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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.
Obesity, Depression, HTN, DM, Seizures, Gout, Chronic back pain.
None pertinent.
Keppra, ASA, Synthroid, Metformin, Lisinopril, Glyburide, Allorpurinol.
1. Bifrontal Craniotomy
2. Endoscopic Endonasal Approach
3. Supraorbital Keyhole Craniotomy
- Images: https://neupsykey.com/anterior-skull-base-surgery/
- Zumofen. A Review of the Literature on the Transciliary Supraorbital Keyhole Approach. World Neurosurgery 2016.
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
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.
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.
Incision:
Superior, Middle, Inferior margin of brow.
Zumofen. A Review of the Literature on the Transciliary Supraorbital Keyhole Approach. World Neurosurgery 2016.
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.
Zumofen. A Review of the Literature on the Transciliary Supraorbital Keyhole Approach. World Neurosurgery 2016.
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.
Zumofen. A Review of the Literature on the Transciliary Supraorbital Keyhole Approach. World Neurosurgery 2016.
Dimensions:
2-3 cm Width, 1.5-2 cm Height
AVOID Frontal Sinus
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.
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.
Cone Out Approach.
1. Vascular
2. Optic Nerve/ Chiasm
3. Hypothalamus/Pituitary
4. Olfactory Nerve
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.
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.
If the frontal sinus is violated :
1) Small Violation -
- Bone Wax
2) Large Violation -
- Pericranial flap (if available)
- Gelfom soaked in Betadine
Minimally Invasive Surgery
Volume 2013 (2013), Article ID 296469, 11 pages
http://dx.doi.org/10.1155/2013/296469
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.