Optic nerve decompression through pterional and supraorbital approaches in the treatment of severe traumatic optic neuropathy.

To investigate the effectiveness of optic nerve decompression (OND) in the treatment of severe traumatic optic neuropathy (TON) through pterional and supraorbital approaches, and to identify the prognostic factor for postoperative visual acuity (VA) following OND. Patients with severe TON treated with OND through either pterional or supraorbital approach in our institute from September 2019 to June 2022 were retrospectively reviewed in this study. Demographic information, trauma factors, the interval between trauma and complete blindness, the interval between trauma and surgery, and the associated craniofacial traumas were recorded. Hospitalization days and the postoperative VA of patients in two groups were compared. There were 54 severe TON patients with NLP included in this study; 21 patients underwent OND through the pterional approach, and the other 33 underwent the supraorbital approach. Respectively, in groups of pterional and supraorbital approaches, the average hospitalization days were 9.8 ± 3.2 and 10.7 ± 2.9 days (p = 0.58), the mean durations of follow-up were 18.9 ± 4.3 and 20.8 ± 3.7 months (p = 0.09), and the average circumference of OND were 53.14 ± 15.89 ◦ (range 220 ◦ -278◦) and 181.70 ± 6.56◦ (range 173 ◦ -193◦) (p<0.001). The overall improvement rates of pterional and supraorbital approaches are 57.1% and 45.5% (p = 0.40), respectively. Optic canal fracture (OCF) was revealed to be significantly associated with postoperative VA in the supraorbital approach (Binary: p = 0.014, CI: 1.573-57.087; Ordinal: p = 0.003, CI: 1.517-5.503), but not in the pterional approach. In the group of supraorbital approach, patients with OFC had a higher rate of a better outcome (78.6%) than those without (21.4%). Patients with severe traumatic TON may benefit from OND through either the pterional or supraorbital approach. OCF is a potential prognostic factor for postoperative VA following OND through the supraorbital approach.

Anterior interhemispheric vs. pterional approach in the microsurgical management of anterior communicating artery aneurysms: a comparative analysis employing a novel multidimensional matching-tool.

The surgical management of anterior communicating artery aneurysms (AcomA) is challenging due to their deep midline position and proximity to complex skull base anatomy. This study compares the pterional craniotomy with the interhemispheric approach based on the specific aneurysm angulation. A total of 129 AcomA cases were analyzed, with 50 undergoing microsurgical clipping via either the pterional or interhemispheric approach. All selected cases had computed tomography-angiography with sagittal imaging slices and 2D-angiography. Using an interactive tool, 14 cases treated via the interhemispheric approach were matched with 14 cases approached pterionally based on clinical and morphological parameters, emphasizing intracranial aneurysm (IA) dome angulation relative to the frontal skull base. Outcomes included IA occlusion, temporary clipping incidence, intraoperative rupture, postoperative strokes, hemorrhages, hydrocephalus, vasospasm, and patient functionality. Matched cohorts had consistent demographics. Both approaches resulted in similar IA occlusion rates, but the interhemispheric approach led to improved clinical outcomes, measured by the modified Rankin Scale. It also had a lower incidence of hydrocephalus and reduced need for permanent ventriculoperitoneal shunt placement. Vasospasms and postoperative infarction rates were comparable between the groups. Our findings suggest potential advantages of the interhemispheric approach in managing AcomA, depending on aneurysm angulation. Despite a small sample size, the results highlight the importance of customized surgical decision-making based on the unique traits of each aneurysm and the surgeon's expertise.

'What's in a name', a systematic review of the pterional craniotomy for aneurysm surgery and its many modifications with a proposal for simplified nomenclature.

