Pure endoscopic clipping of anterior circulation aneurysms through keyhole approach

Pure endoscopic clipping of anterior circulation aneurysms through keyhole approach | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pure endoscopic clipping of anterior circulation aneurysms through keyhole approach Huadong Tang, Pengyuan Niu, Xialin Zheng, Dongqi Shao, Shan Xie, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4560147/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: This retrospective study evaluated the safety and effectiveness of pure endoscopic clipping for anterior circulation aneurysms through the supraorbital keyhole approach and the pterional keyhole approach. Methods: We included 92 patients with anterior circulation aneurysms, all treated with clipping surgery at The First Affiliated Hospital of Bengbu Medical University. Patients were divided into neuroendoscopic and microscopic groups, based on whether endoscopic or microscopic techniques were used for clipping. We analyzed baseline patient characteristics, surgery-related details, postoperative hospitalization duration, complications, and modified Rankin Scale (mRS) scores 3 months after the operation to assess treatment outcomes. Results: No significant differences existed between the neuroendoscopic and microscopic groups in statistical indicators, except for patient gender distribution. Conclusions: Pure neuroendoscopic clipping of anterior circulation aneurysms (≤1cm in diameter, Hunt-Hess grade ≤ III) through supraorbital and pterional keyhole approaches is safe and effective. Its prognosis is comparable to that of the microscopic keyhole approach. Moreover, since the endoscope can provides better light intensity deep in the surgical field, clear close-up images of pathoanatomic details, and wider viewing angles, endoscopic clipping of intracranial aneurysms is more valuable. intracranial aneurysm neuroendoscope microscope keyhole approache clip Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Intracranial aneurysms (IAs) are pathological dilations that occur at major branchs of brain arteries[ 1 ]. The prevalence of unruptured IAs in the general population is approximately 3.2%[ 2 ]. Subarachnoid hemorrhage (SHA) resulting from their rupture is responsible for 80–85% of all non-traumatic subarachnoid hemorrhages and 5% of stroke cases[ 3 ]. The treatment of IAs involves two main approaches: endovascular coiling and surgical clipping. Since the International Subarachnoid Aneurysm Trial (ISAT), endovascular coiling has become a primary treatment method[ 4 ]. However, this method suffers from a high recurrence rate, substantial equipment costs, and the need for long-term follow-up. Consequently, surgical clipping remains an essential treatment option[ 5 ]. In 1975, Yasagil et al. introduced the classic pterional approach as a standard procedure for treating anterior circulation aneurysms[ 6 ]. Despite its effectiveness, this approach may require extensive exposure of skin, bone, and brain, potentially leading to iatrogenic complications[ 7 – 8 ]. To minimize these complications, the concept of keyhole surgery was introduced[ 9 ]. A significant limitation of the less-invasive keyhole approach is the reduced visibility and lighting within the operative field, which significantly impacts optical control during surgery. For the purpose of bringing light into the surgical field and controlling deep-seated microinstruments with adequate magnification, the optical properties of modern surgical microscopes can be effectively supplemented by the optical properties of endoscopes[ 10 ]. Hopf and Perneczky have categorized endoscopic techniques into three types: endoscopic neurosurgery, endoscope-assisted microneurosurgery, and endoscope-controlled microneurosurgery[ 11 ].Previous studies often combine these methods to evaluate the safety and effectiveness of endoscopes in IAs surgery[ 12 – 14 ]. However, the interchange between endoscopic and microscopic tools during surgery can prolong operation times and increase the risks of postoperative infections and mechanical injuries[ 15 ]. Therefore, it is necessary to evaluate the safety and effectiveness of pure endoscopic clipping for anterior circulation aneurysms through the keyhole approach.This article reviews experiences with the keyhole approach for clipping anterior circulation aneurysms and analyzes the safety and effectiveness of pure neuroendoscopic clipping methods applied through the keyhole approach in IAs surgery. Patients and Methods Patient population This retrospective study included a total of 92 patients who underwent intracranial aneurysm clipping through pterional keyhole approach (PKA) or supraorbital keyhole approach (SKA) between January 2021 and January 2024 at the Department of Neurosurgery, First Affiliated Hospital of Bengbu Medical University, China. Of these, 44 patients underwent pure neuroendoscopy and were classified as the endoscopic group, while the remaining 48 underwent microscopic surgery and formed the microscopic group. The inclusion criteria included: (1) CTA or DSA-confirmed diagnosis of anterior circulation aneurysms; (2) IAs was clipped through PKA or SKA. Exclusion criteria were: (1) Multiple IAs are clipped in one operation; (2) SAH with a Hunt-Hess grade of IV or V; (3) secondary IAs, such as traumatic or infectious aneurysms; (4) IAs associated with other cerebrovascular malformations; (5) The clippping process of aneurysm is completed by microscope and neuroendoscope;(6) incomplete records. Data collection Patient clinical data, extracted from the hospital information system, included (1) demographic characteristics such as age and gender; (2) aneurysm morphology, including location, size, and rupture status; (3) preoperative Hunt-Hess grade; (4) time to operation; (5) surgery-related details such as the type of keyhole approach (PKA or SKA), parent vessel occlusion, intraoperative aneurysm rupture, operation duration, and blood loss; (6) postoperative hospitalization duration; (7) complications, including inadequate clipping, cerebral ischemia, hematoma, hydrocephalus, vision loss, intracranial infection, limb hemiplegia, epilepsy, mental symptoms, and death; (8) postoperative imaging, including CT scans on the first day and CTA within 1–3 months post-operation; (9) mRS score 3 months after the operation.The return visit time of all patients ranges from 3 months to 3 years. Surgical procedures For aneurysms located in the anterior communicating artery (ACoA) or anterior cerebral artery (ACA), the SKA is employed (Fig. 1 b). The choice of a left or right incision is determined by the position and direction of the aneurysm. The incision is approximately 4 cm in length, extending from the angular process of the frontal bone to the supraorbital nerve. For aneurysms located in the posterior communicating artery (PCoA) or middle cerebral artery (MCA),the PKA is employed (Fig. 2 b).The incision is approximately 7 cm in length, centering on the symbol of body surface of the lateral fissure pool. Statistical analysis Kolmogorov–Smirnov tests were