Endoscope-assisted Transorbital Keyhole Surgical Approach to Ruptured Supratentorial Aneurysms

Abstract

Background Many different surgical approaches have been described to treat intracranial aneurysms. A common feature of all the approaches has been relatively extensive brain exposure and brain retraction with increasing surgical morbidity. Transorbital keyhole is one of the minimally invasive approaches. Endoscope-assisted transorbital keyhole surgery (EATOKS) combines minimally invasive transorbital keyhole surgery with endoscope-assisted microneurosurgery. We describe our experience with this approach and its efficacy in treating ruptured supratentorial aneurysms.

Materials and Method We retrospectively reviewed 62 patients (18 men [29%] and 44 women [71%]) with a ruptured supratentorial aneurysm who underwent surgical clipping via the EATOKS approach from April 2003 to July 2012. In all our cases, we use a rigid endoscope of 0, 30, or 45 degrees to inspect the aneurysm and its surrounding anatomy before clipping and ultimately to verify the completeness of the aneurysm clipping and the patency of the adjacent neurovascular structures.

Results All patients with ruptured supratentorial aneurysms were successfully clipped including three with multiple aneurysms. Surgically related major and minor as well as medically related complications were 10%, 15%, and 10%, respectively. Three patients (4.8%) died of massive cerebral infarction due to fulminant postoperative vasospasm, multiorgan failure, and adult respiratory distress syndrome. At 6-month follow-up, 81% of patients achieved good outcomes with Glasgow Outcome Scales of 4 and 5. Patients' satisfaction with the cosmetic results was satisfactory to excellent in most cases.

Conclusion EATOKS is a viable and safe option in the neurosurgical armamentarium to treat ruptured supratentorial aneurysms.

Keywords

aneurysms - endoscope assisted - minimally invasive - transorbital keyhole

• References

• 1 Al-Mefty O, Fox JL. Superolateral orbital exposure and reconstruction. Surg Neurol 1985; 23 (6) 609-613
• 2 Al-Mefty O. Supraorbital-pterional approach to skull base lesions. Neurosurgery 1987; 21 (4) 474-477
• 3 Delashaw Jr JB, Jane JA, Kassell NF, Luce C. Supraorbital craniotomy by fracture of the anterior orbital roof. Technical note. J Neurosurg 1993; 79 (4) 615-618
• 4 Smith RR, Al-Mefty O, Middleton TH. An orbitocranial approach to complex aneurysms of the anterior circulation. Neurosurgery 1989; 24 (3) 385-391
• 5 Britz GW, Salem L, Newell DW, Eskridge J, Flum DR. Impact of surgical clipping on survival in unruptured and ruptured cerebral aneurysms: a population-based study. Stroke 2004; 35 (6) 1399-1403
• 6 Clinchot DM, Bogner JA, Kaplan PE. Cerebral aneurysms: analysis of rehabilitation outcomes. Arch Phys Med Rehabil 1997; 78 (4) 346-349
• 7 Ronkainen A, Niskanen M, Rinne J, Koivisto T, Hernesniemi J, Vapalahti M. Evidence for excess long-term mortality after treated subarachnoid hemorrhage. Stroke 2001; 32 (12) 2850-2853
• 8 Saciri BM, Kos N. Aneurysmal subarachnoid haemorrhage: outcomes of early rehabilitation after surgical repair of ruptured intracranial aneurysms. J Neurol Neurosurg Psychiatry 2002; 72 (3) 334-337
• 9 Wilson DH. Limited exposure in cerebral surgery. Technical note. J Neurosurg 1971; 34 (1) 102-106
• 10 Yasargil MG, Fox JL, Ray MW. The operative approach to aneurysms of the anterior communicating artery. In: Krayenbühl H, Brihaye J, Loew F, Logue V, Mingrino S, , eds. Advances and Technical Standards in Neurosurgery. New York, NY: Springer-Verlag; 1975: 113-117
• 11 Yasargil MG, Gasser JC, Hodosh RM , et al. Carotid-ophthalmic aneurysms: direct microsurgical approach. Surg Neuro 1977; 8: 155-165
• 12 Brock M, Dietz H. The small frontolateral approach for the microsurgical treatment of intracranial aneurysms. Neurochirurgia (Stuttg) 1978; 21 (6) 185-191
• 13 van Lindert E, Perneczky A, Fries G, Pierangeli E. The supraorbital keyhole approach to supratentorial aneurysms: concept and technique. Surg Neurol 1998; 49 (5) 481-489 ; discussion 489–490
• 14 Beseoglu K, Lodes S, Stummer W, Steiger HJ, Hänggi D. The transorbital keyhole approach: early and long-term outcome analysis of approach-related morbidity and cosmetic results. Technical note. J Neurosurg 2011; 114 (3) 852-856
• 15 Eliava SS, Filatov YM, Yakovlev SB , et al. Results of microsurgical treatment of large and giant ICA aneurysms using the retrograde suction decompression (RSD) technique: series of 92 patients. World Neurosurg 2010; 73 (6) 683-687
• 16 Fischer G, Stadie A, Reisch R , et al. The keyhole concept in aneurysm surgery: results of the past 20 years. Neurosurgery 2011; 68 (1, Suppl Operative): 45-51 ; discussion 51
• 17 Steiger H-J, Schmid-Elsaesser R, Stummer W, Uhl E. Transorbital keyhole approach to anterior communicating artery aneurysms. Neurosurgery 2001; 48 (2) 347-351 ; discussion 351–352
• 18 Ivan ME, Lawton MT. Mini supraorbital approach to inferior frontal lobe cavernous malformations: case series. J Neurol Surg A Cent Eur Neurosurg 2013; 74 (3) 187-191
• 19 Yamahata H, Tokimura H, Hirahara K , et al. Entry point to the Sylvian fissure for the pterional transsylvian approach. J Neurol Surg A Cent Eur Neurosurg 2013; 74 (4) 228-233
• 20 Mocco J, Komotar RJ, Raper DM, Kellner CP, Connolly ES, Solomon RA. The modified pterional keyhole craniotomy for open cerebrovascular surgery: a new workhorse?. J Neurol Surg A Cent Eur Neurosurg 2013; 74 (6) 400-404
• 21 Nakabayashi H, Shimizu K. Stereoscopic virtual realistic surgical simulation in intracranial aneurysms. Neurol India 2012; 60 (2) 191-197
• 22 Zhao J, Wang Y, Zhao Y, Wang S. Neuroendoscope-assisted minimally invasive microsurgery for clipping intracranial aneurysms. Minim Invasive Neurosurg 2006; 49 (6) 335-341
• 23 Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales: a systematic review. Neurocrit Care 2005; 2 (2) 110-118
• 24 Rhoton Jr AL. Aneurysms. Neurosurgery 2002; 51 (4, Suppl): S121-S158
• 25 Fischer G, Oertel J, Perneczky A. Endoscopy in aneurysm surgery. Neurosurgery 2012; 70 (2, Suppl Operative): 184-190 ; discussion 190–191
• 26 Tawk RG, Binning MJ, Thomas JM, Siddiqui AH, Grand W. Transciliary supraorbital approach (eyebrow approach) for resection of retrochiasmatic craniopharyngiomas: an alternative approach, case series, and literature review. J Neurol Surg A Cent Eur Neurosurg 2014; 75 (5) 354-364