Hu Shen

Lateral supraorbital approach as an alternative to the classical pterional approach

OBJECTIVE The standard pterional approach has been used to approach aneurysms of the anterior circulation and the basilar tip, suprasellar tumors, cavernous lesions. The senior author (JH) established a lateral supraorbital approach as an alternative to the pterional approach after continuous trial and error. We describe the techniques of this approach based on clinical experiences. METHODS The lateral supraorbital approach is more subfrontal and anterior than the pterional approach. This approach has been regularly used by the senior author (JH) in the last decade in more than 2000 operations for mostly aneurysms of anterior circulation, but also for tumors of the anterior fossa and parasellar area as well as the sphenoid wing area. RESULTS This approach can be used to operate on most cases, in which the classical pterional approach would be used. There are almost no craniotomy-related complications with this approach. This approach is not suitable in certain lesions which need to be exposed from a more temporal perspective. CONCLUSION This approach is simpler, faster, safer and less invasive than the classical pterional approach.

Microsurgical clipping of cerebral aneurysms after the ISAT Study

This landmark study [9] – somewhat Twainian at first glance – sets the stage for future microsurgery in cerebral aneurysms and SAH. The ISAT Study does not nail microsurgery – it will nail microsurgery in low case load neurosurgical centers and in inexperienced hands. In future neurovascular centers, exovascular and endovascular surgeons are forced to support each other by having the full responsibility over the population in a defined geographical area. Exosurgeons will become far more experienced – less in number but not the last Mohicans.

Microneurosurgical management of internal carotid artery bifurcation aneurysms

BACKGROUND Internal carotid artery bifurcation aneurysms form 2% to 9% of all IAs. They are more frequent in younger patients than other IAs. In this article, we review the practical microsurgical anatomy, the preoperative imaging, surgical planning, and the microneurosurgical steps in the dissection and the clipping of ICAbifAs. METHODS This review and the whole series on IAs are mainly based on the personal microneurosurgical experience of the senior author (JH) in 2 Finnish centers (Helsinki and Kuopio), which serve, without patient selection, the catchment area in Southern and Eastern Finland. RESULTS These 2 centers have treated more than 11 000 patients with IAs since 1951. In the Kuopio Cerebral Aneurysm Database of 3005 patients with 4253 IAs, 831 (28%) patients had altogether 980 ICA aneurysms, of whom 137 patients had 149 (4%) ICAbifAs. Ruptured ICAbifAs, found in 78 (52%) patients, with median size of 8 mm (range, 2-60 mm), were associated with ICH in 15 (19%) patients. Ten (7%) ICAbifAs were giant (> or = 25 mm). Multiple aneurysms were seen in 59 (43%) patients. The ICAbifAs represented 18% of all IAs ruptured before the age of 30 years. CONCLUSIONS The main difficulty in microneurosurgical management of ICAbifAs is to preserve flow in all the perforators surrounding or adherent to the aneurysm dome. This necessitates perfect surgical strategy based on preoperative knowledge of 3D angioarchitecture and proper orientation during the microsurgical dissection.

Surgical technique to retract the tentorial edge during subtemporal approach : Technical note

OBJECTIVE: To describe a surgical technique to retract the tentorial edge during the subtemporal approach initially introduced and used widely by Drake and Peerless to treat distal basilar artery aneurysms. METHODS: One of the most important parts of the exposure is to reflect the edge of the tentorium downward by 1 cm or more and to tether it with a suture placed lateral to or behind the insertion of the trochlear nerve and then to the dura mater of the floor of the middle fossa. Surgical forceps or a sharp dural hook are used to elevate the tentorial edge, in front of the trochlear nerve. A small incision is made on the surface of the floor of the middle fossa using a sharp bipolar forceps, and a small straight microclip is inserted with one arm through the incision on the surface of the floor of the middle fossa and the other at the free margin of the tentorial edge. RESULTS: The method described has been used by the senior author in more than 100 operations as a simple and fast means of tethering the free margin of the tentorial edge simply and quickly. CONCLUSION: We inserted a small straight microclip with one arm through the incision on the surface of the floor of the middle fossa and the other at the free margin of the tentorial edge as a fast and simple method of retracting the tentorial edge during a subtemporal approach.