employed to assess the normal distribution of all clinical covariates before conducting statistical analyses. Continuous variables are presented as either means ± standard deviations or interquartile ranges, while categorical variables are reported as frequencies (percentages). Continuous variables were analyzed using either the Mann–Whitney U test or independent-samples t test. Categorical variables were examined using the χ2 test or Fisher’s exact test. All statistical analyses were performed using the SPSS 26.0 (IBM Corp., Armonk, NY, USA) software.A p-value of less than 0.05 was considered statistically significant. Results Baseline characteristics In this study, 44 IAs underwent endoscopic keyhole surgery, and 48 IAs underwent microscopic keyhole surgery. Among these, the incidence of ruptured IAs was 79.55% (35 cases) in the endoscopic group and 75.00% (36 cases) in the microscopic group. The mean ages were 59.50 years and 56.92 years, respectively. The percentages of male patients were 45.45% (20 patients) in the endoscopic group and 70.83% (34 patients) in the microscopic group. The mean sizes of the IAs were 5.92 mm in the endoscopic group and 5.55 mm in the microscopic group. In the endoscopic group, IAs were located in the ACA (2 [4.55%]), ACoA (18 [40.91%]), PCoA (6 [13.64%]), and MCA (18 [40.91%]). By contrast, in the microscopic group, IAs were located in the ACA (3 [6.25%]), ACoA (14 [29.17%]), PCoA (10 [20.83%]), and MCA (21 [43.75%]). The severity of patients' conditions upon admission was assessed using the Hunt-Hess scale. In the endoscopic group, the classifications were as follows: grade 0 (9.09%), grade I (25.00%), grade II (56.82%), and grade III (9.09%). In the microscopic group, the classifications were grade 0 (6.25%), grade I (18.75%), grade II (62.50%), and grade III (12.50%). In the endoscopic group, 84.09% of patients (37 individuals) underwent a clipping operation within 3 days of admission, while 15.91% (7 individuals) underwent the procedure within 3–14 days after admission. In the microscope group, 91.67% of patients (44 individuals) had the operation within 3 days, and 8.33% (4 individuals) had it within 3–14 days after admission. There were no statistically significant differences in the baseline characteristics between the two groups, except for gender. Table 1 Baseline characteristics of patients. Characteristics Neuroendoscopic Group Microscopic Group p Value Age, y, mean ± sd 59.50 ± 10.10 56.92 ± 9.70 0.21 Gender, n (%) 0.01 Male 20(45.45%) 34(70.83%) Female 24(54.55%) 14(29.17%) Locations of aneurysms, n (%) 0.62 ACA 2(4.55%) 3(6.25%) ACoA 18(40.91%) 14(29.17%) PCoA 6(13.64%) 10(20.83%) MCA 18(40.91%) 21(43.75%) Aneurysm diameter 5.92 ± 1.65 5.55 ± 1.57 0.27 Hunt–Hess grade, n (%) 0.80 0 4(9.09%) 3(6.25%) Ⅰ 11(25.00%) 9(18.75%) Ⅱ 25(56.82%) 30(62.50%) Ⅲ 4(9.09%) 6(12.50%) Time to operation,days,n(%) 0.26 ≤ 3 37(84.09%) 44(91.67%) 3–14 7(15.91%) 4(8.33%) Ruptured or not,n (%) 0.60 yes 35(79.55%) 36(75.00%) no 9(20.45%) 12(25.00%) Surgery-related details and days of postoperative hospitalization duration In the neuroendoscopic group, PKA procedures were performed in 24 patients (54.55%) and SKA in 20 patients (45.45%). In the microscopic group, PKA was performed in 31 patients (64.58%) and SKA in 17 patients (35.42%). The neuroendoscopic group experienced no cases (0%) of parent vessel occlusion and four cases (9.09%) of intraoperative aneurysm rupture. Conversely, in the microscopic group, one case (2.08%) involved parent vessel occlusion and four cases (8.33%) involved intraoperative aneurysm rupture. Median operation times were 120 minutes (interquartile range: 100–147) in the neuroendoscopic group and 112 minutes (interquartile range: 100-147.5) in the microscopic group. Median blood loss was 100 ml (interquartile range: 50–100) in the neuroendoscopic group and 80 ml (interquartile range: 70–100) in the microscopic group. Median postoperative hospitalization duration were 8 days (interquartile range: 7–10) for the neuroendoscopic group and 9 days (interquartile range: 7–12) for the microscopic group. No statistically significant differences existed in surgery-related details or postoperative hospitalization duration between the two groups (P > 0.05). Table 2 details these surgery-related details and postoperative hospitalization duration for both groups. Table 2 Surgery-related details and Postoperative hospitalization duration. Characteristics Neuroendoscopic Group Microscopic Group p Value Type of keyhole,n (%) 0.33 PKA 24(54.55%) 31(64.58%) SKA 20(45.45%) 17(35.42%) Parent vessel occlusion,n (%) 0.34 yes 0(0%) 1(2.08%) no 44(100.00%) 47(97.92%) intraoperative aneurysm rupture,n (%) 0.90 yes 4(9.09%) 4(8.33%) no 40(90.91%) 44(91.67%) Operative time (minutes) 120(100,147) 112(100,147.5) 0.72 blood loss (ml) 100(50,100) 80(70,100) 0.93 Postoperative hospitalization duration (days) 8(7,10) 9(7,12) 0.88 Postoperative complications In the endoscopic group, 7 patients (15.91%) experienced postoperative complications: one developed epilepsy with an intracranial infection, two had intracranial infections, one died from respiratory failure due to prolonged unconsciousness following severe brain edema from postoperative bleeding, one developed vision loss and limb hemiplegia, one had epilepsy, and one suffered from hydrocephalus with limb hemiplegia. In the microscopic group, 9 patients (18.75%) had postoperative complications: two patients experienced brain edema and prolonged unconsciousness, ultimately dying due to ventilator dependence; one had an intracranial infection with limb hemiplegia and mental symptoms; one had inadequately clipped aneurysms with an intracranial infection; one developed hydrocephalus; one had vision loss with an intracranial infection; one had cerebral ischemia with an intracranial infection; one underwent decompressive craniectomy due to cerebral ischemia and subsequently developed limb hemiplegia and mental symptoms; and one had an intracranial infection with hydrocephalus. No statistically significant differences were found in the incidence of postoperative complications between the groups (P > 0.05), and no complications related to the neuroendoscope were observed. Table 3 presents the postoperative complications for both groups. Table 3 Postoperative complications. Complications Neuroendoscopic Group Microscopic Group p Value Complications occur or not 0.72 yes 7(15.91%) 9(18.75%) no 37(84.09%) 39(81.25%) Inadequately clipped aneurysmsn (%) 0.34 yes 0(0%) 1(2.08%) no 44(100%) 47(97.92%) Cerebral ischemia, n (%) 0.51 yes 0(0%) 2(4.17%) no 44(100%) 46(95.83%) Hematoma, n (%) 0.17 yes 1(2.27%) 0(0%) no 43(97.73%) 48(100%) Hydrocephalus, n (%) 0.61 yes 1(2.27%) 2(4.17%) no 43(97.73%) 46(95.83%) Vision loss, n (%) 0.95 yes 1(2.27%) 1(2.08%) no 43(97.73%) 47(97.92%) Intracranial infection, n (%) 0.54 yes 3(6.82%) 5(10.42%) no 41(93.18%) 43(89.58%) Limb hemiplegia, n (%) 0.93 yes 2(4.55%) 2(4.17%) no 42(95.45%) 46(95.83%) Epilepsy, n (%) 0.14 yes 2(4.5%) 0(0%) no 42(95.5%) 48(100.00%) Mental symptoms, n (%) 0.17 yes 0(0%) 2(4.17%) no 44(100.00%) 