title: Surgical treatment of ruptured anterior circulation aneurysms:  comparison of pterional and supraorbital keyhole approaches.
abstract: 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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania 19107, USA.
authors.forename: Nohra
authors.initials: N
authors.lastname: Chalouhi
authors.forename: Pascal
authors.initials: P
authors.lastname: Jabbour
authors.forename: Ibrahim
authors.initials: I
authors.lastname: Ibrahim
authors.forename: Robert M
authors.initials: RM
authors.lastname: Starke
authors.forename: Philippe
authors.initials: P
authors.lastname: Younes
authors.forename: Gilles
authors.initials: G
authors.lastname: El Hage
authors.forename: Elie
authors.initials: E
authors.lastname: Samaha
mesh_terms: D000768:Anesthesia, General; D017542:Aneurysm, Ruptured / Q000601:surgery*; D002121:Calcium Channel Blockers / Q000627:therapeutic use; D005260:Female; D023261:Glasgow Outcome Scale; D006801:Humans; D002532:Intracranial Aneurysm / Q000601:surgery*; D007431:Intraoperative Complications / Q000453:epidemiology; D008297:Male; D008866:Microsurgery; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D016343:Monitoring, Intraoperative; D019635:Neurosurgical Procedures / Q000379:methods*; D009553:Nimodipine / Q000627:therapeutic use; D011183:Postoperative Complications / Q000517:prevention & control; D012189:Retrospective Studies; D016896:Treatment Outcome; D020301:Vasospasm, Intracranial / Q000517:prevention & control
chemical_list: D002121:Calcium Channel Blockers; D009553:Nimodipine