Approaches for Anterior Circulation Aneurysms: A Systematic Review and Network Meta-analysis

Introduction: The anterior circulation is the most common location for cerebral aneurysms. Although the pterional approach is widely utilized, other techniques have demonstrated promising outcomes. Given the multiple available approaches, there is a need for evidence-based guidance on the optimal access strategy for anterior circulation aneurysms (ACAs). The objective was to simultaneously compare the most relevant surgical approaches for the treatment of ACAs.

Methods: We systematically searched Pubmed, Embase, and Cochrane databases for studies comparing surgical approaches in the treatment of ACAs. A Bayesian network meta-analysis was conducted to evaluate the efficacy and safety of each approach. To assess the neurological level of patients as a binary outcome, the Glasgow Coma Scale (GCS) and the Modified Rankin Score (mRS) were combined to divide patients according to their scores into two groups - "good" and "poor".

Results: We included 34 studies with a total of 6152 patients. Regarding postoperative neurological state, the supraorbital access provided better results when compared with the traditional pterional approach (OR = 0.634; 95% CrI: 0.314, 0.983). No significant difference was found between the interhemipheric and the pterional access for the same outcome (OR = 0.49; 95% CrI: 7.57, 0.01). In respect of the incidence of subarachnoid hemorrhage (SAH), no significant difference was found between the interventions, except for the orbitozygomatic access being associated with a higher risk when compared to the subtemporal approach (RR = 1.77; CrI: 1.01, 2.97). The average surgical duration for the supraorbital approach was 131.74 minutes, while the pterional approach averaged 167.62 minutes. A significant time difference was also observed between the superciliary and pterional accesses, with mean durations of 160 minutes and 233 minutes, respectively.

Conclusion : The findings from this systematic review and network meta-analysis provide evidence that the selection of a specific surgical approach should be carefully analyzed, considering the characteristics of each aneurysm, deviating from the standard pterional approach when considered necessary.