Korean Journal of Cerebrovascular Surgery 2007;9(3):161-167.
Published online September 1, 2007.
The Eyebrow Approach to Anterior Communicating Artery Aneurysms.
Sung, Seng Oun , Jeon, Byung Chan , Kim, Young Su , Kim, Il Sup
Department of Neurosurgery, Kosin University Gospel Hospital, Busan, and Gilmary Neurological Institute1, Ulsan, Korea. gilmary@empal.com
This study reviewed the clinical outcomes of patients with anterior communicating artery (AComA) aneurysms that were treated surgically using an eyebrow approach. The indications and limitations of this approach for the treatment of AComA aneurysms are also suggested. METHODS: Between October 1999 and June 2006, 121 procedures were performed on 115 patients with 146 cerebral aneurysms via a superior orbital rim craniotomy through an eyebrow incision. Of them, 51 patients with AComA aneurysms were reviewed retrospectively according to the patient's age and gender, the Hunt-Hess grade upon admission, the Fisher grade of the subarachnoid hemorrhage, the size of the aneurysm, the direction of the aneurysmal sac, the outcome at 3-month follow-up period, complications and the intraoperative problems. RESULTS: Overall, excellent and good outcomes were achieved in 47 patients (92.1%) and one patient died (2.0%). Clinically, there were 7 patients with a poor grade (Hunt-Hess grade 4); 3 showed a good outcome, 2 fair, 1 poor and 1 died. Premature rupture of the aneurysm during surgery occurred in 5 patients. One procedure was converted to the pterional approach due to severe brain swelling. Postoperative subdural fluid collection was noted in 9 patients, of whom 2 patients required temporary drainage and 1 patient needed a permanent subdural fluid diversion. Vasospasm and a subsequent infarction were observed in 4 patients. Hydrocephalus that required a ventriculoperitoneal shunt was found in only 2 patients. CONCLUSIONS: The favorable indications for eyebrow surgery include good grade patients with a ruptured or unruptured AComA aneurysm, and patients with small and medium sized aneurysms. Furthermore, the poor grade or high Fisher grade patients with or without multiple concomitant aneurysms can also be treated with eyebrow surgery.
Key Words: Anterior communicating artery aneurysm, Clinical outcome, Indication, Eyebrow approach


Physicians have used several approaches for surgically treating anterior communicating artery (AComA) aneurysms.12)14)15) Although the pterional approach is still the most familiar to neurosurgeons, surgeons will use their preferred approaches. Regardless of the types of approaches, making a minimal incision and a short corridor, lessening the brain retraction and securing the surgical field for aneurysm clipping are still prerequisite. Minimally invasive approaches with using an eyebrow incision have recently been reported for the treatment of supratentorial aneurysms.7)10)11)13) Because they involve techniques for which there is minimal exposure and disruption of the normal anatomy, the potential advantages of these approaches include reduced operative morbidity, a swifter recovery and cost effectiveness for patient management. However, because of the unfamiliarity with this approach, the narrow operative field, the physicians’anxiety about intraoperative rupture, the transorbital or supraorbital keyhole approach has never gained full acceptance. Furthermore, this technique was not warranted for AComA aneurysms because of the relatively high associated mortality and morbidity.5) Reisch and Perneczky reported on their surgical experience with 37 AComA aneurysms and using a supraorbital keyhole approach, but they did not describe the detail results of this aneurysm surgery.9) Jeon et al described the surgical experience with 27 AComA aneurysms.3) We report here on the clinical outcomes of the patients with 51 AComA aneurysms and who were surgically treated by the eyebrow approach, and we suggest the indications and limitations of this approach. 

