The Supraorbital Approach: An Alternative to Traditional Exposure for the Surgical Management of Anterior Fossa and Parasellar Pathology

Cosmetic Outcomes of Supraorbital Keyhole Craniotomy Via Eyebrow Incision: A Systematic Review and Meta-Analysis

Background  Supraorbital eyebrow craniotomy is a minimally invasive alternative to a frontotemporal craniotomy and is often used for tumor and vascular pathologies. The purpose of this study was to investigate how patient cosmetic outcomes are affected by technique variations of this approach. Methods  PubMed, Embase, and Scopus databases were systematically searched, and results were reported according to PRISMA guidelines. For the meta-analysis portion, the DerSimonian-Laird random effects model was used, and the primary end points were patient satisfaction and percentage of permanent cosmetic complications. Results  A total of 2,629 manuscripts were identified. Of those, 124 studies (8,241 surgical cases) met the inclusion criteria. Overall, 93.04 ± 11.93% of patients reported favorable cosmetic outcome following supraorbital craniotomy, and mean number of cases with permanent cosmetic complications was 6.62 ± 12.53%. We found that vascular cases are associated with more favorable cosmetic outcomes than tumor cases ( p  = 0.0001). Addition of orbital osteotomy or use of a drain is associated with adverse cosmetic outcomes ( p  = 0.001 and p  = 0.0001, respectively). The location of incision, size of craniotomy, utilization of an endoscope, method of cranial reconstruction, skin closure, use of antibiotics, and addition of pressure dressing did not significantly impact cosmetic outcomes ( p  > 0.05 for all). Conclusions  Supraorbital craniotomy is a minimally invasive technique associated with generally high favorable cosmetic outcomes. While certain techniques used in supraorbital keyhole approach do not pose significant cosmetic risks, utilization of an orbital osteotomy and the addition of a drain correlate with unfavorable cosmetic outcomes.

A case series of gyrus rectus arteriovenous malformation: Clinical characteristics, angioarchitecture, microsurgical treatment, and outcome

Background

Gyrus rectus arteriovenous malformation (AVM) is one of the intricate pathologies that can lead to gyrus rectus hematoma. However, there is a paucity of research on this topic. This case series aims to delineate the characteristics of gyrus rectus AVMs, their outcomes, and treatment strategies.

Methods

We enrolled five cases of gyrus rectus AVM that presented to the Neurosurgery Teaching Hospital in Baghdad, Iraq. Patients with the presence of gyrus rectus AVM were analyzed according to the demographic data, clinical status, radiological imaging, and outcome.

Results

Of the total cases enrolled, all five cases were ruptured at the presentation. Most of the AVMs had arterial feeders from the anterior cerebral artery (80%) and superficial venous drainage through the anterior third of the superior sagittal sinus occurred in four cases (80%). Two of the cases were classified as Spetzler-Martin grade 1 AVMs, two were grade 2, and one was grade 3. With regard to the modified Rankin Score (mRS), four of them had a score of 0 after observation for 30, 18, 26, and 12 months, respectively, while one patient had an mRS score of 1 after 28 months of observation. All five cases presented with seizure and were all treated by surgical resection.

Conclusion

To the best of our knowledge, this is the second report documenting the features of gyrus rectus AVMs and the first one from Iraq. Further, research into gyrus rectus AVMs is required to help better characterize and enhance our knowledge on the outcomes of such lesions.

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.

The Supraorbital Eyebrow Craniotomy for Intra- and Extra-Axial Brain Tumors: A Single-Center Series and Technique Modification

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.

Extended Supraorbital Approach with Modified Eyebrow Incision: Technical Note

BACKGROUND

The extended supraorbital approach through a modified eyebrow incision is a minimally invasive variant of the frontotemporal or pterional approach that enriches a neurosurgeon's armamentarium for the treatment of pathologies lateral to the anterior clinoid process, by advancing laterally with frontal facial nerve branches monitoring. To demonstrate the steps of the approach, we studied 2 formalin-fixed and artery/vein silicone-injected adult cadaveric heads, and reviewed 1 of the 3 clinical cases operated on to illustrate the applicability of the approach.

CLINICAL PRESENTATION

A 56-year-old woman presented with a history of seizures and a complaint of headache that started 2 months ago. She underwent an examination with brain magnetic resonance imaging that showed a dural-based lesion at the medial third of the lesser wing of sphenoid (which is consistent with meningioma). The patient underwent craniotomy with an extended supraorbital approach through a modified eyebrow incision that allowed Simpson grade II removal to be performed and good aesthetic outcome to be achieved.

CONCLUSIONS

The extended supraorbital approach through a modified eyebrow incision is a minimally invasive approach that can add to a neurosurgeon's armamentarium and be used with microscopy, assisted by endoscope, or both to reach the anterior and middle cranial fossae.

[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.