46(95.83%) Death, n (%) 0.61 yes 1(2.27%) 2(4.17%) no 43(97.73%) 46(95.83%) Prognosis After 3 months of operation, we reassessed the patient's modified Rankin Scale (mRS) scores to evaluate their prognosis. In the neuroendoscopic group, 32 (72.73%) patients scored 0–1, 10 (22.73%) scored 2–3, one (2.27%) scored 4–5, and one (2.27%) scored 6. In the microscope group, 36 (75.00%) patients scored 0–1, 8 (16.67%) scored 2–3, two (4.17%) scored 4–5, and two (4.17%) scored 6. Statistical analysis showed no significant difference in prognosis between the two groups (P > 0.05). Table 4 The modified Rankin Scale (mRS) of the postoperative patients. range Neuroendoscopic Group Microscopic Group p Value 0–1 32(72.73%) 36(75.00%) 0.82 2–3 10(22.73%) 8(16.67%) 4–5 1(2.27%) 2(4.17%) 6 1(2.27%) 2(4.17%) Discussion In 1971, Wilson reported that 33 IAs were treated using a "limited exposure" technique, a precursor to the keyhole approach[ 16 ]. Paladino and colleagues later formalized this concept[ 17 ]. The keyhole approach minimizes brain tissue exposure and offers a cosmetically smaller incision, aligning with patient preferences[ 18 ]. However, the limited lighting and angle of traditional microscopes may not adequately address the needs for clipping IAs, as perforating arteries or the aneurysm neck behind the parent vessel might be missed[ 13 ]. Even among experienced surgeons, unexpected perforating arteries occlusion and incomplete clipping of aneurysm neck have been reported[ 19 ].Compared with a microscope, the endoscope provides better light intensity deep in the surgical field, clear close-up images of pathoanatomic details, and wider viewing angles[ 20 ]. These characteristics of endoscope are helpful for surgeons to better expose the neck of aneurysm and understand the relationship between aneurysms and perforating blood vessels and surrounding adjacent blood vessels[ 19 , 21 – 22 ].One of our previous meta-analyses have shown that 77% of endoscopic-assisted surgeries offer crucial visual information over standard microsurgery[ 23 ]. Besides. In Kalavakonda et al.' s report, the use of neuroendoscope significantly shortened the temporary clipping time of the parent artery in two patients[ 24 ].Kang et al.believe that under an endoscopic view, a magnifed and wide surgical view provides less manipulation or traction of the surrounding tissues, resulting in reduced post-clipping cerebral infarction[ 25 ]. In this study, no residual intracranial aneurysm necks and parent vessel occlusion were found in the endoscopic group, underscoring the benefits of the enlarged, multiangled,wellilluminated view of the endoscope, allowing surgeons to observe the neck of IAs and surrounding adjacent structures, thus realizing the safe and effective clipping of IAs during operation. A clear operative field is essential for successful endoscopic surgery. Thus, Taniguchi M, et al suggest that non-ruptured aneurysms or those post-subarachnoid hemorrhage are suitable for endoscopic assistance[ 26 ]. In our practice, ruptured aneurysms are managed by extensive irrigation of the basal and lateral fissure cisterns. For patients with pre-operative hydrocephalus, cerebrospinal fluid can be drained through endoscopic third ventriculostomy (Fig. 3 ) to clear the surgical pathway. This procedure can also be performed post-operatively in patients at risk of persistent hydrocephalus to minimize the need for a shunt. However, due to the risk of severe brain edema, we avoid using neuroendoscopes in patients with a Hunt-Hess grade of IV-V. In our neuroendoscopic group, we have successfully clipped IAs with a maximum diameter of less than 1 cm (9.4 mm). Drawing from our microsurgical clipping experience, we contend that aneurysms larger than 1 cm can also be managed endoscopically. This is possible by intermittently coagulating the aneurysm during surgery to reduce its volume and make space for the endoscopic procedure. While some researchers argue that endoscopy is better suited for smaller IAs, as larger masses may hinder the insertion and fixation of endoscopy[ 27 ], we recognize the merit in this perspective. Nonetheless, the upper size limit for aneurysms amenable to endoscopic clipping warrants further investigation. IA surgery often entails the risk of intraoperative rupture.Massive bleeding during the operation will block the vision of endoscopic operation and threaten the safety of the operation. For IAs with high risk of rupture during operation, the likelihood of rupture can be minimized by temporarily occluding the parent artery (Fig. 4 ). Should a rupture occur and blood obscure the surgical view, the endoscope should be slightly withdrawn while the assistant introduces a wide-bore suction and irrigates with saline. Once the view is clear, the assistant maintains suction near the rupture site, allowing the surgeon to apply a temporary clip after clearing any blood from the proximal vessel. If necessary, a microscope is kept on standby for instances where the rupture is beyond endoscopic control. Conclusion Pure endoscopic clipping of anterior circulation aneurysms with a diameter of 1 cm or less and a Hunt-Hess grade of III or lower through SKA and PKA techniques is safe and effective. The prognosis is comparable to that of the keyhole approach using a microscope.Moreover, since the endoscope can provides better light intensity deep in the surgical field, clear close-up images of pathoanatomic details, and wider viewing angles,endoscopic clipping of intracranial aneurysms is more valuable in protecting perforating blood vessels and parent vessel. Declarations Competing Interests The authors declare no competing interests. Ethics approval The study was approved by the Ethics Committee of the First Affiliated Hospital of Bengbu Medical University (2021KY047). Consent to participate The need for informed consent was waived by the Research Ethics Committee because the study was retrospective. The confdentiality of patient data was protected in accordance with Consent to publish Not applicable. Data Availability Statement The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Funding This research was funded by grants from the Natural Science Foundation of Anhui Province (No. KJ2021KD0078).This research was funded by grants from the Health Commission Foundation of Anhui Province (No. AHWJ2023A10099). Author Contribution HT, PN, and XZ designed the study. DS, SX,and YL collected the data. HT,QL,and KL analyzed the data. HT,TW,HL,and MW wrote the manuscript. ZJ completed the review of the article. