J Neurol Surg A Cent Eur Neurosurg 2013; 74(06): 400-404
DOI: 10.1055/s-0032-1333130
Technical Note
Georg Thieme Verlag KG Stuttgart · New York

The Modified Pterional Keyhole Craniotomy for Open Cerebrovascular Surgery: A New Workhorse?

J. Mocco
1   Department of Neurological Surgery, University of Florida, Gainesville, Florida, United States
Ricardo J. Komotar
2   Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, United States
Daniel M. S. Raper
3   Junior Medical Staff Unit, Royal North Shore Hospital, New South Wales, Australia
Christopher P. Kellner
4   Department of Neurological Surgery, University of Columbia, New York, United States
E. Sander Connolly
4   Department of Neurological Surgery, University of Columbia, New York, United States
Robert A. Solomon
4   Department of Neurological Surgery, University of Columbia, New York, United States
› Author Affiliations
Further Information

Publication History

06 August 2011

02 March 2012

Publication Date:
20 February 2013 (online)


Background The frontotemporal craniotomy is the most commonly used approach for vascular neurosurgery. However, this approach requires significant mobilization of overlying soft tissues, resulting in muscle atrophy and temporomandibular joint pain. We describe a modified pterional keyhole approach and its use in our initial clinical experience.

Patients and Methods Eleven consecutive minimally invasive pterional keyhole approaches were used for 14 aneurysms. Patient demographics, aneurysm characteristics, and morbidities were prospectively collected.

Results Mean aneurysm size was 6.5 mm, and all were in the anterior circulation. All aneurysms were successfully clipped, with no occurrence of intraoperative rupture or perforator occlusion. There were no incidences of frontalis nerve injury. No technical difficulties or limitation to aneurysm access were experienced.

Conclusion In carefully selected patients, a minimally invasive keyhole approach may be a safe and effective alternative to traditional pterional craniotomy for certain anterior circulation aneurysms.

  • References

  • 1 Fox JL. Microsurgical exposure of intracranial aneurysms. J Microsurg 1979; 1: 2-31
  • 2 de Andrade Junior FC, de Andrade FC, de Araujo Filho CM , et al. Dysfunction of the temporalis muscle after pterional craniotomy for intracranial aneurysms. Comparative, prospective and randomized study of one flap versus two flaps dieresis. Arq Neuropsiquiatr 1998; 56: 200-205
  • 3 Cheng WY, Chao SC, Chen WH , et al. Minimally invasive keyhole approach for removal of a migratory balloon complicated by endovascular embolization of a carotid-cavernous fistula. Minim Invasive Neurosurg 2006; 49: 305-308
  • 4 Cheng WY, Lee HT, Sun MH , et al. A pterion keyhole approach for the treatment of anterior circulation aneurysms. Minim Invasive Neurosurg 2006; 49: 257-262
  • 5 Deshmukh VR, Hott JS, Dumont T , et al. Treatment of recurrent previously coiled anterior circulation aneurysm with minimally invasive keyhole craniotomy: report of two cases. Minim Invasive Neurosurg 2006; 49: 70-73
  • 6 Figueiredo EG, Deshmukh P, Nakaji P , et al. The minipterional craniotomy: technical description and anatomic assessment. Neurosurgery 2007; 61: 256-264
  • 7 Lan Q, Gong Z, Kang D , et al. Microsurgical experience with keyhole operations on intracranial aneurysms. Surg Neurol 2006; 66 (Suppl. 01) S2-S9
  • 8 Nathal E, Gomez-Amador JL. Anatomic and surgical basis of the sphenoid ridge keyhole approach for cerebral aneurysms. Neurosurgery 2005; 56: 178-185
  • 9 Paladino J, Mrak G, Miklic P , et al. The keyhole concept in aneurysm surgery–a comparative study: keyhole versus standard craniotomy. Minim Invasive Neurosurg 2005; 48: 251-258
  • 10 Connolly E. Pterional craniotomy. In: Connolly E, , ed. Fundamentals of Operative Techniques in Neurosurgery. New York: Thieme; 2002: 202
  • 11 Brock M, Dietz H. The small frontolateral approach for the microsurgical treatment of intracranial aneurysms. Neurochirurgia (Stuttg) 1978; 21: 185-191
  • 12 Chehrahzi BB. A temporal transsylvian approach to anterior circulation aneurysms. Neurosurgery 1992; 30: 957-961
  • 13 Fukushima T, Miyazaki S, Takusagawa Y, Reichman M. Unilateral interhemispheric keyhole approach for anterior cerebral artery aneurysms. Acta Neurochir Suppl (Wien) 1991; 53: 42-47
  • 14 Coscarella E, Vishteh AG, Spetzler RF, Seoane E, Zabramski JM. Subfascial and submuscular methods of temporal muscle dissection and their relationship to the frontalis branch of the facial nerve: Technical note. J Neurosurg 2000; 92: 877-880
  • 15 Paladino J, Pirker N, Stimac D, Stern-Padovan R. Eyebrow keyhole approach in vascular neurosurgery. Minim Invasive Neurosurg 1998; 41: 200-203
  • 16 Reisch R, Perneczky A. Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery 2005; 57 (ONS Suppl 3) 242-255
  • 17 Fischer G, Stadie A, Reisch R , et al. The keyhole concept in aneurysm surgery: results of the past 20 years. Neurosurgery 2011; 68 (1 Suppl Operative) 45-51
  • 18 Cinalli G, Cappabianca P, de Falco R , et al. Current state and future development of intracranial neuroendoscopic surgery. Expert Rev Med Devices 2005; 2: 351-373
  • 19 Beseoglu K, Lodes S, Stummer W, Steiger HJ, Hanggi D. The transorbital keyhole approach: early and long-term outcome analysis of approach-related morbidity and cosmetic results. Technical note. J Neurosurg [epub ahead of print October 29, 2010; DOI: 10.3171/2010.9.JNS1095]
  • 20 Komotar RJ, Mocco J, Solomon RA. Guidelines for the surgical treatment of unruptured intracranial aneurysms: the first annual J. Lawrence Pool memorial research symposium – controversies in the management of cerebral aneurysms. Neurosurgery 2008; 62: 183-193