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Keyhole Supraorbital Craniotomy
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Preop Presentation -
Supraorbital Keyhole Craniotomy
Amir Goodarzi MD PGY4
UCDMC Neurosurgery
HPI
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PC is a 64 year old woman with hx of Obesity, HTN, DM, and a subfrontal intracranial mass diagnosed during workup for two generalized tonic clonic seizures in July 2016. She has noted progressive decline in her balance, coordination, and short term memory since 2013. She also admits to intermittent speech difficulties. She notes subtle changes in her sensitivity to different smells, however she is still able to smell different scents. She denies any visual dysfunction.
PMHx
Obesity, Depression, HTN, DM, Seizures, Gout, Chronic back pain.
PSHx and Social Hx
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None pertinent.
Medications
Keppra, ASA, Synthroid, Metformin, Lisinopril, Glyburide, Allorpurinol.
Imaging
+
DDX
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Surgical Approaches
1. Bifrontal Craniotomy
2. Endoscopic Endonasal Approach
3. Supraorbital Keyhole Craniotomy
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- Images: https://neupsykey.com/anterior-skull-base-surgery/
- Zumofen. A Review of the Literature on the Transciliary Supraorbital Keyhole Approach. World Neurosurgery 2016.
Indications
1. Anterior Circulation Aneurysms
2. Anterior Cranial Fossa Tumors, Sphenoid Ridge tumors (Anterior tumors limited by bone exposure and frontal sinus)
3. Sellar/Suprasellar region pathology
Indications
Limitations: Frontal Sinus, Size of Pathology, Being too anterior on the floor
- Zumofen. A Review of the Literature on the Transciliary Supraorbital Keyhole Approach. World Neurosurgery 2016.
Positioning
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The Lindert et al. Supraorbital Keyhole Approach to Supratentorial Aneurysms: Concept and Technique. Surgical Neurology
Turn head more if the lesion is midline / Sellar. Goal to have the craniotomy above the lesion.
Anatomy of an Incision
Incision:
Superior, Middle, Inferior margin of brow.
Anatomy of an Incision
Zumofen. A Review of the Literature on the Transciliary Supraorbital Keyhole Approach. World Neurosurgery 2016.
Margins
Location: Lateral 2/3 of brow.
Medial: Supraorbital Notch (~5mm lateral to it)
Lateral: Superior Temporal Line
Note size and lateral extension of frontal sinus.
Margins
Zumofen. A Review of the Literature on the Transciliary Supraorbital Keyhole Approach. World Neurosurgery 2016.
Dissect and Drill
1. Sharp dissection through the dermis and muscle layers, perserving pericranium.
2. C shaped pericranial flap.
3. Expose McCarty's Keyhole with minimal temporalis muscle elevation (*).
Note: Remain subperiosteal / below muscle to avoid injury to the frontalis branch of facial nerve.
Dissect and Drill
Zumofen. A Review of the Literature on the Transciliary Supraorbital Keyhole Approach. World Neurosurgery 2016.
Craniotomy
Dimensions:
2-3 cm Width, 1.5-2 cm Height
AVOID Frontal Sinus
Craniotomy
Drill Inner table flush with frontal fossa floor.
Drill any ridges in orbital roof / fronta fossa floor.
C Shaped dural opening.
Zumofen. A Review of the Literature on the Transciliary Supraorbital Keyhole Approach. World Neurosurgery 2016.
Intradural Portion
1. The frontal lobe is gently retraction.
2. Wide opening of the prechiasmatic, opticocarotid, and carotid-oculomotor cisterns using blunt and sharp dissection to remove CSF.
3. Once pathology addressed.
4. Dura primarily repaired.
5. Bone flap cranioplasty with small titanium plate.
6. Soft tissue reapproximated, subcuticular skin
closure.
Intradural Portion
Cone Out Approach.
Dangers
1. Vascular
2. Optic Nerve/ Chiasm
3. Hypothalamus/Pituitary
4. Olfactory Nerve
Simpsons Grading
Grade 1: Gross total resection of tumor and all dural/bone extension.
Grade 2: Gross total resection of tumor and cautery of all dural extensions.
Grade 3: Gross total resection of tumor without complete removal of extension.
Grade 4: Partial resection.
Grade 5: Decompression/Biopsy.
Simpsons Grading
Complications
1. Chewing difficulty and pain (temporalis muscle) ~6%
2. Frontalis branch facial nerve palsy ~5%
3. Hyposmia (Olfactory nerve injury)
4. Supraorbital nerve injury (forehead anesthesia) ~5%
5. CSF Fistula (violation of frontal sinus) ~4%
Zumofen. A Review of the Literature on the Transciliary Supraorbital Keyhole Approach. World Neurosurgery 2016.
Frontal Sinus Violation
If the frontal sinus is violated :
1) Small Violation -
- Bone Wax
2) Large Violation -
- Pericranial flap (if available)
- Gelfom soaked in Betadine
Frontal Sinus Violation
Minimally Invasive Surgery
Volume 2013 (2013), Article ID 296469, 11 pages
http://dx.doi.org/10.1155/2013/296469
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Study Details
Conclusion
1. When indicated, allows for minimally invasive approach to skull base.
2. Higher learning curve given limited surgical corridor .
3. Allows for good cosmetic outcomes, lower hospital stays, and low complication rates in hands of experienced surgeons.