Transorbital Approach for Clipping of Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

The literature on transorbital approach has skyrocketed recently, but there is no consensus on what "transorbital" means. There are reports using this approach on aneurysms, but the operations mainly involved the frontal bone with the inclusion of the orbital rim.(1) Clipping aneurysms through the orbit remains a rare procedure.(2,)3 We present a case of an anterior communicating artery (ACOM) aneurysm treated through a transpalpebral incision and transorbital approach. The patient was a 66-year-old man who presented with an incidental ACOM aneurysm. Previously, he had a skin graft involving his left forehead, which made this area unusable for cranial surgery. After appropriate discussion regarding risk and alternatives,(4,5) he chose surgical clipping to treat his aneurysm. A left transorbital approach was rehearsed in virtual reality. The skin graft was avoided through a left transpalpebral incision,(6,7) and a superior transorbital approach modified with a superior orbitotomy was performed with clipping of the ACOM aneurysm. Postoperative angiography confirmed complete exclusion of the aneurysm with patent parent vessels. The patient developed a cerebrospinal leak soon after surgery, which resolved with lumbar drainage. We define "transorbital" as an approach in which most of the exposure and surgical freedom at the target is through the removal of portions of the orbital wall or roof. Although this operation involved a small portion of the superior orbital rim, it fits this definition. The video demonstrates that ACOM aneurysm can be safely treated through this approach. The patient consented to the procedure and to the publication of his image. Images from Stieger et al1 were reused after obtaining permission from the Congress of Neurological Surgeons.