Supraorbital eyebrow approach: A single-center experience

Abstract

Background: Keyhole neurosurgery is the notion of safely removing brain and skull base lesions through smaller and more precise openings that lessen collateral damage to the surrounding scalp, brain, blood vessels, and nerves. The traditional frontal and pterional approaches require large craniotomies and this predisposes patients to significant and avoidable morbidity. With the growing expectation for minimally invasive surgery, we present our experience with the supraorbital keyhole craniotomy for surgical lesions in the anterior cranial fossa and parasellar regions. Methods: We retrospectively analyzed and evaluated all cases of neoplastic, vascular, trauma, and infective pathologies of the anterior fossa and parasellar regions treated using a keyhole approach, the supraorbital eyebrow (SOE) approach from January 2018 to June 2022. Treatment outcomes were evaluated based on pathology. Results: A total of 50 patients underwent a SOE craniotomy during the study period (28 females and 22 males). Their average age ranged from 12 to 86 years, with a mean age of 47.4 years. All patients had anterior skull base and/or anterior frontal lobe pathologies: (23 tumors, 17 ruptured aneurysms, five traumatic frontal hematomas, three extradural empyema, one cerebral cavernous malformation, and one traumatic frontal skull base fracture with dural tear and CSF leak). Gross total tumor resection was achieved in 87% of cases (13 meningiomas of which six were giant, three gliomas, two craniopharyngiomas, and two cerebral metastases). Clip ligation occlusion rate for our aneurysm cases was 100% and intraoperative rerupture was observed in three cases. Mean ICU stay was 2.2 days for the entire series. The overall 30-day mortality rate for our series was 16% (eight deaths). This was highest in the ruptured aneurysm subgroup, with all 5 mortality cases in the aneurysmal subgroup presenting as World Federation of Neurological Surgeons (WFNS) grades ≥ III. 4 of the deaths were in WFNS IV and V patients. The most frequent perioperative complication was transient periorbital swelling which resolved within 7 days. It was observed in 18 of the 50 patients. The next common complications in descending frequency were eyebrow alopecia (three cases), supraorbital hypoesthesia (two cases), CSF leak (two cases), and surgical site infection (one case). There was one approach-related intraoperative complication secondary to carotid injury in a giant meningioma redo case. Conversion to a larger craniotomy was never necessary. Clinical outcome for our cases was evaluated according to the Modified Rankin Scale (mRS) at 3-month postsurgery. A good clinical outcome (mRS ≤ 2) was achieved for 78% of our patients. Conclusion: The SOE approach craniotomy is an effective minimally invasive approach for various pathologies of the anterior cranial base and parasellar regions. With experience, giant tumors and complex vascular pathology can be addressed with this keyhole approach.

Microsurgical and endoscopic-assisted supraorbital keyhole approach for intra-suprasellar cysticercosis

“…This involves a limited incision with minimal tissue manipulation and minimizes the frontal lobe retraction, with subsequent decreased pain and rapid healing instead of conventional approaches. [ 16 , 17 , 25 ] In our opinion, SKA is an excellent option for treating lesions in the prechiasmatic and suprasellar areas because it provides a clear and direct view of the neurovascular structures.…”

“…SKA can also be limited by extensive frontal sinus pneumatization and lesions below the sphenoid wing. [ 16 ] Furthermore, retrochiasmatic lesions may pose potential complications when using SKA, and hence, a different approach (pterional or endonasal endoscopic approach), may be required. [ 17 ] An additional inconvenience is the light found through such a corridor for mSKA,[ 17 ] as we specify for the second case.…”

“…[ 15 , 17 ] In addition, some restrictions may be on handling surgical instruments during the procedure. [ 15 , 16 ] It should be mentioned that the cases being presented involve cysts with extensions into the sellar and suprasellar areas, and the authors did not encounter such a limitation.…”