Article
Endoscope assisted key hole craniotomy for surgical treatment of intracranial aneurysms
Die endoskop-assistierte Schlüssellochkraniotomie zur chirurgischen Behandlung intrakranieller Aneurysmata
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Authors
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R. Reisch
- Neurochirurgische Universitätsklinik Mainz
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A. Perneczky
- Neurochirurgische Universitätsklinik Mainz
| Published: | May 8, 2006 |
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Outline
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Objective: Despite the well known-opportunities of surgical therapy (e.g. adequate optical exposure of the aneurysm, high reconstructive capacity of the vessel and high reliability of the aneurysm occlusion, effective improvement of CSF circulation due to rinsing and cleaning of the subarachnoid spaces and opening of the lamina terminalis), the initial data from the ISAT-study showed a significant superiority of endovascular coiling compared to surgical clipping. The cause for this significant difference was the surgical morbidity and the mortality of large standard approaches.
Methods: During a ten-year period between July 1995 and June 2005, 682 patients with intracranial aneurysms were treated surgically in our department. After interdisciplinary discussion with the interventional neuroradiologist, surgical treatment was chosen when endovascular coiling was technically not feasible. 371 patients had acute subarachnoidal hemorrhage, 311 patients were treated electively. In the group of electively clipped patients, 51 had previously been treated with endovascular techniques.
Results: Out of a total of 682 patients, surgical clipping was performed in 656 cases (96%) through key hole approaches. Using limited craniotomies, approach-related complications could be effectively minimized, reducing the size of the skin incision, soft tissue dissection, bony destruction, dural opening and decreasing the extension of brain surface exploration and brain retraction to a necessary minimum limit. However, visualization of the site was limited by the narrow surgical corridor. In order to increase the intraoperative optical control, we have utilized endoscope assisted microsurgical technique in 247 cases. The endoscopes were used 1) for intraoperative anatomical orientation, 2) for the assessment of the individual patho-anatomy of the aneurysm, and 3) for control of clip position.
Conclusions: Surgical clipping will play an important role in the treatment of intracranial aneurysms only, if surgical therapy is able to reduce its approach-related complications. Limited key hole craniotomies and the use of endoscope-assisted surgical technique offer minimal surgical trauma and exquisite optical control of the clipping procedure despite the narrow surgical corridor, thereby allowing minimal invasive and maximal effective aneurysm-closure.
