• Keaton Piper, Miguel Saez-Alegre, Thomas Perillo, Ivo Peto, Edinson Najera, Josef Williams, Jeff Breton, Daniel R Felbaum, and Walter C Jean.
• Department of Neurologic Surgery and Brain Repair, University of South Florida, 2 Tampa General Circle, Tampa, Florida, 33606. Electronic address: keatonpiper@usf.edu.
• World Neurosurg. 2024 Sep 3.

BackgroundThe transorbital approach (TOA) has a unique advantage to the more common lateral approaches as it provides direct access to the anterior middle fossa and medial sylvian fissure (SF) without significant dissection or retraction. However, when to use the TOA for surgical treatment of MCA aneurysms remains unclear.ObjectiveThis study details the feasibility of clipping unruptured middle cerebral artery (MCA) aneurysms via the TOA by highlighting the anatomic features that either facilitate or hinder the approach.MethodsVirtual reality (VR) models of 25 MCA aneurysms from CT angiograms of actual patients were rendered with the relevant anatomic structures, including the neighboring temporal lobe and SF. TOA was performed on the models in VR and the globe was translated medially and inferiorly, replicating retraction used intraoperatively. Anatomic data, including the area of surgical freedom (AOF) at the aneurysm, were recorded. Trials of aneurysm clipping were conducted in VR and each aneurysm was classified as "possible" or "impossible" candidates for clipping via TOA. Separately, the relationship between surgical view and SF visualized was analyzed.ResultsSixteen aneurysms were eliminated as candidates for TOA treatment either through VR clip trial and/or because the SF was inaccessible. The remaining 9 (36%) were candidates for TOA. Comparing the details of these two aneurysm categories with Mann Whitney U tests, there was a statistically significant difference in the AOF of the TOA approach and the width of the aneurysm dome. A clinical case report is also provided highlighting the VR rehearsal similarity with surgery.ConclusionsGiven the minimally-invasive, technically-challenging approach, the feasibility and safety of TOA for MCA aneurysms must be evaluated before wide clinical adoption. This study identified AOF, aneurysm width, and SF accessibility as three features that may significantly impact the possibility of clipping MCA aneurysms via TOA.Copyright © 2024. Published by Elsevier Inc.

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