BACKGROUND: The pterional or frontosphenotemporal craniotomy has stood the test of time and continues to be a commonly used method of managing a variety of neurosurgical pathology. Already described in the beginning of the twentieth century and perfected by Yasargil in the 1970s, it has seen many modifications. These modifications have been a normal evolution for most neurosurgeons, tailoring the craniotomy to the patients' specific anatomy and pathology. Nonetheless, an abundance of variations have appeared in the literature. METHODS: A search strategy was devised according to the 2020 Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) statement. To identify articles investigating the variations in the pterional approach, the following search terms were applied: (pterional OR minipterional OR supraorbital) AND (approach OR craniotomy OR technique). RESULTS: In total, 3552 articles were screened with 74 articles being read in full with 47 articles being included for review. Each article was examined according the name of the technique, temporalis dissection technique, craniotomy technique and approach. CONCLUSION: This systematic review gives an overview of the different techniques and modifications to the pterional craniotomy since it was initially described. We advocate for the use of a more standardised nomenclature that focuses on the target zone to simplify the management approach to supratentorial aneurysms.

Neuroanatomical photogrammetric models using smartphones: a comparison of apps.

OBJECTIVES: A deep knowledge of the surgical anatomy of the target area is mandatory for a successful operative procedure. For this purpose, over the years, many teaching and learning methods have been described, from the most ancient cadaveric dissection to the most recent virtual reality, each with their respective pros and cons. Photogrammetry, an emergent technique, allows for the creation of three-dimensional (3D) models and reconstructions. Thanks to the spreading of photogrammetry nowadays it is possible to generate these models using professional software or even smartphone apps. This study aims to compare the neuroanatomical photogrammetric models generated by the two most utilized smartphone applications in this domain, Metascan and 3D-Scanner, through quantitative analysis. METHODS: Two human head specimens (four sides) were examined. Anatomical dissection was segmented into five stages to systematically expose well-defined structures. After each stage, a photogrammetric model was generated using two prominent smartphone applications. These models were then subjected to both quantitative and qualitative analysis, with a specific focus on comparing the mesh density as a measure of model resolution and accuracy. Appropriate consent was obtained for the publication of the cadaver's image. RESULTS: The quantitative analysis revealed that the models generated by Metascan app consistently demonstrated superior mesh density compared to those from 3D-Scanner, indicating a higher level of detail and potential for precise anatomical representation. CONCLUSION: Enabling depth perception, capturing high-quality images, offering flexibility in viewpoints: photogrammetry provides researchers with unprecedented opportunities to explore and understand the intricate and magnificent structure of the brain. However, it is of paramount importance to develop and apply rigorous quality control systems to ensure data integrity and reliability of findings in neurological research. This study has demonstrated the superiority of Metascan in processing photogrammetric models for neuroanatomical studies.

Supraorbital eyebrow approach and pterional approach in surgical treatment of ruptured and unruptured aneurysms: a propensity score-matched analysis.

The aim of this study is to reveal efficacy and efficiency of the supraorbital eyebrow approach (SEA) in clipping ruptured and unruptured aneurysms where both SEA and pterional approach (PA) are considered feasible by comparing SEA and PA using propensity score matching. A total of 229 patients who underwent surgical clipping of an aneurysm from 2013 to 2022 and met inclusion criteria were recruited in the study. A study group of 67 patients treated via the SEA and a comparison group of 162 patients treated via the PA were formed. Then, the subgroups of 66 patients each, with balanced incoming factors, were analyzed using the propensity score technique. The safety and efficacy endpoints were compared. Successful clipping was achieved in all cases of both groups. There were no patients in the SEA group who required conversion to the standard craniotomy. There were no procedure-related deaths in this series. No patient experienced early or late rebleeding in either group. Mean blood loss volume in the SEA group was lower than in the PA group by approximately 77.5 ml (p < 0.001). There were favorable differences in the SEA group regarding postoperative neurological deficit (p = 0.016), postoperative epileptic seizure rate (p = 0.013), ischemic and hemorrhagic complications (p = 0.028 and 0.0009, respectively), and outcomes (p < 0.001). Patients' satisfaction with cosmetic results measured by the visual analog scale was rated highly in both groups (p = 0.081). For patients where SEA provides adequate exposure, it results in safety and cosmetic outcomes not inferior to the PA.

Supraorbital Keyhole Versus Pterional Approach: A Morphometric Anatomical Study.

