OPERATIVE NUANCES

ANATOMIC AND SURGICAL BASIS OF THE SPHENOID

RIDGE KEYHOLE APPROACH FOR CEREBRAL ANEURYSMS
Edgar Nathal, M.D.,
D.M.Sc.
Division of Neurosurgery,
Department of Cerebrovascular
Surgery, National Institute of
Neurology and Neurosurgery
Manuel Velasco Suarez and
Instituto Nacional de Ciencias
Medicas y de la Nutricion
Salvador Zubiran,
Mexico City, Mexico
Juan Luis Gomez-Amador,
M.D.
Division of Neurosurgery,
Department of Cerebrovascular
Surgery, National Institute of
Neurology and Neurosurgery
Manuel Velasco Suarez,
Mexico City, Mexico
Reprint requests:
Edgar Nathal, M.D.,
Division de Neurociruga, Instituto
Nacional de Neurologia
y Neurocirugia
Manuel Velasco Suarez,
Insurgentes Sur 3877,
Tlalpan, 14269,
Mexico D.F., Mexico.
Email: nathal@edgar.to
Received, January 22, 2004.
Accepted, June 8, 2004.
IN VASCULAR NEUROSURGERY, the pterional approach has been used primarily for the
treatment of a wide variety of diseases (cavernous angiomas, arteriovenous malformations,
etc.), and it is used to take advantage of naturally occurring planes and spaces to expose
the major structures of the circle of Willis. It provides access to the major part of the
anterior circulation aneurysms and those occurring in the upper and most proximal part of
the posterior circulation. Conversely, there has been an increasing interest in the so-called
minimally invasive procedures or keyhole approaches to treating cerebral aneurysms in
specific locations. In this work, we describe a novel keyhole approach that was conceived
to achieve the angle of vision and advantages of the classic pterional approach. This
surgical approach is based on the anatomic location of the sphenoid ridge and its
relationship with the sylvian fissure and basal cisterns. The initial incision is made over the
hairline behind the external border of the eye on the side selected. A skin and muscular
flap is reflected anteriorly, and a small 3 3-cm craniotomy is completed around the
external landmarks of the sphenoid ridge. Further extradural drilling is completed down to
the anterior clinoid process. The dura is opened in a semilunar manner, and the sylvian
fissure is opened completely to reach the sylvian and basal cisterns. Thereafter, the
aneurysm is dissected and clipped according to the standard microtechnique of the
neurosurgeon. Astep-by-step description of the approach is offered in this work to facilitate
a clear understanding of it. We recommend this approach for treatment of aneurysms
arising at the anterior part of the circle of Willis. It has the advantages of less operative time,
fewer days of hospitalization, and similar morbidity and mortality compared with the
standard pterional craniotomy (5.7% on our service for nongiant ruptured aneurysms).
KEY WORDS: Cerebral aneurysm, Cerebrovascular surgery, Keyhole approach, Pterional approach,
Sphenoid ridge, Surgical anatomy
Neurosurgery 56[ONS Suppl 1]:ONS-178ONS-185, 2005 DOI: 10.1227/01.NEU.0000145967.66852.96
T
he pterional approach has been used in
neurosurgery primarily for the treatment
of a wide variety of neurosurgical disor-
ders (26, 10, 11, 16). This approach provides the
opportunity to treat lesions located in the ante-
rior, middle, and upper parts of the posterior
fossae and can be used alone or in combination
with other approaches to make possible the
management of extensive and complex tumors
of the cranial base (1, 2, 9, 1618). In vascular
neurosurgery, the pterional craniotomy is used
to take advantage of naturally occurring planes
and spaces that can be used to expose the base of
the brain and the major structures of the circle of
Willis without significant brain retraction (20,
23, 26). One of its primary anatomic landmarks
is the sphenoid ridge, which represents the bony
frontier between the frontal and temporal lobes.
During the treatment of vascular diseases, re-
moval of the sphenoid ridge down to the ante-
rior clinoid process allows a more comfortable
opening of the sylvian fissure, first exposing the
middle cerebral artery (MCA), and with further
dissection through the basal arachnoid cisterns,
opening the space to manage the ipsilateral in-
ternal carotid artery (ICA), the anterior cerebral
artery, the anterior communicating artery com-
plex, and even the contralateral ICA. Opening of
the membrane of Liliequist provides access to
the posterior circulation vessels (31, 36, 37, 40).
In other words, the standard pterional approach
offers the opportunity to treat more than 70% of
cerebral aneurysms.
Recently, there has been increasing interest
in the keyhole surgery concept, and many ap-
proaches have been reported in the literature
ONS-178 | VOLUME 56 | OPERATIVE NEUROSURGERY 1 | JANUARY 2005 www.neurosurgery-online.com
designed to minimize the exposure and handling of cerebral
tissue without compromising the surgical results and the view
of vascular and tumoral lesions (1215, 19, 3234, 44). Taking
into account that the pterional approach is probably the most
common approach in neurosurgery, we developed the sphe-
noid ridge approach as the keyhole concept of the standard
pterional craniotomy. This approach is based on a well-
planned small craniotomy, extensive bone drilling of the sphe-
noid ridge, and wide exposure and opening of the sylvian
fissure and basal cisterns to reach aneurysms at the anterior
part of the circle of Willis. In this work, we describe the
anatomic and surgical basis of this approach.
