How Safe and Effective Is Shifting from Pterional to Supraorbital Keyhole Approach for Clipping Ruptured Anterior...

Background  Comparative studies between standard pterional and supraorbital keyhole approaches for aneurysms had potential biases with the heterogeneity of patient selection, differences among surgeons, or varying expertise across the surgeon's learning curve. This is a study of a surgeon's transition from pterional to keyhole approach for early clipping of selected consecutive ruptured anterior circulation aneurysms. Methods  Patients more than 18 years, presenting within 72 hours of ictus, in good clinical grades 1 to 3, no midline shift, with saccular aneurysms less than 25 mm at either communicating segment of internal carotid artery, anterior communicating artery, or middle cerebral artery segment till bifurcation were studied between the last 25 cases of pterional and first 25 cases of the keyhole, for the intraoperative and postoperative surgical outcome parameters. Results  There was no significant difference among baseline parameters, including the location of aneurysms across both groups. While only four cases of pterional had an intraoperative ventricular puncture, the lumbar drain was electively inserted in all keyhole patients. The intraoperative parameters, such as a dural tear, adequate parent vessel exposure, temporary clipping, and intraoperative rupture, did not show any significant difference. None had immediate postoperative deficits. While delayed cerebral ischemia and wound complaints were similar in both groups, temporal hollowing and chewing difficulty were significantly more in pterional patients( p = 0.01). Conclusion  A surgeon experienced in pterional approach can comfortably and safely shift to the keyhole for early clipping of selected ruptured aneurysms less than 25 mm, with a comparable surgical outcome but better cosmesis and mastication.