Projection-Based Microsurgical Strategy for Anterior Communicating Artery Aneurysms: Comparative Analysis of the Fronto-Orbitozygomatic and Pterional Approaches

Anterior communicating artery (ACoA) aneurysms with superior or posterior projection present significant microsurgical challenges due to limited exposure and complex vascular relationships. To compare the fronto-orbitozygomatic (FOZ) and pterional approaches in the microsurgical treatment of ACoA aneurysms with superior or posterior projection. The present retrospective single-center study included patients treated with microsurgical clipping between 2016 and March 2025. Only aneurysms with superior or posterior projection were included. Cases were stratified according to surgical approach and rupture status. Among 168 unruptured ACoA aneurysms, 28 (16.7%) had superior or posterior projection, 17 (60.7%) of which were treated using the FOZ approach and 11 (39.3%) using the pterional approach. Among 121 ruptured aneurysms, 19 (15.7%) had this projection, with 16 (84.2%) treated via FOZ and 3 (15.8%) via the pterional approach. The FOZ approach provided wider surgical exposure, improved visualization of bilateral A2 segments, facilitated proximal control, and reduced the need for frontal lobe retraction, particularly in complex and ruptured cases. The pterional approach remained effective in selected cases with favorable anatomy. The FOZ approach appears to be more suitable for ACoA aneurysms with superior or posterior projection, particularly in ruptured cases. Surgical strategy should be individualized based on aneurysm orientation and vascular anatomy.