PATIENTS AND METHODS
During the period from May 2000 to July 2003, 380 patients
with cerebral aneurysms were operated on at the Division of
Neurosurgery of the National Institute of Neurology and Neu-
rosurgery Manuel Velasco Suarez and the National Institute
of Medical Sciences Salvador Zubiran, Mexico City. Of the
total patients, 132 were operated on by the senior author (EN),
and 85 patients harboring 98 aneurysms were selected for a
keyhole sphenoid ridge approach (Table 1). The surgical tech-
nique used in this group is reported here. The patients were
selected according to the position of the aneurysm in the circle
of Willis, neurological grade on admission, and the possible
existence of associated pathological conditions such as cere-
bral hematoma, severe edema, angiographic vasospasm, or
hydrocephalus. Only patients without associated pathological
conditions were selected, as well as those with neurological
Grade 0III of the Hunt and Kosnik classification (Table 2).The
remaining 47 patients did not fulfill the above criteria and
were operated on via another approach according to the char-
acteristics of the aneurysms.
SURGICAL PROCEDURE
(see video at web site)
To clarify the anatomic concepts of this approach, we di-
vided the surgical steps as follows.
Positioning of the Patient
The patient is positioned supine with the head elevated 10
to 15 degrees to ensure that the final position of the head is
above the level of the heart. The neck is maximally extended to
increase the contribution of gravity and venous drainage. The
head is rotated 45 degrees away from the side of the craniot-
omy; however, the rotation of the head may vary according to
the aneurysm location from 15 to 20 degrees for anterior
communicating artery aneurysms to 60 degrees to some MCA
aneurysms. The head is placed in a horseshoe headrest or a
three-point fixation device, such as the Mayfield-Kees head
holder.
Surgical Planning
The main sites to be identified on the scalp before applica-
tion of the surgical drapes are 1) the frontozygomatic point, 2)
the sylvian line, and 3) the pterion. The frontozygomatic point
is located on the orbital rim 2.5 cm above the level at which the
upper edge of the zygomatic arch joins the orbital rim and just
below the junction of the lateral and superior margins of the
orbital rim. The sylvian fissure is located along a line that
extends backward from the frontozygomatic point across the
lateral surface of the head to the three-quarter point (75% of
the distance between the nasion and the inion on the midline)
(29). The pterion, which represents the site on the external
surface of the cranium approximating the lateral end of the
sphenoid ridge, is located 3 cm behind the frontozygomatic
point, on the path of the sylvian fissure line and in close
TABLE 1. Location of the aneurysms
a
Location No.
Paraclinoid-ICA 9
Dorsal type 5
Superior hypophyseal 3
Ophthalmic 1
ICA-PComA 25
ICA-AChor 5
ICA-bifurcation 7
Middle cerebral artery 37
Anterior communicating artery 15
a
ICA, internal carotid artery; PComA, posterior communicating artery
segment; AChor, anterior choroidal artery segment.
TABLE 2. Comparison between the neurological grade on
admission (Hunt and Kosnik) and the Glasgow Outcome
Scale Score
a
H-K grade
Glasgow Outcome Scale score
Total
1 2 3 4 5
0 10 1 1 12
1 17 1 18
2 30 2 1 33
3 20 1 1 22
4 0
5 0
Total 77 5 2 0 1 85
a
H-K, Hunt and Kosnik.
SPHENOID RIDGE APPROACH
NEUROSURGERY VOLUME 56 | OPERATIVE NEUROSURGERY 1 | JANUARY 2005 | ONS-179
relationship with the hairline (Figs. 1 and 2). Even when this area
shows anatomic variations from one individual to another, there
is a bony depression following the main axis of the sylvian line.
If we press firmly over the temporal area beneath the temporal
muscle, this depression is easily detected. If we follow this de-
pression caudally until it crosses the hairline on the skin surface,
we are actually following the course of the sphenoid ridge up to
the pterion. Thus, the sphenoid ridge is closely related to the
vallecula of the sylvian fissure and to the MCA.
Incision
A 4- to 5-cm incision is planned at the level of the hairline,
centered at the estimated location of the end of the sphenoid
ridge (Fig. 2). After the extension of the incision has been
planned, the hair is strip-shaved 1 cm behind the hairline to
avoid hair extending into the surgical field. After the surgical
area has been wrapped, the skin is infiltrated with xylocaine
with 2% epinephrine to avoid excessive bleeding from the
superficial layers. The skin is incised over the planned line,
and skin clips are not used to stop bleeding; rather, the bleed-
ing points are cauterized with a bipolar coagulator of Malis to
avoid a bulky skin flap. If it is planned to preserve the super-
ficial temporal artery, we should locate the course of the artery
before the incision is made, because, as a result of anatomic
variations, the artery may run rostral or caudal at the border
of the incision in the areolar tissue under the skin. In addition,
the skin is dissected from the superficial temporal fascia and
retracted with silk stitches or fishhooks.