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4560147","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":319964209,"identity":"677f17fd-70e4-41a6-9fa3-98bad7405ee2","order_by":0,"name":"Huadong Tang","email":"","orcid":"","institution":"The First Afliated Hospital of Bengbu Medical University","correspondingAuthor":false,"prefix":"","firstName":"Huadong","middleName":"","lastName":"Tang","suffix":""},{"id":319964212,"identity":"3d45b8df-7266-4848-b6cf-ea9eea386b29","order_by":1,"name":"Pengyuan Niu","email":"","orcid":"","institution":"The First Afliated Hospital of Bengbu 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University","correspondingAuthor":false,"prefix":"","firstName":"Qingshu","middleName":"","lastName":"Li","suffix":""},{"id":319964221,"identity":"66269349-75f7-45d4-b8d8-66daa0289186","order_by":8,"name":"Tianyang Wu","email":"","orcid":"","institution":"The First Afliated Hospital of Bengbu Medical University","correspondingAuthor":false,"prefix":"","firstName":"Tianyang","middleName":"","lastName":"Wu","suffix":""},{"id":319964222,"identity":"bb14bc08-0e84-4a06-bbd6-024f5443a9de","order_by":9,"name":"Hao Lang","email":"","orcid":"","institution":"The First Afliated Hospital of Bengbu Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Lang","suffix":""},{"id":319964223,"identity":"b01919ca-e755-46fd-be8f-5cedf1f37ae2","order_by":10,"name":"Meiqi Wu","email":"","orcid":"","institution":"The First Afliated Hospital of Bengbu Medical University","correspondingAuthor":false,"prefix":"","firstName":"Meiqi","middleName":"","lastName":"Wu","suffix":""},{"id":319964224,"identity":"72fd148d-c5f7-4f59-ad7e-6f21c82df254","order_by":11,"name":"Zhiquan Jiang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYBACAwmGhANgBgPzgQMffpCmhS3x4Mwe4rRAGQw8xoc52IjQYi7d8PDAzx219ubsOR8OM/AwyPOLHcCvxXLOgYSDvWeOM1v2vN1wuMCCwXDm7AQCDruRkHCAt+0Ym8GN3A2HZ/AwJBjcJkLLwb9tx3gMbuQ8OMzDRqSWw7xtNRJALQzEaQH55bBs2wEDgzPPDICBLEHYL+bSPckf37bV2RscT3784cMPG3l+aQJaGBh4QCoOAzFYpQQ+pTDAfgBI1MG0jIJRMApGwSjABACYO0/HHsoDCQAAAABJRU5ErkJggg==","orcid":"","institution":"The First Afliated Hospital of Bengbu Medical University","correspondingAuthor":true,"prefix":"","firstName":"Zhiquan","middleName":"","lastName":"Jiang","suffix":""}],"badges":[],"createdAt":"2024-06-10 21:38:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4560147/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4560147/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60188611,"identity":"57df64c9-c17e-43d3-8fcb-c62d58a8d6f6","added_by":"auto","created_at":"2024-07-12 19:16:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1086757,"visible":true,"origin":"","legend":"\u003cp\u003eA patient with an ACoA aneurysm who sufferred from SKA under the neuroendoscope. (a)DSA before operation showed that the IA was located in the ACoA.(b)SKA incision on the right.(c)Aneurysm is exposed through neuroendoscope.(d)Aneurysm is clipped.(e)CT scan on the first day after operation.(f)CTA scan at 1 month after operation.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4560147/v1/57167846fd59ca6098ac47bb.png"},{"id":60189030,"identity":"496a851e-2d66-4ba0-a77a-18d0061b8916","added_by":"auto","created_at":"2024-07-12 19:24:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1105727,"visible":true,"origin":"","legend":"\u003cp\u003eA patient with a MCA aneurysm who sufferred from PKA under the neuroendoscope. (a)DSA before operation showed that the IA was located in the MCA.(b)PKA incision on the left.(c)Aneurysm is exposed through neuroendoscope.(d)Aneurysm is clipped.(e)CT scan on the first day after operation.(f)CTA scan at 1 month after operation.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4560147/v1/6f603d92f48d896e70112cbf.png"},{"id":60188613,"identity":"5a64ae60-b882-4149-a516-27a2668d6a1a","added_by":"auto","created_at":"2024-07-12 19:16:13","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":737771,"visible":true,"origin":"","legend":"\u003cp\u003eendoscopic third ventriculostomy.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4560147/v1/fa5da0d100119e0f103f05c2.png"},{"id":60188614,"identity":"0a758c9c-8821-4e27-bb27-fc51bd46ea6a","added_by":"auto","created_at":"2024-07-12 19:16:13","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":696554,"visible":true,"origin":"","legend":"\u003cp\u003eA-B:Block A1 before clipping the anterior communicatingarteryaneurysm;C-D:Block M1 before clipping the middle cerebral aneurysm.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-4560147/v1/30b315020e8f8c009bb9635d.png"},{"id":64617900,"identity":"42ae9dcd-8c7f-41f0-bec1-a5fd396f5fe8","added_by":"auto","created_at":"2024-09-16 15:44:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6177762,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4560147/v1/d0014aca-ab05-4148-9cbf-dc96ebe67b44.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pure endoscopic clipping of anterior circulation aneurysms through keyhole approach","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIntracranial aneurysms (IAs) are pathological dilations that occur at major branchs of brain arteries[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The prevalence of unruptured IAs in the general population is approximately 3.2%[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Subarachnoid hemorrhage (SHA) resulting from their rupture is responsible for 80–85% of all non-traumatic subarachnoid hemorrhages and 5% of stroke cases[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The treatment of IAs involves two main approaches: endovascular coiling and surgical clipping. Since the International Subarachnoid Aneurysm Trial (ISAT), endovascular coiling has become a primary treatment method[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, this method suffers from a high recurrence rate, substantial equipment costs, and the need for long-term follow-up. Consequently, surgical clipping remains an essential treatment option[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In 1975, Yasagil et al. introduced the classic pterional approach as a standard procedure for treating anterior circulation aneurysms[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Despite its effectiveness, this approach may require extensive exposure of skin, bone, and brain, potentially leading to iatrogenic complications[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e–\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. To minimize these complications, the concept of keyhole surgery was introduced[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A significant limitation of the less-invasive keyhole approach is the reduced visibility and lighting within the operative field, which significantly impacts optical control during surgery. For the purpose of bringing light into the surgical field and controlling deep-seated microinstruments with adequate magnification, the optical properties of modern surgical microscopes can be effectively supplemented by the optical properties of endoscopes[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Hopf and Perneczky have categorized endoscopic techniques into three types: endoscopic neurosurgery, endoscope-assisted microneurosurgery, and endoscope-controlled microneurosurgery[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].Previous studies often combine these methods to evaluate the safety and effectiveness of endoscopes in IAs surgery[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e–\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, the interchange between endoscopic and microscopic tools during surgery can prolong operation times and increase the risks of postoperative infections and mechanical injuries[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Therefore, it is necessary to evaluate the safety and effectiveness of pure endoscopic clipping for anterior circulation aneurysms through the keyhole approach.This article reviews experiences with the keyhole approach for clipping anterior circulation aneurysms and analyzes the safety and effectiveness of pure neuroendoscopic clipping methods applied through the keyhole approach in IAs surgery.