Supraorbital Keyhole Craniotomy for Basilar Artery Aneurysms: Accounting for the “Cliff” Effect

2017 ◽  
Vol 13 (2) ◽  
pp. 182-187 ◽  
Author(s):  
Melissa M. Stamates ◽  
Andrew K. Wong ◽  
Anita Bhansali ◽  
Ricky H. Wong
Keyword(s):  
Skull Base ◽  
Basilar Artery ◽  
Pairwise Comparison ◽  
Anterior Skull Base ◽  
Base Line ◽  
Vascular Control ◽  
Surgical Clipping ◽  
Orbital Roof ◽  
True Value ◽  
Cliff Effect

Abstract BACKGROUND: Treatment of basilar artery aneurysms is challenging. While endovascular techniques have dominated, there still remain circumstances where open surgical clipping is required or preferred. Minimally invasive “keyhole” approaches are being used more frequently to provide the durability of surgical clipping with a lower morbidity profile; however, careful patient selection is required. The supraorbital “keyhole” approach has been described for the treatment of basilar artery aneurysms, but careful assessment of the basilar exposure is necessary to ensure proper visualization of the aneurysm and ability to obtain proximal vascular control. Various methods of estimating the basilar artery exposure in this approach have been described, including the anterior skull base line and the posterior clinoid line, but both are unreliable and inaccurate. OBJECTIVE: To propose a new method, the orbital roof-dorsum line, to simply and accurately predict the basilar artery exposure. METHODS: CT angiograms for 20 consecutive unique patients were analyzed to obtain the anterior skull base line, posterior clinoid line, and the orbital roof-dorsum line. CT angiograms were then loaded onto a Stealth neuronavigation system (Medtronic, Minneapolis, Minnesota) to obtain “true” visualization lengths. A case illustration is presented. RESULTS: Pairwise comparison tests demonstrated that both the anterior skull base and the posterior clinoid estimation lines differed significantly from the “true”  value (P < .0001). Our orbital roof-dorsum estimation provided results that accurately predicted the “true” value (P = .71). CONCLUSION: The orbital roof-dorsum line provides a simple and reliable method of estimating basilar artery exposure and should be used whenever considering patients for surgical clipping by this approach.

Residual and Recurrent Disease Following Endoscopic Endonasal Approach as a Reflection of Anatomic Limitation for the Resection of Midline Anterior Skull Base Meningiomas

2021 ◽  
Author(s):  
Pradeep Setty ◽  
Juan C Fernandez-Miranda ◽  
Eric W Wang ◽  
Carl H Snyderman ◽  
Paul A Gardner
Keyword(s):  
Optic Nerve ◽  
Skull Base ◽  
Retrospective Chart Review ◽  
Residual Tumor ◽  
Average Diameter ◽  
Anterior Skull Base ◽  
Endoscopic Endonasal ◽  
Olfactory Groove ◽  
Orbital Roof ◽  
Skull Base Meningiomas

Abstract BACKGROUND Endoscopic endonasal approaches (EEAs) to anterior skull base meningiomas have grown in popularity, though anatomic limitations remain unclear. OBJECTIVE To show the anatomic limits of EEA for meningiomas. METHODS Retrospective chart review for all patients that underwent EEA for anterior skull base meningiomas from 2005 to 2014. RESULTS A total of 100 patients averaged follow-up of 46.9 mo (24-100 mo). A total of 35 patients (35%) had olfactory groove, 33 planum sphenoidale (33%), and 32 tuberculum sella (32%) meningiomas. The average diameter was 2.9 cm (0.5-8.1 cm). Vascular encasement was seen in 11 patients (11%) and calcification in 20 (20%). Simpson Grade 1 (SG1) resection was achieved in 64 patients (64%). Only calcification impacted degree of resection (40% SG1, P = .012). The most common residual was on the anterior clinoid dura (11 patients [11%]). Six (6%) had residual superior/lateral to the optic nerve. Residual tumor was adherent to the optic apparatus or arteries in 5 patients (5%) each, and 3 patients (3%) had residual lateral to the mid-orbit. Rates of residual decreased over time. A total of 11 patients (11%) had tumor recurrence (mean of 40 mo): 4 (4%) on the anterior clinoid, 2 (2%) each on the lateral orbital roof, adherent to optic apparatus and superolateral to the optic nerve, and 1 (1%) was at the anterior falx. CONCLUSION Anterior skull base meningiomas can effectively be approached via EEA in most patients; tumors extending to the anterior clinoid, anterior falx, or superolateral to the optic nerve or orbital roof, especially if calcified, may be difficult to reach via EEA.

