Transblepharo-Preseptal Modified Orbitozygomatic Craniotomy for Treatment of Ruptured Aneurysm: 3-Dimensional Operative Video.

Various supraorbital approaches to the anterior cranial fossa using a transciliary or supraciliary incision have been described. An orbitotomy is a valuable addition to the standard supraorbital keyhole approach offering an extended angle of exposure with minimal frontal lobe retraction. The transpalpebral approach is common in oculoplastic surgery and offers excellent cosmetic outcomes using the natural crease of the superior eyelid. This approach avoids risk of eyebrow alopecia and damage to the frontalis muscle or frontalis branches of the facial nerve. A transblepharo-preseptal or transpalpebral modified orbitozygomatic approach for the treatment of unruptured anterior circulation aneurysms has been reported. Our experience with this approach has been that it has potential to offer anterior skull base access and outcomes that are not inferior to traditional approaches for selected cases including ruptured anterior circulation aneurysms. Moreover, we believe this approach can provide excellent cosmetic results and could minimize surgical time and hospitalization stay. This 3-dimensional video presents the case of a 47-year-old female with sudden-onset headache and seizure (Video 1). She was found to have a subarachnoid hemorrhage resulting from rupture of a carotid terminus aneurysm. Considering the location and morphology of the aneurysm, as well as the patient's eyelid anatomy, clip ligation via a transblepharo-preseptal modified orbitozygomatic craniotomy was recommended. Aneurysm clipping was uneventful, and postoperative imaging showed complete occlusion. The patient was discharged neurologically intact.