\u003c/p\u003e "},{"header":"Patients and Methods","content":"\u003cp\u003ePatient population\u003c/p\u003e\u003cp\u003eThis retrospective study included a total of 92 patients who underwent intracranial aneurysm clipping through pterional keyhole approach (PKA) or supraorbital keyhole approach (SKA) between January 2021 and January 2024 at the Department of Neurosurgery, First Affiliated Hospital of Bengbu Medical University, China. Of these, 44 patients underwent pure neuroendoscopy and were classified as the endoscopic group, while the remaining 48 underwent microscopic surgery and formed the microscopic group. The inclusion criteria included: (1) CTA or DSA-confirmed diagnosis of anterior circulation aneurysms; (2) IAs was clipped through PKA or SKA. Exclusion criteria were: (1) Multiple IAs are clipped in one operation; (2) SAH with a Hunt-Hess grade of IV or V; (3) secondary IAs, such as traumatic or infectious aneurysms; (4) IAs associated with other cerebrovascular malformations; (5) The clippping process of aneurysm is completed by microscope and neuroendoscope;(6) incomplete records.\u003c/p\u003e\u003cp\u003eData collection\u003c/p\u003e\u003cp\u003ePatient clinical data, extracted from the hospital information system, included (1) demographic characteristics such as age and gender; (2) aneurysm morphology, including location, size, and rupture status; (3) preoperative Hunt-Hess grade; (4) time to operation; (5) surgery-related details such as the type of keyhole approach (PKA or SKA), parent vessel occlusion, intraoperative aneurysm rupture, operation duration, and blood loss; (6) postoperative hospitalization duration; (7) complications, including inadequate clipping, cerebral ischemia, hematoma, hydrocephalus, vision loss, intracranial infection, limb hemiplegia, epilepsy, mental symptoms, and death; (8) postoperative imaging, including CT scans on the first day and CTA within 1–3 months post-operation; (9) mRS score 3 months after the operation.The return visit time of all patients ranges from 3 months to 3 years.\u003c/p\u003e\u003cp\u003eSurgical procedures\u003c/p\u003e\u003cp\u003eFor aneurysms located in the anterior communicating artery (ACoA) or anterior cerebral artery (ACA), the SKA is employed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). The choice of a left or right incision is determined by the position and direction of the aneurysm. The incision is approximately 4 cm in length, extending from the angular process of the frontal bone to the supraorbital nerve.\u003c/p\u003e\u003cp\u003eFor aneurysms located in the posterior communicating artery (PCoA) or middle cerebral artery (MCA),the PKA is employed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb).The incision is approximately 7 cm in length, centering on the symbol of body surface of the lateral fissure pool.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eKolmogorov–Smirnov tests were employed to assess the normal distribution of all clinical covariates before conducting statistical analyses. Continuous variables are presented as either means ± standard deviations or interquartile ranges, while categorical variables are reported as frequencies (percentages). Continuous variables were analyzed using either the Mann–Whitney U test or independent-samples t test. Categorical variables were examined using the χ2 test or Fisher’s exact test. All statistical analyses were performed using the SPSS 26.0 (IBM Corp., Armonk, NY, USA) software.A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBaseline characteristics\u003c/p\u003e \u003cp\u003eIn this study, 44 IAs underwent endoscopic keyhole surgery, and 48 IAs underwent microscopic keyhole surgery. Among these, the incidence of ruptured IAs was 79.55% (35 cases) in the endoscopic group and 75.00% (36 cases) in the microscopic group. The mean ages were 59.50 years and 56.92 years, respectively. The percentages of male patients were 45.45% (20 patients) in the endoscopic group and 70.83% (34 patients) in the microscopic group. The mean sizes of the IAs were 5.92 mm in the endoscopic group and 5.55 mm in the microscopic group. In the endoscopic group, IAs were located in the ACA (2 [4.55%]), ACoA (18 [40.91%]), PCoA (6 [13.64%]), and MCA (18 [40.91%]). By contrast, in the microscopic group, IAs were located in the ACA (3 [6.25%]), ACoA (14 [29.17%]), PCoA (10 [20.83%]), and MCA (21 [43.75%]). The severity of patients' conditions upon admission was assessed using the Hunt-Hess scale. In the endoscopic group, the classifications were as follows: grade 0 (9.09%), grade I (25.00%), grade II (56.82%), and grade III (9.09%). In the microscopic group, the classifications were grade 0 (6.25%), grade I (18.75%), grade II (62.50%), and grade III (12.50%). In the endoscopic group, 84.09% of patients (37 individuals) underwent a clipping operation within 3 days of admission, while 15.91% (7 individuals) underwent the procedure within 3\u0026ndash;14 days after admission. In the microscope group, 91.67% of patients (44 individuals) had the operation within 3 days, and 8.33% (4 individuals) had it within 3\u0026ndash;14 days after admission. There were no statistically significant differences in the baseline characteristics between the two groups, except for gender.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNeuroendoscopic\u003c/p\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMicroscopic Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, y, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;sd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.50\u0026thinsp;\u0026plusmn;\u0026thinsp;10.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.92\u0026thinsp;\u0026plusmn;\u0026thinsp;9.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(45.45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34(70.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(54.55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14(29.17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocations of aneurysms, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eACA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(4.55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3(6.25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eACoA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(40.91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14(29.17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePCoA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(13.64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(20.