title: Engaging in a Keyhole Concept for the Management of Ruptured and Unruptured Aneurysms.
abstract: OBJECTIVE
  Many new endovascular devices have been used under the guidance of the International Subarachnoid Aneurysm Trial. Clipping still offers higher occlusion rates, and its technique continues to evolve, resulting in smaller exposures and reduced manipulation to brain tissue. We sought to evaluate the routine use of the minisphenoidal approach to manage intracranial aneurysms in a high-volume institution.
  
  
  METHODS
  We retrospectively reviewed our database of patients with aneurysm from October 2013 to May 2016. Data were originally collected prospectively. The minisphenoidal approach has been progressively replacing the pterional approach for managing aneurysms in our department. Occlusion rates for ruptured and unruptured aneurysms were analyzed using late follow-up angiograms. Functional outcome assessment and the impact on quality of life were also measured.
  
  
  RESULTS
  We performed 124 minisphenoidal craniotomies in 117 patients to clip 147 aneurysms. Patient mean age was 53.9 years. Seventy patients (59.8%) presented with subarachnoid hemorrhage. Middle cerebral artery aneurysms represented 48% of the total number of aneurysms; posterior communicating artery aneurysms represented 24%. The minisphenoidal craniotomy was helpful in managing superior cerebellar artery aneurysms and 1 ruptured orbitofrontal artery aneurysm. We achieved an occlusion rate of 97.8%, with a mean follow-up of 13.2 months. Favorable outcomes were achieved for 79% of patients with subarachnoid hemorrhage and for 98% of unruptured patients.
  
  
  CONCLUSIONS
  Evolution of endovascular techniques has paved the way for minimizing surgical exposures. Routine use of the minisphenoidal approach for managing ruptured, unruptured, and previously coiled aneurysms is safe and provides adequate exposure with robust occlusion rates.
authors.affiliation: Department of Neurosurgery, Paulo Niemeyer State Brain Institute, Rio de Janeiro, RJ, Brazil. Electronic address: danieldc.neuro@gmail.com.
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Cavalcanti
authors.affiliation: Department of Neurosurgery, Paulo Niemeyer State Brain Institute, Rio de Janeiro, RJ, Brazil.
authors.forename: Roberto C
authors.initials: RC
authors.lastname: de Paula
authors.affiliation: Department of Neurosurgery, Paulo Niemeyer State Brain Institute, Rio de Janeiro, RJ, Brazil.
authors.forename: Paula L
authors.initials: PL
authors.lastname: Alvarenga
authors.affiliation: Department of Neurosurgery, Paulo Niemeyer State Brain Institute, Rio de Janeiro, RJ, Brazil.
authors.forename: Paulo José da Mata
authors.initials: PJDM
authors.lastname: Pereira
authors.affiliation: Department of Neurosurgery, Paulo Niemeyer State Brain Institute, Rio de Janeiro, RJ, Brazil.
authors.forename: Paulo
authors.initials: P
authors.lastname: Niemeyer Filho
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D017542:Aneurysm, Ruptured / Q000000981:diagnostic imaging / Q000523:psychology / Q000601:surgery*; D015901:Angiography, Digital Subtraction; D000072226:Computed Tomography Angiography; D057510:Endovascular Procedures / Q000295:instrumentation* / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002532:Intracranial Aneurysm / Q000000981:diagnostic imaging / Q000523:psychology / Q000601:surgery*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011788:Quality of Life / Q000523:psychology; D012189:Retrospective Studies; D013525:Surgical Instruments; D016896:Treatment Outcome; D055815:Young Adult
keywords: Cerebral aneurysms; Clipping; Keyhole craniotomy; Minimally invasive surgery; Minisphenoidal approach; Quality of life