Comparative Analysis of Pterional, Supraorbital, Extended Supraorbital, and Transtubercular-Transplanum Approaches for Exposing the Anterior Communicating Artery Complex: A Cadaveric Study

Abstract

We aimed to quantify and compare surgical exposure and freedom at the anterior communicating artery (ACoA) complex using pterional (PT), supraorbital (SO), extended supraorbital withorbital osteotomy (SOO), and endonasal endoscopic transtubercular-transplanum (EEATT) approaches. Right-sided PT, SO, SOO, and EEATT approaches were performed using 10 cadaveric heads. Surgical exposure and freedom (horizontal and vertical attack angle) at the ACoA complex were measured. The farthest clipping distance from ACoA to A1 (precommunicating segment of the anterior cerebral artery)/A2 (postcommunicating segment of the anterior cerebral artery) was also quantified. There was a significantly greater exposure length of right A1 in the PT approach (12.20 ± 2.48 mm) compared with the EEATT approach (9.52 ± 2.09 mm; P= 0.029). Among the 4 approaches, EEATT provided the shortest clipping distance for right A1 (6.56 ± 1.33 mm; P= 0.001) and the longest clipping distance for right A2 (3.36 ± 1.24 mm; P= 0.003). SO, SOO, and PT approaches (2.9 ± 0.9) had more observations on perforators from ACoA than did the EEATT approach (2.0 ± 0.66; P= 0.029). The EEATT approach (50.90 ± 17.45 mm2) provided better exposure of the superior part of the ACoA complex compared with the SO approach (29.37 ± 17.27 mm2; P= 0.05). PT and SOO approaches provided the greatest horizontal (36.88° ± 5.85°) and vertical (19.37° ± 4.70°) attack angle, respectively. The SO, SOO, and PT approaches provided a better hemilateral view of the ACoA complex and similar surgical exposure, whereas the EEATT approach offered greater exposure in the upper part of the ACoA complex, with relatively limited exposure of perforators from ACoA and surgical freedom. The EEATT approach can play a role in exposure of lesion involving the ACoA complex.