Supraorbital approach for repair of open anterior skull base fracture

2008 ◽  
Vol 2 (6) ◽  
pp. 420-423 ◽  
Author(s):  
Katalin A. Szabo ◽  
Samuel H. Cheshier ◽  
M. Yashar S. Kalani ◽  
Jonathan W. Kim ◽  
Raphael Guzman
Keyword(s):  
Skull Base ◽  
Recovery Time ◽  
Anterior Skull Base ◽  
Dural Tear ◽  
Penetrating Injuries ◽  
Skull Base Fracture ◽  
Orbital Roof ◽  
Supraorbital Approach ◽  
Left Eyelid ◽  
Orbital Roof Fractures

To the authors' knowledge, this is the first report of the use of anterior orbitotomy via the supraorbital eyelid crease to repair a dural tear caused by an orbital roof fracture. When transorbital penetrating injuries occur in children, they are commonly caused by accidental falls onto pointed objects. The authors report on their experience with a 7-year-old girl who fell onto a blunt metal rod hanger that penetrated her left eyelid, traversed superior to the eye globe, and penetrated the orbital roof at a depth of 3–4 cm, lacerating the dura mater and entering the cerebrum. An anterior transpalpebral transorbital approach was used to perform the microsurgical anterior skull base and dural repair. The authors advocate the application of this approach to orbital roof fractures because it provides excellent access to the orbital roof, eliminates the need for more invasive craniotomy, results in a small and well-hidden scar in the eye crease, and overall offers a shorter recovery time with less psychological stress to the patient.

The 1-piece transbasal approach: operative technique and anatomical study

2014 ◽  
Vol 121 (6) ◽  
pp. 1446-1452 ◽  
Author(s):  
Sabih T. Effendi ◽  
Vikas Y. Rao ◽  
Eric N. Momin ◽  
Jovany Cruz-Navarro ◽  
Edward A. M. Duckworth
Keyword(s):  
Skull Base ◽  
Surface Area ◽  
Nasal Bone ◽  
Anatomical Study ◽  
Anterior Skull Base ◽  
Illustrative Case ◽  
Vertical Angle ◽  
Bone Removal ◽  
Orbital Roof ◽  
Suprasellar Region

Object The transbasal approach (TBA) is an anterior skull base approach, which provides access to the anterior skull base, sellar-suprasellar region, and clivus. The TBA typically involves a bifrontal craniotomy with orbital bar and/or nasal bone osteotomies performed in 2 separate steps. The authors explored the feasibility of routinely performing this approach in 1 piece with a quantitative cadaveric anatomical study, and present an operative case example of their approach. Methods Seven latex-injected cadaveric heads underwent a 1-piece TBA, followed by additional bone removal typical for a traditional 2-piece approach. Six surgical angles relative to the pituitary stalk, as well as the surface area of the orbital roof osteotomy, were measured before and after additional bone removal. The vertical angle from the frontonasal suture to the foramen cecum was measured in all specimens. In addition to an anatomical study, the authors have used this technique in the operating room, and present an illustrative case of resection of an anterior skull base meningioma. Results Morphometric results were as follows: the vertical angle from the frontonasal suture to the foramen cecum ranged from 17.4° to 29.7° (mean 23.8° ± 4.8°) superiorly. Of the 6 surgical angle measures, only the middle horizontal angle was increased in the 2-piece versus the 1-piece approach (mean 43.4° ± 4.6° vs 43.0° ± 4.3°, respectively; p = 0.049), with a mean increase of 0.4°. The surface area of the orbital osteotomy was increased in the 2-piece versus the 1-piece approach (mean 2467 mm2 ± 360 mm2 vs 2045 mm2 ± 352 mm2, respectively; p < 0.001). The patient in the illustrative clinical case had a good outcome, both clinically and cosmetically. Conclusions The 1-piece TBA provides an alternative to the traditional 2-piece approach. It allows easier reconstruction, potentially decreased operative time, and improved cosmesis. While more of the orbital roof can be removed with the 2-piece approach, this additional bone removal offers only a small increase in 1 of 6 surgical angles that were measured.

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