Lateral Supraorbital Versus Pterional Approach: Analysis of Surgical, Functional, and Patient-Oriented Outcomes

doi:10.1016/j.wneu.2018.07.091

World Neurosurgery

Volume 119, November 2018, Pages e192-e199

https://doi.org/10.1016/j.wneu.2018.07.091 Get rights and content

Highlights

•
The LSO approach resulted in complications and outcomes similar to those using the PT approach.
•
The LSO approach reduced the incidence of early clinical minor complications.
•
The LSO approach resulted in a shorter hospital stay.
•
The LSO provided better masticatory and functional results.
•
Finally, the LSO approach resulted in superior aesthetic results and patient satisfaction.

Background

Recently, the lateral supraorbital (LSO) keyhole variant of the standard pterional (PT) approach has been popularized for anterior skull base surgery, because it provides good anatomic exposition, reduced complications, and better aesthetic and functional results. However, these aspects have been formally compared only by a limited number of studies. We reviewed our experience with 50 consecutive anterior communicating artery (AComA) and A1/A2 aneurysms. Of these 50 patients, 25 had undergone the standard PT approach and 25, the LSO variant. We report the results in terms of exclusion of the aneurysm, postoperative complications, functional/masticatory outcomes, and aesthetic and patient satisfaction.

Methods

From January 2014 to December 2015, 25 patients with unruptured AComA and A1/A2 aneurysms underwent the standard PT craniotomy. From January 2016 to March 2017, another 25 patients underwent the LSO technique.

Results

No statistically significant differences were observed in the aneurysmal exclusion rate at angiographic follow-up or major complications. A statistically significant difference in the clinical outcome (Glasgow Outcome Scale) was evident only for the immediate postoperative time and was not significant during the follow-up period. The hospital stay was shorter in the LSO group. Minor complications, patient satisfaction, aesthetics, and functional and masticatory outcomes were significantly better statistically in the LSO group.

Conclusions

The LSO approach demonstrated a lower rate of early clinical minor complications, with a reduction in hospitalization. The LSO approach provides better results for patient satisfaction, masticatory comfort, and cosmetic results. In our experience, the LSO approach is a safe and effective substitute to the standard PT craniotomy to treat unruptured AComA and A1/A2 aneurysms.

Introduction

Pterional craniotomy is the standard approach for most anterior circulation aneurysms.1, 2 It provides access to the anterior and middle cranial fossa, sellar and parasellar regions, superior orbital fissure, and cavernous sinus.2, 3 However, the risk of temporalis muscle atrophy, damage to the frontal branch of the facial nerve, and cosmetic issues has limited this extremely versatile approach.

The pterional approach (PT), first described by Yasargil and Fox¹ in 1975 has undergone adaptations over time with the aim of reducing the potential cosmetic defects. Also, alternative craniotomies that provide a similar surgical corridor have been used. These are believed to minimize the incision length, and craniotomy size and, thus, provide better cosmetic results. The lateral supraorbital (LSO), mini-supraorbital, supraorbital keyhole, sphenoid ridge keyhole, modified PT with temporalis muscle splitting, and eyebrow approaches represent the most common variants.4, 5, 6, 7, 8, 9, 10, 11, 12, 13

Several techniques to preserve the integrity of the temporalis muscle and facial nerve have been also described, including subfascial, interfascial, and subperiosteal dissections. These limit exposure of the frontal branch and preserve the vascular and fascial integrity of the temporalis muscle.14, 15, 16 Several investigators have shown that the LSO approach allows for the same anatomic exposure provided by the standard PT approach for unruptured anterior communicating artery (AComA) aneurysms with equivalent results in terms of aneurysm exclusion and postoperative complications.

We reviewed our experience with 50 patients with consecutive AComA and A1/A2 aneurysms, 25 of whom had undergone the standard PT approach and 25, the LSO variant. We report our results in terms of exclusion of the aneurysm, postoperative complications, functional and masticatory outcomes, and aesthetic and patient satisfaction.