OBJECTIVE: Although the supraorbital (SO) keyhole approach has a wide range of indications, its routine usefulness with the advance of current technology has not been fully evaluated. In an attempt to address this issue, a cadaveric morphometric analysis to the supra- and parasellar regions was performed, comparing the standard Pterional craniotomy (PT) with the SO keyhole. METHODS: ETOH-fixed and silicone-injected human cadaveric heads were used. SO (n = 8) and PT craniotomies (n = 8) were performed. Pre- and post-dissection CT, along with pre-dissection MRI scans were also completed for neuro-navigation purposes, aimed to verify predetermined anatomical landmarks selected for morphometric analysis. RESULTS: Notwithstanding the smaller craniotomy, the SO approach allowed optimal anatomical exposure when compared to the PT approach. With 30° of head rotation, the SO keyhole showed a wider surgical field of the suprasellar region. CONCLUSIONS: Using detailed preoperative image-guided surgical planning, the SO keyhole approach offered an appropriate alternative route to the supra- and parasellar regions, compared to the PT craniotomy.

Injury of the Internal Carotid Artery During Dissection of a Craniopharyngioma via the Pterional Approach: Case Report.

Among the various causes of intraoperative neurosurgical complications, a major arterial injury is one of the most devastating. Herein, the authors present a case of a 76-year-old patient who underwent removal of a craniopharyngioma via the pterional approach and experienced severe damage of her sclerotic left internal carotid artery because it was retracted excessively by a brain spatula, which resulted in complete sacrifice of the vessel. Despite stable parameters on intraoperative monitoring of motor evoked potentials and sufficient collateral blood flow, confirmed by Doppler flowmetry, a large infarct in the left cerebral hemisphere was noted after surgery. Although retraction of movable arteries, veins, and cranial nerves can often be done safely during neurosurgical procedures for effective exposure of the operative field, forced displacement of a sclerotic internal carotid artery in its paraclinoid portion anchored to the fixed distal dural ring should definitely be avoided because it poses a significant risk of major vessel damage.

How I do it-Helsinki style mini-pterional craniotomy for clipping of middle cerebral artery bifurcation aneurysms.

BACKGROUND: Different versions of the mini-pterional (MPT) approach have been described often with the idea the smaller the better. Attempts to reduce incision and craniotomy size for better cosmetic results should not be performed at the expense of safety. METHOD: We present our take on the MPT as a balance between size and safety which can be adopted by vascular neurosurgeons in training. The craniotomy stays within the confines of the superior temporal line and is completely covered by temporal muscle after closure. CONCLUSION: This approach is cosmetically superior while still offering anatomical familiarity and sufficient instrument maneuverability.

Technical note: the use of frameless stereotactic guidance in the treatment of peripheral intracranial aneurysms.

Frameless stereotactic guidance (FSG) has previously been reported to have advantages over intraoperative computed tomography (CT) and frame-based imaging guidance methods in the targeting of intracranial lesions. We report our experience using FSG to minimize brain dissection during microsurgical repair of peripheral aneurysms. We used FSG as a surgical adjunct in the management of 91 peripheral aneurysms. It was used to localise and avoid larger bridging veins, enabling us to minimise unnecessary brain dissection by coming directly down on the aneurysm dome in unruptured lesions or targeting the parent artery just proximal to the aneurysm in ruptured cases. We treated 72 aneurysms located on the distal ACA (79%), 7 on the PCA (7.7%), 6 on the MCA distal to the MCA bifurcation (6.6%), and 6 on the SCA (6.6%). There were no complications related to FSG use. However, we noted a tendency to create an overly limited corridor to the aneurysm, which did not allow sufficient proximal or distal control of the parent artery. In these cases, we had to widen our exposure by further opening the interhemispheric fissure to obtain more proximal control once the aneurysm was reached. Subsequently, we learned to avoid this problem by creating a slightly wider corridor during the initial exposure. Using FSG as a surgical adjunct for peripheral intracranial aneurysms allowed us to safely limit craniotomy size and brain dissection while more confidently exposing these unusually situated lesions, facilitating aneurysm clipping in our series.

