The Minimally Invasive Supraorbital Subfrontal Key-Hole Approach for Surgical Treatment of Temporomesial Lesions of the Dominant Hemisphere

Abstract

Introduction: Surgery in the temporomesial region is generally performed using a subtemporal, transtemporal, or pterional-transsylvian approach. However, these approaches may lead to approach-related trauma of the temporal lobe and frontotemporal operculum with subsequent postoperative neurological deficits. Iatrogenic traumatisation is especially significant if surgery is performed in the dominant hemisphere.

Methods: During a five-year period between January 2003 and December 2007, we have approached the temporomesial region in 21 cases via the supraorbital approach. In 15 cases, the lesion was located within the dominant hemisphere, all lesions had space-occupying effects. In all cases, meticulous approach planning was performed, demonstrating a close proximity of the lesion to the pial surface on the upper anterior mesial aspect of the temporal lobe. An extension within the parahippocampal gyrus or with deep temporobasal tumor growth below the sphenoid wing were considered as exclusion criteria for using the supraorbital approach.

Results: In all cases surgery was performed without intraoperative complications. Pathological investigation showed 7 low-grade astrocytomas, 4 high-grade astrocytomas, 2 gangliogliomas and 2 cavernomas. Early postoperative MRI scans confirmed a complete removal of the lesion in 14 cases. In one case of a subtotal resection, the residual tumor was removed through a posterior subtemporal approach. The postoperative neurological examination was unchanged in 14 cases. In one case a transient hemiparesis was observed. In patients with dominant-sided lesions no speech or mental deficits were present.

Conclusion: In selected cases, the minimally invasive supraorbital craniotomy offers excellent surgical efficiency in the temporomesial region with no approach-related morbidity compared to a standard transtemporal or pterional-transsylvian approach.

Key words

eyebrow skin incision - minimally invasive neurosurgery - preoperative planning - supraorbital approach - temporomesial lesions

