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Surgical Treatment of Ruptured Anterior Circulation Aneurysms: Comparison of Pterional and Supraorbital Keyhole Approaches

Chalouhi, Nohra MD*; Jabbour, Pascal MD*; Ibrahim, Ibrahim MD; Starke, Robert M. MD*; Younes, Philippe MD; El Hage, Gilles MD; Samaha, Elie MD

doi: 10.1227/NEU.0b013e3182804e9c
Research-Human-Clinical Studies

BACKGROUND: Recent advancements in microsurgical techniques and instrumentation have allowed the development of the keyhole approach in aneurysm surgery.

OBJECTIVE: To compare the safety, efficacy, and 1-year clinical outcome of supraorbital keyhole and standard pterional approaches for ruptured anterior circulation aneurysms.

METHODS: A total of 87 patients underwent surgical clipping, 40 through the pterional and 47 through the supraorbital keyhole approach. Baseline demographics, operative time, procedural complications, and 1-year patient outcome were retrospectively compared.

RESULTS: The 2 groups were comparable with respect to baseline characteristics, with the exception of a higher proportion of small aneurysms (<7 mm) in the supraorbital group (70.2% vs 37.5%, P = .002). Total operative time was significantly shorter in the supraorbital group (205 minutes, P < .001) compared with the pterional group (256 minutes). The rate of procedural complications was lower in patients treated through the pterional (17.5%) vs the supraorbital approach (23.4%, P = .4). Intraoperative aneurysm ruptures occurred more frequently in the supraorbital group (10.6% vs 2.5%). No patient experienced early or late rebleeding in either group. One year after treatment, 75% (30/40) of patients achieved a favorable outcome (Glasgow Outcome Scale IV or V) in the pterional group vs 76.6% (36/47) in the supraorbital group (P = .8).

CONCLUSION: The rate of procedural complications may be higher with the supraorbital keyhole approach, but overall patient outcomes appear to be comparable. The pterional approach is a simple, reliable, and efficient procedure. The keyhole approach may be an acceptable alternative for neurosurgeons who have gained sufficient experience with the technique, especially for small noncomplex aneurysms.

*Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania

Department of Neurosurgery, Hotel-Dieu De France Hospital, Saint-Joseph University, Beirut, Lebanon

Correspondence: Pascal M. Jabbour, MD, Associate Professor, Department of Neurological Surgery, Division of Neurovascular Surgery and Endovascular Neurosurgery, Thomas Jefferson University Hospital, 901 Walnut St, 3rd Floor, Philadelphia, PA 19107. E-mail:

Received August 24, 2012

Accepted November 19, 2012

Copyright © by the Congress of Neurological Surgeons