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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

2

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.

Conclusion

.

The End

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