The document discusses the supraorbital craniotomy technique in neurosurgery. It provides a brief history of the approach, beginning with Krause first demonstrating it in 1900. Indications for its use include aneurysms of the anterior circulation, tumors of the anterior cranial fossa and sphenoid ridge, and pathologies of the sella and suprasellar region. The technique involves a supraorbital incision and craniotomy to access structures like the orbital roof, anterior clinoid processes, cavernous sinus, and anterior circulation vessels. Complications can include bleeding, infection, supraorbital numbness, and CSF leaks. The approach provides good exposure with minimal brain retraction and smooth postoperative recovery.

1. Supraorbital Craniotomy In
Neurosurgery:
Dr Saurav Hamal
ANIAS.

2. Historical Evolution
• In 1900 Krause first demonstrated supra-orbital, subfrontal
approach on cadaver, then eight years later he reported the first
resection of skull base meningioma through this approach.
• In 1913, Frazier advocated a supraorbital ridge resection, which was
found useful in surgery for pituitary adenomas.
• In the 1990, Perneczky and colleagues popularized the keyhole
concept and the technique commonly used today, the supraorbital
keyhole craniotomy. The evolution, however, began with Fedor
Krause's .
• More recently, Jane and Delashaw , described a supraorbital
craniotomy in the approach to orbital tumors. Other variants have
been proposed by Al-Mefty et al.
Neurology India, Vol. 57, No. 5, September-October, 2009, pp. 599-606

3. Indications:-
1.Aneurysm of Anterior circulation
except those of distal anterior
cerebral artery.
2.For high positioned basilar
bifurcation of basilar-Superior
cerebellar artery aneurysm.
3.Tumor of anterior cranial fossa,
sphenoid ridge.
4.Pathologies of sellar and
suprasellar region.

4. Location that can be assesed after supraorbital craniotomy:-
Ipsilateral Midline
Orbital roof, CN I, II, III, IV.
Anterior & Posterior clinoid process.
Roof and lateral wall of Cavernous Sinus.
Basal Frontal Lobe, Gyrus rectus, Sylvian
fissure.
Anteromedial temporal lobe.
Uncus hippocampi.
ICA, Opth.Artery, PCoA, AchA including
perforator.
A1, A2,M1, M2 including perforator.
P1,P2, SCA including perforator,
Superficial temporal vein.
Crista Galli.
Olfactory groove, Planum sphenoidale.
Tuberculum sellae.
Lamina terminalis.
Anterior third ventricle
Pituitary stalk.
Interpeduncular fossa.
ACoA, Distal Basilar Artery with perforator.

5. Technique:-
1. Positioning:-
- Head is Elevated.
- Head is Extended as it allows relaxation of
frontal lobe.
- Contralateral rotation:
For lateral Suprasellar and temporomesial
lesion - 20 degree.
For Anterior Suprasellar /Planum sphenoidale
lesion - 30 degree.
For cribriform plate lesion- 45 degree.
For Olfactory groove lesion - 60 degree.
Furthur adjusment of view can be done by
rotating the operating table during surgery
.
.

6. 2. Skin incision-
Type-Superciliary, transciliary,
transpalpebral.
- The incision is made in the lateral
2/3rd of eyebrow, atleast 5mm lateral
to the supraorbital notch.
- 3-10mm in size.
- Initial incision via skin and dermis
only.
- S.c dissection,more dorsally and
cutting along the fibre of
orbicularis oculi, pericranium and
temporalis .
.

7. • Craniotomy
- Supraorbital craniotomy, bone flap
with shape of “D”.
- Dura is opened in semilunar
fashion with base at orbital rim.
- The limitation with the lighting of
microscope deep down a narrow corridor
can be overcome by Endoscope , which can
be held by assistant or retractor arm.
- A second look with endoscope can also
allow visualization of gross resection of
lesion.

8. Complication:-
- Common surgical complication like Bleeding, infection etc.
- Complication related to anesthesia
- Complication relation to craniotomy:
1.Depressed deformities in the frontotemporal area which result from temporal
muscle atrophy .
- Complication due to incision:
1. Transient loss of supraorbital sensation(7.5%)
2. Frontal paresis (5.5%)
3. Opening of frontal sinus can cause CSF leak(4%)
4. Burning of eyebrow due to microscopic light on 100% intensity.
(Not seen with intensity below 70%).
5. Bone flap resorption.

