfascial dissection during the SOTE to preserve the nerves to the FM. Methods Slight modification of the standard technique of the SOTE was performed in 6 cadaveric specimens (12 sides). Results Distal rami to the FM were exposed. The standard "u-shape" incision of the FM can cross over the nerves. Alternatively, an "l-shape" incision was performed until the superior temporal line (STL). An interfascial dissection was performed near to the STL and the interfascial fat pad was used as a protective layer for the nerves. Conclusion Various pathologies can be addressed with the SOTE. In the majority of the cases the cosmetic results are good, but FM palsy remains a drawback of this approach. The interfascial dissection may be used in an attempt to prevent frontalis rami palsy.

Review of the management of pneumocephalus

Background:

Pneumocephalus (PNC) is the presence of air in the intracranial cavity. The most frequent cause is trauma, but there are many other etiological factors, such as surgical procedures. PNC with compression of frontal lobes and the widening of the interhemispheric space between the tips of the frontal lobes is a characteristic radiological finding of the “Mount Fuji sign.” In addition to presenting our own case, we reviewed the most relevant clinical features, diagnostic methods, and conservative management for this condition.

Case Description:

A 74-year-old male was diagnosed with meningioma of olfactory groove several years ago. After no improvement, surgery of the left frontal craniotomy keyhole type was conducted. A computed tomography (CT) scan of the skull performed 24 h later showed a neuroimaging that it is described as the silhouette of Mount Fuji. The treatment was conservative and used continuous oxygen for 5 days. Control CT scan demonstrated reduction of the intracranial air with normal brain parenchyma.

Conclusion:

The review of the literature, we did not find any cases of tension pneumocephalus documented previously through a supraorbital keyhole approach. There are a few cases reported of patients with Mount Fuji signs that do not require surgical procedures. The conservative treatment in our report leads to clinical and radiological improvement as well as a reduction in hospitalization time.