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(40.91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21(43.75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAneurysm diameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.92\u0026thinsp;\u0026plusmn;\u0026thinsp;1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHunt\u0026ndash;Hess grade, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(9.09%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3(6.25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eⅠ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(25.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9(18.75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eⅡ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25(56.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30(62.50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eⅢ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(9.09%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(12.50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to operation,days,n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37(84.09%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44(91.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(15.91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(8.33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRuptured or not,n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35(79.55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36(75.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(20.45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(25.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgery-related details and days of postoperative hospitalization duration\u003c/h2\u003e \u003cp\u003eIn the neuroendoscopic group, PKA procedures were performed in 24 patients (54.55%) and SKA in 20 patients (45.45%). In the microscopic group, PKA was performed in 31 patients (64.58%) and SKA in 17 patients (35.42%). The neuroendoscopic group experienced no cases (0%) of parent vessel occlusion and four cases (9.09%) of intraoperative aneurysm rupture. Conversely, in the microscopic group, one case (2.08%) involved parent vessel occlusion and four cases (8.33%) involved intraoperative aneurysm rupture. Median operation times were 120 minutes (interquartile range: 100\u0026ndash;147) in the neuroendoscopic group and 112 minutes (interquartile range: 100-147.5) in the microscopic group. Median blood loss was 100 ml (interquartile range: 50\u0026ndash;100) in the neuroendoscopic group and 80 ml (interquartile range: 70\u0026ndash;100) in the microscopic group. Median postoperative hospitalization duration were 8 days (interquartile range: 7\u0026ndash;10) for the neuroendoscopic group and 9 days (interquartile range: 7\u0026ndash;12) for the microscopic group. No statistically significant differences existed in surgery-related details or postoperative hospitalization duration between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e details these surgery-related details and postoperative hospitalization duration for both groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgery-related details and Postoperative hospitalization duration.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNeuroendoscopic\u003c/p\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMicroscopic Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of keyhole,n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(54.55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31(64.58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(45.45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17(35.42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParent vessel occlusion,n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(2.08%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44(100.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47(97.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eintraoperative aneurysm rupture,n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(9.09%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(8.33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40(90.91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44(91.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time (minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120(100,147)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e112(100,147.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eblood loss (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100(50,100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80(70,100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative hospitalization duration (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(7,10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9(7,12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePostoperative complications\u003c/p\u003e \u003cp\u003eIn the endoscopic group, 7 patients (15.91%) experienced postoperative complications: one developed epilepsy with an intracranial infection, two had intracranial infections, one died from respiratory failure due to prolonged unconsciousness following severe brain edema from postoperative bleeding, one developed vision loss and limb hemiplegia, one had epilepsy, and one suffered from hydrocephalus with limb hemiplegia.\u003c/p\u003e \u003cp\u003eIn the microscopic group, 9 patients (18.75%) had postoperative complications: two patients experienced brain edema and prolonged unconsciousness, ultimately dying due to ventilator dependence; one had an intracranial infection with limb hemiplegia and mental symptoms; one had inadequately clipped aneurysms with an intracranial infection; one developed hydrocephalus; one had vision loss with an intracranial infection; one had cerebral ischemia with an intracranial infection; one underwent decompressive craniectomy due to cerebral ischemia and subsequently developed limb hemiplegia and mental symptoms; and one had an intracranial infection with hydrocephalus.\u003c/p\u003e \u003cp\u003eNo statistically significant differences were found in the incidence of postoperative complications between the groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), and no complications related to the neuroendoscope were observed. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the postoperative complications for both groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative complications.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNeuroendoscopic\u003c/p\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMicroscopic Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications occur or not\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(15.91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9(18.75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37(84.09%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39(81.25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInadequately clipped aneurysmsn (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(2.08%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44(100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47(97.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebral ischemia, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(4.17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44(100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46(95.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematoma, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(2.27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43(97.73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48(100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHydrocephalus, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(2.27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(4.17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43(97.73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46(95.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVision loss, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(2.27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(2.08%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43(97.73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47(97.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntracranial infection, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(6.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(10.42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41(93.18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43(89.58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLimb hemiplegia, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(4.55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(4.17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42(95.45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46(95.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpilepsy, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(4.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42(95.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48(100.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental symptoms, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(4.17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44(100.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46(95.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeath, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(2.27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(4.17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43(97.73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46(95.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePrognosis\u003c/p\u003e \u003cp\u003eAfter 3 months of operation, we reassessed the patient's modified Rankin Scale (mRS) scores to evaluate their prognosis. In the neuroendoscopic group, 32 (72.73%) patients scored 0\u0026ndash;1, 10 (22.73%) scored 2\u0026ndash;3, one (2.27%) scored 4\u0026ndash;5, and one (2.27%) scored 6. In the microscope group, 36 (75.00%) patients scored 0\u0026ndash;1, 8 (16.67%) scored 2\u0026ndash;3, two (4.17%) scored 4\u0026ndash;5, and two (4.17%) scored 6. Statistical analysis showed no significant difference in prognosis between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe modified Rankin Scale (mRS) of the postoperative patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003erange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeuroendoscopic\u003c/p\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMicroscopic Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32(72.73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36(75.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10(22.73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8(16.67%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1(2.27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2(4.17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1(2.27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2(4.17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn 1971, Wilson reported that 33 IAs were treated using a \"limited exposure\" technique, a precursor to the keyhole approach[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Paladino and colleagues later formalized this concept[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The keyhole approach minimizes brain tissue exposure and offers a cosmetically smaller incision, aligning with patient preferences[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, the limited lighting and angle of traditional microscopes may not adequately address the needs for clipping IAs, as perforating arteries or the aneurysm neck behind the parent vessel might be missed[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Even among experienced surgeons, unexpected perforating arteries occlusion and incomplete clipping of aneurysm neck have been reported[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].Compared with a microscope, the endoscope provides better light intensity deep in the surgical field, clear close-up images of pathoanatomic details, and wider viewing angles[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These characteristics of endoscope are helpful for surgeons to better expose the neck of aneurysm and understand the relationship between aneurysms and perforating blood vessels and surrounding adjacent blood vessels[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].One of our previous meta-analyses have shown that 77% of endoscopic-assisted surgeries offer crucial visual information over standard microsurgery[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Besides. In Kalavakonda et al.' s report, the use of neuroendoscope significantly shortened the temporary clipping time of the parent artery in two patients[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].Kang et al.believe that under an endoscopic view, a magnifed and wide surgical view provides less manipulation or traction of the surrounding tissues, resulting in reduced post-clipping cerebral infarction[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In this study, no residual intracranial aneurysm necks and parent vessel occlusion were found in the endoscopic group, underscoring the benefits of the enlarged, multiangled,wellilluminated view of the endoscope, allowing surgeons to observe the neck of IAs and surrounding adjacent structures, thus realizing the safe and effective clipping of IAs during operation.\u003c/p\u003e \u003cp\u003eA clear operative field is essential for successful endoscopic surgery. Thus, Taniguchi M, et al suggest that non-ruptured aneurysms or those post-subarachnoid hemorrhage are suitable for endoscopic assistance[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In our practice, ruptured aneurysms are managed by extensive irrigation of the basal and lateral fissure cisterns. For patients with pre-operative hydrocephalus, cerebrospinal fluid can be drained through endoscopic third ventriculostomy (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) to clear the surgical pathway. This procedure can also be performed post-operatively in patients at risk of persistent hydrocephalus to minimize the need for a shunt. However, due to the risk of severe brain edema, we avoid using neuroendoscopes in patients with a Hunt-Hess grade of IV-V.