Minim Invasive Neurosurg 2007; 50(4): 195-201
DOI: 10.1055/s-2007-985837
Original Article

© Georg Thieme Verlag KG Stuttgart · New York

Pterional Keyhole Approach to Middle Cerebral Artery Aneurysms through an Outer Canthal Skin Incision

K. Mori 1 , H. Osada 1 , T. Yamamoto 1 , Y. Nakao 1 , M. Maeda 1
  • 1Department of Neurosurgery, Juntendo University Shizuoka Hospital, Shizuoka, Japan
Further Information

Publication History

Publication Date:
19 October 2007 (online)

Abstract

Object: The supraorbital keyhole approach via an eyebrow skin incision provides a method for the minimally invasive clipping of aneurysms located in the circle of Willis, but has disadvantages for aneurysms located in the lateral Sylvian fissure. The pterional keyhole minicraniotomy via an outer canthal skin incision is proposed for the clipping of unruptured aneurysms of the middle cerebral artery (MCA).

Methods: The procedure consists of a 35-mm outer canthal skin incision, partial temporal muscle dissection restricted in the pterion, a 20-25-mm keyhole minicraniotomy, and a 15-20-mm dural incision to expose the lateral Sylvian fissure. Twenty keyhole clipping procedures were performed in 20 patients with unruptured MCA aneurysms.

Results: Only one patient showed a temporary mild hemiparesis (reversible ischemic neurological deficit) due to lacunar infarction. No shaving of scalp hair, drain placement, or anticonvulsant drug administration were required. Most patients were discharged on the 2nd or 3rd postoperative day. One patient showed a weakness of the frontalis muscle, but this complication was eliminated by the definition of a safety zone to avoid damage to the frontal branch of the facial nerve.

Conclusions: The pterional keyhole approach via outer an canthal skin incision is another treatment option for relatively small, unruptured MCA aneurysms.

References

  • 1 Perneczky A, MullerForell W, Lindert E van, Fries G. Current strategies in keyhole and endoscope-assisted microneurosurgery. In: Perneczky A (ed.). Keyhole Concept in Neurosurgery. Stuttgart: Thieme Medical Publishers 1999: 37-51
  • 2 Reisch R, Perneczky A, Filippi R. Surgical technique of the supraorbital key-hole craniotomy.  Surg Neurol. 2003;  59 223-227
  • 3 Reisch R, Perneczky A. Ten-year experience with the supraorbital subfrontal approach through eyebrow skin incision.  Neurosurgery. 2005;  54 242-255
  • 4 Czirjak S, Szeifert GT. Surgical experience with frontolateral keyhole craniotomy through a superciliary skin incision.  Neurosurgery. 2004;  48 145-150
  • 5 Steiger HJ, Schmid-Elsaesser R, Stummer W, Uhl E. Transorbital keyhole approach to anterior communicating artery aneurysms.  Neurosurgery. 2001;  48 347-352
  • 6 Perneczky A, Fries G. Endoscope-assisted brain surgery. Part 1 - Evolution, basic concept, and current technique.  Neurosurgery. 1998;  42 219-225
  • 7 Park J, Hamm IS. Cortical osteotomy technique for mobilizating the temporal muscle in pterional craniotomies.  J Neurosurg. 2005;  102 174-178
  • 8 Oikawa S, Mizuno M, Muraoka S, Kobayashi S. Retrograde dissection of the temporalis muscle preventing muscle atrophy for pterional craniotomy.  Technical note. J Neurosurg. 1996;  84 297-299
  • 9 Spetzler RF, Lee KS. Reconstruction of the temporalis muscle for the pterional craniotomy.  J Neurosurg. 1990;  73 636-637
  • 10 Ammirati M, Spallone A, Ma J, Cheatham M, Becker D. An anatomicosurgical study of the temporal branch of the facial nerve.  Neurosurgery. 1993;  33 1038-1044
  • 11 Bernstein L, Nelson RH. Surgical anatomy of the extraparotid distribution of the facial nerve.  Arch Otolaryngol. 1984;  110 177-183
  • 12 Coscarella E, Vishteh AG, Spetzler RF, Seoane E, Zabramski J. Subfascial and submuscular methods of temporal muscle dissection and their relationship to the frontal branch of the facial nerve.  J Neurosurg. 2000;  92 877-880
  • 13 Salas E, Ziyal TM, Bejjani GK, Sekhar LN. Anatomy of the frontotemporal branch of the facial nerve and indications for interfascial dissection.  Neurosurgery. 1998;  43 563-569
  • 14 Yasargil MG, Reichman MV, Kubik S. Preservation of the frontotemporal branch of the facial nerve using the interfascial temporalis flap for pterional craniotomy.  J Neurosurg. 1987;  67 463-466
  • 15 Arai H, Sato K, Katsuta T, Rhoton Jr AL. Lateral approach to intraorbital lesions: Anatomic and surgical considerations.  Neurosurgery. 1996;  39 1157-1163
  • 16 Maroon JC, Kennerdell JS. Lateral microsurgical approach to intraorbital tumors.  J Neurosurg. 1976;  44 556-561
  • 17 Lijima A, Piotin M, Mounayer C, Spelle L, Weill A, Moret J. Endovascular treatment with coils of 149 middle cerebral artery berry aneurysms.  Radiology. 2005;  237 611-619
  • 18 Moroi J, Hadeishi H, Suzuki A, Yasui N. Morbidity and mortality from surgical treatment of unruptured cerebral aneurysms at research institute for brain and blood vessels-akita.  Neurosurgery. 2005;  56 224-231

Correspondence

Prof. K. MoriMD, PhD 

Department of Neurosurgery

Juntendo University Shizuoka Hospital

1129 Nagaoka

Izunokuni

410-2295 Shizuoka

Japan

Phone: +81/55/948 31 11

Fax: +81/55/948 50 88

Email: kmori@med-juntendo.jp