Lateral Supraorbital versus Pterional Approach for Clipping of Unruptured Anterior Circulation Aneurysms

Background: A lateral supraorbital (LSO) craniotomy is a less-invasive approach that can be utilized in surgical management of a variety of cranial pathologies. Early studies have demonstrated potential benefits of an LSO approach for surgical clipping of aneurysms. This study analyzes the benefits of an LSO approach compared with a standard pterional (PT) approach in a variety of unruptured, anterior circulation aneurysms.

Methods: A retrospective database was constructed using medical records from patients that underwent anterior circulation aneurysm clipping between 2012 and 2019. Quality of life metrics were obtained via a phone survey.

Results: This analysis included 158 patients, 107 PT, and 51 LSO who underwent surgery for clipping of anterior circulation aneurysms. Most commonly these were middle cerebral artery aneurysms (MCA, 76 PT, and 39 LSO) but also included the anterior communicating artery (ACOM), anterior cerebral artery (ACA), ophthalmic artery (OA), and internal carotid artery (ICA). Factors, such as age, comorbidity index, and aneurysm size, were comparable between surgical groups (Table 1).

Patients who underwent an LSO craniotomy had a median intensive care unit (ICU) stay of 1 day which is significantly shorter than the median PT ICU stay of 3 days. This further translated to a shorter total hospital stay, with a median of 4 days for LSO patients and 7 days for PT patients. Surgeries conducted with an LSO craniotomy were also found to be significantly shorter than those with a PT craniotomy. Average operative times were 274 and 320 minutes, respectively. Intraoperatively, there was a trend toward fewer aneurysm ruptures via LSO craniotomies. Zero intraoperative ruptures occurred in LSO patients compared with eight ruptures in PT patients; however, this difference was not statistically significant (p = 0.107; Table 2).

Phone surveys regarding quality of life metrics did not reveal any significant differences between surgical approaches. Specifically, the incidence of postoperative jaw-related issues was similar in both groups (6/25 LSO, 6/28 PT, p = 0.88).

Conclusion: A lateral supraorbital approach is a less-invasive surgical method effective for clipping of anterior circulation aneurysms. This approach yields shorter ICU and total hospital stays in addition to a shorter operative duration. This study was underpowered to detect differences in aneurysm rupture rate but the potential of fewer ruptures is yet another advantage of an LSO approach. Combined these, benefits serve to both patients and institutions compared with traditional pterional approaches.

Table 1

Table 2

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
12 February 2021