Extended Lateral Orbital Craniotomy: Anatomic Study and Initial Clinical Series of a Novel Minimally Invasive Pterional Approach

Abstract

Background Of the minimally invasive “keyhole” alternatives to the pterional region, the supraorbital eyebrow approach is the most widely adopted. Yet it can prove disadvantageous when a more direct lateral microsurgical trajectory of attack to the Sylvian fissure and anterior middle fossa are needed.

Objective The extended lateral orbital (XLO) approach was designed to be direct and minimally invasive, with the sphenoid ridge at the center of exposure.

Methods Five injected cadaver heads were used for anatomic study of the XLO approach. The anatomic course of the frontalis branch of facial nerve was studied in relation to the XLO incision. Following XLO incision, the bone exposure was measured. The intracranial microsurgical exposure was assessed subjectively. Application of the technique in representative clinical operative cases is provided.

Results The frontalis nerve was protected in the subgaleal fat pad, with an average minimum distance of 2.3 cm from the XLO incision. The mean calvarial area exposure was 4.95 cm² and consistently centered on the sphenoid ridge. Excellent access to ipsilateral Sylvian's fissure, perisylvian regions, and supra-/parasellar structures was possible. The main limitations related to exposure of the posterior Sylvian fissure and the expected limitations of microsurgical instrument manipulation from a smaller craniotomy.

Conclusions The XLO approach is a minimally invasive keyhole approach to the pterional region that affords a unique lateral trajectory via a craniotomy centered on the sphenoid ridge. Excellent exposure to properly selected lesions is possible. The incision is at a safe distance from the frontalis branch and shows excellent cosmetic healing.

Keywords

minimally invasive craniotomy - pterional keyhole approach - middle cerebral artery aneurysm - sphenoid ridge - micro surgical clipping - frontalis branch of facial nerve - Sylvian fissure

