Keyhole approaches for surgical treatment of intracranial aneurysms: a short review

ABSTRACT

Objective: To clarify the reported experience with keyhole approaches for the treatment of intracranial aneurysms.

Methods: The PubMed and Embase databases were searched up to December 2017 for full-text publications that report the treatment of aneurysms with the eyebrow variant of the supraorbital craniotomy (SOC), the minipterional craniotomy, or the eyelid variant of the SOC. The anatomical distribution of aneurysms, the postoperative aneurysm occlusion rate, and the type and rate of complications were examined using univariate analysis.

Results: Sixty-seven publications covering treatment of 5770 aneurysms met the eligibility criteria. The reported experience was the largest for the eyebrow variant of the SOC (69.4% of aneurysms), followed by the minipterional approach (28.2%), and the eyelid variant of the SOC (2.4%). The anterior communicating artery (ACoA) was the most frequent aneurysm location for the SOC (eyebrow variant: 33.2%; eyelid variant: 31.2%). The middle cerebral artery (MCA) was the most frequent aneurysm location in the minipterional cohort (55.2%). In the eyelid variant of the SOC cohort, the rate of complete aneurysm occlusion was the lowest (eyelid variant: 90.8%; eyebrow variant: 97.8%, p < 0.001; minipterional approach: 97.9%, p < 0.001), and the postoperative infarction rate was the highest (eyelid variant: 7.2%; eyebrow variant: 3.5%, p = 0.025; minipterional approach: 2.6%, p = 0.003).

Conclusion: Each approach has a specific safety and efficacy profile. Surgeons selected the eyebrow variant of the SOC for many aneurysm locations including in particular the ACoA. There is a recent tendency however to opt for the minipterional approach above all for MCA aneurysms.

Abbreviations: SOC: Supraorbital Craniotomy; MPT: Minipterional; MCA: Middle Cerebral Artery; ACoA: Anterior Communicating Artery; PCoA: Posterior Communicating Artery; aSAH: Aneurysmal Subarachnoid Hemorrhage; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; MINORS: Methodological Index For Non-Randomized Studies.

KEYWORDS:

• Minimally invasive neurosurgery
• keyhole neurosurgery
• pterional craniotomy
• aneurysm
• minipterional approach
• supraorbital craniotomy

Acknowledgments

The authors thank Dr Selina Ackermann for editorial support. Her position is funded by the Department of Surgery, Basel University Hospital, Basel, Switzerland.

Disclosure statement

No potential conflict of interest was reported by the authors.

Supplementary material

Supplementary data for this article can be accessed here.

Additional information

Funding

This research was supported by departmental funds of the Department of Surgery, Basel University Hospital, Basel, Switzerland.

Notes on contributors

Jonathan Rychen

Jonathan Rychen, MD is Senior Resident in Neurosurgery at the Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland, and at the Department of Neurosurgery, Bern University Hospital, University of Bern, Bern, Switzerland. Dr Rychen obtained this MD degree for his anatomical work on the supraorbital approach. His research interests include the development of minimally invasive techniques in vascular and skull base neurosurgery.

Davide Croci

Davide Croci, MD is Chief Resident in Neurosurgery at the Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland. Dr Croci obtained this MD degree for his work on subarachnoid hemorrhage-related vasospasms. His clinical and research interests include spinal, vascular, and skull base neurosurgery.

Michel Roethlisberger

Michel Roethlisberger, MD is Assistant Professor in Neurosurgery at the Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland. Dr Roethlisberger has taken his residency training at the Departments of Neurosurgery at the Basel University Hospital, the Kantonsspital Aarau, and the Zurich University Hospital, Switzerland. His clinical and research interests include skull base and vascular neurosurgery.

Erez Nossek

Erez Nossek, MD is Assistant Professor in Neurosurgery at the Lenox Hill Hospital at Hofstra/Northwell, New York, and the Maimonides Medical Center, Brooklyn, NY, USA. Dr Nossek has completed his residency in Neurosurgery at the Tel Aviv Medical Center, Tel Aviv, Israel. He accomplished fellowship training in Cerebrovascular and in Endovascular Neurosurgery at the North Shore University Hospital, Long Island, NY, USA, and in Interventional Neuroradiology at the NYU Langone Medical Center, New York University School of Medicine, New York, NY, USA. His clinical and research interests focus on flow diversion for treating brain aneurysms and cranial bypass surgery.