Dissection of the Superficial Layers and
Temporalis Muscle
After the skin and subcutaneous tissue are dissected, the
superficial temporal fascia and muscle are opened in the same
FIGURE 1. Intraoperative photographs showing anatomic basis (left-sided
craniotomy). A, external projection of the sphenoid ridge in relation to the
external orbital rim; the red arrow shows the frontozygomatic point, and
the black arrow points to the sylvian line at the pterion. B, schematic
position of the initial burr hole and craniotomy. The triangle shows the
additional amount of bone removed with a high-speed drill down to the
anterior clinoid process. C, intracranial projection of the sphenoid ridge
related to the external position of the pterion. D, after dural opening, the
sylvian veins overlying the sylvian fissure are seen. After dissection of the
veins, the sylvian fissure is wide open up to the basal cisterns under
microscopic magnification to release CSF and expand the surgical field.
FIGURE 2. Intraoperative photographs showing surgical procedure. A,
incision planning. The lines show the relationship of the external orbital
rim and malar bone with the incision, the expected direction of the sphe-
noid ridge (sylvian line), and the extension of the surgical incision. B, the
skin flap is elevated without the use of skin hemostats. The fascia of the
temporal muscle is exposed. C, the muscular and skin flaps have been
retracted anteriorly with fishhooks. The bone is already exposed, and the
bony depression of the sphenoid ridge, representing the anatomic and
external landmarks of the frontal and temporal lobes, is visible. D, initial
burr hole centered at the most caudal part of the surgical field centered
over the sphenoid ridge. The additional cuts are made with a craniotome.
Sometimes, a small bridge of bone remains over the sphenoid ridge at the
most rostral part of the craniotomy and is completed with a bone chisel. E,
dural exposure over the frontal and temporal lobes after drilling the sphe-
noid ridge. F, the dura mater has been opened in a semicircular manner
and retracted anteriorly. The brain is covered with blood at the subarach-
noid space. No edema is present. G, after the aneurysm has been clipped,
the dura mater is closed in a watertight manner and the bone fragment
repositioned with silk sutures or a fixation device. H, the muscular flap is
closed with an absorbable 2-0 suture, and the skin incision is closed
according to the preference of the neurosurgeon.
NATHAL AND GOMEZ-AMADOR
ONS-180 | VOLUME 56 | OPERATIVE NEUROSURGERY 1 | JANUARY 2005 www.neurosurgery-online.com
direction as the skin incision, following the natural direction of
the muscle fibers (Fig. 2). At this point, it is not necessary to
take care of the frontal branch of the facial nerve that runs
rostral to the point of incision. To date, we have not had any
patient with a postoperative lesion of the nerve. The bone is
exposed after subperiosteal dissection, and the hooks are re-
positioned to include the skin and muscular layers. The exter-
nal representation of the end of the sphenoid ridge is identi-
fied. Usually, at this point, the location of the sphenoid ridge
is felt by touch as a small depression over the bone surface,
pointing up the separation between the frontal and temporal
lobes of the brain.
Craniotomy
A single burr hole is made with a craniotome placed at the
most caudal aspect of the surgical exposure and centered over
the bony depression representing the sphenoid ridge on the
external surface of the cranium (Figs. 1C and 2C). After com-
pleting the burr hole, one can see the depression of the dura
covering the sylvian fissure and the spike-shaped bone point-
ing up the sphenoid ridge on the inner part of the cranium.
Sometimes the burr hole is deviated slightly over the frontal or
temporal area, primarily if the sphenoid ridge is very promi-
nent. In such a case, we can extend the opening with a high-
speed drill or bone rongeurs to the opposite side to completely
expose the dural folding between the frontal and temporal
areas. Thereafter, a dural dissector is used to separate the dura
mater from the bone, especially in elderly patients, to avoid
the possibility of a dural tearing with the craniotome. The
bone cut starts superiorly up to 1 cm before the temporal line,
then curving gradually anteriorly and inferiorly. At this point,
a large sphenoid ridge is sometimes encountered, and further
inferior cutting with the craniotome is blocked. In this case, a
second cut is made from the burr hole to the inferior edge of
the sphenoid wing, symmetrical with the upper cut. In this
way, an oval-shape craniotomy approximately 2 2.5 cm in
diameter is completed (Fig. 2). Sometimes, it is necessary to
use a small bone chisel to complete the cut line over the
sphenoid ridge when this structure is prominent to avoid bone
fragmentation. After the bone flap is elevated, the dura is
freed in an epidural manner away from the orbital roof and
the sphenoid wing. By use of a high-speed drill with a dia-
mond burr, the lateral part of the sphenoid wing is removed as
dictated by the individual anatomy in each patient. It is best to
remove the maximal amount of the sphenoid wing down to
the superior orbital fissure to enlarge the opening at the level
of the basal cisterns, especially for ICA or anterior communi-
cating artery aneurysms. In patients with MCA aneurysms, it
is not necessary to extend the drilling down to the anterior
clinoid process.
