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Nearly Scarless Brain Aneurysm Surgery with Transpalpebral “Eyelid” Approach

Combo Therapy Stroke Trial Ends One Debate

A novel, minimally invasive approach to microsurgical clipping offers patients nearly scarless brain surgery when endovascular treatment for cerebral aneurysm is not possible or risky. Transorbital trans-eyelid surgery (TOTES) via a superior eyelid incision is an innovative technique for accessing and treating anterior circulating aneurysms, including middle cerebral aneurysms (MCA), without performing a traditional craniotomy.


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Mauricio Mandel, MD, PhD, is an early adopter of TOTES and has contributed to the advancement of this field for more than a decade. He is one of the few neurosurgeons in Florida using the approach to treat anterior circulation aneurysms as well as skull base and temporal lobe tumors.

Dr. Mandel has performed nearly two dozen transorbital surgeries using the trans-eyelid approach since joining Cleveland Clinic Tradition Hospital in 2022, and about 75% of these cases have been to treat brain aneurysms.

MCA aneurysms

The MCA is the largest branch of the internal carotid artery (ICA) and part of the anterior circulation of the brain. With its extensive branching, the MCA supplies blood to the frontal, parietal and temporal lobes as well as many deep brain structures.

It is the most common blood vessel involved in ischemic stroke and the site of approximately 20-40% of intracranial aneurysms. According to Dr. Mandel, MCA aneurysms most often occur at the bifurcation of the M1 (sphenoidal) and M2 (insular) segments.

Microsurgical versus endovascular

It’s been nearly a decade since the American Heart Association/American Stroke Association (AHA/ASA) last issued guidelines for managing patients with unruptured intracranial aneurysms. They note microsurgical repair is associated with higher rates of aneurysm obliteration and lower rates of recurrence than endovascular repair but with higher perioperative morbidity. The guidelines also specify an advantage to microsurgery treatment for most middle cerebral artery aneurysms.

“Microsurgical clipping remains the first-line treatment for MCA aneurysms despite the growing popularity of endovascular treatments, like coiling and flow diverters,” says Dr. Mandel. “This is especially true for wide-neck aneurysms and those with branching vessels.”

A growing body of research, including a 2017 study led by Dr. Mandel, shows the newer trans-eyelid approach for microsurgical clipping to be a safe, definitive treatment for MCA aneurysms.

“Transorbital surgery is a more straightforward approach for clipping an MCA aneurysm that reduces the morbidity of open surgery and avoids some of the complications seen with endovascular treatments, including intraoperative aneurysm rupture and thrombosis,” Dr. Mandel explains.


Transorbital “eyelid” surgery

The transpalpebral route Dr. Mandel uses to access MCA aneurysms entails making a small incision in a natural crease of the patient’s upper eyelid, similar to a blepharoplasty, allowing it to be largely hidden postoperatively. Orbital roof resection and burr-hole craniotomy are performed to expose the neurovascular structures, eliminating the need for a scalp incision and larger craniotomy.

“This approach minimizes soft tissue disruption, injury to nerves and the temporal muscle, and brain retraction,” says Dr. Mandel. “Patients experience less postoperative pain and no difficulty masticating, and the cosmetic outcome is far superior.”

He recalls one of his patients relaying to him an encounter with an ER physician on an unrelated issue. “During the taking of her personal medical history, the physician did not believe she had undergone microsurgical clipping for an aneurysm because he couldn’t see a scar,” says Dr. Mandel.

Other advantages associated with TOTES over traditional surgery include reduced operative times, shorter hospital stays, a more rapid recovery, and a faster return to a more normal lifestyle. Dr. Mandel was principal investigator of a more recent clinical trial that demonstrated superior cosmetic, satisfaction, and quality-of-life outcomes with MIS techniques, including the transpalpebral approach, when compared to open surgery using a standard pterional approach.


“Transorbital surgery is my go-to approach whenever a patient needs their unruptured MCA aneurysm clipped,” says Dr. Mandel. “There is rarely a need for open surgery anymore. Even giant aneurysms larger than 2.5 cm can be clipped using this technique.”

He emphasizes, however, that the decision to use a surgical or endovascular approach to treat an aneurysm must be made on a case-by-case basis by a multidisciplinary team of specialists involving neurosurgeons, interventional neurologists, endovascular specialists, and neuroradiologists. AHA/ASA guidelines also recommend that surgical treatment of unruptured intracranial aneurysms be performed at higher-volume centers.

Skull base tumors and more

In addition to treating unruptured brain aneurysms, Dr. Mandel uses the transpalpebral approach to access and treat skull base and temporal lobe tumors. His colleagues at Cleveland Clinic’s Neurological Institute in Ohio also report that transorbital surgery is ideal for patients with tumors of the orbit, frontal sinus, anterior cranial fossa, sphenoid bone and anterior-lateral parts of the middle cranial fossa.

“Modern neuroimaging, detailed 3D surgical planning, and advanced neurosurgical equipment, including a high definition neuroendoscope and operating microscope, make it possible to perform transorbital surgery safely and effectively for a variety of tumor types,” says Dr. Mandel. He points out that these tools also are used to perform endonasal endoscopic surgery, another minimally invasive approach for skull base tumors.

“Performing endoscopic surgery using the transorbital and endonasal routes has dramatically changed how we treat a majority of skull base and temporal tumors,” says Dr. Mandel. “These approaches can also be combined to provide very innovative neurosurgical treatments.”

Cleveland Clinic in Florida is hosting a two-day stroke and cerebrovascular disease conference in November that will spotlight the latest updates in the management of an array of cerebrovascular diseases. Dr. Mandel’s presentation, entitled “Neurosurgical Revascularization, is Benefit Worth the Risk,” will include a discussion of minimally invasive techniques for extracranial-intracranial (EC-IC) arterial bypass as well as a brief conversation on transorbital surgery for brain aneurysms.

For more information, visit Cleveland Clinic Florida ConsultQD. Subscribe to the Florida Physician Newsletter.
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