J Korean Neurosurg Soc.  2021 Jul;64(4):524-533. 10.3340/jkns.2020.0215.

Postoperative Clipping Status after a Pterional versus Interhemispheric Approach for High-Positioned Anterior Communicating Artery Aneurysms

• Kim M
• Kim BJ
• Son W
• Park J

• KMID: 2517685
• DOI: http://doi.org/10.3340/jkns.2020.0215

Abstract

Objective
: When treating high-positioned anterior communicating artery (ACoA) aneurysms, pterional-transsylvian and interhemispheric approaches are both viable options, yet comparative studies of these two surgical approaches are rare. Accordingly, this retrospective study investigated the surgical results of both approaches.
Methods
: Twenty-four patients underwent a pterional approach (n=11) or interhemispheric approach (n=13), including a unilateral low anterior interhemispheric approach or bifrontal interhemispheric approach, for high-positioned ACoA aneurysms with an aneurysm dome height >15 mm and aneurysm neck height >10 mm both measured from the level of the anterior clinoid process. The clinical and radiological data were reviewed to investigate the surgical results and risk factors of incomplete clipping.
Results
: The pterional patient group showed a significantly higher incidence of incomplete clipping than the interhemispheric patient group (p=0.031). Four patients (36.4%) who underwent a pterional approach showed a postclipping aneurysm remnant, whereas all the patients who experienced an interhemispheric approach showed complete clipping. In one case, the aneurysm remnant was obliterated by coiling, while follow-up of the other three cases showed the remnants remained limited to the aneurysm base. A multivariate analysis revealed that a pterional approach for a large aneurysm with a diameter >8 mm presented a statistically significant risk factor for incomplete clipping.
Conclusion
: For high-positioned ACoA aneurysms with a dome height >15 mm and neck height >10 mm above the level of the anterior clinoid process, a large aneurysm with a diameter >8 mm can be clipped more completely via an interhemispheric approach than via a pterional approach.

Keyword

Intracranial aneurysm; Anterior communicating aneurysm; High positioned

Figure

• 

  Fig. 1. Illustrations depicting the craniotomies for high-positioned anterior communicating artery aneurysms. A : Pterional approach. B : Unilateral low anterior interhemispheric approach. C : Subfrontal interhemispheric approach. Dotted lines show dural incision.

• 

  Fig. 2. Case 1 with incomplete clipping. A : DSA showing a ruptured high-positioned ACoA aneurysm (arrow) with a diameter of 8.8 mm. B : Postoperative DSA showing the incompletely clipped ACoA aneurysm with a remnant (arrow). DSA : digital subtraction angiography, ACoA : anterior communicating artery.

Reference

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