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The Supraorbital Endoscopic Approach for Aneurysms Robert Reisch1, Gerrit Fischer2,3, Axel Stadie4, Ralf Kockro1, Evaldas Cesnulis1, Nikolai Hopf 5

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The Supraorbital Endoscopic Approach for Aneurysms Robert Reisch1, Gerrit Fischer2,3, Axel Stadie4, Ralf Kockro1, Evaldas Cesnulis1, Nikolai Hopf 5 Peer-Review Reports The Supraorbital Endoscopic Approach for Aneurysms Robert Reisch1, Gerrit Fischer2,3, Axel Stadie4, Ralf Kockro1, Evaldas Cesnulis1, Nikolai Hopf 5 Key words - OBJECTIVE: To review our surgical experience in minimally invasive trans- - Intracranial aneurysms cranial endoscope-assisted microsurgical treatment of intracranial aneurysms, - Keyhole neurosurgery using the supraorbital keyhole craniotomy. - Minimally invasive neurosurgery - Supraorbital craniotomy - METHODS: The supraorbital keyhole approach was performed through an - Transcranial endoscope-assisted microneurosurgery eyebrow skin incision in 793 cases for treatment of 989 intracranial aneurysms. Of patients, 474 were operated on after subarachnoid hemorrhage, and 319 were Abbreviations and Acronyms operated on under elective conditions. After lateral frontobasal burr hole ISAT: International Subarachnoid Aneurysm Trial MCA: Middle cerebral artery trephination, a limited subfrontal craniotomy was created. To achieve adequate mRS: Modified Rankin scale intraoperative exposure through the limited approach, endoscopes were used TEAM: Transcranial endoscope-assisted routinely. Surgical outcome was assessed using the modified Rankin scale. microneurosurgery - RESULTS: The transcranial endoscope-assisted microneurosurgery technique 1 From the Centre for Endoscopic and was used routinely via a supraorbital approach. In 152 operations (19.1%), the Minimally Invasive Neurosurgery, Zurich, Switzerland; 2Department of Neurosurgery, Johannes endoscope provided important visual information in the vicinity of the aneurysm, Gutenberg-University Mainz, Mainz, Germany; 3Department revealing subsequent clip repositioning. The results of incidental aneurysms of Neurosurgery, University of Saarland, Homburg, Germany; were excellent with a modified Rankin scale score £2 in 96.52%. The overall 4Department of Neurosurgery, University Hospital Mannheim, Mannheim, Germany; and 5Department of outcome of ruptured aneurysms was good with a modified Rankin scale score £2 Neurosurgery, Katharinenhospital, Stuttgart, Germany in 72.2% of patients. There were no approach-related intraoperative or post- To whom correspondence should be addressed: operative complications. Robert Reisch, M.D., Ph.D. [E-mail: [email protected]] - CONCLUSIONS: The minimally invasive supraorbital keyhole approach Citation: World Neurosurg. (2014) 82, 6S:S130-S137. allowed safe surgical treatment of intracranial aneurysms, including after http://dx.doi.org/10.1016/j.wneu.2014.07.038 subarachnoid hemorrhage. The markedly improved endoscopic visualization Journal homepage: www.WORLDNEUROSURGERY.org increased the assessment of clip placement with ideal control of surrounding Available online: www.sciencedirect.com vessels including perforators for identification of incorrect clip position. 1878-8750/$ - see front matter ª 2014 Published by Elsevier Inc. INTRODUCTION the subarachnoid spaces may decrease the Several cases of insufficient aneurysm oc- The initial data from the International risk of cerebral vasospasm and chronic clusion and postinterventional aneurysm Subarachnoid Aneurysm Trial (ISAT) hydrocephalus (14, 17, 20-22, 24, 29, 43, recanalization were reported associated published in 2002 showed a significant 46, 47, 53). With an additional opening of with increased risk of rebleeding (8, 33, superiority of endovascular coiling the lamina terminalis, the intracranial ce- 44, 49). compared with surgical clipping as rebrospinal fluid circulation also can be Nevertheless, operative therapy requires defined by the proportion of patients dead effectively improved (3, 27, 45). An oper- a surgical approach involving manipula- or disabled at 1 year in a carefully selected ative approach allows adequate optical tion and retraction of the cortical surface group of patients deemed suitable for exposure of the individual anatomy of the and functionally relevant neurovascular either therapy (31). The results of this aneurysm, with safe assessment of perfo- structures. Almost all neurosurgical cen- randomized, prospective, international rators and neighboring neurovascular ters included in ISAT used standard controlled trial represented a landmark structures (29, 33). In the case of rerupture microneurosurgical approaches to treat and radical change in the treatment of the aneurysm, immediate control of the ruptured aneurysm (31). We hypothe- of intracranial aneurysms (6, 9, 10, 28, 32, bleeding is possible (19). In addition, size that the reason for the significant 33, 48). surgical clipping of the aneurysm offers