title: Endoscopic controlled clipping of anterior circulation aneurysms via keyhole approach: Our initial experience.
abstract: BACKGROUND
  Surgical clipping is the most definite treatment for intracranial aneurysms. Its aim is to achieve complete aneurysmal occlusion without compromising the lumen of a parent vessel or perforators, and with minimal brain tissue trauma.
  
  
  OBJECTIVE
  To evaluate the role of endoscopic controlled keyhole approach in clipping of anterior circulation aneurysms.
  
  
  METHODS
  In this retrospective study, all consecutive patients undergoing endoscopic controlled clipping via the keyhole approach by the senior author during the last 1 year were included. The cases in which a microscope was used at any stage of surgery were excluded.
  
  
  RESULTS
  Fourteen patients with anterior circulation aneurysms underwent clipping via the endoscopic keyhole approach (supraorbital and mini-pterional). Seven patients had anterior communicating (ACom) artery aneurysms, four had middle cerebral artery (MCA) bifurcation aneurysms, two had internal carotid artery bifurcation aneurysms, and one had a posterior communicating artery aneurysm. Ten patients presented with subarachnoid hemorrhage (Hunt and Hess grade I in 6 and grade II in 4 patients), whereas the remaining four were incidentally detected. The pre-clipping dissection as well as the clipping were successfully performed endoscopically in all patients. The post-clipping inspection revealed inclusion of a perforator within the clip blades in 2 patients (ACom and MCA bifurcation) that required clip readjustment. There was no residual neck/incompletely clipped aneurysm detected on post-clipping inspection. There was no morbidity directly attributable to the use of keyhole approach or the endoscope.
  
  
  CONCLUSIONS
  Endoscopic keyhole approach for intracranial aneurysms combines the advantages of both keyhole approach and endoscopy. Endoscopic visualization can help to reduce chances of an incompletely clipped aneurysms/residual neck and the risk of parent vessel/perforator occlusion. However, the use of an endoscope in narrow corridors with space constraints has a learning curve that can be overcome by practicing on cadavers and initially performing several simple endoscopic procedures.
authors.affiliation: Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Bhawani S
authors.initials: BS
authors.lastname: Sharma
authors.forename: Amandeep
authors.initials: A
authors.lastname: Kumar
authors.forename: Duttaraj
authors.initials: D
authors.lastname: Sawarkar