Section snippets

Methods

From January 2013 to March 2017, we performed 50 consecutive craniotomies for the treatment of unruptured AComA and A1-A2 aneurysms at the “A. Gemelli” Hospital (Catholic University School of Medicine, Rome, Italy). All the patients provided written informed consent for inclusion in the present study before the procedure. Of the 50 patients, 25 had undergone the standard PT approach from January 2013 to December 2015, and 25 had undergone the LSO technique for aneurysm clipping from January

Demographic Data

Of the 50 patients, 16 women and 9 men were in the PT group and 19 women and 6 men were in the LSO group (P = NS). The mean age of the patients was 60.6 ± 6.39 years in the PT group and 63.4 ± 5.22 years in the LSO group (P = NS). Among the 25 patients treated using the standard PT approach, 18 (72%; 95% CI, 52.42–85.72) had an AComA aneurysm, 3 (12%; 95% CI, 4.17–29.96) had a right A1-A2 bifurcation, and 4 (16%; 95% CI, 6.40–34.65) had a left A1-A2 bifurcation. Among the 25 patients treated

Discussion

For many years, the PT has been the standard approach for the treatment of anterior circulation aneurysms. Several minimally invasive approaches have been proposed to reduce the incidence of postoperative complications, surgical trauma, associated pain, poor cosmetic results, neurologic deficit, length of the surgical procedure and hospitalization, and costs.² Some of these variations do not allow for a comparable operating field, and others are equally invasive in temporal muscle dissection.13

Conclusions

In our study, the LSO approach demonstrated a significant reduction in early clinical minor complications. No outcome differences were noted during the follow-up period with the standard PT approach. The reduction in hospitalization with the LSO approach reached statistical significance, as did patient satisfaction, masticatory comfort, and cosmetic results. In our experience, LSO approach was shown to be a safe and effective substitute to the standard PT craniotomy to treat unruptured AComA

Acknowledgments

Giuseppe La Rocca and Giuseppe Maria Della Pepa contributed equally to this repor.

