Supraorbital Keyhole Craniotomy via Eyebrow Incision: A Systematic Review and Meta-analysis

Objective: Supraorbital keyhole craniotomy via an eyebrow incision is a minimally invasive alternative to frontotemporal craniotomy. This approach is used for tumor resection and aneurysm clipping, and there is significant variability in the use of the endoscope as an assistive visualization device. The purpose of this study was to provide a contemporary systematic review and meta-analysis on the outcomes related to this surgical approach and to determine if they vary with the type of pathology (vascular vs. neoplasm) and the addition of an endoscope. Methods: PubMed, Embase, and Scopus databases were systematically searched on August 11, 2020, for pertinent articles and the results were reported according to the PRISMA guidelines. Original retrospective and prospective studies published in English language were included. For the meta-analysis portion, the DerSimonian–Laird random effects model was used as high variability between the studies was expected. The t -test was used to compare the different groups and a p -value of <0.05 was considered statistically significant. Results: A total of 2,629 records were identified. Of those, 124 studies (8,241 surgical cases) met the inclusion criteria. Majority of studies were published in 2017 and 2018. The mean age was 46.7 ± 15.5 years of age. Mean total complication rate was 26.7 ± 25.7%. Mean approach-related mortality rate was 1.3 ± 2.8%. Technical success, defined as gross-total tumor resection, complete aneurysm clipping, or otherwise satisfying the authors’ surgical aims, was achieved in 83.6 ± 21.5% of the cases. Furthermore, outcomes were also analyzed based on type of operative pathology. Vascular lesions or clipped aneurysms comprised the majority of the pathology (74.6%), and were associated with higher technical success, lower total complications, but longer length of hospital stay compared to tumor pathology ( p < 0.05 for all). However, there was no significant difference in approach-related mortality ( p = 0.777), operative time ( p = 0.566), or reoperation rate ( p = 0.464) between tumor and vascular cases. When the endoscopic-assisted supraorbital approach and the nonendoscopic-assisted supraorbital approach were compared for tumor cases, there was significant difference in technical success, complications, mortality, length of hospital stay, operative time, or reoperation rate ( p > 0.05 for all). For vascular cases, the addition of endoscope yielded lower technical success ( p = 0.001), and lower complication rate ( p = 0.041) compared to nonendoscopic aneurysm cases. The mortality was not statistically significant ( p = 0.200). Conclusion: The supraorbital craniotomy via an eyebrow incision is a feasible minimally invasive approach with an overall high technical success rate. We found that this approach has a higher success rate for vascular pathology, and the addition of endoscope does not confer better outcomes except for lower complication rate for endoscopic-assisted aneurysm cases. Publication History Article published online: 15 February 2022 © 2022. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany