Superior Eyelid Endoscopic Transorbital Approach for Middle Cerebral Artery Aneurysms Clipping: A Surgical Case Series

BACKGROUND AND OBJECTIVE: Middle cerebral artery (MCA) aneurysms often present anatomic features that favor microsurgical clipping, despite advances in endovascular techniques. Traditional transcranial approaches provide reliable exposure but are associated with soft tissue manipulation and brain retraction. The superior eyelid endoscopic transorbital approach (SETOA) has recently emerged as a minimally invasive corridor to the sylvian fissure, but its role in MCA aneurysm surgery remains largely unexplored. This study aimed to evaluate the feasibility, safety, and preliminary clinical outcomes of SETOA for the treatment of selected MCA aneurysms. METHODS: A retrospective analysis was performed on 10 consecutive patients harboring 11 MCA aneurysms treated by SETOA between September 2024 and May 2025. All procedures were conducted under full endoscopic visualization. Clinical, radiological, and intraoperative data were reviewed. Primary endpoints included surgical feasibility, aneurysm occlusion rate, intraoperative and postoperative complications, and cosmetic outcomes. RESULTS: Complete aneurysm occlusion was achieved in all cases, with no residual perfusion on postoperative imaging. One intraoperative aneurysm rupture occurred and was successfully managed without conversion or adverse sequelae. No postoperative cerebrospinal fluid leaks, infections, cranial nerve deficits, or wound complications were observed. Transient periorbital edema and mild upper eyelid paresis occurred in all patients and resolved spontaneously within the first postoperative week. Mean operative time was 141 minutes, and no conversion to transcranial approaches was required. Cosmetic outcomes were judged favorable in all cases. CONCLUSION: The SETOA represents a feasible and safe minimally invasive option for microsurgical clipping of carefully selected MCA aneurysms in this feasibility study. By providing a direct anterior corridor to the sylvian fissure with minimal brain manipulation and favorable cosmetic results, SETOA may expand the surgical armamentarium for selected cerebrovascular lesions. Further studies with larger cohorts are required to better define its indications and long-term outcomes.