Surgical results of 158 petroclival meningiomas with special focus on standard craniotomies.

OBJECTIVE: The goal of this retrospective study is the evaluation of risk factors for postoperative neurological deficits after petroclival meningioma (PCM) surgery with special focus on standard craniotomies. MATERIALS AND METHODS: One-hundred-fifty-eight patients were included in the study, of which 133 patients suffered from primary and 25 from recurrent PCM. All patients were operated on and evaluated concerning age, tumor size, histology, pre- and postoperative cranial nerve (CN) deficits, morbidity, mortality, and surgical complications. Tumor-specific features-e.g., consistency, surface, arachnoid cleavage, and location-were set in a four-grade classification system that was used to evaluate the risk of CN deficits and tumor resectability. RESULTS: After primary tumor resection, new CN deficits occurred in 27.3% of patients. Preoperative ataxia improved in 25%, whereas 10% developed new ataxia. Gross total resection (GTR) was achieved in 59.4%. The morbidity rate, including hemiparesis, shunt-dependence, postop-hemorrhage, and tracheostomy was 22.6% and the mortality rate was 2.3%. In recurrent PCM surgery, CN deficits occurred in 16%. GTR could be achieved in three cases. Minor complications occurred in 20%. By applying the proposed new classification system to patients operated via standard craniotomies, the best outcome was observed in type I tumor patients (soft tumor consistency, smooth surface, plane arachnoid cleavage, and unilateral localization) with GTR in 78.7% (p < 0.001) and 11.9% new CN deficits (p = 0.006). CONCLUSION: Standard craniotomies as the retrosigmoid or subtemporal/pterional approaches are often used for the resection of PCMs. Whether these approaches are sufficient for GTR-and avoidance of new neurological deficits-depends mainly on the localization and intrinsic tumor-specific features.

Surgical Approach to Thalamic Tumors.

Thalamic tumors are deep-seated lesions. Recent improvements in therapeutic approaches and surgical techniques have allowed a more accurate approach to these lesions and a reduction in morbidity and mortality. In this article, the various surgical approaches for the resection of thalamic tumors are described. Each of these approaches has its own indications and risk of complications. Resection of thalamic tumors needs specific anatomical knowledge, especially the vascular anatomy of the region and the thalamic peduncles.

Comparison of postoperative temporalis muscle atrophy between the muscle-preserving pterional approach and the mini-pterional approach in the treatment of unruptured intracranial aneurysms.

This study aimed to compare the muscle-preserving pterional approach (modified classic pterional approach, mCP) and the mini-pterional approach (mPA) with respect to postoperative temporalis muscle atrophy.From November 2013 to April 2020, 78 patients with unruptured intracranial aneurysm of the anterior circulation underwent surgery using mCP or mPA in our institution. Patients' background characteristics, postoperative complications, and temporalis muscle volume (MV) rates (operative side/healthy side) were retrospectively investigated. In 64 patients (n = 31, mCP group; n = 33, mPA group), excluding 14 patients with missing imaging data from 6 to 24 months after surgery, associations between the MV rate and clinical variables were assessed. A multiple regression model was used to examine the association between the MV rate and the surgical method, which is a predictor of postoperative atrophy.The mCP group had a significantly higher mean MV rate than the mPA group (0.955 ± 0.040 and 0.915 ± 0.070, respectively; p = 0.008). Based on the results of the univariate analysis, a multiple regression model was established using sex, age, follow-up period, and the presence of diabetes in addition to the surgical method. Patients who underwent mCP had a higher MV rate than those who underwent mPA (t value = 2.33, p = 0.023).The present result suggested that mCP has a preventive effect on postoperative temporalis muscle atrophy. However, further studies are needed in order to prove that mCP is also effective in terms of postoperative aesthetic and functional outcomes.

Endocrinological outcomes after transcranial resection of tuberculum sellae meningiomas: a systematic review and meta-analysis.

