Objective: Modify the pterional approach for intracranial aneurysms clipping with minimally invasive concept to reduce the risk of iatrogenic surgical trauma.
Methods: A 4.0 cm skin incision was made along the temporal hairline and centered on the pterion, temporal muscle was incised along the sylvian fissure.A bone flap with 2.0 to 2.5 cm in diameter was milled after a bone hole was drilled just on the sphenoid ridge, which was drilled off as needed then.Aneurysms were exposed after dissection of sylvian fissure and cistern, as well as cerebrospinal fluid releasing.A total of 123 cases with 140 intracranial aneurysms were treated surgically via the pterional keyhole approach, including 6 large aneurysms, 4 giant aneurysms, and 17 cases with multiple aneurysms (34 aneurysms). Of 3 cases with bilateral aneurysms, 2 were treated via bilateral approach as well as 1 via unilateral approach. Contralateral approach was used in 1 case with ophthalmic artery aneurysm, which pointed medial. Concomitant intracranial tumors were removed simultaneously in 2 cases, and one of them was diagnosed with middle cerebral artery aneurysm and tuberculum sellae meningioma, the other one with posterior communicating artery aneurysm and middle cranial fossa menigioma.
Results: Of the 140 aneurysms, 139 aneurysms were clipped and 1 was trapped.Postoperative image showed 4 cases had residual of aneurysm neck. 3 cases had incomplete dysfunction of oculomotor nerve and 1 had mild hemiplegia after surgery and recovered eventually. 4 cases presented with aggravated disturbance of consciousness, of whom 3 cases were caused by ischemia and 1 by brain edema.Unusual ipsilateral hemiplegia occurred in 1 case in Hunt&Hess grade IV, which caused by contralateral vasospasm. Postoperative courses in other cases were uneventful.
Conclusions: As a minimally invasive and effective approach, the pterional keyhole approach is applicable to intracranial aneurysms clipping for patients without any necessary for decompressive craniectomy. Surgical related complications and operative duration can be reduced significantly.