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Lateral supraorbital approach as an alternative to the classical pterional approach
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The decision for treatment for unruptured intracranial aneurysms (UIAs) is often difficult. Innovation in endovascular devices have improved the benefit-to-risk profile especially for elderly patients; however, the treatment guidelines from the past decade often recommend conservative management. It is unknown how these changes have affected the overall age of the patients selected for treatment. Herein, we aimed to study potential changes in the average age of the patients that are being treated over time.
A systematic search of the literature was performed to identify all studies describing the age of the UIAs that were treated by any modality. Scatter diagrams with trend lines were used to plot the age of the patients treated over time and assess the presence of a potential significant trend via statistical correlation tests.
A total of 280 studies including 83,437 UIAs treated between 1987 and 2021 met all eligibility criteria and were entered in the analysis. Mean age of the patients was 55.5 years, and 70.7% were female. There was a significant increasing trend in the age of the treated patients over time (Spearman r: 0.250; P < 0.001), with a 1-year increase in the average age of the treated patients every 5 years since 1987.
The present study indicates that based on the treated UIA patient data published in the literature, older UIAs are being treated over time. This trend is likely driven by safer treatments while suggesting that re-evaluation of certain UIA treatment decision scores may be of great interest.
Application of protective superficial temporal artery to middle cerebral artery bypass through the lateral supraorbital approach: Technical note
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The lateral supraorbital (LSO) approach is a minimally invasive craniotomy widely used in the surgical treatment of intracranial aneurysms (IAs). A protective bypass is considered a safety measure in high-risk and complex clipping procedures to maintain distal cerebral flow. However, the protective bypass has so far only been applied through a pterional or larger craniotomy. We aimed to describe the characteristics of the superficial temporal artery to middle cerebral artery (STA-MCA) bypass through the LSO craniotomy to treat complex IAs.
We retrospectively identified six patients with complex IAs who underwent clipping and a protective STA-MCA bypass through the LSO approach between January 2016 and December 2020. The STA donor artery was harvested through the same curvilinear skin incision with a small extension, and it was anastomosed to the opercular segment of the MCA. Subsequently, aneurysm clipping followed standardized steps.
Anastomosis was successful in all patients. Despite requiring temporary occlusion of the parent artery, all aneurysms were successfully clipped without any neurological deterioration.
A protective STA-MCA bypass is feasible through the LSO approach with certain technical modifications. This technique helps protect distal cerebral flow for safe clip placement in the treatment of complex IAs with the associated benefits of a less invasive craniotomy.
Supraorbital vs pterional keyhole for anterior circulation aneurysms: A systematic review and meta-analysis
2023, World Neurosurgery: X
The supraorbital approach is a modification of the traditional pterional approach, and it offers the benefits of a shorter skin incision and a smaller craniotomy than the pterional approach. The purpose of this systemic review study was to compare the two surgical approaches for raptured and unruptured anterior cerebral circulation aneurysms.
We searched PubMed, EMBASE, Cochrane Library, SCOPUS, and MEDLINE, up to August 2021, for published studies on the supraorbital vs pterional keyhole approach for anterior cerebral circulation aneurysms, and reviewers performed a brief qualitative descriptive analysis of both approaches.
Fourteen eligible studies were included in this systemic review. Results indicated that the supraorbital approach for anterior cerebral circulation aneurysms had fewer ischemic events compared to pterional approach. However, no significant difference between both groups in terms of complications such as intraoperative aneurysm rupture, brain hematoma, and postoperative infections for ruptured aneurysms.
The meta-analysis suggests that the supraorbital method for clipping anterior cerebral circulation aneurysms might be a viable alternative to the traditional pterional method as the supraorbital group had decreased ischemic events compared to the pterional group, however, the associated difficulties in utilizing this approach among ruptured aneurysms with cerebral oedema and midline shifts further needs to be understood.
Supraorbital Keyhole Craniotomy in Pediatric Neurosurgery: A Systematic Review of Clinical Outcomes and Cosmetic Outcomes
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Citation Excerpt :
Notable advantages of the supraorbital approach include shorter operative times owing to easier cranial base closure in addition to a decreased risk of postoperative cerebrospinal fluid (CSF) leak.2,6 Furthermore, cosmetic results for adults have been repeatedly reported as being superior with the supraorbital approach,3,10-12 along with a shorter patient recovery time, lower risk of infection, and shorter hospital stay compared with larger craniotomies.3,6,13,14 Despite its advantages, the supraorbital approach has limitations worth noting.
Supraorbital keyhole craniotomy is a minimally invasive approach used to access the parasellar region with advantages of decreased cortical exposure, simple closure, and decreased risk of postoperative cerebrospinal fluid leak. The incision of this approach, however, has raised cosmetic concerns, especially for pediatric patients. The aim of this study is to assess postoperative complications and cosmeses of the supraorbital keyhole approach for resection of intracranial lesions in pediatric patients.
A literature search of PubMed, Scopus, and Web of Science databases was performed on June 1, 2021, searching for all studies of pediatric patients undergoing supraorbital keyhole craniotomy for surgical resection of lesions in the anterior fossa/sellar region.
Of 729 unique hits, 15 supraorbital keyhole studies reporting on 177 pediatric cases were included in the final review. Quality of all included studies was moderate. Overall, the surgery was well tolerated with a low number of severe adverse events. A wide variety of pathologies were treated with this approach. Complications of surgery included changes in vision, epidural hematoma, subdural hematoma, cerebrospinal fluid leak, and wound infection. At 6 weeks of follow-up, surgical scars in most patients were noted to be minimally detectable. At 3–6 months of follow-up, scars were no longer visible. Cosmetic complications included 5 bone defects, 1 split eyebrow, and 1 case of ptosis.
This study suggests that supraorbital keyhole craniotomy is a safe and effective approach to access the parasellar region in pediatric patients with excellent cosmetic outcomes reported across multiple institutions.
Comparison Between Minipterional Craniotomy Associated With Focused Sylvian Fissure Opening and Standard Pterional Approach With Extended Sylvian Fissure Dissection for Treatment of Unruptured Middle Cerebral Artery Aneurysms
2021, World Neurosurgery
Citation Excerpt :
Pterional craniotomy (PC) was first designed in the 1970s by Yasargil and Fox5 for clipping MCA aneurysms. In 2007, Figuereido et al.6 introduced the minipterional variant for unruptured presentations that allowed for clipping in a sufficiently wide surgical window and simultaneously reduced the functional and aesthetic complications.7,8 Subsequently, Elsharkawy et al.9 further refined the miniaturization of the approach by proposing a tailored opening of the Sylvian fissure with sufficient exposure and control of the proximal MCA trunk, which is crucial for safe aneurysmal dissection and clipping.
In our institution, standard pterional craniotomy (PC) with an extended Sylvian fissure opening (ESFO) represented the standard approach for unruptured middle cerebral artery (MCA) aneurysm clipping until 2014, when we progressively started to prefer minipterional craniotomy (MPC) associated with a focused Sylvian fissure opening (FSFO). In the present study, we compared our results in terms of the efficacy of clipping and the rate of complications with these 2 different techniques.
We included patients with small- and medium-size unruptured MCA aneurysms from January 2008 to December 2018 with follow-up of >12 months. The clinical and radiologic data were reviewed from the medical records. The outcomes were measured in terms of efficacy (aneurysmal exclusion rate) and safety (intracranial complication rate).
Overall, 134 patients who had presented with unruptured MCA aneurysms <1.5 cm were treated at our institution from January 2007 to December 2018: PC and ESFO were used in 73 patients and MPC and FSFO in 61. The demographics and angioarchitectural features were comparable between the 2 groups, except for age, which was older in the FSFO group. The aneurysm exclusion rate was not different between the 2 groups. The intracranial complication rate was, overall, significantly lower in the FSFO group (P < 0.001), especially for the rate of postoperative seizures. Finally, the FSFO group had had shorter postoperative hospitalization and better short- and long-term clinical outcomes.
The association between MPC and FSFO should represent the standard of treatment of unruptured MCA aneurysms in all referral cerebrovascular centers, allowing for the achievement of the same efficacy of standard PC with ESFO and minimizing the complications.
Meta-Analysis of Pterional Versus Supraorbital Keyhole Approach for Clipping Intracranial Aneurysms: Direct Comparison of Approach-Related Complications
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Citation Excerpt :
However, only 1 study had included the mean skin incision length. La Rocca et al.23 performed a retrospective study and reported that in the PT and SKA groups, the mean skin incision length was 14.04 ± 1.23 cm and 6.3 ± 0.93 cm, respectively (P < 0.00001). The mean craniotomy area was 12.53 ± 1.49 cm2 for the PT group and 5.66 ± 1.25 cm2 for the SKA group (P < 0.00001).
The supraorbital keyhole approach (SKA) and pterional approach (PA) have been recommended for clipping intracranial aneurysms (IAs). We conducted a meta-analysis to systematically and comprehensively compare the clinical outcomes between the 2 approaches.
We retrieved potential academic studies that had compared the clinical outcomes of SKA and PA for clipping IAs from the Cochrane Library, Medline, PubMed, and EMBASE databases. The references of the identified studies were carefully reviewed to ensure that all available documents had been included in the present study. The meta-analysis was conducted in accordance with the acknowledged PRISMA (prioritized reported items for systematic review and meta-analysis) guidelines.
A total of 8 studies with 1016 participants were included in our study. Of these 1016 patients with IAs, 518 were assigned to the SKA group and 498 to the PA group. Our results showed that the SKA is preferable for clipping IAs compared with the PA because of its shorter operative time (weighted mean difference, −3.163; 95% confidence interval [CI], −5.577 to −0.749; P = 0.01) and length of stay, especially for the patients with unruptured IAs (weighted mean difference, −52.107; 95% CI, −81.597 to −22.618). However, a lower risk of postoperative infection was found in the SKA group (4.6% vs. 8.5%; odds ratio, 0.398; 95% CI, 0.186–0.850; P = 0.017), which seemed to derive from the ruptured IAs (OR, 0.330; 95% CI, 0.136–0.800; P = 0.014). However, no significant difference was found in the incidence of frontal sinus opening, completed occlusion, procedural complications, intraoperative rupture, postoperative hematoma, or cerebral vessel spasm.
The SKA was associated with a shorter length of stay and operation time and a lower risk of postoperative infection. Hence, the SKA seems to be equally effective and safe for clipping IAs compared with PA and should be recommended for surgeons who have acquired sufficient experience with this technique owing to its advantages compared with the PA.

