Piper Keaton, Saez-Alegre Miguel, Perillo Thomas, Peto Ivo, Najera Edinson, Williams Josef, Breton Jeff, Felbaum Daniel R, Jean Walter C
Department of Neurologic Surgery and Brain Repair, University of South Florida, Tampa, Florida, USA.
Division of Neurosurgery, Fleming Neuroscience Institute, Lehigh Valley Network, Allentown, Pennsylvania, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
World Neurosurg. 2024 Nov;191:e429-e437. doi: 10.1016/j.wneu.2024.08.152. Epub 2024 Sep 3.
The transorbital approach (TOA) has a unique advantage to the more common lateral approaches as it provides direct access to the anterior middle fossa and medial sylvian fissure (SF) without significant dissection or retraction. However, when to use the TOA for surgical treatment of middle cerebral artery (MCA) aneurysms remains unclear. This study details the feasibility of clipping unruptured MCA aneurysms via the TOA by highlighting the anatomic features that either facilitate or hinder the approach.
Virtual reality (VR) models of 25 MCA aneurysms from computed tomography angiograms of actual patients were rendered with the relevant anatomic structures, including the neighboring temporal lobe and SF. TOA was performed on the models in VR and the globe was translated medially and inferiorly, replicating retraction used intraoperatively. Anatomic data, including the area of surgical freedom (AOF) at the aneurysm, were recorded. Trials of aneurysm clipping were conducted in VR and each aneurysm was classified as "possible" or "impossible" candidates for clipping via TOA. Separately, the relationship between surgical view and SF visualized was analyzed.
Sixteen aneurysms were eliminated as candidates for TOA treatment either through VR clip trial and/or because the SF was inaccessible. The remaining 9 (36%) were candidates for TOA. Comparing the details of these 2 aneurysm categories with Mann Whitney U tests, there was a statistically significant difference in the AOF of the TOA approach and the width of the aneurysm dome. A clinical case report is also provided highlighting the VR rehearsal similarity with surgery.
Given the minimally invasive, technically challenging approach, the feasibility and safety of TOA for MCA aneurysms must be evaluated before wide clinical adoption. This study identified AOF, aneurysm width, and SF accessibility as three features that may significantly impact the possibility of clipping MCA aneurysms via TOA.
经眶入路（TOA）相较于更常用的外侧入路具有独特优势，因为它无需进行广泛的解剖或牵拉就能直接进入前中颅窝和内侧大脑外侧裂（SF）。然而，何时使用TOA进行大脑中动脉（MCA）动脉瘤的手术治疗仍不明确。本研究通过突出有助于或阻碍该入路的解剖特征，详细阐述了经TOA夹闭未破裂MCA动脉瘤的可行性。
利用实际患者的计算机断层血管造影构建了25个MCA动脉瘤的虚拟现实（VR）模型，并呈现了相关解剖结构，包括邻近的颞叶和SF。在VR模型上进行TOA操作，并将眼球向内下方平移，模拟术中使用的牵拉。记录包括动脉瘤处手术操作空间面积（AOF）在内的解剖数据。在VR中进行动脉瘤夹闭试验，并将每个动脉瘤分类为经TOA夹闭的“可行”或“不可行”候选者。另外，分析了手术视野与可视化的SF之间的关系。
通过VR夹闭试验和/或因无法显露SF，16个动脉瘤被排除在TOA治疗候选者之外。其余9个（36%）为TOA候选者。通过Mann-Whitney U检验比较这两类动脉瘤的细节，TOA入路的AOF和动脉瘤瘤顶宽度存在统计学显著差异。还提供了一份临床病例报告，突出了VR预演与手术的相似性。
鉴于该入路具有微创性且技术难度大，在广泛临床应用前必须评估TOA治疗MCA动脉瘤的可行性和安全性。本研究确定AOF、动脉瘤宽度和SF的可显露性是可能显著影响经TOA夹闭MCA动脉瘤可能性的三个特征。
