1189. Pterional Versus Orbitozygomatic Craniotomy: A Single Institution Comparison of Surgical Approach for Ruptured Anterior Communicating Artery Aneurysms

Authors: Zachary R. Barnard, MD; Michael Schiraldi, MD, PhD; Moheet Asma; Wouter Schievink, MD; Gregory Lekovic, MD, PhD (Los Angeles, CA)

Introduction:

Orbitozygomatic craniotomy (OZ) provides superior visualization of the anterior communicating artery (ACOM) complex with minimal retraction compared to a standard pterional craniotomy (PT), but may incur additional approach related morbidity. We reviewed our experience with ruptured ACOM aneurysms to determine whether the OZ was associated with poorer neurologic outcomes at a single institution.

Methods:

The charts of all patients undergoing craniotomy for clipping of ACOM aneurysms at Cedars-Sinai Medical Center between 2011 and 2018 were retrospectively reviewed. Patients undergoing clipping for elective, unruptured aneurysms were excluded. Charts were analyzed for patient presentation, length of stay, neurological morbidity and mortality, disposition, Glasgow Outcome Score at discharge, and completeness of aneurysm obliteration. Statistical analysis was performed between groups using two-way ANOVA testing (Graphpad, La Jolla, CA).

Results:

A total of 35 patients were identified (16 OZ and 19 PT). Patient presentation was similar between groups with no statistical difference in GCS (P>0.99), Fisher grade (P>0.99), H&H (P>0.99), or WFNS (P>0.99); PT patients were however significantly older than OZ patients (mean 59 years vs. 51 years, P=0.01). Mean aneurysm size was 4.8mm in both groups. There was no statistical difference in GOS (P>0.99) or length of stay (P=0.07) when compared using two-way ANOVA.  Six residual aneurysms were found (5OZ, 1PT). One aneurysm clipping required revision (OZ). One aneurysm rebled (PT). Neurologic complications included Heubner infarct (n=3, 1OZ, 2PT) and A2 infarct (n=1, OZ). There were two mortalities (both PT). Surviving patients were either discharged home (PT n=8, OZ n=8) or to a facility (PT n=9, OZ n=8).

Conclusion:

In our comparison of PT and OZ for ruptured ACOM aneurysms, we found no significant differences in outcomes. We conclude the additional morbidity of the OZ approaches does not significantly adversely affect outcome in the treatment of ruptured ACOM aneurysms.