J Cerebrovasc Endovasc Neurosurg.  2013 Sep;15(3):177-183. 10.7461/jcen.2013.15.3.177.

Pterional-subolfactory Approach for Treatment of High Positioned Anterior Communicating Artery Aneurysms

• Kim H
• Kim TS
• Joo SP
• Moon HS

• KMID: 1491436
• DOI: http://doi.org/10.7461/jcen.2013.15.3.177

Abstract

OBJECTIVE
The purpose of this study is to compare the surgical outcomes of pterional-subolfactory approach for the high positioned anterior communicating artery (ACoA) aneurysm with the conventional pterional approach.
METHODS
Between February 2005 and December 2012, 463 ACoA aneurysms were surgically treated in our institution. Forty eight high positioned ACoA aneurysms were treated with pterional-subolfactory or conventional pterional approach. High positioned ACoA aneurysms were defined as aneurysms located higher than 10 mm above the anterior clinoid process. Pterional-subolfactory approach is a procedure including dissection of olfactory tract and resection of the gyrus rectus inferior and medial to the olfactory tract. Thirty-four of the 48 cases were treated with pterional-subolfactory approach and 14 were treated conventionally.
RESULTS
There were 2 postoperative cerebral infarction with the conventional pterional approach, but none with the pterional-subolfactory approach group (p = 0.026). Postoperative digital subtraction angiography revealed significant remnant aneurysm in the conventional pterional approach group. All patients with unruptured aneurysms had good clinical outcomes with Glasgow outcome score of 5. Among ruptured ACoA aneurysm patients, 2 patients with conventional pterional approach had postoperative cerebral infarctions but permanent neurologic deficit was found in only 1 patient. Three patients treated with the pterional-subolfactory approach, who had preoperative ruptured aneurysms had poor clinical outcomes. The mean operation time for the conventional pterional approach was 58 minutes longer than for the pterional-subolfactory approach (p = 0.001).
CONCLUSION
We concluded that pterional-subolfactory approach is highly preferable for cases of high positioned ACoA aneurysm, giving a wide and effective operation view.

Keyword

Subolfactory; Anterior communicating aneurysm

MeSH Terms

Aneurysm
Aneurysm, Ruptured
Angiography, Digital Subtraction
Arteries
Cerebral Infarction
Humans
Intracranial Aneurysm
Neurologic Manifestations
Olfactory Pathways

Figure

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  Fig. 1 Schematic drawing of subolfactory approach; dissection of olfactory tract and suck out of rectus gyrus inferomedial of olfactory tract allows no need for retractor and direct visualization of high-positioned anterior communicating artery aneurysm (Arrow: direction of approach).

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  Fig. 2 (A) Operative photo of subolfactory approach: direct visualization of high-positioned anterior communicating artery aneurysm with minimal retraction with no retractor. (B) Operative photo of subolfactory approach: direct visualization of high-positioned anterior communicating artery aneurysm with minimal retraction with no retractor (clipped state). $: olfactory nerve, *: anterior communicating artery aneurysm.

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