Supraorbital Keyhole Approach to Upper Basilar Artery Aneurysms via the Optico-Carotid Window: A Cadaveric Anatomic Study and Preliminary Application

Abstract

Background:

No anatomic data are available addressing the surgical indication for upper BA aneurysms via the supraorbital keyhole approach (SOKA).

Objective:

An anatomic study of the SOKA to the upper BA via the optico-carotid window (OCW) was designed. Our clinical experience is reported.

Methods:

After completing the SOKA craniotomy on 8 cadaveric heads, the width and length of OCW and the length of the supraclinoid internal carotid artery (SCICA) were measured. Measurement of the following was carried out through the OCW: (i) linear distance (a) of the BA from the most proximal point of visualization of the BA to the posterior clinoid process level, (ii) perpendicular distance (b) from the most distal point of visualization along the elongation of the BA to the anterior fossa level. After posterior clinoidectomy and orbitectomy, the measurement of (a) and (b) was repeated.

Results:

The width and length of OCW and the SCICA length were 7.6±2.1 mm, 11.6±2.3 mm, and 12.7±2.4 mm. The distance (a) was 5.0±1.2 mm, increased by 3.4±1.0 mm after posterior clinoidectomy. The distance (b) was 12.8±2.6 mm, increased by 3.3±1.2 mm after orbitectomy. 9 aneurysms were completely clipped.

Conclusion:

When the width and length of the OCW are > 5 mm and > 7 mm, respectively, the SOKA can meet the requirement of exposure and manipulation of the upper BA. The upper BA aneurysms located < 10 mm higher than the anterior fossa and not more than 5 mm lower than the PCP can be treated via the SOKA. Posterior clinoidectomy and orbitectomy can increase the proximal and the distal exposure of the BA, respectively.

Key words

microanatomy - optico-carotid window - supraorbital keyhole approach - upper basilar aneurysm

Publication History

Publication Date:
25 January 2012 (online)

• References

• 1 Yasargil MG. Microneurosurgery. Vol. II. Stuttgart, New York: 001-371 Theme; 1984
• 2 Henkes H, Fischer S, Mariushi W. et al. Angiographic and clinical results in 316 coil-treated basilar artery bifurcation aneurysms. J Neurosurg 2005; 103: 990-999
• 3 Molyneux AJ, Kerr RS, Yu LM. et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 2005; 366 9488 809-817
• 4 Juvela S, Porras M, Heiskanen O. Natural history of unruptured intracranial aneurysms: a long-term follow-up study. J Neurosurg 1993; 79: 174-182
• 5 Juvela S, Porras M, Poussa K. Natural history of unruptured intracranial aneurysms: probability and risk factors for aneurysm rupture. Neurosurg Focus 2000; 8: 379-387 Preview 1
• 6 Wiebers DO, Whisnant JP, Huston 3rd J. et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 2003; 362 9378 103-110
• 7 Sanai N, Tarapore P, Lee AC. et al. The current role of microsurgery for posterior circulation aneurysms: a selective approach in the endovascular era. Neurosurgery 2008; 62: 1236-1249
• 8 Wilson DH. Limited exposure in cerebral surgery. Technical note. J Neurosurg 1971; 34: 102-106
• 9 Fukushima T, Miyazaki S, Takusagawa Y. et al. Unilateral interhemispheric keyhole approach for anterior cerebral artery aneurysms. Acta Neurochir Suppl (Wien) 1991; 53: 42-47
• 10 Perneczky A, Muller-Forell W, Lindert EV. et al. Keyhole concept in neurosurgery. Stuttgart: Thieme; 1999
• 11 Lan Q, Gong Z, Kang D. et al. Microsurgical experience with keyhole operations on intracranial aneurysms. Surg Neurol 2006; 66 (Suppl. 01) S2-S9
• 12 Reisch R, Perneczky A. Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery 2005; 57 (04) Suppl 242-255
• 13 Hopf NJ, Stadie A, Reisch R. Surgical management of bilateral middle cerebral artery aneurysms via a unilateral supraorbital key-hole craniotomy. Minim Invasive Neurosurg 2009; 52: 126-131
• 14 Mori K, Yamamoto T, Nakao Y. et al. Lateral supraorbital keyhole approach to clip unruptured anterior communicating artery aneurysms. Minim Invasive Neurosurg 2008; 51: 292-297
• 15 Menovsky T, Grotenhuis JA, de Vries J. et al. Endoscope-assisted supraorbital craniotomy for lesions of the interpeduncular fossa. Neurosurgery 1999; 44: 106-110
• 16 Evans JJ, Hwang YS, Lee JH. Pre- versus post-anterior clinoidectomy measurements of the optic nerve, internal carotid artery, and opticocarotid triangle: a cadaveric morphometric study. Neurosurgery 2000; 46: 1018-1021
• 17 Ramos-Zuniga R. The trans-supraorbital approach. Minim Invasive Neurosurg 1999; 42: 133-136
• 18 Figueiredo EG, Deshmukh V, Nakaji P. et al. An anatomical evaluation of the mini-supraorbital approach and comparison with standard craniotomies. Neurosurgery 2006; 59 (Suppl. 02) ONS212-ONS220
• 19 Figueiredo EG, Zabramski JM, Deshmukh P. et al. Comparative analysis of anterior petrosectomy and transcavernous approaches to retrosellar and upper clival basilar artery aneurysms. Neurosurgery 2006; 58 (01) Suppl ONS13-ONS21
• 20 Dong J, Lan Q. Microanatomical studies of the subtemporal anterior transpetrous keyhole approach (in Chinese). Chin J Nerv Mental Dise 2007; 33: 321-324
• 21 Kawase T, Toya S, Shiobara R. et al. Transpetrosal approach for aneurysms of the lower basilar artery. J Neurosurg 1985; 63: 857-861
• 22 Fulkerson DH, Horner TG, Payner TD. et al. Endovascular retrograde suction decompression as an adjunct to surgical treatment of ophthalmic aneurysms: analysis of risks and clinical outcomes. Neurosurgery 2009; 64 (03) Suppl 107-111
• 23 Paladino J, Mrak G, Miklić P. et al. The keyhole concept in aneurysm surgery  −  a comparative study: keyhole versus standard craniotomy. Minim Invasive Neurosurg 2005; 48: 251-258