Lateral Supraorbital Approach for the Surgical Clipping of Ruptured Tiny Anterior Circulation Aneurysms

Object Fenestration of the lamina terminalis (FLT) during aneurysm surgery for subarachnoid hemorrhage can, in theory, improve CSF circulation from the lateral and third ventricles to the cortical subarachnoid space, which may, in turn, decrease the incidence of hydrocephalus and vasospasm. However, the actual effects of FLT on CSF circulation have been difficult to determine, due to confounding factors. In addition, it is unclear whether the lamina terminalis remains functionally patent when the brain resumes its normal position. The goal of this study was to assess the functional patency of the fenestrated lamina terminalis in patients who underwent surgery for ruptured aneurysms. Methods This prospective study included 15 patients who underwent surgical clipping of ruptured anterior circulation aneurysms, with FLT performed during surgery. On postoperative Day 1, the external ventricular drain of each patient was closed, and 1 ml of Omnipaque 300, an iodine based contrast agent, was injected intraventricularly, accompanied by cranial maneuvering designed to position the contrast agent adjacent to the lamina terminalis. Three to 5 minutes after cranial maneuvering, the flow of contrast agent into the basal cisterns was assessed with CT imaging. Flow was verified by an increase in Hounsfield units in a prespecified “region of interest” within the basal cisterns on the CT scan. This procedure was performed using a standardized protocol designed in consultation with the Department of Radiology and approved by the institutional review board. One patient who underwent endoscopic third ventriculostomy was recruited as a positive control to validate the technique, and 1 patient who underwent aneurysm clipping but not FLT was recruited as a negative control. Results Seventeen patients consented to study participation. In the 15 patients who underwent aneurysm clipping and FLT, and the negative control patient who underwent aneurysm clipping but not FLT, the contrast agent followed the normal ventricular pathway from the lateral ventricles into the fourth ventricle, and did not appear in the basal cisterns. In the positive control patient, the contrast agent robustly and immediately filled the basal cisterns. Conclusions Fenestration of the lamina terminalis did not result in functional patency of the lamina terminalis when performed as part of surgical clipping for ruptured aneurysms.

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Surgical Treatment of Ruptured Anterior Circulation Aneurysms

Neurosurgery ◽

10.1227/neu.0b013e3182804e9c ◽

2012 ◽

Vol 72 (3) ◽

pp. 437-442 ◽

Cited By ~ 34

Author(s):

Nohra Chalouhi ◽

Pascal Jabbour ◽

Ibrahim Ibrahim ◽

Robert M. Starke ◽

Philippe Younes ◽

...

Keyword(s):

Operative Time ◽

Anterior Circulation ◽

Efficient Procedure ◽

Supraorbital Approach ◽

Procedural Complications ◽

Microsurgical Techniques ◽

One Year ◽

Keyhole Approach ◽

Small Aneurysms ◽

Anterior Circulation Aneurysms

Abstract BACKGROUND: Recent advancements in microsurgical techniques and instrumentation have allowed the development of the keyhole approach in aneurysm surgery. OBJECTIVE: To compare the safety, efficacy, and 1-year clinical outcome of supraorbital keyhole and standard pterional approaches for ruptured anterior circulation aneurysms. METHODS: A total of 87 patients underwent surgical clipping, 40 through the pterional and 47 through the supraorbital keyhole approach. Baseline demographics, operative time, procedural complications, and 1-year patient outcome were retrospectively compared. RESULTS: The 2 groups were comparable with respect to baseline characteristics, with the exception of a higher proportion of small aneurysms (<7 mm) in the supraorbital group (70.2% vs 37.5%, P = .002). Total operative time was significantly shorter in the supraorbital group (205 minutes, P < .001) compared with the pterional group (256 minutes). The rate of procedural complications was lower in patients treated through the pterional (17.5%) vs the supraorbital approach (23.4%, P = .4). Intraoperative aneurysm ruptures occurred more frequently in the supraorbital group (10.6% vs 2.5%). No patient experienced early or late rebleeding in either group. One year after treatment, 75% (30/40) of patients achieved a favorable outcome (Glasgow Outcome Scale IV or V) in the pterional group vs 76.6% (36/47) in the supraorbital group (P = .8). CONCLUSION: The rate of procedural complications may be higher with the supraorbital keyhole approach, but overall patient outcomes appear to be comparable. The pterional approach is a simple, reliable, and efficient procedure. The keyhole approach may be an acceptable alternative for neurosurgeons who have gained sufficient experience with the technique, especially for small noncomplex aneurysms.

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Outcome of Microsurgical Clipping of Ruptured Anterior Circulation Aneurysms

Pakistan Journal Of Neurological Surgery ◽

10.36552/pjns.v23i4.383 ◽

2019 ◽

Vol 23 (4) ◽

Author(s):

MUHAMMAD JAHANGIR KHAN ◽

MUHAMMAD HAMMAD NASIR ◽

SIKANDAR ALI ◽

SARFRAZ KHAN ◽

MUHAMMAD WAQAS ◽

...

