Supraorbital Eyebrow Craniotomy for an ACoA Aneurysm
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This video reviews technical analysis for a supraorbital "eye-brow" craniotomy, for a clip ligation of a 10 millimeter and true communicating artery aneurysm as demonstrated here, pointing inferiorly with a very broad base. This is the positioning and incision right above the eyebrow. I placed incision right above the brow and not within it to avoid the risk of alopecia, bipolar cautery and coagulation is minimized during a skin incision. The scalp is mobilized using fish hooks, generously. The keyhole is exposed on the left side. In this case, I did not feel removal of the rim of the orbit was possible since the aneurysm was pointing inferiorly however, removal of the rim can expand the operative corridor as necessary. Now the inferior aspect of the craniotomy is being further drilled away to be flat just to the level of the roof of the orbit. The dura is open in a curvilinear fashion. Gentle mobilization and elevation of the frontal lobe allowed me to open the Sylvian fissure and release CSF to achieve further brain relaxation. The anterior limb of the Sylvian fissure is now open to allow the frontal lobe to fall away. Next, the optic nerve and carotid artery are exposed. You can see the optic nerve and carotid artery just underneath the arachnoid membranes. Here is at the magnified view, demonstrating our working zone. The frontal lobe is now mobilized away from the ipsilateral optic nerve. The arachnoid membranes are sharply cut. Here's the carotid artery and the medial perforators and the posterior communicating artery. I'm just demonstrating the reach of this approach even to the posterior wall of the carotid artery. Here is A-1, proximal control is secured. We'll move more anteriorly and find the dome of the aneurysm. You can see the dome is buried underneath the frontal lobe. Opening the arachnoid membranes contralaterally over the optic nerve would mobilize the frontal lobe further. Here is exposure of a blister on the dome of the aneurysm and careful mobilization of the cap of frontal lobe over the aneurysm. You can see fixed retractors are not used in gentle retraction, allows exposure of the aneurysm adequately. Temporary clip was placed on A-1. One of the perforators was sharply resected over the neck. You can see ipsilateral A-2, contralateral, A-2 right here, as well as A-1. And here is the neck of the aneurysm. The aneurysm is relatively atherosclerotic. After two minutes of brief perfusion, the temporary clip is replaced. You can see another dome of the aneurysm demonstrated here. I'm going to place a clip right at this juncture. The first angled clip caught most of the proximal neck of the aneurysm, however, there is a residual aneurysm neck distally. The brain was re-perfused. The temporary clip was replaced and the angled clip was advanced, however, this clip was honorable to catch the entire distal portion of the neck of the aneurysm despite its advancement. This is partially related to the fact that there is a little space between the ipsilateral A-2 and the neck of the aneurysm. I repositioned, then clip as far as I can without compromising the ipsilateral A-2 here. You can see under direct vision, the clip is advanced. The lumina of A-2 is not compromised. Despite this maneuver residual aneurysm neck was detected as you can see here, I created additional space between the ipsilateral A-2 and the aneurysm neck, and placed a fenestrated clip across the neck of the aneurysm to catch that distal residual neck. This allowed a complete exclusion of the aneurysm from the entire circulation. Direct vision is necessary to make sure that the blades are not necessarily on top of each other, but rather are in tandem. The first clip provides additional space for the second clip to work through. Here's the final fine adjustments to make sure that the clip is sitting just where it needs to be. Gentle maneuvers would allow a nice fit for the aneurysm neck and complete exclusion of the aneurysm. You can see intraoperative fluorescein angiography, which is superior to ICG in these small locations to demonstrate complete exclusion of the aneurysm and seal of surrounding vessels. Here's the condition of the brain at the end of the operation. Closure is standard, using cranioplasty and postoperative angiogram revealed complete exclusion of the aneurysm without any complications. Again, here is the result of the postoperative angiogram and the two weeks photo demonstrates a good cosmetic result. Thank you.
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