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn our neuroendoscopic group, we have successfully clipped IAs with a maximum diameter of less than 1 cm (9.4 mm). Drawing from our microsurgical clipping experience, we contend that aneurysms larger than 1 cm can also be managed endoscopically. This is possible by intermittently coagulating the aneurysm during surgery to reduce its volume and make space for the endoscopic procedure. While some researchers argue that endoscopy is better suited for smaller IAs, as larger masses may hinder the insertion and fixation of endoscopy[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], we recognize the merit in this perspective. Nonetheless, the upper size limit for aneurysms amenable to endoscopic clipping warrants further investigation.\u003c/p\u003e \u003cp\u003eIA surgery often entails the risk of intraoperative rupture.Massive bleeding during the operation will block the vision of endoscopic operation and threaten the safety of the operation. For IAs with high risk of rupture during operation, the likelihood of rupture can be minimized by temporarily occluding the parent artery (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Should a rupture occur and blood obscure the surgical view, the endoscope should be slightly withdrawn while the assistant introduces a wide-bore suction and irrigates with saline. Once the view is clear, the assistant maintains suction near the rupture site, allowing the surgeon to apply a temporary clip after clearing any blood from the proximal vessel. If necessary, a microscope is kept on standby for instances where the rupture is beyond endoscopic control.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePure endoscopic clipping of anterior circulation aneurysms with a diameter of 1 cm or less and a Hunt-Hess grade of III or lower through SKA and PKA techniques is safe and effective. The prognosis is comparable to that of the keyhole approach using a microscope.Moreover, since the endoscope can provides better light intensity deep in the surgical field, clear close-up images of pathoanatomic details, and wider viewing angles,endoscopic clipping of intracranial aneurysms is more valuable in protecting perforating blood vessels and parent vessel.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthics approval\u003c/h2\u003e \u003cp\u003e The study was approved by the Ethics Committee of the First Affiliated Hospital of Bengbu Medical University (2021KY047).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to participate\u003c/strong\u003e \u003cp\u003e The need for informed consent was waived by the Research Ethics Committee because the study was retrospective. The confdentiality of patient data was protected in accordance with\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent to publish\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eData Availability Statement\u003c/h2\u003e \u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research was funded by grants from the Natural Science Foundation of Anhui Province (No. KJ2021KD0078).This research was funded by grants from the Health Commission Foundation of Anhui Province (No. AHWJ2023A10099).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHT, PN, and XZ designed the study. DS, SX,and YL collected the data. HT,QL,and KL analyzed the data. HT,TW,HL,and MW wrote the manuscript. ZJ completed the review of the article. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEtminan N, Rinkel GJ (2016) Unruptured intracranial aneurysms: development, rupture and preventive management. Nat Rev Neurol 12(12):699\u0026ndash;713. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/nrneurol.2016.150\u003c/span\u003e\u003cspan address=\"10.1038/nrneurol.2016.150\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTawk RG, Hasan TF, D\u0026rsquo;Souza CE, Peel JB, Freeman WD (2021) Diagnosis and Treatment of Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage. \u003cem\u003eMayo Clin Proc\u003c/em\u003e. ;96(7):1970\u0026ndash;2000. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.mayocp.2021.01.005\u003c/span\u003e\u003cspan address=\"10.1016/j.mayocp.2021.01.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Gijn J, Kerr RS, Rinkel GJE (2007) Subarachnoid haemorrhage. 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Neurol Med Chir (Tokyo) 55(6):469\u0026ndash;478. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2176/nmc.ra.2014-0428\u003c/span\u003e\u003cspan address=\"10.2176/nmc.ra.2014-0428\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"intracranial aneurysm, neuroendoscope, microscope, keyhole approache, clip","lastPublishedDoi":"10.21203/rs.3.rs-4560147/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4560147/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective: This retrospective study evaluated the safety and effectiveness of pure endoscopic clipping for anterior circulation aneurysms through the supraorbital keyhole approach and the pterional keyhole approach.\u003c/p\u003e\n\u003cp\u003eMethods: We included 92 patients with anterior circulation aneurysms, all treated with clipping surgery at The First Affiliated Hospital of Bengbu Medical University. Patients were divided into neuroendoscopic and microscopic groups, based on whether endoscopic or microscopic techniques were used for clipping. We analyzed baseline patient characteristics, surgery-related details, postoperative hospitalization duration, complications, and modified Rankin Scale (mRS) scores 3 months after the operation to assess treatment outcomes.\u003c/p\u003e\n\u003cp\u003eResults: No significant differences existed between the neuroendoscopic and microscopic groups in statistical indicators, except for patient gender distribution.\u003c/p\u003e\n\u003cp\u003eConclusions: Pure neuroendoscopic clipping of anterior circulation aneurysms (≤1cm in diameter, Hunt-Hess grade ≤ III) through supraorbital and pterional keyhole approaches is safe and effective. Its prognosis is comparable to that of the microscopic keyhole approach. Moreover, since the endoscope can provides better light intensity deep in the surgical field, clear close-up images of pathoanatomic details, and wider viewing angles, endoscopic clipping of intracranial aneurysms is more valuable.\u003c/p\u003e","manuscriptTitle":"Pure endoscopic clipping of anterior circulation aneurysms through keyhole approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-12 19:16:08","doi":"10.21203/rs.3.rs-4560147/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d846092b-9aa4-44bf-a503-30accee6898c","owner":[],"postedDate":"July 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-16T15:36:26+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-12 19:16:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4560147","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4560147","identity":"rs-4560147","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}