• Diapo Gerald Mohale, Denver Naicker, Blessing Ndlovu, Keletso Leola, Makhosazana Dlamini, Brian Gardner, Raazik Gani, Murimisi Mukansi, John Richard Ouma, Morena Nthuse Mpanza, and Christos Profyris.
• Department of Neurosurgery, Helen Joseph Hospital, Johannesburg, South Africa.
• World Neurosurg. 2022 Dec 1; 168: 209218209-218.

BackgroundEvolution of keyhole techniques in aneurysm surgery allows for definitive surgical management of aneurysmal pathology with little disruption of normal surrounding tissue. While experienced vascular neurosurgeons are increasingly applying keyhole techniques to unruptured aneurysms, experience with ruptured aneurysms is limited.ObjectiveWe sought to explore technical nuances and present operative outcomes for our series of 40 consecutive patients presenting with ruptured intracerebral aneurysms treated with surgical clipping via a keyhole approach.MethodsThis study is a consecutive, single-surgeon, single-center retrospective case series of aneurysms clipped with keyhole approaches at Helen Joseph Hospital in Johannesburg, South Africa. Patients presenting with subarachnoid hemorrhage were worked up exclusively with computed tomography. On the basis of vessel location and unique anatomic features, aneurysms were clipped through one of these approaches: minipterional, supraorbital, or keyhole interhemispheric. Operative details were assessed on retrospective file review, and patient outcomes were assessed on clinic follow-up.ResultsA minipterional approach was used for 55% of cases, the supraorbital approach in 30% of cases, and the mini-interhemispheric approach in 15% of cases. The intraoperative aneurysm rupture rate was 26.2%. Complete aneurysm occlusion was achieved in 97.4% with none of the 40 cases requiring conversion of a keyhole to a larger craniotomy. A good outcome was achieved for 72.5% of patients (modified Rankin Scale score ≤2). For patients presenting with World Federation of Neurological Surgeons grade I to III subarachnoid hemorrhage, 92.9% achieved a good outcome.ConclusionsThe present series supports the concept that sound technical execution of keyhole approaches, even in the setting of acutely ruptured cerebral aneurysms, is a viable option for clipping of intracranial aneurysms.Copyright © 2022 Elsevier Inc. All rights reserved.

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