Dural Opening
The dura is opened in a semilunar manner, providing a
2-mm margin from the craniotomy to facilitate the dural clo-
sure, creating a flap that can be retracted anteriorly and se-
cured with sutures or small fishhooks. Even when we do not
use spinal drainage in our patients, if a spinal drainage cath-
eter was placed for cerebrospinal fluid (CSF) release at the
lumbar thecal sac, this is opened at this moment. Otherwise,
furosemide or mannitol can be used at the convenience of the
neurosurgeon. In a very few patients, we have found that the
former maneuvers were not enough to provide a slack brain;
then, a ventricular tap was performed whenever ventricular
enlargement was seen on a computed tomographic scan. From
this point, the effectiveness of the technique will rely on a
wide dissection of the sylvian fissure, avoiding the use of
brain retractors to maximize the working space.
Sylvian Fissure Dissection
At this point of the operation, the operating microscope is
brought into the field, and the surgical view will include the
sylvian fissure at the center and the frontal and temporal lobes
on both sides (Fig. 1D). The sylvian veins are identified super-
ficially. Usually, the veins run over the temporal side of the
sylvian fissure, and one to three secondary veins cross from
the frontal to the temporal side. These veins should be maxi-
mally protected. The sylvian fissure is opened superficially
over the frontal side, to avoid the veins, with the aid of an
arachnoid knife or with the tip of a simple hypodermic needle
(the preferred choice of the authors). This maneuver cuts the
superficial layer of the arachnoid and provides access to the
sylvian fissure itself. First, we go deeply into a small space,
and thereafter, we open the fissure wide. As has been reported
previously, the sylvian fissure has many anatomic variations,
and one should be familiar with them. The dissection is main-
tained totally in the subarachnoid space to minimize trauma to
any cortical surface. In cases of MCA bifurcation aneurysms,
opening the distal part of the vallecula will expose the MCA
bifurcation and the aneurysm itself. Before dissecting the an-
eurysm, we should ensure a proximal control from M1, and
the sylvian fissure is opened as far as necessary to visualize
the main trunk of the MCA. Thereafter, the aneurysm is dis-
sected and clipped. For deeper aneurysms, there is usually a
need to dissect the anterior portion of the vallecula, where the
sylvian cistern communicates with the basal cisterns. These
cisterns should be opened wide for visualization, dissection,
and clipping of the ICA or anterior communicating artery
aneurysms. With proper brain relaxation, opening of the syl-
vian fissure requires minimal brain retraction to visualize the
parasellar area. In some patients, the brain is tight at the
beginning of the dissection, and if necessary, we can make a
small opening at the carotid cistern to release CSF and then
proceed to complete the sylvian fissure opening. After dissec-
tion of the basal cisterns, we can reach the lamina terminalis to
open it and facilitate a complete relaxation of the brain. With
all these maneuvers, switching from a keyhole approach to a
larger craniotomy has never been necessary.
SPHENOID RIDGE APPROACH
NEUROSURGERY VOLUME 56 | OPERATIVE NEUROSURGERY 1 | JANUARY 2005 | ONS-181
Dural Closure and Bone Flap Placement
After the aneurysm is visualized, dissected, and clipped, a
proper hemostasis is verified. The dura mater is closed tight in
a water-seal manner with a 4-0 nylon suture. If necessary, a
small piece of muscle is used to seal small leakages of CSF. The
bone flap is fixed with silk, miniplates, or Craniofix (Aesculap
Co., Tuttlingen, Germany), and the temporal fascia and mus-
cle are closed with a 2-0 absorbable suture (Fig. 2).
Skin Closure
The skin is closed with nylon (subdermic or continuous
anchored suture) or skin staples, and usually, no drainages are
left in place. A small pad is positioned covering the line of
suture. We remove the sutures 1 week after surgery unless an
absorbable intradermic suture was used for closure (Fig. 3).
DISCUSSION
Recently, the keyhole surgery concept applied to neurosur-
gical procedures has gained acceptance among neurosur-
geons, with the understanding that the keyhole surgery is not
the miniaturization of any standard technique but rather the
natural evolution into a more precise and refined act. Until
now, many approaches have been designed to minimize the
surgical exposure. In 1971, Wilson (35) described a limited
exposure for aneurysm and tumor surgery with excellent re-
sults. Later, Brock and Dietz (8) described a small frontolateral
approach for cerebral aneurysms using the subfrontal route.
At present, one of the most used keyhole approaches for
treating cerebral aneurysms is the subfrontal transciliary ap-
proach (synonyms: frontolaterobasal, eyebrow approach) (13
15, 34, 44). This approach provides access to the majority of the
anterior circulation aneurysms and basilar top aneurysms,
except those located at the distal anterior cerebral artery, in
which an interhemispheric craniotomy is commonly used.
