Reliability of the supraorbital ethmoid cell vs Keros classification in predicting the course of the anterior ethmoid artery

Background: We previously showed that the supraorbital ethmoid cell (SOEC) is a reliable landmark for identifying the anterior ethmoid artery (AEA). Recent data have suggested that Keros classification is also a dependable predictor. We aim to characterize the location of the AEA and its relation to the skull base in patients with and without SOEC using the Keros classification. Methods: Retrospective radiographic evaluation of computed tomography (CT) scans of 76 patients (40 with SOEC, 36 without) was conducted. Distance of AEA from skull base and prevalence of AEA outside of the skull base were measured on each side and compared between groups using the 2-sample t test and χ² test, respectively. Subgroup analysis was carried out based on the Keros classification. Results: Mean distance of AEA from the skull base was 1.32 ± 1.5 mm in patients with SOEC and 0.47 ± 1.08 mm in those without (p < 0.001). Prevalence of AEA outside of the skull base was 53.8% in those with SOEC and 18.1% in those without (p < 0.001). Comparing patients with SOEC to those without, AEA was found below the skull base in 30% vs 0% of cases with Keros type 1 (p = 0.45), 58% vs 14.5% with Keros type 2 (p < 0.001), and 60% vs 50% with Keros type 3 (p = 0.72). Conclusion: The presence of SOEC is associated with a higher prevalence of the AEA coursing below the level of the skull base in all Keros types, thus placing the artery at greater risk for injury. Careful surgical planning is needed to avoid potential orbital complications.