Supraorbital eyebrow keyhole approach for microsurgical management of ruptured anterior communicating artery aneurysm

Abstract

The mortality and disability rate of patients with ruptured anterior communicating artery (AComA) aneurysm after bleeding is high. Even with the most advanced treatment methods, the incidence of complications remains high. The purpose of the present study was to determine the efficacy of microsurgery via supraorbital eyebrow keyhole approach (SOEK) in clipping ruptured AComA aneurysms. Between September 2010 and October 2018, 543 patients with intracranial aneurysms were admitted to the Department of Neurosurgery of the Third Affiliated Hospital of Sun Yat-Sen University (Guangzhou, China). Among them, 85 patients with ruptured AComA aneurysm and subarachnoid hemorrhage (SAH) underwent microsurgical clipping via the SOEK approach. In those patients, the clipping rate, complications and clinical efficacy of treatment were evaluated. The average age of the patients was 52.69±9.94 years (range, 28-78 years). The proportions of small, medium and large aneurysms were 83.5, 15.3 and 1.2%, respectively. Procedural complications occurred in 9 cases (10.5%). The occlusion rate of the aneurysms was 98.8%. The average follow-up period was 37.9 (±24.5) months. A total of 81.2% of the patients with SAH had a good clinical prognosisat 1 year (modified Rankin scale score, ≤2). In conclusion, for a skilled and experienced surgeon, SOEK was indicated to be a safe procedure for the treatment of ruptured AComA aneurysms; it provided sufficient intra-operative exposure and a high clipping rate.

Keywords: aneurysm; anterior communicating artery aneurysm; keyhole approach; supraorbital craniotomy.

Figure 1

Schematic drawing of the supraorbital eyebrow keyhole approach. (A) The head was elevated to approximately 15˚ to facilitate venous drainage. (B) The head was rotated to the contralateral side. (C) The maneuver of retroflexion supported gravity-associated self-retraction of the frontal lobe. (D) The skin incision in the eyebrow and the craniotomy are represented by dotted lines. (E) Drilling of the inner cortical layer of the orbital rim in to achieve optimal alignment with the orbital roof. (F) Preparation of the frontal and temporal muscle flaps caudally and laterally.

Figure 2

Intra-operativeimages of the procedure, supraorbital eyebrow keyhole approach. (A) The skin incision is planned along the eyebrow; (B) the muscular and skin flaps retracted with silk sutures. (C) A single burr hole is made below the superior temporal line and posterior to the keyhole. (D) A small supraorbital craniotomy is formed and the dura is opened with the base along the orbital rim. (E) Intra-operative exposure of aneurysm. (F) Clipping of anterior communicating artery aneurysm. (G) The bone flap produced after the supraorbital craniotomy (ruler units, cm). (H) Surgical incision 20 days after the operation.

Figure 3

CT and CT angiography of 42-year-old female presenting with a headache and decreased consciousness disorder. (A) Pre-operative CT with subarachnoid hemorrhage. (B) Pre-operative CT angiography (white arrow indicates the aneurysm). (C) Postoperative CT with clipped aneurysm. (D) Post-operative CT angiography displaying complete clipping of the anterior communicating artery aneurysm via supraorbital eyebrow keyhole approach (arrowhead).

Figure 4

CT and CT angiography of a 29-year-old female presenting with a headache and vomiting. (A) Pre-operative CT with subarachnoid hemorrhage. (B) Pre-operative CT angiography (white arrow indicates the aneurysm). (C) Postoperative CT with clipped aneurysm. (D) Post-operative CT angiography displaying complete clipping of the anterior communicating artery aneurysm via supraorbital eyebrow keyhole approach (arrowhead).