Some variations to the subfrontal transciliary approach have
been reported, designed to gain additional angle of vision (27,
28); however, in our experience, there are two main limitations
to this approach. At first, in some cases of MCA bifurcation
aneurysms, the M1 segment is too long, and the direction of
the dome is lateral and caudal to the surgical view from this
approach. In such a case, the amount of dissection required is
extensive, and the surgical view and work are in a very deep
plane. Furthermore, the occurrence of a thick blood clot
around the aneurysm makes the dissection even more diffi-
cult. Second, in cases of posterior communicating artery seg-
ment aneurysms, the angle of vision with the subfrontal tran-
sciliary approach is more rostral than that obtained with the
pterional approach, and visualization of the neck area of the
aneurysm is not good, primarily if the dome has a caudal
direction. In these patients, clipping may be difficult, and the
neurosurgeon will never be sure whether a remnant dome is
left unless an angiogram is performed during or after the
surgical procedure. This problem could be solved in some
patients with the aid of a surgical neuroendoscope; however,
this device is not available in all hospitals and requires previ-
ous training to be used effectively in narrow spaces.
Taking these points into consideration, the standard pteri-
onal approach provides a much better access to the MCA
region from the M1 segment to the insular branches, so dis-
section and clipping of any kind of MCA aneurysm is usually
in a more superficial plane. Also, visualization of the neck area
in cases of ICA-posterior communicating artery aneurysms is
from a more lateral angle; then, aneurysms with a dome with
a caudal direction are better visualized through this route. The
main disadvantages of the standard pterional approach are
primarily functional and cosmetic. At first, most neurosur-
geons continue to use extensive hair shaving to expose the
surgical area, even though there has been no clear demonstra-
tion that extensive hair shaving is better in preventing skin
infection, and this is sometimes psychologically distressing for
some patients. Second, even with the description of many
techniques to avoid damage to the frontal branch of the facial
nerve and temporal muscle atrophy, these problems continue
to occur frequently in neurosurgical practice; and third, if a
large incision is made over this area, there will be a marked
soft tissue edema, thus increasing the days of hospitalization.
Previously, Chehrazi (12) described the temporal transsylvian
approach for anterior circulation aneurysms; however, even
when this approach is centered over the sylvian fissure and
solves some disadvantages of the pterional approach, the line
of incision is still located behind the hairline, proceeding from
the zygomatic arch toward the anterior extent of the so-called
superior keyhole, which has disadvantages in patients with
a receding hairline. Also, not enough emphasis was placed on
an extensive drilling of the sphenoid ridge and the anterior
clinoid process, which provides a wide surgical passage for
FIGURE 3. Angiograms and photographs showing illustrative case. The
patient is a 32-year-old woman with a wide-neck unruptured right MCA
aneurysm. A and B, preoperative and postoperative angiograms. C, com-
puted tomographic 3-D reconstruction and view of the bone flap in rela-
tion to the cranium. The most rostral area corresponds to the drilled space.
D and E, patient at the second postoperative day and 3 months after sur-
gery. The incision is not cosmetically visible.
NATHAL AND GOMEZ-AMADOR
ONS-182 | VOLUME 56 | OPERATIVE NEUROSURGERY 1 | JANUARY 2005 www.neurosurgery-online.com
deeply located aneurysms, relying in this way on the use of
mannitol and hyperventilation to attain enough space.
We focused our surgical technique on trying to avoid these
problems associated with the classic pterional approach while
maintaining the excellent angle of vision that it affords. With
the sphenoid ridge approach we describe here, we do not need
to shave the hair but only 1 cm behind the natural hairline in
the selected area (Fig. 2). Second, the incision over the fascia
and temporalis muscle is almost straight, following the natural
course of the muscular fibers, thus diminishing the possibility
of muscular atrophy. Also, we do not have to make any special
kind of dissection to avoid damage to the frontal branch of the
facial nerve, because it runs almost parallel to the skin inci-
sion. Nevertheless, in our opinion, the most important point to
consider in the sphenoid ridge approach is the cisternal dis-
section and location of the aneurysm. If we analyze any stan-
dard craniotomy, our surgical corridor is through the space
created by drilling of the sphenoid ridge, which also creates a
triangular prism over which lies the vallecula. Thus, it makes
no sense to expose extensive areas of the brain behind the
sphenoid ridge while we are actually trying to go anterior and
medial to it. This approach provides the opportunity to expose
the amount of brain necessary to ensure a comfortable open-
ing of the sylvian fissure without special instrumentation and
to direct the dissection to the basal cisterns to achieve enough
space for gaining vascular control before facing the aneurysm.
Again, it should be pointed out that an unavoidable prereq-
uisite before trying to perform this approach is to have enough
skills to dissect and open the sylvian fissure and basal arach-
noid cisterns without the need of using bulky brain retractors.
The main indications for this approach are 1) all anterior
circulation aneurysms except distal anterior cerebral artery
aneurysms (Table 1), 2) nonruptured aneurysms, and 3) rup-
tured aneurysm in good neurological grade (Grades IIII of
the Hunt and Kosnik classification). On the other side, the
main contraindications to the use of this approach are 1)
aneurysms associated with a large blood clot with mass effect,
2) paraclinoid or giant aneurysms in which a high-flow bypass
is precluded, 3) subarachnoid hemorrhage associated with
brain edema and small ventricular size, and 4) patients in poor
neurological grade.
