Keyhole Approach for Clipping Intracranial Aneurysm: Comparison of Supraorbital and Pterional Keyhole Approach

Objective: The aim of this research was to compare the functional outcome and safety between supraorbital keyhole approach (SKA) and pterional keyhole approach (PKA) for clipping intracranial aneurysms.

Methods: This is a retrospective study involving 318 patients with a total of 365 aneurysms who underwent keyhole surgery, comprising 195 cases in SKA group and 123 cases in PKA group. The outcome measures include Glasgow Outcome Scale, complete clipping rate, adverse events incidence, operation view angle, working distance, and surgical incision condition.

Results: Of a total of 356 aneurysms that were clipped and 9 trapped, no significant difference was observed in Glasgow Outcome Scale score, adverse events incidence, or complete clipping rate between the SKA and PKA groups. The distance from skin incision to anterior clinoid process was 5.87 ± 0.24 cm in SKA and 5.12 ± 0.27 cm in PKA. The operation view angle (from midline to the operating channel in sagittal plane) was 30°-40° in the SKA group and 60°-68° in the PKA group.

Conclusions: Our research demonstrates that both SKA and PKA are safe and effective for most anterior circulation aneurysms and parts of posterior circulation aneurysms. The SKA exposures aneurysm better on deep and sagittal directions and is more suitable for clipping aneurysms by the contralateral approach due to the short distance. The PKA has a good exposure on the neck of aneurysm with dorsal direction of parent artery and can be used to evacuate hematoma in the temporal lobe when clipping the aneurysm. Integrating multimodal 3-dimensional images could help neurosurgeon in selecting an appropriate and effective approach.