Keyword(s):

Anterior Communicating Artery ◽

Sex Distribution ◽

Surgical Clipping ◽

Anterior Circulation ◽

Efficient Treatment ◽

Microsurgical Clipping ◽

The Mean ◽

Anterior Circulation Aneurysms ◽

Grading Scales

Objective: The objective of the study was to analyze the operative outcome of microsurgical clipping in Ruptured Anterior Circulation Aneurysms.Materials and Methods: Twenty patients with Ruptured Anterior Circulation aneurysms were treated with surgical clipping. All the patients were evaluated pre-operatively according to Hunt & Hess and WFNS grading scales. Patients with grade I, II, and III were operated. All the aneurysms were clipped through Pterional approach under General anesthesia and Yasargil Aneurysm clips of appropriate sizes were used in each patient. Outcome was analyzed according to Glasgow Outcome Scale at the end of six months of follow up in each patient.Results: In this series of twenty cases, the mean patient age was 49 years. Lesion location included, the ACA/A. Com 55% (n = 11), the Middle Cerebral artery 25% (n = 5), P. Com 15% (n = 3), Ophthalmic artery 5% (n = 1). Sex distribution, female 55% (n = 11) and male 45% (n = 9). Per-operative complications, rupture of aneurysm 20% (n = 4), and damage to perforating branches of MCA 5% (n = 1). Conclusions: Surgical clipping still is the most efficient treatment of Ruptured Anterior Circulation aneurysm at the beginning of the new millennium. Anterior Communicating Artery is the commonest location of aneurysms. Major determinants of outcome are Hunt & Hess, WFNS grades on admission and the age of the patient.

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Incidence and Risk Factors of Chronic Subdural Hematoma after Surgical Clipping for Unruptured Anterior Circulation Aneurysms

Journal of Korean Neurosurgical Society ◽

10.3340/jkns.2015.57.4.271 ◽

2015 ◽

Vol 57 (4) ◽

pp. 271 ◽

Cited By ~ 8

Author(s):

Won Jae Lee ◽

Kyung-Il Jo ◽

Je Young Yeon ◽

Seung-Chyul Hong ◽

Jong-Soo Kim

Keyword(s):

Risk Factors ◽

Subdural Hematoma ◽

Chronic Subdural Hematoma ◽

Surgical Clipping ◽

Anterior Circulation ◽

Anterior Circulation Aneurysms

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Extradural minipterional approach for giant intracranial aneurysms

Surgical Neurology International ◽

10.25259/sni_368_2020 ◽

2020 ◽

Vol 11 ◽

pp. 382

Author(s):

Rafael Martinez-Perez ◽

Asterios Tsimpas ◽

Holger Joswig ◽

Victor Hernandez-Alvarez ◽

Jorge Mura

Keyword(s):

Carotid Artery ◽

Nerve Palsy ◽

Internal Carotid ◽

Surgical Clipping ◽

Anterior Circulation ◽

Anterior Clinoidectomy ◽

Aneurysm Occlusion ◽

Third Cranial Nerve Palsy ◽

Key Steps ◽

Anterior Circulation Aneurysms

Background: The clinical applicability of the minipterional (MPT) craniotomy is still limited to small and superficial anterior circulation aneurysms. We discuss the technical nuances of a modified MPT approach, the extradural MPT approach (eMPTa), for the treatment of a giant intracranial aneurysm (GIA) arising from the paraclinoid carotid artery. Case Description: A 44-year-old female presented with facial hypoesthesia and third cranial nerve palsy. Further investigations revealed the presence of a 27 mm aneurysm arising from the communicating segment of the internal carotid artery. The patient underwent surgical clipping through an extradural MPT craniotomy and combined anterior clinoidectomy. Postoperative angio-computed tomography demonstrated complete aneurysm occlusion and patency of the parent vessels. The patient recovered fully from her previous deficits. Conclusion: The skull base drilling, interdural dissection, and anterior clinoidectomy are key steps during the eMPTa that optimizes the use of the extradural corridor. Such adaptations are enough to improve the surgical maneuverability along the paraclinoid region and adapt the MPT suitability for the treatment of complex GIA.

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Minipterional craniotomy for surgical clipping of anterior circulation aneurysms: compatibility between the feasibility, safety and efficiency

Journal of Cerebrovascular and Endovascular Neurosurgery ◽

10.7461/jcen.2020.22.2.65 ◽

2020 ◽

Vol 22 (2) ◽

pp. 65-77

Author(s):

Jung-Sik Park ◽

Min-Yong Kwon ◽

Chang-Young Lee

Keyword(s):

Surgical Clipping ◽

Anterior Circulation ◽

Anterior Circulation Aneurysms

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Quantitative Anatomic Study of the Transciliary Supraorbital Approach

Operative Neurosurgery ◽

10.1227/01.neu.0000369948.37233.70 ◽

2010 ◽

Vol 66 (suppl_2) ◽

pp. ons205-ons210 ◽

Cited By ~ 11

Author(s):

Daniel D. Cavalcanti ◽

Ulises García-González ◽

Abhishek Agrawal ◽

Neil R. Crawford ◽

Paulo Leonardo M. S. Tavares ◽

...