The goal of the surgical treatment for cerebral aneurysms is
to occlude the lesion without causing harm to the patient.
There was a great improvement in surgical results after intro-
duction of the surgical microscope and the description of the
microtechniques that are still in use today (3843). At present,
a new alternative for treatment of cerebral aneurysms is avail-
able through endovascular therapy. Also, a new generation of
neurosurgeons is emerging with new concepts based on min-
imally invasive neurosurgery (14, 15, 19, 30, 32, 34, 44). In this
way, new technological advances, such as neuroendoscopes
and navigators, have become a useful aid in surgical proce-
dures; however, many people are afraid that all these ad-
vances go against the precise anatomic knowledge that is
required to treat a vascular lesion. However, because small
approaches require much better anatomic planning, many
experienced neurosurgeons have moved away from classic
approaches to a keyhole surgery to treat vascular and tumoral
lesions (12, 24, 25, 34), so the reports about surgical results and
new techniques based on the keyhole concept are increasing
worldwide (7, 1315, 19, 21, 22, 27, 28, 30, 3234, 44). Perhaps
the two main concerns about the keyhole surgery are, first,
whether the surgical field we attain through one of these
approaches is enough to deal with an intracranial aneurysm,
and second, what is the possibility of solving a problem if it
occurs during operation (e.g., intraoperative aneurysm rup-
ture, etc.). The response to the first question is related to the
surgical planning itself. First, the patient should be carefully
selected before surgery according to the recommended indi-
cations. In addition, it has been our practice to achieve the
softest brain possible before trying to make any dissection
over the aneurysm. If we work with a tight brain, the results
will be as bad as with any large craniotomy under this con-
dition. If we attain enough space by releasing CSF and using
some kind of osmotic agent or any other described maneuver,
the anatomic structures will be easily confirmed and the vas-
cular control will be reached without any problems. At the
moment of the aneurysm dissection and vascular control, your
deep anatomic view should be the same as with any standard
craniotomy. The answer to the second question is related to
the surgical technique. If you have a comfortable surgical view
and vascular control before dealing with the aneurysm, any
unexpected complication, such as an intraoperative rupture,
should be managed without space limitations. In this sense,
the only condition that should be strictly observed is that the
craniotomy should be at least 3 2.5 cm in size (Fig. 2).
While using the sphenoid ridge approach, we are anticipat-
ing that the neurosurgeon will take care of the brain tissue to
avoid retraction and damage. The success of this and other
keyhole approaches relies on a wide dissection of the cisterns
and fissures to open the natural spaces surrounding the brain
tissue. It is necessary to acquire laboratory practice to know
the use of the aspirator as dissector and retractor at the same
time, as well as the use of the bipolar forceps in the same
sense. At present, on our service, 60% of cerebral aneurysms
are treated through a keyhole approach (sphenoid ridge, sub-
frontal transciliary, micro-interhemispheric). The most impor-
tant point is that our morbidity and mortality rates did not
increase with the use of this approach (5.7% for nongiant
ruptured anterior circulation aneurysms on our service) (Table
2). We now have less operative time (3.9 h with this approach
versus 5.7 h for a standard pterional craniotomy), fewer days
of hospitalization (7.3 versus 9.2 d), and fewer complications
related to the approach itself, and overall, the patients are
much more satisfied with the cosmetic results.
REFERENCES
1. Alaywan M, Sindou M: Fronto-temporal approach with orbito-zygomatic
removal: Surgical anatomy. Acta Neurochir (Wien) 104:7983, 1990.
2. Alleyne CH Jr, Barrow DL, Oyesiku NM: Combined transsphenoidal and
pterional craniotomy approach to giant pituitary tumors. Surg Neurol 57:
380390, 2002.
SPHENOID RIDGE APPROACH
NEUROSURGERY VOLUME 56 | OPERATIVE NEUROSURGERY 1 | JANUARY 2005 | ONS-183
3. Al-Mefty O: Supraorbital-pterional approach to skull base lesions. Neuro-
surgery 21:474477, 1987.
4. Anson JA: Treatment strategies for intracranial fusiform aneurysms.
Neurosurg Clin N Am 9:743753, 1998.
5. ArnoldH, HerrmannHD: Skull base chordoma withcavernous sinus involvement:
Partial or radical tumor removal? Acta Neurochir (Wien) 83:3137, 1986.
6. Backlund EO: Pterional approach for orbital decompression. Acta
Ophthalmol (Copenh) 46:535540, 1968.
7. Bognar L, Czirjak S, Madarassy G: Frontolateral keyhole craniotomy through a
superciliary skin incision in children. Childs Nerv Syst 19:765768, 2003.
8. Brock M, Dietz H: The small frontolateral approach for the microsurgical treatment
of intracranial aneurysms. Neurochirurgia (Stuttg) 21:185191, 1978.
