Endoscopic Endonasal Transclival Approach versus Dual Transorbital Port Technique for Clip Application to the Posterior Circulation: A Cadaveric Anatomical and Cerebral Circulation Simulation Study

Purpose Simulation training offers a useful opportunity to appreciate vascular anatomy and develop the technical expertise required to clip intracranial aneurysms of the posterior circulation. Materials and Methods In cadavers, a comparison was made between the endoscopic transclival approach (ETA) alone and a combined multiportal approach using the ETA and a transorbital precaruncular approach (TOPA) to evaluate degrees of freedom, angles of visualization, and ergonomics of aneurysm clip application to the posterior circulation depending on basilar apex position relative to the posterior clinoids. Results ETA alone provided improved access to the posterior circulation when the basilar apex was high riding compared with the posterior clinoids. ETA + TOPA provided a significantly improved functional working area for instruments and visualization of the posterior circulation for a midlevel basilar apex. A single-shaft clip applier provided improved visualization and space for instruments. Proximal and distal vascular control and feasibility of aneurysmal clipping were demonstrated. Conclusions TOPA is a medial orbital approach to the central skull base; a transorbital neuroendoscopic surgery approach. This anatomical simulation provides surgical teams an alternative to the ETA approach alone to address posterior circulation aneurysms, and a means to preoperatively prepare for intraoperative anatomical and surgical instrumentation challenges.

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Extended Endoscopic Endonasal Approaches for Cerebral Aneurysms: Anatomical, Virtual Reality and Morphometric Study

BioMed Research International ◽

10.1155/2014/703792 ◽

2014 ◽

Vol 2014 ◽

pp. 1-9 ◽

Cited By ~ 16

Author(s):

Alberto Di Somma ◽

Matteo de Notaris ◽

Vita Stagno ◽

Luis Serra ◽

Joaquim Enseñat ◽

...

Keyword(s):

Virtual Reality ◽

Cerebrospinal Fluid Leak ◽

Posterior Circulation ◽

Morphometric Study ◽

Vascular Control ◽

Present Contribution ◽

Endoscopic Endonasal ◽

Arterial Bleeding ◽

Simulation Step ◽

Posterior Circulation Aneurysms

Introduction. The purpose of the present contribution is to perform a detailed anatomic and virtual reality three-dimensional stereoscopic study in order to test the effectiveness of the extended endoscopic endonasal approaches for selected anterior and posterior circulation aneurysms.Methods. The study was divided in two main steps: (1) simulation step, using a dedicated Virtual Reality System (Dextroscope, Volume Interactions); (2) dissection step, in which the feasibility to reach specific vascular territory via the nose was verified in the anatomical laboratory.Results. Good visualization and proximal and distal vascular control of the main midline anterior and posterior circulation territory were achieved during the simulation step as well as in the dissection step (anterior communicating complex, internal carotid, ophthalmic, superior hypophyseal, posterior cerebral and posterior communicating, basilar, superior cerebellar, anterior inferior cerebellar, vertebral, and posterior inferior cerebellar arteries).Conclusion. The present contribution is intended as strictly anatomic study in which we highlighted some specific anterior and posterior circulation aneurysms that can be reached via the nose. For clinical applications of these approaches, some relevant complications, mainly related to the endonasal route, such as proximal and distal vascular control, major arterial bleeding, postoperative cerebrospinal fluid leak, and olfactory disturbances must be considered.

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Radial Artery Access for Treatment of Posterior Circulation Aneurysms Using the Pipeline Embolization Device: Case Series

Operative Neurosurgery ◽

10.1093/ons/opy378 ◽

2019 ◽

Vol 17 (4) ◽

pp. 340-347 ◽

Cited By ~ 6

Author(s):

Eytan Raz ◽

Maksim Shapiro ◽

Razvan Buciuc ◽

Peter Kim Nelson ◽

Erez Nossek

Keyword(s):

