Introduction: Aneurysms of the anterior circulation have been approached by the pterional craniotomy for decades, but the search for smaller incisions and craniotomies led to the development of keyhole approaches. We sought the most relevant evidence-based data, to establish the safety of the less invasive cranial approaches for anterior circulation aneurysms.
Methods: This study consist of a systematic review according to the recommendations of Cochrane and PRISMA, proceeding to conduct meta-analysis when plausible. The search strategy was conducted in Embase, PubMed and Scopus, through January 2017. Terms used included variants for aneurysm surgery, pterional, minipterional and supraorbital craniotomies. Safety were measured by the intraoperative rupture rates.
Results: A total of 8189 articles were found, with only 37 included in the final analysis. No randomized controlled trial was found. The included articles did sum 3719 aneurysms treated, 661 by minipterional and 3.058 by supraorbital approaches. The intraoperative aneurysm rupture rates (including unruptured and previously ruptured aneurysms) were 7,8% for minipterional and 7,0% for supraorbital approaches. A high number of 60% and 55%, respectively, of the articles didn’t mention or provided enough data of intraoperative aneurysm ruptures. There’s a lack of uniformity throughout the articles, from the surgery variations (i.e. transcilliary or transpalpebral incisions; with or without orbitotomies) to the description and outcome measurements, hampering adequate correlations.
Conclusions: There's very little and weak evidence to address the real safety of less invasive cranial approaches for anterior circulation aneurysms. With the provided best evidence we could found, the minimally invasive approaches for anterior circulation aneurysms seems as safe as the standard approaches. There wasn’t enough information to adequately analyze surgical complications and outcomes.
Patient Care: We seek to examen the best evidence-based care to the treatment of aneurysms through less invasive surgeries.
Learning Objectives: By the conclusion of this session, participants should be able to:
1- Review the most common Minimally Invasive Approaches for Anterior Circulation Aneurysms;
2- Know the safety of the less invasive surgeries;
3- Discuss the lack of evidence and trials on the neurosurgical field.
References: 1. Yasargil MG, Fox JL: The microsurgical approach to intracranial aneurysms. Surg Neurol 1975; 3: 7-14
2. Figueiredo EG, Deshmukh P, Nakaji P, Crusius MU, Crawford N, Spetzler RF, Preul MC: The minipterional craniotomy: technical description and anatomic assessment. Neurosurgery 2007; 61: 256-64; discussion 64-5
3. van Lindert E, Perneczky A, Fries G, Pierangeli E: The supraorbital keyhole approach to supratentorial aneurysms: concept and technique. Surg Neurol 1998; 49: 481-9; discussion 9-90
4. Wong JH, Tymianski R, Radovanovic I, Tymianski M: Minimally Invasive Microsurgery for Cerebral Aneurysms. Stroke 2015; 46: 2699-706
5. Fischer G, Stadie A, Reisch R, Hopf NJ, Fries G, Bocher-Schwarz H, van Lindert E, Ungersbock K, Knosp E, Oertel J, Perneczky A: The keyhole concept in aneurysm surgery: results of the past 20 years. Neurosurgery 2011; 68: 45-51; discussion
6. Choi YJ, Son W, Park KS, Park J: Intradural Procedural Time to Assess Technical Difficulty of Superciliary Keyhole and Pterional Approaches for Unruptured Middle Cerebral Artery Aneurysms. J Korean Neurosurg Soc 2016; 59: 564-9
7. Hsu CE, Lin TK, Lee MH, Lee ST, Chang CN, Lin CL, Hsu YH, Huang YC, Hsieh TC, Chang CJ: The Impact of Surgical Experience on Major Intraoperative Aneurysm Rupture and Their Consequences on Outcome: A Multivariate Analysis of 538 Microsurgical Clipping Cases. PLoS One 2016; 11: e0151805
8. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D: The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009; 339: b2700
9. Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA, Cochrane Bias Methods G, Cochrane Statistical Methods G: The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928