References

• 1 Jorge CL, Nagahashi-Marie SK, Pereira CC. et al . Clinical characteristics and surgical outcome of patients with temporal lobe tumors and epilepsy.  Arq Neuropsiquiart. 2000;  58 1002-1008
• 2 Schramm J, Kral T, Grunwald T. et al . Surgical treatment for neocortical temporal lobe epilepsy: clinical and surgical aspects and seizure outcome.  J Neurosurg. 2001;  94 33-42
• 3 Smith KA, Spetzler RF. Supratentorial-infraoccipital approach for posteromedial temporal lobe lesions.  J Neurosurg. 1995;  82 940-944
• 4 Yonekawa Y, Imhof HG, Taub E. et al . Supracerebellar transtentorial approach to posterior temporomedial structures.  J Neurosurg. 2001;  94 339-345
• 5 Otsubo H, Hoffman HJ, Humpreys RP. et al . Evaluation, surgical approach and outcome of seizure in patients with gangliogliomas.  Pediatr Neurosurg. 1990;  16 208-212
• 6 Santoro A, Salvati M, Frati A. et al . Surgical approaches to tumors of the lateral ventricles in the dominant hemisphere.  J Neurosurg Sci. 2002;  46 60-65
• 7 Vajkoczy P, Krakow K, Stodieck S. et al . Modified approach for selective treatment of temporal lobe epilepsy: transsylvian-transcisternal mesial en bloc resection.  J Neurosurg. 1998;  88 855-862
• 8 Gleissner U, Sassen R, Lendt M. et al . Pre- and postoperative verbal memory in pediatric patients with temporal lobe epilepsy.  Epilepsy Res. 2002;  51 287-296
• 9 Helmstaedter C, Reuber M, Elger C. Interaction of cognitive aging and memory deficits related to epilepsy surgery.  Ann Neurol. 2002;  52 89-94
• 10 Hori T, Tabuchi S, Kurosaki M. et al . Subtemoral amygdalohippocampectomy for treating medical intractable temporal lobe epilepsy.  Neurosurgery. 1993;  33 50-56
• 11 Andoh T, Shinoda J, Miwa Y. et al . Tumors at the trigone of the lateral ventricle – clinical analysis of eight cases.  Neurol Med Chir. 1990;  30 676-684
• 12 Arita K, Kurisu K, Iida K. et al . Surgical treatment for intractable epilepsy caused by cavernous angioma in the temporal lobe of the dominant hemisphere – three case reports.  Neurol Med Chir. 2000;  40 439-445
• 13 Clusmann H, Schramm J, Kral T. et al . Prognostic factors and outcome after different types of resection for temporal lobe epilepsy.  J Neurosurg. 2002;  97 1131-1141
• 14 Fries G, Perneczky A. Endoscope-assisted keyhole surgery for aneurysms of the anterior circulation and the basilar apex.  Operative Techniques in Neurosurgery. 2000;  3 216-230
• 15 Perneczky A. Planning strategies for the suprasellar region. Philosophy of approaches.  Neurosurgeons. 1992;  11 343-348
• 16 Perneczky A, Fries G. Endoscope-assisted brain surgery: Part 1 – Evolution, basic concept, and current technique.  Neurosurgery. 1998;  42 219-225
• 17 Perneczky A, Müller-Forell W, van Lindert E. et al . Keyhole Concept in Neurosurgery. Stuttgart, New York: Thieme Medical Publishers 1999
• 18 Krause F. Chirurgie des Gehirns und Rückenmarks nach eigenen Erfahrungen. Vol. 1. Urban & Schwarzenberg, Berlin 1908
• 19 Brock M, Dietz H. The small frontolateral approach for the microsurgical treatment of intracranial aneurysms.  Neurochirurgia. 1978;  21 185-191
• 20 Jane JA, Park TS, Pobereskin LH. et al . The supraorbital approach: Technical note.  Neurosurgery. 1982;  11 537-542
• 21 Delashaw JB, Tedeschi H, Rhoton AL. Modified supraorbital craniotomy: Technical note.  Neurosurgery. 1992;  30 954-956
• 22 Delashaw JB, Jane JA, Kassel NF. et al . Supraorbital craniotomy by fracture of the anterior orbital roof.  Technical note. J Neurosurg. 1993;  79 615-618
• 23 Delfini R, Raco A, Artico M. et al . A two-step supraorbital approach to lesions os the orbital apex. Technical note.  J Neurosurg. 1992;  77 959-961
• 24 Al-Mefty O. The supraorbital-pterional approach to skull base lesions.  Neurosurgery. 1987;  21 474-477
• 25 Smith RR, Al-Mefty O, Middleton TH. An orbitocranial approach to complex aneurysms of the anterior circulation.  Neurosurgery. 1989;  24 385-391
• 26 Cohen AR, Perneczky A, Rodziewicz GS. et al . Endoscope-assisted craniotomy: Approach to the rostral brain stem.  Neurosurgery. 1995;  36 1128-1130
• 27 Fries G, Perneczky A. Endoscope-assisted brain surgery: Part 2 – Analysis of 380 procedures.  Neurosurgery. 1998;  42 226-232
• 28 Menovsky T, Grotenhuis A, de Vries J. et al . Endoscope-assisted supraorbital craniotomy for lesions of the interpeduncular fossa.  Neurosurgery. 1999;  44 106-112
• 29 van Lindert E, Perneczky A, Fries G. et al . The supraorbital keyhole approach to supratentorial aneurysms: Concept and technique.  Surg Neurol. 1998;  49 481-490
• 30 Czirják S, Szeifert Gy. Surgical experience with frontolateral keyhole craniotomy through a superciliary skin incision.  Neurosurgery. 2001;  48 145-150
• 31 Czirják S, Nyáry I, Futó J. et al . Bilateral supraorbital keyhole approach for multiple aneurysms via superciliary skin incision.  Surg Neurol. 2002;  57 314-324
• 32 Ramos-Zúniga R, Velázquez H, Barajas M. et al . Trans-supraorbital approach to supratentorial aneurysms.  Neurosurgery. 2002;  51 125-131
• 33 Steiger HJ, Schmid-Elsaesser R, Stummer W. et al .Transorbital key-hole approach to anterior communicating artery aneurysms.  Neurosurgery. 2001 48: 347-352
• 34 Perneczky A, Reisch R. Key Hole Approaches in Neurosurgery.  Volume I. Concept and surgical technique. Springer Verlag Wien 2008 ISBN: 978-3-211-83885-3
• 35 Reisch R, Perneczky A, Filippi R. Surgical technique of the supraorbital key-hole craniotomy.  Surg Neurol. 2003;  59 223-227
• 36 Reisch R, Perneczky A. The Supraorbital craniotomy for frontobasal meningeomas. In Kobayashi (ed): Neurosurgery of Complex Vascular Lesions and Tumors. Thieme Verlag Stuttgart New York 2005 pp: 201-206
• 37 Reisch R, Perneczky A. Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision.  Neurosurgery. 2005;  57 242-255
• 38 Hopf N, Stadie A, Reisch R. Surgical management of bilateral middle cerebral artery aneurysms via a unilateral supraorbital key-hole craniotomy.  Minim Invasive Neurosurg. 2009;  52 126-131

Correspondence