Patients and Methods 

   Between October 1999 and June 2006, 371 surgeries were performed for 352 patients with 419 cerebral aneurysms in our institute. The surgeries consisted of 234 traditional approaches, 121 eyebrow approaches, and 16 interventional approaches. Among them, 121 eyebrow surgeries were performed for 115 patients with 146 cerebral aneurysms. Of the 115 patients, 51 patients with AcomA aneurysms were retrospectively reviewed for determining the patients’age and gender, the Hunt-Hess grade on admission, the Fisher grade of the subarachnoid hemorrhage, the size and the direction of aneurysms, the outcome at 3 months’follow-up, the complications and the intraoperative problems. The outcomes were assessed as follows: excellent (return to a normal social life), good (mild neurological deficits, but independent in their social life), fair (neurological deficits, dependent on others for daily social life), poor (neurological deficits, dependent on others for daily support), and dead. The patients' ages ranged from 27 to 79 years with a mean age of 53.3 years. There were 28 women and 23 men. Of the 51 patients, 10 patients had 2 or more aneurysms, so that the total number of aneurysms was 63, including 51 AcomA aneurysms. Since September 2002, computerized tomography (CT) angiography with 3-dimensional (3D) reconstruction has been primarily used for making decisions on the proper surgery. 

Surgical Technique 
   Details of the surgical technique for superior orbital rim craniotomy have already been described elsewhere.3) Briefly, the patient lies in the supine position with the head fixed in a Mayfield head rest. The head is positioned above the heart, and the head is rotated less than 15 degrees to the contralateral side. Fine adjustment of the head rotation during the procedure is accomplished by rotating the operating table. An incision is made along the superior margin of the eyebrow, started just lateral to the supraorbital notch; the incision is usually 4 to 5 cm in length. The periorbita is dissected away from the orbital roof. The frontal bone is drilled out from the anterior portion of the superior temporal line to the frontozygomatic suture laterally, and just lateral to the supraorbital foramen medially (Fig. 1). After protecting the periorbita and orbital contents with using a hand-held retractor, the medial and lateral parts of the superior orbital rim are drilled out using a 2-mm drill bit. The one-piece bone flap, measuring about 3×4cm in size, is then elevated and it is fractured together with the anterior part of the orbital roof (Fig. 2). The dura is opened in a semicircular fashion to expose the orbitofrontal cortex. The anteriorly reflected dura is tacked up to the overlying skin to yield a greater working space. We have prepared another approach for ventriculostomy at contralateral Kocher's point if the patient had intraventricular hemorrhage (IVH) or severe hydrocephalus. However, we have never performed any spinal drainage or ventriculostomy. Brain retractors are not usually used (Fig. 3). 