Tuberculum sellae meningiomas (TSMs) arise from the anterior skull base. Endocrine status after TSM resection is an important determinant of quality of life. We sought to better characterize the risk of postoperative endocrinopathy for patients with TSM undergoing open transcranial approach (TCA) microsurgical resection. A systematic review was conducted following MOOSE and PRISMA guidelines. Results were screened against predefined criteria, which included studies evaluating endocrinopathy rates after open transcranial microsurgery for TSM. Outcome incidence was calculated using random-effect meta-analysis of proportions. Eight studies met the inclusion criteria, comprising 406 patients. The average age of the cohort was 52.2 years, and a majority (70%) of the patients were female. The pooled incidence of postoperative transient diabetes insipidus (DI) was 7.5% (95% CI 2.9-12%; p = 0.001; I2 = 75.9%) and permanent DI was 1.6% (95% CI 0.3-2.7%; p = 0.01; I2 = 0%). The pooled rate of postoperative hypopituitarism was 3.6% (95% CI 1.6-5.7%; p < 0.001; I2 = 22.2%), while the incidence of hyperprolactinemia was 1.3% (95% CI 0.1 = 2.6%; p = 0.036; I2 = 8.74%). The incidence of SIADH was 4% in one study but was not included in the meta-analysis. Endocrinopathy after TSM microsurgical resection is rare, but the available studies' poor quality of evidence and inconsistent methodology may reflect that it is underreported in the literature. Nevertheless, clinicians should consider the risk of hormonal impairment and counsel their patients accordingly when selecting a TCA for these lesions.

Morphological types and localization patterns of pterion in the skulls of adults from southeastern China.

PURPOSE: To study the morphological types and relative location of the pterion and its precise relationship with the middle meningeal artery (MMA) in the skulls of adults from southeastern China. METHODS: Dry skulls (n = 250) of adults were obtained from a university specimen bank and analyzed. The morphological types of the pterions were observed. The distances from the center of the external pterion (Pec) to the relevant intracranial and extracranial marker points were measured using a digital vernier caliper. The anterior, middle, and posterior end points of the external pterion were drilled perpendicular to the bone surface. The precise relationships of the external pterion with the internal pterion and the groove of the frontal branch of the MMA were observed and measured after sawing the skull. RESULTS: The morphological types of the pterion in the skulls of adults from southeastern China were sphenoparietal suture (SP) (85%), epipteric (12.4%), frontotemporal suture (1.4%), and stellate (1.2%) types. The mean widths of the external and internal pterions were R, 10.68 ± 4.22 mm; L, 11.13 ± 4.40 mm and R, 14.66 ± 4.04 mm; L, 14.14 ± 4.29 mm, respectively, and the width of the internal pterion was slightly longer than that of the external (P < 0.05). No significant difference in pterion width was found between the genders or sides of the skull (both P > 0.05). The distances from the Pec to the posterolateral aspect of the frontozygomatic suture, zygomatic process of the frontal bone, midpoint of the zygomatic arch, and external acoustic meatus were 29.95 ± 3.75 mm, 34.88 ± 4.08 mm, 40.86 ± 3.59 mm, and 53.79 ± 3.82 mm, respectively. These distances were slightly longer on the right side of the skull than on the left side (P < 0.01) and longer in men than in women (P < 0.01). The distances from the Pec to the frontal crest, optic canal, and anterior clinoid process were 62.79 ± 1.15 mm, 45.39 ± 2.48 mm, and 45.47 ± 2.05 mm, respectively. The external and internal pterions were not on the same level, and all the internal pterions were located below the external ones. In the vast majority of the skulls, the groove of the frontal branch of the MMA passed through the posterior end of the external pterion (Pep) or the area between the Pec and Pep. CONCLUSION: The morphology of the pterion in the skulls of adults from southeastern China is predominantly of the SP type, mostly symmetrically distributed. The distance from the pterion to the extracranially relevant marker points differs among the ethnic groups, between the genders, and between the sides of the skull. All the internal pterions are located below the external ones. Most of the frontal branch of the MMA is located below the mid-posterior segment of the lateral pterion. The characterization of the morphology, the relative position of the pterion and the precise relationship of this structure with the MMA in the skulls of adults from southeastern China may provide an anatomical basis for teaching and clinical practices.