Case Series ◽

Vascular Anatomy ◽

Artery Aneurysm ◽

Posterior Circulation ◽

Femoral Access ◽

Pipeline Embolization Device ◽

Aneurysm Treatment ◽

Posterior Circulation Aneurysm ◽

Device Placement ◽

Posterior Circulation Aneurysms

AbstractBACKGROUNDThe treatment of selected wide-neck and fusiform posterior circulation aneurysms is challenging for clipping as well as for endovascular route.OBJECTIVETo describe an endovascular approach for vertebral artery aneurysm treatment using transradial access (TRA) instead of the conventional transfemoral access.METHODSWe collected cases from two institutions in which TRA was used for posterior circulation Pipeline Embolization Device (Medtronic, Dublin, Ireland) deployment.RESULTSA total of four patients were treated. TRA was useful in the setting of extreme vessel tortuosity. We utilized 5F Terumo Glidesheath (Terumo Medical, Somerset, New Jersey), intermediate catheter, and a 027 microcatheter for Pipeline deployment. TRA was not associated with any access or deployment difficulties.CONCLUSIONSEarly experience suggests that TRA for Pipeline Embolization Device placement for posterior circulation aneurysm is a safe and efficient alternative to standard transfemoral access. While this approach was initially applied to patients with vascular anatomy that may not allow for safe femoral access or navigation, experience so far argues for considering a radial approach towards some posterior circulation aneurysm treatment.

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Extended endoscopic endonasal transclival clipping of posterior circulation aneurysms—an alternative to the transcranial approach

Acta Neurochirurgica ◽

10.1007/s00701-015-2609-z ◽

2015 ◽

Vol 157 (12) ◽

pp. 2087-2088 ◽

Cited By ~ 3

Author(s):

Mohamed Labib ◽

Amir R. Dehdashti

Keyword(s):

Posterior Circulation ◽

Endoscopic Endonasal ◽

Posterior Circulation Aneurysms ◽

Transcranial Approach

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Extended endoscopic endonasal transclival clipping of posterior circulation aneurysms—an alternative to the transcranial approach

Acta Neurochirurgica ◽

10.1007/s00701-015-2610-6 ◽

2015 ◽

Vol 157 (12) ◽

pp. 2077-2085 ◽

Cited By ~ 14

Author(s):

Sampath Somanna ◽

R. Arun Babu ◽

Dwarakanath Srinivas ◽

Kannepalli V. L. Narasinga Rao ◽

Vikas Vazhayil

Keyword(s):

Posterior Circulation ◽

Endoscopic Endonasal ◽

Posterior Circulation Aneurysms ◽

Transcranial Approach

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Microsurgical Evaluation of the Pterional Approach to Aneurysms of the Distal Basilar Circulation

Neurosurgery ◽

10.1227/00006123-197809000-00001 ◽

1978 ◽

Vol 3 (2) ◽

pp. 135-141 ◽

Cited By ~ 54

Author(s):

Duke S. Samson ◽

Richard M. Hodosh ◽

Kemp W. Clark

Keyword(s):

Basilar Artery ◽

Cerebral Aneurysms ◽

Posterior Circulation ◽

Human Cadaver ◽

Pterional Approach ◽

Posterior Displacement ◽

Clip Application ◽

Posterior Circulation Aneurysms ◽

Posterior Clinoid Process ◽

Brain Retraction

Abstract The microsurgical correlates of the pterional approach to the distal basilar circulation were evaluated in 20 cases of posterior circulation aneurysms, 50 human cadaver dissections, and a variety of other intracranial surgical lesions. The pterional approach permitted successful clipping of the aneurysm in 13 of 15 basilar bifurcation aneurysms, 1 of 2 basilarposterior cerebral aneurysms, and 2 of 3 basilar-superior cerebellar aneurysms. In each of the failed attempts via the pterional approach, the subtemporal route ultimately resulted in proper clip application. The interposition of the posterior clinoid process was the impediment to successful clipping in three of the four cases that could not be managed via the pterional approach. All 3 of these patients had a basilar bifurcation that was below the level of the posterior clinoid on angiography, whereas none of the remaining 17 aneurysm patients demonstrated a low-lying bifurcation. Posterior displacement of the basilar artery away from the posterior clinoid exceeded 1 cm in only 13% of our cases and was not an impediment to successful clipping of the aneurysm via the pterional route. We conclude that, when the anatomical situation is appropriate, the pterional approach offers the advantages of less brain retraction and better visualization of the parent arteries and important perforating branches when compared to the subtemporal approach.

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