Potential Risks and Limited Indications of the Supraorbital Keyhole Approach for Clipping Internal Carotid Artery Aneurysms

Abstract

Background Internal carotid artery (ICA) aneurysm may be a good target for supraorbital keyhole clipping. We discuss the surgical indications and risks of keyhole clipping for ICA aneurysms based on long-term clinical and radiologic results. Methods This was a retrospective analysis of 51 patients (aged 35–75 years, mean 62 years) with ICA aneurysms (mean 5.8 ± 1.8 mm) who underwent clipping via the supraorbital keyhole approach between 2005 and 2017. Neurologic and cognitive functions were examined by several methods, including the modified Rankin Scale and Mini-Mental Status Examination. The state of clipping was assessed 1 year and then every few years after the operation. Results Complete clipping was confirmed in 45 patients (88.2%), dog-ear remnants behind the clip persisted in 4 patients, and wrapping was performed in 2 patients. Mean duration of postoperative hospitalization was 3.4 ± 6.9 days. The mean clinical follow-up period was 6.6 ± 3.2 years. The overall mortality was 0, and overall morbidity (modified Rankin Scale score ≥2 or Mini-Mental Status Examination <24) was 3.9%. Completely clipped aneurysms did not show any recurrence during the mean follow-up period of 6.3 ± 3.1 years, but the 2 (3.9%) aneurysms with neck remnants showed regrowth. Conclusions The risk of neck remnant behind the clip blade is a drawback of supraorbital keyhole clipping. The surgical indication requires preoperative simulation and careful checking of the clip blade state is essential.

Supraorbital keyhole approach for paraclinoid aneurysms clipping: A case series with literature review

“…Recently, SOK was introduced as an alternative approach for clipping ICA aneurysms,[ 15 ] due to an increase in the demand for a shorter operation time and a less invasive method for achieving a better effect without complications,[ 4 ] However, reports about surgical treatment of PcA through this approach are limited.…”

“…The SOK is not generally indicated to clip PcA, as suggested by Toyooka et al ., who performed keyhole clipping in only two PcAs (3.7%) among the 54 PcAs, which were very small in size and required partial anterior clinoidectomy;[ 15 ] yet, this limitation of SOK is explained by SOK that has a straight-axis trajectory, so limited operative angle hinders multidirectional observation and the manipulation of the target aneurysm. Therefore, in our opinion, the indication can be influenced by a sum of three criteria related to the aneurysm, including its dome size, direction, and neck sites.…”

Keyhole approach in anterior circulation aneurysm: Current indication, advantages, technical limitations, complications and their avoidance

“…Tang Y et al [ 43 ], Yu LB et al [ 51 ] and Chen L et al [ 7 ] reported 93.6%, 97.87% and 92% occlusion rate respectively for the treatment of ruptured anterior circulation aneurysm via SOKA. Toyooka T et al [ 45 ] found 100% occlusion rate for unruptured ICA aneurysm via SOKA.…”

Value of 3D-DSA in the detection of intracranial aneurysms

“…Timely detection and treatment of intracranial aneurysms are crucial in prevention of rupture of intracranial aneurysms and subarachnoid hemorrhage 2 . Detection and precise morphologic evaluation of the aneurysm neck is important for intracranial aneurysm management and for the choice of treatment method [3][4][5] . Digital subtraction angiography (DSA) is the gold standard method in the diagnosis of preoperative intracranial aneurysms because of excellent depiction of cerebrovascular anatomy structures and superior spatial resolution in comparison with three-dimensional (3D)-computed tomography (CT) and magnetic resonance angiography (MRA) 6,7 .…”