Fusiform dilatation of internal carotid artery after pterional but not subfrontal craniotomy in 6 patients.

PURPOSE: Our study aimed to evaluate potential risk factors for the development of FDICA after suprasellar tumor resection. MATERIALS AND METHOD: After reviewing all cases of pediatric patients who benefited from a suprasellar lesion resection in our two medical institutions, we found 6 patients with a FDICA. Surgical approach strategy (pterional or subfrontal approaches) was noted. Postoperative cranial MRI was performed in each patient 3 months after surgery and every year. When a FDICA occurred, MRI was performed 6 months after the diagnosis and 1 year later to detect any progression. RESULTS: There were 6 males with a mean age at treatment of 11 years (6 to 15). Pterional approach was performed in these 6 patients. At the 2 institutions, we have done at least 50 pterional craniotomies for suprasellar lesion resection. No FDICA was reported after subfrontal approach in 27 consecutive pediatric patients operated on from a craniopharyngioma. The delay between the surgery and the diagnosis of the FDICA was 9 months (3 to 17 months). No symptoms related to the FDICA were recorded. The mean maximal diameter of the aneurysm was 14 mm (10 to 21). ICA bifurcation was involved in 2 cases. Asymptomatic FDICA progression was noted in 2 cases but no treatment was proposed. CONCLUSION: The pathogenesis of FDICA is unclear, and might involve arterial wall necrosis caused by postoperative arachnoid fibrosis which might be worsened by the pterional approach.

Bony landmarks in the endoscopic endonasal transoculomotor approach.

The endoscopic endonasal transoculomotor approach (EETA) has been recently described as a doorway to access the parapeduncular space and treat pituitary adenomas with oculomotor extension. Intraoperative identification of the oculomotor triangle endonasally is challenging and dissection can put the internal carotid artery (ICA) at risk. The aim of the present study is to find reliable landmarks that identify the oculomotor triangle (OCMT) during the EETA and protect the ICA from injury. Several lines were defined for calculations. Among them, one oblique line that extends from the inferior margin of the lateral orbital canal recess to the vidian canal was named the clinoid-to-vidian line (CVL), while a vertical line that extends over the most medial point of the paraclival ICA was titled the sagittal paraclival line (SPL). Anatomic relationships between the OCMT to these lines were assessed in 7 cadaveric heads. The intersecting point between the CVL and SPL is located within 2 mm of the center of the OCMT (mean 0.8 ± 0.5 mm), and 1.1 ± 0.8 mm medially and above the parasellar ICA. CVL and SPL are reliable landmarks during the EETA that can both protect the parasellar ICA and anatomically orientate to the blind spot that corresponds with the OCMT. We recommend starting dissection medial and superior to the CVL-SPL intersecting point, and carry the dissection laterally thereafter to avoid inadvertent injury of the ICA.

The transsylvian corridor through minimally invasive transcranial approaches: a comparative anatomical study.

Minimally invasive transcranial approaches (MITAs) continue to expand in popularity in neurosurgery. Only few MITAs allow sufficient sylvian exposure to enable wide use of the transsylvian corridor. In this study, we aim to compare the transsylvian corridor in two MITAs: the minipterional (MPTa) and the extended supraorbital eyebrow approaches (XSEa). Eight cadaver heads were used to quantify the surgical exposure and maneuverability along the sylvian fissure and the insular lobe provided by the MPTa and the XSEa. Surgical exposure was calculated by means of the exposed length of the sylvian fissure and by the area framed within three extreme points in the insular lobe. Maneuverability was assessed by means of the surgical freedom along the sylvian cistern. XSEa provides twice the frontal exposure and half of the temporal exposure in comparison to the MPTa (p < 0.001 and p = 0.02, respectively). No significant differences were found between the two craniotomies in the length of the exposure of the sylvian fissure, area of insular exposure, or surgical freedom. Both the MPTa and the XSEa afford sufficient grades of exposure along the sylvian fissure and the insular lobe, although the viewing angle is significantly different between the two approaches. Such properties allow either to be used for microsurgery deep within the sylvian cistern. The use of additional corridors, such as the subfrontal route (XSEa) and pretemporal route (MPTa), may influence selection of either the minipterional or the extended supraorbital approaches according to the origin of the surgical pathology addressed.

