Abstract：
OBJECTIVE: Axel Perneczky is responsible for conceptualizing the \"keyhole\" philosophy as a new paradigm of minimal invasiveness within cranial neurosurgery. Keyhole neurosurgery aims to limit approach-related traumatization and minimize brain retraction while still enabling the neurosurgeon to achieve operative goals. The supraorbital keyhole craniotomy (SOKC) and minipterional (pterional keyhole, PKC) approaches have become mainstays for clipping intracranial aneurysms. While studies have compared these approaches to the traditional pterional craniotomy for clipping cerebral aneurysms, head-to-head comparisons of these workhorse keyhole approaches remain limited.
METHODS: The authors queried three databases per PRISMA guidelines to identify all studies comparing the SOKC to the PKC for microsurgical clipping of cerebral aneurysms. Of 148 unique studies returned on initial query, a total of 5 studies published between 2013 and 2019 met inclusion criteria. Where applicable, quantitative meta-analysis was performed via the Mantel-Haenszel method using Review Manager v5.4 (Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen, Denmark). Risk of bias (ROB) was assessed using the Cochrane ROBINS-I tool, and all studies were assigned a Level of Evidence (I-V).
RESULTS: Across all five studies, the mean age ranged from 53.0 to 57.5 years old, and the cohort consisted of more females (n = 403, 60.6%) than males. The proportion of patients presenting with ruptured aneurysmal SAH was comparable between the SOKC and PKC cohorts (p = 0.43). Clipping rate [defined as the rate of successful aneurysm clip deployment with successful intraoperative occlusion] (OR 1.52 [0.49, 4.71], I2 = 0%, p = 0.47), final occlusion rates (OR 1.27 [0.37, 4.32], p = 0.70), and operative durations (SMD 0.33 [-0.83. 1.49], I2 = 97%, p = 0.58) were comparable regardless of approach used. Furthermore, rates of intraoperative rupture (OR 1.51 [0.64, 3.55], I2 = 0, p = 0.34), postoperative hemorrhage (OR 1.49 [0.74, 3.01], I2 = 0, p = 0.26), postoperative vasospasm (OR 0.94 [0.49, 1.80], I2 = 63, p = 0.86), and postoperative infection (OR 0.70 [0.16, 2.99], I2 = 0%, p = 0.63) were equivocal across SOKC and PKC cohorts.
CONCLUSIONS: The PKC and SOKC approaches appear to afford comparable outcomes when used for open microsurgical clipping of cerebral aneurysms in select patients with both ruptured and unruptured aneurysms. Both are associated with excellent clipping and occlusion rates, minimal perioperative complication profiles, and favorable postoperative neurologic outcomes. Further investigations are merited so clinicians can further parse out the indications and contraindications for each keyhole approach.
METHODS: The authors queried three databases per PRISMA guidelines to identify all studies comparing the SOKC to the PKC for microsurgical clipping of cerebral aneurysms. Of 148 unique studies returned on initial query, a total of 5 studies published between 2013 and 2019 met inclusion criteria. Where applicable, quantitative meta-analysis was performed via the Mantel-Haenszel method using Review Manager v5.4 (Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen, Denmark). Risk of bias (ROB) was assessed using the Cochrane ROBINS-I tool, and all studies were assigned a Level of Evidence (I-V).
RESULTS: Across all five studies, the mean age ranged from 53.0 to 57.5 years old, and the cohort consisted of more females (n = 403, 60.6%) than males. The proportion of patients presenting with ruptured aneurysmal SAH was comparable between the SOKC and PKC cohorts (p = 0.43). Clipping rate [defined as the rate of successful aneurysm clip deployment with successful intraoperative occlusion] (OR 1.52 [0.49, 4.71], I2 = 0%, p = 0.47), final occlusion rates (OR 1.27 [0.37, 4.32], p = 0.70), and operative durations (SMD 0.33 [-0.83. 1.49], I2 = 97%, p = 0.58) were comparable regardless of approach used. Furthermore, rates of intraoperative rupture (OR 1.51 [0.64, 3.55], I2 = 0, p = 0.34), postoperative hemorrhage (OR 1.49 [0.74, 3.01], I2 = 0, p = 0.26), postoperative vasospasm (OR 0.94 [0.49, 1.80], I2 = 63, p = 0.86), and postoperative infection (OR 0.70 [0.16, 2.99], I2 = 0%, p = 0.63) were equivocal across SOKC and PKC cohorts.
