Supraorbital Craniotomy In Neurosurgery:

Dr Saurav HamalANIAS.

  Historical Evolution• In 1900 Krause first demonstrated supra-orbital, subfrontal approach

on cadaver, then eight years later he reported the first  resection of skull base meningioma through this approach.

• In 1913, Frazier advocated a supraorbital ridge resection, which was found useful in surgery for pituitary adenomas.

• In the 1990, Perneczky  and  colleagues  popularized the keyhole concept and the technique commonly used today, the supraorbital keyhole craniotomy. The evolution, however, began with Fedor Krause's .

• More recently, Jane  and  Delashaw  , described a supraorbital craniotomy in the approach to orbital tumors. Other variants have been proposed by Al-Mefty et al.

Neurology India, Vol. 57, No. 5, September-October, 2009, pp. 599-606

Indications:-

1.Aneurysm of Anterior circulation except those of distal anterior cerebral artery.

2.For high positioned basilar bifurcation of basilar-Superior cerebellar artery aneurysm.

3.Tumor of anterior cranial fossa, sphenoid ridge.

4.Pathologies of sellar and suprasellar region.

Location that can be assesed after supraorbital craniotomy:-

Ipsilateral Midline

Orbital roof, CN I, II, III, IV.Anterior & Posterior clinoid process.Roof and lateral wall of Cavernous Sinus.Basal Frontal Lobe, Gyrus rectus, Sylvian fissure.Anteromedial temporal lobe. Uncus hippocampi.ICA, Opth.Artery, PCoA, AchA including perforator.A1, A2,M1, M2 including perforator.P1,P2, SCA including perforator,Superficial temporal vein.

Crista Galli.Olfactory groove, Planum sphenoidale.Tuberculum sellae.Lamina terminalis.Anterior third ventriclePituitary stalk.Interpeduncular fossa.ACoA, Distal Basilar Artery with perforator.

Technique:-1. Positioning:-

- Head is Elevated.- Head is Extended as it allows relaxation of

frontal lobe.

- Contralateral rotation:   For lateral Suprasellar and temporomesial lesion - 20 degree.

For Anterior Suprasellar /Planum sphenoidale lesion - 30 degree.

For cribriform plate lesion- 45 degree. For Olfactory groove lesion - 60 degree.Furthur adjusment of view can be done by rotating

the operating table during surgery.

.

2. Skin incision-Type-Superciliary, transciliary,

transpalpebral.- The incision is made in the lateral

2/3rd of eyebrow, atleast 5mm lateral to the supraorbital notch.

- 3-10mm in size.- Initial incision via skin and dermis

only.- S.c dissection,more dorsally and

cutting along the fibre of orbicularis oculi, pericranium and temporalis .

.

• Craniotomy- Supraorbital craniotomy, bone flap

with shape of “D”.- Dura is opened in semilunar

fashion with base at orbital rim.

- The limitation with the lighting of microscope deep down a narrow corridor can be overcome by Endoscope , which can be held by assistant or retractor arm.

- A second look with endoscope can also allow visualization of gross resection of lesion.

Complication:-

-  Common surgical complication like Bleeding, infection etc.

- Complication related to anesthesia

- Complication relation to craniotomy:

1.Depressed deformities in the frontotemporal area which result from temporal muscle atrophy .

- Complication due to incision:

1. Transient loss of supraorbital sensation(7.5%) 2. Frontal paresis (5.5%)3. Opening of frontal sinus can cause CSF leak(4%)4. Burning of eyebrow due to microscopic light on 100% intensity. (Not seen with intensity below 70%).5. Bone flap resorption.

Some operative variant:

1.Lateral variation:- the essence of this variation is to partially remove the lesser sphenoid wing exposing the frontal and temporal dura mater. 

Also on removing clinoid process, paraclinoid segment of ICA can be visualised.

2.Medial Modification: The essence of this approach is

surgical view of suprasellar and interhemispheric structure.

With possibility of interhemispheric and subfrontal dissection.

3.Basal variation: The essence of this approach is to gain more oblique view of deep seated prepontine and interpeduncular region via subfrontal exposure after removing orbital rim and partial removal of orbital roof.

Some studies on supraorbital incision and craniotomy:

1. Shanno  et  al.,developed an image-guided suprabrow approach to treat a series of 72 patients and concluded that this approach provides excellent exposure of the orbit, anterior fossa, and parasellar region.

2. Perneczky et al use of this approach to treat 197 aneurysms. The vast majority of the aneurysms (94%) could be effectively clipped.

3. Menovsky  et  al. described the supraorbital approach combined to neuroendoscopy to treat aneurysm and tumor located in the interpeduncular fossa.

ILLUSTRATION OF OUR CASES:-1.A  62 yr f presented with c/o headache on and off associated with vomiting since 1 yr &

decreasing vision, progressive and now since 2-3 week she cant see thing properly.O/e – Thin built, ill looking,GCS -15/15, Pupil b/l nonreactive 1mm .Visual acuity -NPL.CNS – No other focal deficit except vision loss.Chest/CVS/P/A – wnl.Diagnosis:- Craniopharyngioma

Tumor being excisedTumor has been removed completely.

Intraoperative picture:

Intraoperative video:

Post-Operative pics:

Histopathology :-Adamantinomatous craniopharyngioma WHO Grade1.

2.A 50 yr female presented with c/o headache , decrease vision 6month .no h/o htn.dm.O/e - GCS-15/15, Visual acuity right eye –npl, left eye finger count at 6feet.No other focal deficit,Systemic examination – normal. Diagnosis:- Tuberculum sella meningioma.

Intraoperative video:

Post-Operative pics:

HPE- Transitional Meningioma WHO grade 1.

3.A 26 yr male presented with c/o RTA 10am yesterday , LOC ½ hr, no ent bleed, vomiting, seizure.

On arrival GCS-13/15, Pupil B/L 2mm and reactive, right side face and chin abrasion.

Systemic examination - normal.

Right MCA Aneurysm.

Intraop picture of clipping of aneurysm. After clipping of Aneurysm.

Intraoperative pictures:

Intraoperative video:

Postoperative pics:

Advantage

1.Less time consuming.

2.Minimum brain retraction with good exposure of anterior fossa, sellar, suprasellar and sylvian cistern.

3.Smooth postoperative period and Decrease hospital stay for patient.

4.Less complication.

Disadvantage

1.Difficult for less experience surgeon.

2. Diminished opportunity for a change of plan if unexpected findings occur during surgery.

3.Limited size for surgical corridor.

4.Risk of complication like visible skin scar. supraorbital numbness,CSF fistula and eyelid paresis.

Conclusion• Since the introduction in 1900, numerous shortcomings of this approach

has been overcomed.

• Supraorbital keyhole approach should be considered as part of the neurosurgical armamentarium to manage skull base lesions when indicated and not to replace other well recognized skull base approaches.

• Simpler lesion should be performed before moving on to larger, complex lesions.

• Endoscopy can play a major role in improving visualisation through the corridor.

• With consideration of minor details, superb cosmesis can be obtained with minimal complication.

References:1.The supraorbital keyhole craniotomy through eyebrow incision, its origin and

evolution.D.Ryan ormond.minim invasive surg.2013:296469.2,.

2. Arquivos de Neuro-Psiquiatria :Yvens Barbosa Fernandes, Daniel Maitrot, Pierre Kehrli, Oswaldo Ignácio de Tella Jr, Ricardo Ramina, Guilherme Borges Print version ISSN 0004-282X.

3. George jallo MD , John hopkins university Baltimore.

4.Keyhole approach in Neurosurgery. A perneczky, R Reisch.

Dr Saurav Hamal.