Transciliary supraorbital keyhole approach in the management of aneurysms of anterior circulation: Operative nuances

Background : With improvement in neuroimaging, instrumentation and operative microscope optics, and with better understanding of microneuroanatomy, it is now possible to approach intracranial aneurysms of anterior circulation through a small eyebrow incision.
Aim : The objective of the study is to highlight the advantages and limitations of transciliary supraorbital keyhole craniotomy for clipping of these aneurysms.
Materials and Methods : We present our experience with 55 intracranial aneurysms in the anterior circulation in 52 consecutive patients (23 females and 29 males, age range 22-70 years) operated between 2003 and 2009. All these aneurysms were clipped by a supraorbital transciliary incision and a craniotomy measuring 2.5x1.5 cm. One patient required bilateral keyhole craniotomies for bilateral aneurysms.
Results : Of the 52 patients, 37 patients were in Grade I/II, and the rest were in Grade III-IV. Clipping could be done in all the patients, and in twelve patients there was intraoperative rupture of the aneurysm. While there was a learning curve, no limitations were apparent, and none of the patients required revision of the procedure or wrapping. None of the patients had suboptimal clip application. Postoperative check angiogram showed obliteration of the aneurysm in all the patients. Patients with preoperative Grade I/II could be discharged from the hospital within seven days, and cosmetic result was excellent in all the patients. Four patients with preoperative Grade IV died in the postoperative period due to vasospasm.
Conclusion : The transciliary supraorbital approach offers clipping of intracranial aneurysm in anterior circulation with low approach related morbidity as compared to standard approach.