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

In the modern era of neurosurgery, the use of the operative microscope, rigid rod-lens endoscope, and neuronavigation has helped to overcome some of the previous limitations of surgery due to poor lighting and anatomic localization available to the surgeon. Over the last thirty years, the supraorbital craniotomy and subfrontal approach through an eyebrow incision have been developed and refined to play a legitimate role in the armamentarium of the modern skull base neurosurgeon. With careful patient selection, the supraorbital "keyhole" approach offers a less invasive but still efficacious approach to a number of lesions along the subfrontal corridor. Well over 1000 cases have been reported in the literature utilizing this approach establishing its safety and efficacy. This paper discusses the nuances of this approach, including the benefits and limitations of its use described through our technique, review of the literature, and case illustration.

Supraorbital trans-eyebrow craniotomy and fluorescence-guided resection of fronto-basal high grade gliomas

OBJECT

To determine the effectiveness of fluorescence-guided resection of fronto-basal high grade gliomas by using the supraorbital trans-eyebrow craniotomy.

METHODS

We present a single-institution experience of 6 consecutive patients presenting high grade brain glioma located on the fronto-basal area that were operated through a supraorbital trans-eyebrow craniotomy. Previous to surgery all patients were administered 20mg/kg of 5 aminolevulic acid so microscopic fluorescence-guided resection could be accomplished. Tumors were located on gyrus rectus (3 patients), medial orbital gyrus (2 patients), and anterior orbital gyrus (1 patient).

RESULTS

Despite the narrow surgical corridor, fluorescence was useful in all cases. Fluorescence-guided resection allowed inclusion into the margins of resection of areas previously considered as normal under white light. Complete resection was obtained in 5 patients. No neurological postoperative new deficit was observed in this series. All six cases corresponded to glioblastoma. Only one case of superficial infection with delayed wound healing was reported as complication. All patients expressed a high level of satisfaction related to cosmetic result.

CONCLUSIONS

Fluorescence-guided resection of fronto-basal high grade gliomas can be successfully achieved through supraorbital trans-eyebrow craniotomy. Benefits of supraorbital craniotomy in the management of fronto-basal high grade gliomas as well as usefulness of fluorescence-guided resection through a very narrow corridor are exposed.

Different microsurgical approaches to meningiomas of the anterior cranial base

INTRODUCTION

Meningiomas of the anterior skull base show specific characteristics, which render them difficult to handle. These tumors include olfactory groove, supra- and parasellar, anterior sphenoid ridge, cavernous sinus, and spheno-orbital meningiomas. Tumor localization and size, encasement of important structures as well as the extent of dural attachment may influence the decision for an adequate approach.

DISCUSSION

Various approaches to the anterior cranial fossa exist, each with corresponding advantages and disadvantages. Recently, endoscopic approaches have increasingly been used. In this review, the different approaches to meningiomas of the anterior cranial fossa in respect of anatomical issues, indications, and associated risks are discussed.

Tuberculum sellae meningiomas: high route or low route? A series of 51 consecutive cases

OBJECTIVE

Tuberculum sellae meningiomas represent 5 to 10% of all intracranial meningiomas. Such lesions are classically removed through a variety of well-standardized transcranial approaches. The extended endonasal transsphenoidal route, under either microscopic or endoscopic visualization, has only recently been proposed as a viable surgical technique for the management of such tumors.

MATERIAL AND METHODS

A total of 51 consecutive patients with tuberculum sellae meningiomas were treated at our institution during a 21-year period. Forty-four patients had transcranial surgery, and the last seven were treated via the extended endoscopic transsphenoidal approach. We also compared our data with those reported in the pertinent literature related to the surgical, ophthalmological, and endocrinological outcome.

RESULTS

The significant difference among the transcranial and transsphenoidal series, both in our experience and in the reviewed literature, did not allow us to draw statistically significant results but rather a reporting of the outcomes. In the transcranial group, 86.4% had a gross total removal of the lesion, whereas the percentage was 83.3% in the transsphenoidal group. Concerning the visual outcome, we experienced postoperative improvement in 61.4% of the transcranial patients and a worsening of 13.6%, whereas improvement was reported in 71.4% of the patients in the transsphenoidal group; in the last group, we did not observe any postoperative worsening. The main drawback of the transsphenoidal approach still remains the difficulty in reconstructing the cranial base dural and bone defects, which expose patients to a greater risk of postoperative cerebrospinal fluid leakage (28.6% in our series) and related complications.

CONCLUSION

When treating a patient with a diagnosis of tuberculum sellae meningioma, a neurosurgeon should know that, aside from the classical transcranial approach, the possibility of an extended transsphenoidal approach exists. Although it is still not a standardized procedure, in carefully selected cases (i.e., small midline lesions, without major vessel encasement, or parasellar extension) and in experienced hands, it could be considered a viable alternative, especially in overcoming the reconstruction-related problems.