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: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Original ArticleLateral Supraorbital Versus Pterional Approach: Analysis of Surgical, Functional, and Patient-Oriented Outcomes

Highlights

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Demographic Data

Discussion

Conclusions

Acknowledgments

Surg Neurol

Clin Neurol Neurosurg

The microsurgical approach to intracranial aneurysms

Surg Neurol

Perspective of the frontolateral craniotomies

Arq Neuropsiquiatr

The pterional-transsylvian approach: an analytical study

Neurosurgery

Minipterional craniotomy for treatment of unruptured middle cerebral artery aneurysms: a single-center comparative analysis with standard pterional approach as regard to safety and efficacy of aneurysm clipping and the advantages of reconstruction

Acta Neurochir Suppl

Lateral supraorbital approach as an alternative to the classical pterional approach

Acta Neurochir Suppl

An anatomical evaluation of the mini-supraorbital approach and comparison with standard craniotomies

Neurosurgery

The supraorbital keyhole approach to supratentorial aneurysms: concept and technique

Surg Neurol

Anatomic and surgical basis of the sphenoid ridge keyhole approach for cerebral aneurysms

Neurosurgery

The minipterional craniotomy: technical description and anatomic assessment

Neurosurgery

Surgical experience with frontolateral keyhole craniotomy through a superciliary skin incision

Neurosurgery

Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision

Neurosurgery

Modification of the standard pterional approach for aneurysms of the anterior circle of Willis

Br J Neurosurg

Preservation of the frontotemporal branch of the facial nerve using the interfascial temporalis flap for pterional craniotomy: technical article

J Neurosurg

Original Article
Lateral Supraorbital Versus Pterional Approach: Analysis of Surgical, Functional, and Patient-Oriented Outcomes