   Fifty two surgeries were preformed for the 51 patients with 63 aneurysms. Of the 51 AComA aneurysms, 46 had ruptured and 5 were unruptured. The operations were performed within 3 days after onset of subarachnoid hemorrhage in 45 patients, and delayed surgery was performed in 6 patients. Forty nine AComA aneurysms were clipped, 2 were wrapped and 2 received additional coiling for treatment of the residual sac. 
   Overall, excellent and good outcomes were achieved by 47 patients (92.1%) and 1 patient died (2.0%). Forty four patients, who were Hunt and Hess grade 3 or less, were all improved to a state of an independent social life. Clinically, there were 7 poor grade patients (Hunt and Hess grade 4), and 3 of them showed a good outcome, 2 of them showed a fair, 1 of them showed a poor outcome and 1 died. We never treated Hunt-Hess grade 5 patients by this approach. The outcomes according to clinical grades are summarized in Table 1. The 39 patients who were Fisher grade 3 or less all showed excellent and good outcomes. Among the 12 patients suffering with intracerebral hemorrhage (ICH) or intraventricular hemorrhage (IVH), 4 showed excellent outcomes, 4 showed good outcomes, 2 showed fair outcomes, 1 a poor outcome and 1 died (Table 1). A patient who showed a poor clinical and radiological grade is illustrated in Fig. 4
   Forty four aneurysms were less than 10 mm in size. The largest sac was 17mm in diameter. There were no cases of giant aneurysms (Table 2). The superior direction of the aneurysm sac was the most common, and this was noted in 22 patients. The inferior direction was seen in 15 patients, the posterior direction seen in 8 patients and the anterior direction was seen in 6 patients (Table 2). 
   Ten patients had two or more aneurysms, including AComA aneurysm; there were 5 middle cerebral artery bifurcation aneurysms, 4 posterior communicating artery aneurysms, 1 anterior choroidal artery aneurysm, 1 paraclinoid aneurysm and 1 internal carotid artery terminus aneurysm. In these cases, the side of the approach was decided on according to the combined aneurysm location, and the multiple aneurysms were simultaneously obliterated in one session. Only one patient, who had A-com and bilateral middle cerebral artery aneurysms, needed an additional contralateral approach. A patient with AcomA and right middle cerebral artery aneurysms is illustrated in Fig. 5
   Premature rupture of the aneurysm during surgery occurred in 5 patients. Two occurred during clip application and three occurred during dissection of the aneurysmal fundus. However, all were successfully controlled without any deficit. One patient harboring a ruptured AcomA aneurysm was converted to the pterional approach, following initial eyebrow approach, due to the severe brain edema. A postoperative collection of subdural fluid was noted in 9 patients; of them, 2 patients needed temporary drainage and 1 patient needed a subduroperitoneal shunt. Vasospasm and subsequent infarction were noted in 4 patients; 1 infarction was in the head of the caudate nucleus, 2 were in the frontal lobes and 1 was multiple infarctions. Three patients with small areas of infarction stayed a relatively long time in the intensive care unit; however, these patients never ended up with permanent neurologic deficits. One patient died, and this patient showed multiple areas of infarction. Thirty seven patients initially showed acute hydrocephalus and among them, only 2 patients needed a ventriculoperitoneal shunt. There was no craniotomy-related hemorrhage or infarction. 


   The clinical outcome of patients with AcomA aneurysms does not depend on the surgical approach, but rather, it depends on the disease itself. The minimally invasive eyebrow approach can have some benefits such as a relatively good outcome, less surgery-related complications, a decreased operation time, no shaving of hair, no transfusion and a good cosmetic result. To the best of our knowledge, this is the first study that's demonstrate the indications and limitations of orbital roof craniotomy with using an eyebrow incision for the treatment of AComA aneurysms. 

