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

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.

Analysis Surgical Outcomes of Ruptured Anterior Communicating Artery Aneurysm: Lateral Supraorbital Versus Pterional Approach.

Objective To compare lateral supraorbital approach with pterional approach to determine the most effective routine to clip anterior communicating artery aneurysm.Method A total of 85 patients with anterior communicating artery aneurysm underwent surgical clipping, 34 through the lateral supraorbital approach and 51 through the pterional approach from June 2016 to June 2018 in the department of neurosurgery,Jinhua central hospital. We retrospectively analyzed the demographic and clinical variables including age, sex and Hunt-Hess grade. Accordingly, operative data, clinical outcome and postoperative complications were analyzed. The mRS at discharge and 6 months later were evaluated.Outcome All aneurysms were completely clipped. There was no significant difference in intraoperative aneurysm rupture rate and intensive care time between the two groups (P>0.05). Compared with the pterional approach, the operation time of the lateral approach was shorter, the amount of bleeding was less, and the bone flap was small, and there was a statistical difference (P<0.05). There was no statistically significant difference in complications between the two groups (P <0.05). There was no significant difference in mRS between the two groups at different time points (P>0.05). There was no significant difference in hospital stay between the two groups (P>0.05).Conclusion According to our results, we recommend the lateral supraorbital approach for ACoAA and A1/A2 to neurosurgeons who have gained sufficient experience due to its advantages over the pterional approach.

REMOVAL OF SUPRASELLAR MENINGIOMAS VIA THE TRANSCILIARY SUPRAORBITAL APPROACH

The study objective is to compare the outcomes of surgeries performed via the transciliary supraorbital approach and traditional lateral supraorbital approach in patients with suprasellar meningiomas. Material and methods. The experimental group included 17 patients (8 males and 9 females aged between 38 and 67 years (mean age 48.7 ± 5.9 years)) with meningotheliomatous meningiomas (size between 15 and 46 mm (mean size 24.5 ± 5.7 mm) that underwent surgery via the transciliary supraorbital approach. All surgeries were performed by one surgeon. The control group included 20 patients (10 males and 10 females) that underwent surgery via the lateral supraorbital approach. These surgeries were also performed by one surgeon. The 2 groups were matched for size and location of meningiomas. We compared the extent of surgery, frequency of complications, severity of cosmetic defects, and other parameters between the groups. Preoperative examination, microsurgical removal of the tumor, anesthesia, and postoperative management were the same in both groups. Results. We observed no differences in the extent of surgery, frequency of complaints, complications, and neurological status between participants in the experimental and control groups. There were no deaths in either group. Patients that underwent surgery via the transciliary supraorbital approach had lower blood loss than those who underwent surgery via the lateral supraorbital approach (145 ± 18 mL vs 186 ± 24 mL). The duration of surgery was also lower in the experimental group than in the control group (145 ± 24 min vs 167 ± 32 min). Cosmetic outcomes were evaluated using the Cosmetic Visual Analogue Scale. Participants in the experimental group had higher score (>90) than controls (2 patients reported scores of 70 and 80). Possible negative effects of the transciliary supraorbital approach include the risk of scarring in the eyebrow area, skin numbness in the frontal area, paralysis of the frontalis muscle, and the need for more accurate preoperative markings using neuronavigation. Conclusion. In general, the therapeutic effect of surgeries via the transciliary supraorbital and lateral supraorbital approaches do not differ. However, the use of the transciliary supraorbital approach allowed smaller incisions (in both skin and dura mater) and smaller trepanation holes (and as a result minimal displacement of brain structures during surgery). It also ensured lower blood loss and duration of surgery and improved the cosmetic effect. The decision on the surgical approach should be based on tumor characteristics with the consideration of patient’s opinion.

The surgical approach for clipping anterior communicating artery Aneurysm

Anterior communicating artery (ACoA) aneurysm, accounts for 30%-35% of all the aneurysm making it one of the most common intracranial aneurysms. Although the Pterional approach is considered as the safe and appropriate method in ACoA aneurysm surgery, temporalis atrophy and injury to a frontal branch of the facial nerve are few inexorable complications. With the advancement of minimally invasive surgery several modified approaches, such as the supraorbital eyebrow incision approach, the minipterional approach, the mini-supraorbital approach, and the lateral supraorbital approach has been recently introduced and has been used as an alternative.