9. Cantore G, Santoro A, Da Pian R: Spontaneous occlusion of supraclinoid
aneurysms after the creation of extra-intracranial bypasses using long grafts:
Report of two cases. Neurosurgery 44:216220, 1999.
10. Carmel PW, Antunes JL, Chang CH: Craniopharyngiomas in children.
Neurosurgery 11:382389, 1982.
11. Carrizo A, Basso A: Current surgical treatment for sphenoorbital meningi-
omas. Surg Neurol 50:574578, 1998.
12. Chehrazi BB: A temporal transsylvian approach to anterior circulation an-
eurysms. Neurosurgery 30:957961, 1992.
13. Czirjak S, Szeifert GT: Surgical experience with frontolateral keyhole crani-
otomy through a superciliary skin incision. Neurosurgery 48:145150, 2001.
14. Czirjak S, Nyary I, Futo J, Szeifert GT: Bilateral supraorbital keyhole ap-
proach for multiple aneurysms via superciliary skin incisions. Surg Neurol
57:314324, 2002.
15. Dare AO, Landi MK, Lopes DK, Grand W: Eyebrow incision for combined
orbital osteotomy and supraorbital minicraniotomy: Application to aneurysms
of the anterior circulationTechnical note. J Neurosurg 95:714718, 2001.
16. Day AL: Aneurysms of the ophthalmic segment: A clinical and anatomical
analysis. J Neurosurg 72:667691, 1990.
17. Day JD, Giannotta SL, Fukushima T: Extradural temporopolar approach to
lesions of the upper basilar artery and infrachiasmatic region. J Neurosurg
81:230235, 1994.
18. Dolenc VV: A combined transorbital-transclinoid and transsylvian approach
to carotid-ophthalmic aneurysms without retraction of the brain. Acta
Neurochir Suppl (Wien) 72:8997, 1999.
19. Fukushima T, Miyazaki S, Takusagawa Y, Reichman M: Unilateral inter-
hemispheric keyhole approach for anterior cerebral artery aneurysms. Acta
Neurochir Suppl (Wien) 53:4247, 1991.
20. Hua SE, Gluckman TJ, Batjer HH: Middle cerebral artery occlusion after
pterional approach to basilar bifurcation aneurysm: Technical case report.
Neurosurgery 39:10501054, 1996.
21. Kang SD: Pterional craniotomy without keyhole to supratentorial cerebral
aneurysms: Technical note. Surg Neurol 60:457462, 2003.
22. Kocaogullar Y, Avci E, Fossett D, Caputy A: The extradural subtemporal
keyhole approach to the sphenocavernous region: Anatomic considerations.
Minim Invasive Neurosurg 46:100105, 2003.
23. Nagasawa S, Ohta T, Tsuda E: Surgical results and the related topographic
anatomy in paraclinoid internal carotid artery aneurysms. Neurol Res 18:
401408, 1996.
24. Perneczky A, Boecher-Schwarz HG: Endoscope-assisted microsurgery for
cerebral aneurysms. Neurol Med Chir (Tokyo) 38[Suppl]:3334, 1998.
25. Perneczky A, Fries G: Use of a new aneurysm clip with an inverted-spring
mechanism to facilitate visual control during clip application: Technical
note. J Neurosurg 82:898899, 1995.
26. Pritz MB, Chandler WF: The transsylvian approach to middle cerebral artery
bifurcation/trifurcation aneurysms. Surg Neurol 41:217220, 1994.
27. Ramos-Zuiga R: The trans-supraorbital approach. Minim Invasive
Neurosurg 42:133136, 1999.
28. Ramos-Zuiga R, Velazquez H, Barajas MA, Lopez R, Sanchez E, Trejo S:
Trans-supraorbital approach to supratentorial aneurysms. Neurosurgery
51:125131, 2002.
29. Rhoton AL Jr: Operative techniques and instrumentation for neurosurgery.
Neurosurgery 53:907934, 2003.
30. Schramm J, Kral T, Clusmann H: Transsylvian keyhole functional hemi-
spherectomy. Neurosurgery 49:891901, 2001.
31. Sugita K, Kobayashi S, Shintani A, Mutsuga N: Microneurosurgery for
aneurysms of the basilar artery. J Neurosurg 51:615620, 1979.
32. Taniguchi M, Perneczky A: Subtemporal keyhole approach to the suprasel-
lar and petroclival region: Microanatomic considerations and clinical appli-
cation. Neurosurgery 41:592601, 1997.
33. Tobler WD, Stanley M: Stereotactic resection of brain metastases in eloquent
brain. Stereotact Funct Neurosurg 63:3844, 1994.
34. van Lindert E, Perneczky A, Fries G, Pierangeli E: The supraorbital keyhole
approach to supratentorial aneurysms: Concept and technique. Surg Neurol
49:481490, 1998.
35. Wilson D: Limited exposure in cerebral surgery. J Neurosurg 34:102106,
1971.
36. Wright DC, Wilson CB: Surgical treatment of basilar aneurysms. Neuro-
surgery 5:325333, 1979.