9. Some operative variant:
1.Lateral variation:-
the essence of this variation is
to partially remove the lesser
sphenoid wing exposing the
frontal and temporal dura
mater.
Also on removing clinoid
process, paraclinoid segment of
ICA can be visualised.

10. 2.Medial Modification:
The essence of this approach is
surgical view of suprasellar and
interhemispheric structure.
With possibility of interhemispheric
and subfrontal dissection.

11. 3.Basal variation:
The essence of this approach
is to gain more oblique view of
deep seated prepontine and
interpeduncular region via
subfrontal exposure after
removing orbital rim and partial
removal of orbital roof.

12. Some studies on supraorbital incision and craniotomy:
1. Shanno et al.,developed an image-guided suprabrow approach to
treat a series of 72 patients and concluded that this approach provides
excellent exposure of the orbit, anterior fossa, and parasellar region.
2. Perneczky et al use of this approach to treat 197 aneurysms. The vast
majority of the aneurysms (94%) could be effectively clipped.
3. Menovsky et al. described the supraorbital approach combined to
neuroendoscopy to treat aneurysm and tumor located in the
interpeduncular fossa.

13. ILLUSTRATION OF OUR CASES:-
1.A 62 yr f presented with c/o headache on and off associated with vomiting since 1 yr &
decreasing vision, progressive and now since 2-3 week she cant see thing properly.
O/e – Thin built, ill looking,GCS -15/15, Pupil b/l nonreactive 1mm .
Visual acuity -NPL.
CNS – No other focal deficit except vision loss.
Chest/CVS/P/A – wnl.
Diagnosis:- Craniopharyngioma

14. Tumor being excised
Tumor has been removed completely.
Intraoperative picture:

15. Intraoperative video:

16. Post-Operative pics:
Histopathology :-Adamantinomatous craniopharyngioma WHO Grade1.

17. 2.A 50 yr female presented with c/o headache , decrease vision 6month .no h/o
htn.dm.
O/e - GCS-15/15, Visual acuity right eye –npl, left eye finger count at 6feet.
No other focal deficit,
Systemic examination – normal. Diagnosis:- Tuberculum sella meningioma.

18. Intraoperative video:

19. Post-Operative pics:
HPE- Transitional Meningioma WHO grade 1.

20. 3.A 26 yr male presented with c/o RTA 10am yesterday , LOC ½ hr, no
ent bleed, vomiting, seizure.
On arrival GCS-13/15, Pupil B/L 2mm and reactive, right side face and
chin abrasion.
Systemic examination - normal.
Right MCAAneurysm.

21. Intraop picture of clipping of aneurysm. After clipping of Aneurysm.
Intraoperative pictures:

22. Intraoperative video:

23. Postoperative pics:

24. Advantage
1.Less time consuming.
2.Minimum brain retraction with good
exposure of anterior fossa, sellar,
suprasellar and sylvian cistern.
3.Smooth postoperative period and
Decrease hospital stay for patient.
4.Less complication.
Disadvantage
1.Difficult for less experience surgeon.
2. Diminished opportunity for a change of
plan if unexpected findings occur during
surgery.
3.Limited size for surgical corridor.
4.Risk of complication like visible skin scar.
supraorbital numbness,CSF fistula and
eyelid paresis.

25. Conclusion
• Since the introduction in 1900, numerous shortcomings of this approach
has been overcomed.
• Supraorbital keyhole approach should be considered as part of the
neurosurgical armamentarium to manage skull base lesions when
indicated and not to replace other well recognized skull base approaches.
• Simpler lesion should be performed before moving on to larger, complex
lesions.
• Endoscopy can play a major role in improving visualisation through the
corridor.
• With consideration of minor details, superb cosmesis can be obtained with
minimal complication.

26. References:
1.The supraorbital keyhole craniotomy through eyebrow incision, its origin
and evolution.
D.Ryan ormond.minim invasive surg.2013:296469.2,.
2. Arquivos de Neuro-Psiquiatria :Yvens Barbosa Fernandes, Daniel Maitrot,
Pierre Kehrli, Oswaldo Ignácio de Tella Jr, Ricardo Ramina, Guilherme
Borges Print version ISSN 0004-282X.
3. George jallo MD , John hopkins university Baltimore.
4.Keyhole approach in Neurosurgery. A perneczky, R Reisch.

27. Dr Saurav Hamal.