Keyhole Approaches Applied to Clipping of Acutely Ruptured Intracerebral Aneurysms - A Technical Note and Case Series.

BACKGROUND: Evolution of keyhole techniques in aneurysm surgery allows for definitive surgical management of aneurysmal pathology with very little disruption of normal surrounding tissue. While experienced vascular neurosurgeons are increasingly applying keyhole techniques to unruptured aneurysms, experience with ruptured aneurysms is limited.

OBJECTIVE: To explore technical nuances and present operative outcomes for our series of 40 consecutive patients presenting with ruptured intracerebral aneurysms treated with surgical clipping via a keyhole approach.

METHODS: This study is a consecutive, single surgeon, single centre retrospective case series of aneurysms clipped with keyhole approaches at Helen Joseph Hospital in Johannesburg, South Africa. Patients presenting with SAH were worked-up exclusively with CT. Based on vessel location and unique anatomical features, aneurysms were clipped through either a mini-pterional approach, supraorbital approach or a keyhole interhemispheric approach. Operative details were assessed on retrospective file review and patient outcomes assessed on clinic follow-up.

RESULTS: A mini-pterional approach was used for 55% of cases, the supraorbital approach in 30% and the mini-interhemispheric approach in 15% of cases. Intraoperative aneurysm rupture rate was 26.2%. Complete Aneurysm occlusion was achieved in 97.4% with none of the 40 cases requiring conversion of a keyhole to a larger craniotomy. A good outcome was achieved for 72.5% of patients (mRS≤ 2). For patients presenting with WFNS grade I to III SAH, 92.9% achieved a good outcome.

CONCLUSIONS: The present series supports the concept that sound technical execution of keyhole approaches, even in the setting of acutely ruptured cerebral aneurysms, are a viable option for clipping of intracranial aneurysms.