ABSTRACT
Se presenta la experiencia personal en el tratamiento de 5 pacientes con 7 aneurismas paraclinoideos tratados quirúrgicamente en el Hospital Regional Temuco durante junio de 2015 y julio de 2016 (13 meses). Todos los pacientes fueron previamente discutidos con neurorradiologo Intervencional local y considerados no favorables para terapia endovascular. En todos ellos se realizó una craneotomía mini pterional con clinoidectomía extradural y exposición de la arteria carótida interna cervical. Cuatro pacientes consultaron con hemorragia subaracnoidea y requirieron cirugía cerebral de urgencia. En 6 aneurismas se realizó clipaje y en 1 trapping. Cuatro pacientes no tuvieron deterioro neurológico y evolucionaron favorablemente mientras que 1 paciente falleció por hipoperfusión secundario al trapping de la carótida supraclinoidea. Se enfatiza el manejo interdisciplinario, el plan preoperatorio y el conocimiento de la neuroanatomía en el tratamiento de esta patología.
A personal experience is presented in treating 5 patients with 7 paraclinoid aneurysm who underwent surgery at Hospital Regional Temuco between june 2015 and july 2016 (13 months). All patients were previously discussed with local interventional neuroradiologist considering them not favorable to endovascular therapy. Mini pterional craniotomy with extradural clinoidectomy and internal cervical carotid artery exposure was performed in all of them. 4 patients presented with subarachnoid hemorrhage and required urgent brain surgery. Direct clipping was optimal in 6 aneurysm and 1 was treated with trapping. 4 patients had no neurological deteriotation with excellent outcome and 1 patient died because of hypoperfusion secondary to the supraclinoid carotid trapping. Interdisciplinary management, preoperative planning and neuroanatomy knowledge are emphasized in order to treat this pathology.
Subject(s)
Humans , Female , Adult , Middle Aged , Aged , Ophthalmic Artery , Carotid Artery, Internal/surgery , Intracranial Aneurysm/surgery , Intracranial Aneurysm/epidemiology , Chile , Aneurysm, Ruptured/surgery , Computed Tomography Angiography/methodsABSTRACT
OBJECTIVE: Keyhole craniotomy is a modification of pterional craniotomy that allows for use of a minimally invasive approach toward cerebral aneurysms. Currently, mini-pterional (MPKC) and supraorbital keyhole craniotomies (SOKC) are commonly used. In this study, we measured and compared the geometric configurations of surgical exposure provided by MPKC and SOKC. METHODS: Nine patients underwent MPKC and four underwent SOKC. Their postoperative contrast-enhanced brain computed tomographic scans were evaluated. The transverse and longitudinal diameters and areas of exposure were measured. The locations of the anterior communicating artery, bifurcation of the middle cerebral artery (MCAB), and the internal carotid artery (ICA) terminal were identified, and the working angles and depths for these targets were measured. RESULTS: No significant differences in the transverse diameters of exposure were observed between MPKC and SOKC. However, the longitudinal diameters and the areas were significantly larger, by 1.5 times in MPKC. MPKC provided larger operable working angles for the targets. The angles by MPKC, particularly for the MCAB, reached up to 1.9-fold of those by SOKC. Greater working depths were required in order to reach the targets by SOKC, and the differences were the greatest in the MCAB by 1.6-fold. CONCLUSION: MPKC provides larger exposure than SOKC with a similar length of skin incision. MPKC allows for use of a direct transsylvian approach, and exposes the target in a wide working angle within a short distance. Despite some limitations in exposure, SOKC is suitable for a direct subfrontal approach, and provides a more anteromedial and basal view. MCAB and posteriorly directing ICA terminal aneurysms can be good candidates for MPKC.