• References

• 1 Yasargil MG, Fox JL. The microsurgical approach to intracranial aneurysms. Surg Neurol 1975; 3 (01) 7-14
• 2 van Lindert E, Perneczky A, Fries G, Pierangeli E. The supraorbital keyhole approach to supratentorial aneurysms: concept and technique. Surg Neurol 1998; 49 (05) 481-489 , discussion 489–490
• 3 Hage ZA, Charbel FT. Clipping of bilateral MCA aneurysms and a coiled ACOM aneurysm through a modified lateral supraorbital craniotomy. Neurosurg Focus 2015; 38 (VideoSuppl1): o19
• 4 Cha KC, Hong SC, Kim JS. Comparison between lateral supraorbital approach and pterional approach in the surgical treatment of unruptured intracranial aneurysms. J Korean Neurosurg Soc 2012; 51 (06) 334-337
• 5 Mori K. Keyhole concept in cerebral aneurysm clipping and tumor removal by the supraciliary lateral supraorbital approach. Asian J Neurosurg 2014; 9 (01) 14-20
• 6 Salma A, Alkandari A, Sammet S, Ammirati M. Lateral supraorbital approach vs pterional approach: an anatomic qualitative and quantitative evaluation. Neurosurgery 2011; 68 (2, Suppl Operative): 364-372 , discussion 371–372
• 7 Yeremeyeva E, Salma A, Chow A, Ammirati M. Microscopic and endoscopic anterior communicating artery complex anatomy as seen through keyhole approaches. J Clin Neurosci 2012; 19 (10) 1422-1425
• 8 Nathal E, Gomez-Amador JL. Anatomic and surgical basis of the sphenoid ridge keyhole approach for cerebral aneurysms. Neurosurgery 2005; 56 (1, Suppl): 178-185 , discussion 178–185
• 9 Figueiredo EG, Deshmukh P, Nakaji P. , et al. The minipterional craniotomy: technical description and anatomic assessment. Neurosurgery 2007; 61 (05) (Suppl. 02) 256-264 , discussion 264–265
• 10 Dare AO, Landi MK, Lopes DK, Grand W. Eyebrow incision for combined orbital osteotomy and supraorbital minicraniotomy: application to aneurysms of the anterior circulation. Technical note. J Neurosurg 2001; 95 (04) 714-718
• 11 Hopf NJ, Stadie A, Reisch R. Surgical management of bilateral middle cerebral artery aneurysms via a unilateral supraorbital key-hole craniotomy. Minim Invasive Neurosurg 2009; 52 (03) 126-131
• 12 Brydon HL, Akil H, Ushewokunze S, Dhir JS, Taha A, Ahmed A. Supraorbital microcraniotomy for acute aneurysmal subarachnoid haemorrhage: results of first 50 cases. Br J Neurosurg 2008; 22 (01) 40-45
• 13 Perneczky A, Fries G. Endoscope-assisted brain surgery: part 1--evolution, basic concept, and current technique. Neurosurgery 1998; 42 (02) 219-224 , discussion 224–225
• 14 Reisch R, Perneczky A. Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery 2005; 57 (4, Suppl): 242-255 , discussion 242–255
• 15 Reisch R, Perneczky A, Filippi R. Surgical technique of the supraorbital key-hole craniotomy. Surg Neurol 2003; 59 (03) 223-227
• 16 Fischer G, Stadie A, Reisch R. , et al. The keyhole concept in aneurysm surgery: results of the past 20 years. Neurosurgery 2011; 68 (1, Suppl Operative): 45-51 , discussion 51
• 17 Mori K, Osada H, Yamamoto T, Nakao Y, Maeda M. Pterional keyhole approach to middle cerebral artery aneurysms through an outer canthal skin incision. Minim Invasive Neurosurg 2007; 50 (04) 195-201
• 18 Mocco J, Komotar RJ, Raper DMS, Kellner CP, Connolly ES, Solomon RA. The modified pterional keyhole craniotomy for open cerebrovascular surgery: a new workhorse?. J Neurol Surg A Cent Eur Neurosurg 2013; 74 (06) 400-404
• 19 Kang H-J, Lee Y-S, Suh S-J, Lee J-H, Ryu K-Y, Kang D-G. Comparative analysis of the mini-pterional and supraorbital keyhole craniotomies for unruptured aneurysms with numeric measurements of their geometric configurations. J Cerebrovasc Endovasc Neurosurg 2013; 15 (01) 5-12
• 20 Mori K, Esaki T, Yamamoto T, Nakao Y. Individualized pterional keyhole clipping surgery based on a preoperative three-dimensional virtual osteotomy technique for unruptured middle cerebral artery aneurysm. Minim Invasive Neurosurg 2011; 54 (5, 6): 207-213
• 21 Yaşargil MG, Reichman MV, Kubik S. Preservation of the frontotemporal branch of the facial nerve using the interfascial temporalis flap for pterional craniotomy. Technical article. J Neurosurg 1987; 67 (03) 463-466
• 22 Babakurban ST, Cakmak O, Kendir S, Elhan A, Quatela VC. Temporal branch of the facial nerve and its relationship to fascial layers. Arch Facial Plast Surg 2010; 12 (01) 16-23
• 23 Agarwal CA, Mendenhall III SDI, Foreman KB, Owsley JQ. The course of the frontal branch of the facial nerve in relation to fascial planes: an anatomic study. Plast Reconstr Surg 2010; 125 (02) 532-537
• 24 Tokimura H, Hirabaru M, Miyajima S. , et al. Electrophysiological mapping of the temporal branch of the facial nerve. J Neurol Surg A Cent Eur Neurosurg 2014; 75 (02) 116-119
• 25 Salas E, Ziyal IM, Bejjani GK, Sekhar LN. Anatomy of the frontotemporal branch of the facial nerve and indications for interfascial dissection. Neurosurgery 1998; 43 (03) 563-568 , discussion 568–569