Abstract
Background Different surgical approaches have been developed to manage lesions of the anterior
and middle skull base areas. Frontal, pterional, bifrontal, and fronto-orbito-zygomatic
approaches are traditionally used to reach these regions. With advancements in the
neurosurgical field, skull opening should be simple and as minimally invasive as possible,
tailored on the surgical corridor to the target. The supraorbital approach and the
“keyhole” concept have been introduced and popularized by Axel Perneczky starting
from 1998 and are now considered a part of everyday practice. The extended possibilities
of this surgical route, considering the reachable targets and surgical limits, are
described and systematically analyzed, including a description of the salient surgical
anatomy, presenting different illustrative cases.
Methods and Results Different illustrative cases are presented and discussed to underline the potentials
and limits of the minimally invasive subfrontal approach (MISFA) and the possibilities
to tailoring the craniotomy on the basis of the targets: extra-axial lesions with
different localizations (anterior roof of the orbit, olfactory groove, tuberculum
sellae, medial third of the sphenoid wing, anterior and posterior clinoid process),
deeper intra-axial lesions (gyrus rectus, medial temporal lobe-uncus-amygdala-anterior
hippocampus), and vascular lesions (anterior communicating aneurysm). Each case has
been preoperatively planned considering the anatomical and radiologic features and
using virtual simulation software to tailor the best possible corridor to reach the
surgical target.
Conclusions The MISFA is a safe multicorridor approach that can be used efficiently to manage
lesions of the anterior and middle skull base areas with extremely low approach-related
morbidity.
Keywords
minimally invasive subfrontal approach - key hole craniotomy - upsurgeon