Indications and limitations of eyebrow surgery for A-com aneurysms 
   The overall surgical results have been reported to be good for about 85% of AComA aneurysms. Comparable surgical results via an eyebrow incision for various aneurysms have also been reported.2)5)8) Reisch and Perneczky have reported their 10 year results of using the supraorbital approach for various intracranial lesions.9) That study included 37 AComA aneurysms among the 229 aneurysms. However, they did not describe the detailed tactics and results of aneurysm surgery. Brydon and Mileki reported that a favorable outcome was achieved in 82% in 22 AComA aneurysms patients who were surgically treated with supraorbital eyebrow minicraniotomy.1) Our results were confined to AComA aneurysms, and 92% of the patients had a favorable outcome. All the good grade patients, at the time of admission, with AComA aneurysms in our series had favorable outcomes. 
   The surgeon often encounters a severely swollen brain when performing early surgery in a patient of Hunt and Hess grade 3. We have successful managed 17 patients of Hunt and Hess grade 3. One patient was converted to the pterional approach due to severe brain edema. Seven poor grade patients of Hunt and Hess grade 4 in our series showed 3 good outcomes, 2 fair outcomes, 1 poor outcome and 1 died. This result is comparable to the overalloutcome of poor grade patients with ACom A aneurysms.4)6) Therefore, the eyebrow approach can be performed even for poor grade patients, if there is no associated severe brain swelling or a large hematoma. The senior author developed the method of a whole eyebrow incision to prepare for a larger craniotomy than is usual for the treatment of poor grade patients. Furthermore, brain retractors can be also applied in these cases if needed. 
   It is likely that most vascular surgeons prefer the pterional approach rather than the eyebrow approach for the patients who are Fisher grade 3 at admission. We have encountered 25 cases of Fisher grade 3, and all achieved favorable outcomes without any lumbar drainage. Extraventricular drainage was not necessary even for the 12 patients who were Fisher grade 4 at admission, which indicates intraventricular or intracerebral hemorrhage; among them, 8 patients achieved a favorable outcome. The minimally invasive approach usually requires a slack brain. However, additional infusion of mannitol, head elevation and prompt opening of the carotid cistern during this approach can offer successful access, and this is regardless of observing a high Fisher grade on the CT scan. 
   We did not encounter a giant aneurysm during this study period. The usual size (approximately 1 cm for A-com artery aneurysm) does not matter for this approach. Reisch and Perneczky illustrated a case of giant aneurysm that was treated successfully9) however, it is likely that the minimally invasive approach may not be appropriate for patients with giant aneurysm.
   For patients with multiple aneurysms, the guiding principle is the approach side should be selected to accomplish aneurysmal obliteration for all the aneurysms in one session. The contralateral internal carotid bifurcation area, the proximal portion of the contralateral M1 and the whole length of contralateral A1 can be visualized via this small craniotomy. However, exposure of both sides of the middle cerebral artery bifurcation area was not possible for our patient with multiple aneurysms, so this case underwent an additional incision and craniotomy. 
   The favorable indications for eyebrow surgery include a good grade (Hunt and Hess grade 1
~3) of a ruptured or unruptured AComA aneurysm, and small/medium sized aneurysms. Delayed surgery is available, as well as performing early surgery, with using this technique. Eyebrow approach also is possible for patients with thick subarachnoid hemorrhage, IVH or small ICH. Furthermore, poor grade patients with or without multiple concomitant aneurysms can be offered by eyebrow surgery as well. 
   Many surgeons worry about minimally invasive aneurysm surgery because of the limited exposure of the surgical field, so that they recommend wide craniotomy and opening of the sylvian fissure. In fact, even though the pterional appaoch it also would be difficult to manage intraoperative premature rupture. We experienced premature rupture of the aneurysm in 5 patients during their eyebrow surgery, which were successfully controlled without exception by using increased suction power or applying a temporary clip. However, intraoperative rupture can be a big problem if the surgeon is not highly experienced or if they lack specific experience with the minimally invasive eyebrow approach. 

Surgical tactics for eyebrow surgery according to the direction of the A-com aneurysms 
   Regarding the aneurysm direction, we have performed different techniques during the eyebrow approach. We never opened the sylvian fissure in this eyebrow approach to treat ACom A aneurysm. For successful eyebrow aneurysm surgery, the most important and basic step is to find the optic nerve. Sometimes, the pterional approach-oriented surgeon can have a lot of difficulty to find out the optic nerve if the head is rotated or tilted too much. Next, the surgeon can move to open the carotid cistern laterally to then confirm the ICA terminus and A1. Next, the chiasmatic cistern should be opened completely. However, if the aneurysm is directed anteriorly or inferiorly, premature rupture should be guarded against during opening of the chiasmatic cistern or during frontal lobe retraction, with using the same principles as the pterional approach. To prevent premature rupture when the aneurysm is directed anteriorly, the surgeon can apply a temporary clip to A1, even though a small craniotomy. We have partially removed the gyrus rectus for the treatment of superiorly or posteriorly directed A-comA aneurysms. If these are of a large size, then the surgeon can also apply a temporary clip ipsilaterally or at both sides. 


   Superior orbital rim craniotomy using an eyebrow incision can be used for the primary treatment of AcomA aneurysms. The favorable indications for eyebrow surgery can include good grade patients with ruptured aneurysm, and patients with medium sized aneurysms. Furthermore, poor grade or high Fisher grade patients with or without multiple concomitant aneurysms can also be offered by this approach. However, eyebrow aneurysm surgery needs steep-learning curve, and only highly experienced vascular surgeons can try this approach to treat ACom A aneurysms. We demonstrated that in this selected group of patients, the eyebrow approach is a viable alternative to the traditional pterional approach or to the coiling procedure. 


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