Keyword(s):

Carotid Artery ◽

Image Guidance ◽

Internal Carotid ◽

Anatomic Study ◽

Vertical Angle ◽

Anterior Circulation ◽

Supraorbital Approach ◽

Before And After ◽

Orbital Rim ◽

Anterior Circulation Aneurysms

Abstract BACKGROUND The transciliary supraorbital approach (TCSO) provides an anterior view for visualizing sellar, parasellar, and suprasellar structures. Whether an orbital osteotomy adds to this exposure has not been quantified. OBJECTIVE We quantitatively evaluated the TCSO and benefits of an additional orbital osteotomy for exposing common sites of anterior circulation aneurysms. METHODS Under image guidance, TCSO and orbital osteotomy were performed on 10 sides of 5 cadaver heads to quantify exposures of 4 surgical targets: (1) the junction of the anterior cerebral and anterior communicating arteries (ACoA); (2) the internal carotid artery (ICA) at the level of the posterior communicating artery (PCoA); (3) the bifurcation of the ICA; and (4) the middle cerebral artery (MCA) bifurcation. Horizontal and vertical angles of attack and surgical freedom for instrument manipulation were measured before and after the orbital rim and roof were removed. RESULTS An orbital osteotomy significantly increased surgical freedom to the ACoA (from 471.15 ± 182.14 mm2 to 683.35 ± 283.78 mm2, P = .021); PCoA (from 746.58 ± 242.78 mm2 to 966.23 ± 360.22 mm2, P = .007); ICA bifurcation (from 616.08 ± 310.95 mm2 to 922.38 ± 374.88 mm2, P = .002); and MCA bifurcation (from 1160.77 ± 412.03 mm2 to 1597.71 ± 733.18 mm2, P = .004). There were no significant differences in horizontal angles of attack. The vertical angles of attack were significantly greater after orbital osteotomy, principally with the ACoA and ICA bifurcation as targets. CONCLUSION TCSO combined with orbital osteotomy improves exposure. Removing the orbital rim and roof increases the area for instrument use and improves the vertical angle of attack to common sites in the anterior circulation involving aneurysms.

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Comparative Anatomical Analysis between Minipterional and Supraorbital Approaches in the Treatment of Anterior Circulation Aneurysms

10.1055/s-0040-1702577 ◽

2020 ◽

Author(s):

Rafael Martinez-Perez ◽

Thiago Albonette-Felicio ◽

Giuliano Silveira-Bertazzo ◽

Luis Requena ◽

Ruichun Li ◽

...

Keyword(s):

Anterior Circulation ◽

Anatomical Analysis ◽

Anterior Circulation Aneurysms

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Microsurgical Management of the Middle Cerebral Artery Bifurcation Aneurysms: An Anatomic Feasibility Study

ORL ◽

10.1159/000514177 ◽

2021 ◽

pp. 1-9

Author(s):

Ali Karadag ◽

Baran Bozkurt ◽

Kaan Yagmurlu ◽

Ada Irmak Ozcan ◽

Sean Moen ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Surgical Complications ◽

Digital Camera ◽

Head Rotation ◽

Complex Aneurysms ◽

Head Positioning ◽

Supraorbital Approach ◽

Lateral Supraorbital Approach ◽

Head Positions

Background: The proper head positioning decreases the surgical complications by enabling a better surgical maneuverability. Middle cerebral artery (MCA) bifurcation aneurysms have been classified by Dashti et al. [Surg Neurol. 2007 May;67(5):441–56] as the intertruncal, inferior, lateral, insular, and complex types based on dome projection. Our aim was to identify the optimum head positions and to explain the anatomic variables, which may affect the surgical strategy of MCA bifurcation aneurysms. Methods: The lateral supraorbital approach bilaterally was performed in the 4 cadaveric heads. All steps of the dissection were recorded using digital camera. Results: The distal Sylvian fissure (SF) dissection may be preferred for insular type and the proximal SF dissection may be preferred for all other types. Fifteen degrees head rotation was found as the most suitable position for the intertruncal, lateral type and subtype of complex aneurysms related with superior trunk. Thirty degrees head rotation was found the most suitable position for the inferior type, insular type, and subtype of complex aneurysms related with inferior trunk. Conclusions: The head positioning in middle cerebral bifurcation aneurysms surgery is a critical step. It should be tailored according to the projection and its relationship with the parent vessels of the middle cerebral bifurcation.

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