Microneurosurgery for Paraclinoid Aneurysms in the Context of Flow Diverters.

The advent of flow diverter (FD) stents has apparently reduced the role of microneurosurgery for paraclinoid aneurysms despite sparse high-quality evidence about their long-term effects.The present study critically reviews the overall results of a microneurosurgical series of 57 paraclinoid aneurysms.Of these aneurysms, 47.4% were regular in size while 19.3 were giant. Barami type I was predominant. In 21 aneurysms a hemorrhagic onset occurred. Pterional approach with intradural anterior clinoidectomy was preferred by far. Clipping was possible in 91.2% of aneurysms and a high-flow bypass was the choice in five cases. An mRS of 0-2 was achieved in 77.3% of patients, typically <50 years old.Visual field appeared improved or unchanged in 36.3% and 63.6% of the symptomatic patients, respectively. In 76.1% of incidental aneurysms, campimetry was unaffected by surgery.A complete aneurysm exclusion was achieved in 93% of cases using a single procedure. No recurrences were documented on an average follow-up of 54.1 ± 34 months.Microneurosurgery is still a valuable, definitive, and durable option for Barami type Ia, Ib, or II paraclinoid aneurysm, especially in patients <50 years old and visually symptomatic. Conditions other than these are ideal candidates for FD stents.

Retractorless combined pterional and interhemispheric approach to achieve proximal control in pericallosal artery aneurysm: how I do it.

BACKGROUND: Pericallosal artery aneurysms differ from other cerebral aneurysms for the difficulty in establishing proximal vascular control during surgical clipping. A frontomedial craniotomy with combined pterional and interhemispheric approach allows obtaining a better proximal control. MATERIALS AND METHODS: We present our surgical technique to achieve a proximal vessel control in pericallosal artery aneurysm clipping using a combined pterional and interhemispheric approach through frontomedial craniotomy. This surgical technique is illustrated by an intraoperative video. CONCLUSION: Proximal control for pericallosal artery aneurysm clipping can be challenging. In selected cases, a single craniotomy allows performing two approaches and obtaining a safer proximal control for surgical clipping.

Supraorbital keyhole versus pterional craniotomies for ruptured anterior communicating artery aneurysms: a propensity score-matched analysis.

The safety and efficacy of the supraorbital keyhole approach for aneurysm surgery have not been well researched through a high-quality controlled study. The objective of the study was to compare the safety and efficacy of the supraorbital and pterional approaches for ruptured anterior communicating aneurysm (AComAn). A total of 140 patients, with 70 patients in each group, were enrolled after 1:1 propensity score matching. Clinical variables, postoperative complications, and long-term outcomes were retrospectively compared. Baseline characteristics were equivalent between the two groups. Significantly shorter operative time and less intraoperative blood loss were observed in the supraorbital group compared to the pterional group (141.9 min vs. 184.5 min, P < 0.001; 160.4 ml vs. 250.7 ml, P = 0.008). The incidence of intraoperative aneurysm rupture was similar between the groups (20% vs. 18.6%, P = 0.830). The rate of procedural complications involving subdural hematoma and intracranial infection was lower in patients treated through the supraorbital (10.0%) vs. the pterional approach (32.9%, P < 0.001), but no significant difference was observed for the incidence of ischemic events (15.7% vs. 18.6%, P = 0.654). Within a median 33.4-month (range, 11-67 months) follow-up, a similar proportion of patients achieved a favorable outcome (Glasgow Outcome Scale IV or V) across the two groups (83.6% vs. 80.0%, P = 0.285), while better cosmetic results were observed in the supraorbital group (94.0%) vs. the pterional group (86.2%, P = 0.129). According to our results, we recommend the keyhole approach for AComAn surgery for neurosurgeons who have gained sufficient experience with this technique due to its advantages over the pterional approach.