37. Yamaura A, Ise H, Makino H: Treatment of aneurysms arising from the
terminal portion of the basilar artery: With special reference to the radio-
metric study and accessibility of trans-sylvian approach. Neurol Med Chir
(Tokyo) 22:521532, 1982.
38. Yasargil MG: The advent of microsurgery. Mt Sinai J Med 64:164165, 1997.
39. Yasargil MG, Fox JL: The microsurgical approach to intracranial aneurysms.
Surg Neurol 3:714, 1975.
40. Yasargil MG, Antic J, Laciga R, Jain KK, Hodosh RM, Smith RD: Microsur-
gical pterional approach to aneurysms of the basilar bifurcation. Surg
Neurol 6:8391, 1976.
41. Yasargil MG, Boehm WB, Ho RE: Microsurgical treatment of cerebral aneu-
rysms at the bifurcation of the internal carotid artery. Acta Neurochir
(Wien) 41:6172, 1978.
42. Yasargil MG, Reichman MV, Kubik S: Preservation of the frontotemporal
branch of the facial nerve using the interfascial temporalis flap for pterional
craniotomy: Technical article. J Neurosurg 67:463466, 1987.
43. Yasargil MG, Vise WM, Bader DC: Technical adjuncts in neurosurgery. Surg
Neurol 8:331336, 1977.
44. Zhao J, Wang S, Sui D: Treatment of intracranial anterior circulatory aneu-
rysms via keyhole approach [in Chinese]. Zhonghua Yi Xue Za Zhi 81:323
325, 2001.
COMMENTS
M
inimally invasive surgery constantly struggles to perfect
the balance between minimizing tissue trauma and
maintaining maximal effectiveness. In aneurysm surgery, ex-
posure is everything. No approach should compromise the
principal goals of surgery: safe dissection of the aneurysm,
preservation of the perforating vessels, and complete exclu-
sion of the aneurysm from the circulation in a manner that
neither endangers the parent vessels nor leaves a remnant.
The optimal angle of attack for dissection and clipping
varies for each aneurysm on the basis of its location on the
vascular tree, the orientation of its neck, and the position of
adjacent neurovascular structures. The authors approach
seems adequate to access aneurysms of the middle cerebral
artery distribution and most aneurysms arising from branches
of the internal carotid artery. It does limit the range of avail-
able angles in the axial plane from the frontal trajectory.
For most aneurysms involving the anterior circle of Willis
and the upper posterior circulation, we favor variations of the
orbitozygomatic approach. Although more invasive, the mod-
ified supraorbital and full orbitozygomatic approaches offer
much wider access and a broader range of possible angles of
attack than the keyhole approach. The orbitozygomatic ap-
proach is well tolerated, is associated with a low rate of
morbidity, and is easily mastered. The larger opening and
NATHAL AND GOMEZ-AMADOR
ONS-184 | VOLUME 56 | OPERATIVE NEUROSURGERY 1 | JANUARY 2005 www.neurosurgery-online.com
more extensive dissection are the costs paid to achieve the best
possible clipping.
The above being said, the goals of the minimally invasive
approach are laudable. In selected cases in which the anatomy
is favorable, equally good results may well be achieved
through a smaller opening. The authors technique is one
option, and its efficacy is validated by their good results.
Peter Nakaji
Robert F. Spetzler
Phoenix, Arizona
I
n this well-written report, Nathal and Gomez-Amador de-
scribe the sphenoid ridge minimally invasive approach for
cerebral aneurysms. The described approach has a number of
key limitations. The limited bony opening (3 3 cm) limits the
opening of the sylvian fissure and thus limits access and visual-
ization of aneurysmal parent vessels and associated perforators.
The limited access would in turn increase the tendency toward
more significant brain retraction. The strategy of clip reconstruc-
tion of the aneurysm and circumferential study of and oblitera-
tion of the aneurysm is limited. In situations in which untoward
events occur, i.e., intraoperative aneurysmal rupture, the surgeon
would be limited in effectively controlling the situation with
temporary clips in a reasonable manner and thus increasing the
morbidity of the procedure.
The pterional transsylvian approach has been time-tested in the
effective management of cerebral aneurysms as well as in the sce-
narios mentioned above. Interestingly, the incision described by the
authors (5 cm) is not substantially shorter than that of the pterional
approach, whichwouldaddonly a fewadditional centimeters, with
no significant difference in the cosmetic outcome.
M. Gazi Yasargil
Little Rock, Arkansas
Saleem I. Abdulrauf
St. Louis, Missouri
Drawing of an aneurysm surgery. Inset on the
left shows the operative entry with Dandys
concealed incision. Inset on the right shows
clip placed on the neck of the aneurysm and the
cautery shriveling the sac. Drawing by Dorcas
Hager Padget during her work with Dandy,
1929 to 1946 (from, Dandy WE: The Brain,
Hagerstown, W.F. Prior Co., Inc., 1966).
SPHENOID RIDGE APPROACH
NEUROSURGERY VOLUME 56 | OPERATIVE NEUROSURGERY 1 | JANUARY 2005 | ONS-185