Matthew B. Potts

Matthew B. Potts, MD is Assistant Professor of Neurological Surgery and Radiology at the Northwestern University Feinberg School of Medicine in Chicago, Illinois, USA. Dr Potts completed his residency program in Neurosurgery at the University of California, San Francisco, CA, USA. During his residency, he was awarded an NIH National Research Service Award. He completed fellowship training in Endovascular and Cerebrovascular Neurosurgery at the NYU Langone Medical Center, New York University School of Medicine, New York, NY, USA. His clinical and research focus include aneurysms, arteriovenous malformations, cavernous malformations, arteriovenous fistulas, and stroke.

Ivan Radovanovic

Ivan Radovanovic, MD PhD is Assistant Professor of Surgery at the Faculty of Medicine, University of Toronto, and Head of Laboratory at the Toronto Western Research Institute, University Health Network, Toronto, ON, Canada. Dr Radovanovic has completed residency training in Neurosurgery at the University of Geneva, Switzerland. He also completed a diploma in molecular biology and genetics, and received his PhD from the Institute of Neuropathology at the University of Zurich, Switzerland. Dr Radovanovic has accomplished his fellowship training in neuro-oncology, skull base surgery, and in cerebrovascular surgery at the Toronto Western Hospital.

Howard A. Riina

Howard A. Riina, MD is Full Professor of Neurosurgery, Radiology, and Neurology at the New York University Langone Medical Center, New York, USA. He is the Vice Chair of the Department Neurosurgery, and he is the Director of the NYU Center for Stroke and Neurovascular Diseases. He took his residency training in Neurosurgery at the University of Pennsylvania in Philadelphia, and completed fellowship training in Diagnostic Neuroradiology at the University of Pennsylvania, in Interventional Neuroradiology at the Beth Israel Medical Center in New York, and in Cerebrovascular and Skull Base Surgery at the Barrow Neurological Institute in Phoenix, USA.

Luigi Mariani

Luigi Mariani, MD is Full Professor and Chairman at the Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland. He is Head of the Brain Tumor Center and the Brain Tumor Biology Laboratory at the Department of Biomedicine, University of Basel, Basel, Switzerland. Dr Mariani took his residency training in Neurosurgery at the Lausanne, Zurich, and Bern University Hospitals as well as the Cantonal Hospital in Lugano, Switzerland. He accomplished an observational and research fellowship in neuro-oncological, neurovascular, and skull base surgery at the Barrow Neurological Institute in Phoenix, Arizona, USA.

Raphael Guzman

Raphael Guzman, MD is Full Professor, Chief of Pediatric Neurosurgery, and Vice-Chairman of the Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland. He is also Head of Laboratory at the Department of Biomedicine, University of Basel, Basel, Switzerland. Dr Guzman took his residency training in Neurosurgery at the Bern University Hospital, Switzerland. He accomplished fellowship training in Pediatric Neurosurgery at the Hospital Necker, Department of Pediatric Neurosurgery, Paris, France, and the Department of Neurosurgery, Stanford University, CA, USA. He also accomplished Cerebrovascular and Skull Base Neurosurgery fellowship training at the Department of Neurosurgery, Stanford University.

Daniel W. Zumofen

Daniel W. Zumofen, MD is Assistant Professor in Neurosurgery and in Diagnostic and Interventional Neuroradiology at the Basel University Hospital, University of Basel, Basel Switzerland. Dr Zumofen took his residency training in Neurosurgery at the Lausanne, Zurich, and Basel University Hospitals, Switzerland, and at the Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada. He accomplished fellowship training in Endovascular Neurosurgery, and in Diagnostic and Interventional Neuroradiology at the NYU Langone Medical Center, New York University School of Medicine, New York, NY, USA.