CONCLUSIONS: The PKC and SOKC approaches appear to afford comparable outcomes when used for open microsurgical clipping of cerebral aneurysms in select patients with both ruptured and unruptured aneurysms. Both are associated with excellent clipping and occlusion rates, minimal perioperative complication profiles, and favorable postoperative neurologic outcomes. Further investigations are merited so clinicians can further parse out the indications and contraindications for each keyhole approach.
摘要：
目的：AxelPerneczky负责将“锁孔”哲学概念化为颅神经外科中最小侵入性的新范式。锁孔神经外科旨在限制与方法相关的创伤并最大程度地减少大脑收缩，同时仍使神经外科医生能够实现手术目标。眶上锁孔开颅术（SOKC）和小翼点（翼点锁孔，PKC）方法已成为夹闭颅内动脉瘤的主要方法。尽管有研究将这些方法与传统的翼状开颅术进行了比较，以夹闭脑动脉瘤，这些主力钥匙孔方法的头对头比较仍然有限。
方法：作者根据PRISMA指南查询了三个数据库，以确定将SOKC与PKC进行显微手术夹闭脑动脉瘤的所有研究。在最初查询时返回的148项独特研究中，2013年至2019年发表的5项研究符合纳入标准.如果适用,定量荟萃分析通过Mantel-Haenszel方法使用ReviewManagerv5.4(NordicCochraneCenter，Cochrane协作,哥本哈根,丹麦)。使用CochraneROBINS-I工具评估偏倚风险(ROB)，所有研究均分配了证据水平（I-V）。
结果：在所有五项研究中，平均年龄从53.0到57.5岁，队列中女性（n=403，60.6%）多于男性。在SOKC和PKC队列中，出现破裂动脉瘤性SAH的患者比例相当（p=0.43）。夹闭率[定义为成功的术中闭塞成功的动脉瘤夹展开率](OR1.52[0.49,4.71],I2=0%，p=0.47),最终闭塞率(OR1.27[0.37,4.32]，p=0.70),和手术持续时间（SMD0.33[-0.83。1.49],I2=97%，p=0.58)是可比的，无论使用何种方法。此外，术中破裂率（OR1.51[0.64，3.55]，I2=0，p=0.34），术后出血（OR1.49[0.74，3.01]，I2=0，p=0.26），术后血管痉挛（OR0.94[0.49，1.80]，I2=63，p=0.86），和术后感染（OR0.70[0.16，2.99]，I2=0%，p=0.63)在SOKC和PKC队列中是模棱两可的。
结论：PKC和SOKC方法用于脑动脉瘤破裂和未破裂患者的开放性显微外科手术夹闭时，似乎可提供可比的结果。两者都与出色的剪切和遮挡率相关，围手术期并发症发生率最低，和良好的术后神经系统结局。值得进一步研究，以便临床医生可以进一步解析出每种锁孔方法的适应症和禁忌症。
方法：作者根据PRISMA指南查询了三个数据库，以确定将SOKC与PKC进行显微手术夹闭脑动脉瘤的所有研究。在最初查询时返回的148项独特研究中，2013年至2019年发表的5项研究符合纳入标准.如果适用,定量荟萃分析通过Mantel-Haenszel方法使用ReviewManagerv5.4(NordicCochraneCenter，Cochrane协作,哥本哈根,丹麦)。使用CochraneROBINS-I工具评估偏倚风险(ROB)，所有研究均分配了证据水平（I-V）。
结果：在所有五项研究中，平均年龄从53.0到57.5岁，队列中女性（n=403，60.6%）多于男性。在SOKC和PKC队列中，出现破裂动脉瘤性SAH的患者比例相当（p=0.43）。夹闭率[定义为成功的术中闭塞成功的动脉瘤夹展开率](OR1.52[0.49,4.71],I2=0%，p=0.47),最终闭塞率(OR1.27[0.37,4.32]，p=0.70),和手术持续时间（SMD0.33[-0.83。1.49],I2=97%，p=0.58)是可比的，无论使用何种方法。此外，术中破裂率（OR1.51[0.64，3.55]，I2=0，p=0.34），术后出血（OR1.49[0.74，3.01]，I2=0，p=0.26），术后血管痉挛（OR0.94[0.49，1.80]，I2=63，p=0.86），和术后感染（OR0.70[0.16，2.99]，I2=0%，p=0.63)在SOKC和PKC队列中是模棱两可的。
结论：PKC和SOKC方法用于脑动脉瘤破裂和未破裂患者的开放性显微外科手术夹闭时，似乎可提供可比的结果。两者都与出色的剪切和遮挡率相关，围手术期并发症发生率最低，和良好的术后神经系统结局。值得进一步研究，以便临床医生可以进一步解析出每种锁孔方法的适应症和禁忌症。
