J Cerebrovasc Endovasc Neurosurg.  2020 Jun;22(2):65-77. 10.7461/jcen.2020.22.2.65.

Minipterional craniotomy for surgical clipping of anterior circulation aneurysms: compatibility between the feasibility, safety and efficiency

Affiliations
  • 1Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea

Abstract


Objective
The aim of this study was to assess the feasibility, safety and efficiency of minipterional craniotomy (MPT) for surgical clipping of anterior circulation aneurysms.
Methods
A retrospective study was conducted to compare the MPT from Jan 2015 to Dec 2018 and conventional pterional craniotomy (CPT) from Jan 2012 to Dec 2013 in unruptured intracranial aneurysms (UIA) and ruptured intracranial aneurysms (RIA). The feasibility and safety of MPT and CPT were assessed by analyzing medical records, radiologic imaging, and clinical outcomes. The efficiency of MPT and CPT were based on a survey research of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry.
Results
Total 628 patients who underwent 458 MPT (UIA:313, RIA:145) and 170 CPT (UIA: 106, RIA: 64) with anterior circulation aneurysms were included in this study. The baseline characteristics between MPT and CPT had no difference (p>0.05). There was no difference in the incidence of postoperative hemorrhage or ischemic lesions between MPT and CPT (p>0.05). The incidence of surgical wound infection was lower in MPT (0.4%) than CPT (3.5%) (p=0.002). More than 90% of postoperative pain disappeared faster in MPT (14.25±4.83 days) than CPT (27.59±10.35 days), and the feeling of facial asymmetry in surgical side was also lower for MPT (1.7%) than CPT (7.6%) (p<0.001). In the MPT, no patients presented with progress to chronic pain, masticatory disability, discomfort of maximal mouth opening or permanent facial palsy.
Conclusions
We suggest that MPT and CPT had similar clinical outcomes, and MPT showed better functional and cosmetic outcomes than CPT in terms of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry. Therefore, MPT for surgical clipping of anterior circulation aneurysms can be a compatible technique that satisfies the feasibility, safety and efficiency.

Keyword

Anterior circulation aneurysm; Minimally invasive surgery; Minipterional craniotomy; Surgical clipping; Surgical technique

Figure

  • Fig. 1 A curvilinear scalp incision was made from the height of the lateral epicanthus to the ipsilateral midpupillary line, such that the incision line was just posterior to hairline. The patient’s head was only shaved up to 2–3 cm posterior to the incision line.

  • Fig. 2 The scalp flap was reflected using a subfascial dissection, and an incision was made in the temporalis fascia along the superior temporal line (STL). The craniotomy was performed inferior and lateral to the STL, using the pterion as a distal landmark, and burr-hole (red dotted circle) was performed only once on the superoposterior side of the bone flap.

  • Fig. 3 After sphenoid ridge drilling and semilunar dural incision, the anterior ascendant ramus of Sylvian fissure, and part of the inferior frontal gyrus and superior temporal gyrus were partially exposed.

  • Fig. 4 Unruptured anterior choroidal artery (AchA) aneurysms in a 58-year-old female patient were exposed after securing the microsurgical field through frontal retraction using a Greenberg retractor, and aneurysmal clipping has been completed.

  • Fig. 5 Fisher scale 4 hemorrhage was observed in a 72-year-old female patient, due to a ruptured anterior communicating artery (ACoA) aneurysm. The brain swelling was alleviated by cerebrospinal fluid (CSF) drainage through Paine’s point, and 3×2 cm craniotomy was performed just to expose this point.

  • Fig. 6 The 2.5×2 cm sized bone flap was fixed appropriately using cranial plate hardware consisting of a burr-hole cover and two straight bars.

  • Fig. 7 The craniotomy scar was completely concealed by reattaching the temporal muscle and the incised temporalis fascia under adequate tension.


Cited by  1 articles

Effects of Scalp Nerve Block on the Quality of Recovery after Minicraniotomy for Clipping of Unruptured Intracranial Aneurysms : A Randomized Controlled Trial
Seungeun Choi, Young Hoon Choi, Hoo Seung Lee, Kyong Won Shin, Yoon Jung Kim, Hee-Pyoung Park, Won-Sang Cho, Hyongmin Oh
J Korean Neurosurg Soc. 2023;66(6):652-663.    doi: 10.3340/jkns.2023.0010.


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