a superiority of endovascular coiling This significant superiority of interven- high reconstructive capacity of the vessel compared with surgical therapy in ISAT tional therapy is difficult to comprehend and high reliability of the occlusion was the surgical morbidity and mortality from a surgical point of view, particularly resulting in minimal risk of postoperative of “standard,” large surgical approaches after comparison of both methods. Using rebleeding (39). Interventional therapy that were usually employed in this study surgical exposure, operative removal of cannot offer careful exploration of the (12). We believe that operative clipping as blood clots with rinsing and cleaning of subarachnoid spaces or the aneurysm. treatment of intracranial aneurysms can be S130 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.07.038 PEER-REVIEW REPORTS ROBERT REISCH ET AL. SUPRAORBITAL ENDOSCOPIC APPROACH FOR ANEURYSMS improved if surgeons are able to reduce its (e.g., clip appliers, scissors, suction de- approach-related complications allowing vices) can effectively resolve this short- minimally invasive and maximally effective coming (13, 35-37, 39, 42). aneurysm closure. The most effective so- The most important disadvantage of lution for reducing intraoperative manip- small, less invasive keyhole approaches is ulation and retraction is the use of the loss of intraoperative light and sight minimally invasive keyhole approaches in causing significantly reduced optical con- neurosurgery (7, 11, 23, 30, 35-38, 41, 49). trol during surgery (39). For the purpose of However, marked reduction of the crani- bringing light into the surgical field, the otomy size may result in different short- optical properties of surgical microscopes comings during the procedure (39). can be effectively supplemented by the Because of the predefined direction of intraoperative use of endoscopes (5, 7, the operative exposure, the surgical 11-13, 15, 19, 23, 30, 37-39, 49). The main corridor cannot be changed intra- advantages of endoscopes are the operatively. Preoperative planning of the increased light intensity, broadening of approach, including 1) thorough evalua- the viewing angles, enlarged focus range, Figure 2. Transcranial endoscope-assisted microneurosurgery—TEAM-work between tion of preoperative diagnostic imaging of and clear depiction of pathoanatomic de- microscope and endoscope. the lesion with respect to the individual tails in close-up positions (Figure 2). anatomy of the patient, 2) definition of the size and site of the tailored craniotomy, After interdisciplinary discussion with 3) positioning of the patient according to MATERIALS AND METHODS the interventional neuroradiologist, surgi- the planned surgical corridor, and 4) skin- We retrospectively evaluated 793 consecu- cal treatment was chosen when endovas- to-skin performance of the exact tive cases of intracranial aneurysms oper- cular coiling was deemed technically not approach, is of particular importance in ated through a supraorbital keyhole feasible. In every case, the surgical keyhole surgery of intracranial aneurysms craniotomy. There were 269 male patients approach was determined after careful (11, 12, 37, 46). An additional problem is and 524 female patients; patient age preoperative study of diagnostic images to the application and maneuverability of ranged from 14e82 years (mean age, 51.8 determine the least traumatic access to the conventional instruments; the use of such years). Of procedures, 474 were performed lesion taking into consideration the indi- instruments becomes limited if the size of following an acute subarachnoid hemor- vidual anatomy of the patient. To improve the craniotomy is <15 mm (Figure 1). The rhage, and 319 were performed on patients intraoperative visualization and optical application of special keyhole-adapted with aneurysms that were found control during surgical manipulation, we slender microsurgical instruments incidentally. routinely used the technique of trans- cranial endoscope-assisted micro- neurosurgery (TEAM). The endoscopic imaging was evaluated with respect to the different routes that are available for the endoscope (e.g., the space between the eloquent neurovascular structures). The endoscopes were used for 1) intraoperative anatomic orientation, 2) assessment of the individual anatomy of the aneurysm including small perforators, and 3) control of clip position including the evaluation of neck occlusion or reconstructive capacity of the clip. Supraorbital Keyhole Technique After positioning the patient supine, anatomic landmarks of the frontal area, such as the supraorbital foramen, tempo- ral line, level of the frontal cranial base, impression of the sylvian fissure, and zygomatic arch, are determined. Based on Figure 1. (A) Photograph comparing a conventional (left) and slender-type clip applier (Aesculap AG, this careful anatomic surface orientation, Tuttlingen, Germany).
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