Morphometric Comparison of the Pterional Trans-Sylvian and the Pretemporal Trans-Clinoidal Approaches to the Posterior Communicating Artery

2020 ◽  
Vol 20 (1) ◽  
pp. E22-E30
Author(s):  
Jaafar Basma ◽  
Kenneth A Moore ◽  
Khaled Krisht ◽  
Tarek Abuelem ◽  
Kenan Arnautovic ◽  
...  
Keyword(s):  
Optic Nerve ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Oculomotor Nerve ◽  
Pterional Approach ◽  
Pterional Craniotomy ◽  
Working Space ◽  
Area 5 ◽  
Modern Era

Abstract BACKGROUND Posterior communicating (Pcom) aneurysms in the modern era have tended toward increased complexity and technical difficulties. The pretemporal approach is a valuable extension to the pterional approach for basilar apex aneurysms, but its advantages for Pcom aneurysms have not been previously elucidated. OBJECTIVE To quantify characteristics of the pretemporal approach to the Pcom. METHODS We dissected 6 cadaveric heads (12 sides) with a pretemporal transclinoidal approach and measured the following variables: (1) exposed length of internal carotid artery (ICA) proximal to the Pcom artery; (2) exposed circumference of ICA at the origin of Pcom; (3) deep working area between the optic nerve and tentorium/oculomotor nerve; (4) superficial working area; (5) exposure depth; and (6) the frontotemporal (superior posterolateral) and (7) orbito-sphenoidal (inferior anterolateral) angles of exposure. RESULTS Compared with pterional craniotomy, the pretemporal transclinoidal approach increased the exposed length of the proximal ICA from 3.3 to 11.7 mm (P = .0001) and its circumference from 5.1 to 7.8 mm (P = .0003), allowing a 210° view of the ICA (vs 137.9°). The deep and superficial working areas also significantly widened from 53.7 to 92.4 mm2 (P = .0048) and 252.8 to 418.2 mm2 (P = .0001), respectively; the depth of the exposure was equivalent. The frontotemporal and spheno-Sylvian angles increased by 17° (P = .0006) and 10° (P = .0037), respectively. CONCLUSION The pretemporal approach can be useful for complex Pcom aneurysms by providing easier proximal control, wider working space, improved aneurysm visualization, and more versatile clipping angles. Enhanced exposure results in a potentially higher rate of complete aneurysm obliteration and complication avoidance.

Parameters for Contralateral Approach to Ophthalmic Segment Aneurysms of the Internal Carotid Artery

Neurosurgery ◽  
2000 ◽  
Vol 47 (5) ◽  
pp. 1130-1137 ◽  
Author(s):  
Yukinari Kakizawa ◽  
Yuichiro Tanaka ◽  
Yasser Orz ◽  
Tomomi Iwashita ◽  
Kazuhiro Hongo ◽  
...  
Keyword(s):  
Optic Nerve ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Bone Resection ◽  
Pterional Approach ◽  
Aneurysm Neck ◽  
Contralateral Approach ◽  
Ophthalmic Segment Aneurysms ◽  
Contralateral Pterional Approach

Abstract OBJECTIVE This study was undertaken to define more accurately the feasibility and indications of the contralateral pterional approach to ophthalmic segment aneurysms of the internal carotid artery (ICA). METHODS Between 1995 and 1999, 46 patients with ophthalmic segment aneurysms of the ICA were surgically treated in our institution. Eleven of the 46 aneurysms were operated using the contralateral pterional approach. All aneurysms were successfully clipped without complications; three patients required bone resection around the aneurysm neck. We studied the 11 patients who were treated with the contralateral approach by defining six parameters to assess the feasibility of the approach and to predict the necessity for bone resection: 1) Parameter A, the distance between the anterior aspect of the optic chiasm and the limbus sphenoidale; 2) Parameter B, the distance between the bilateral optic nerves at the entrance to the optic canal; 3) Parameter C, the interrelation of the optic nerve and the ICA, expressed as a/b in which a is the length from the midline to the optic nerve and b is the length from the midline to the ICA; 4) Parameter D, the size of the aneurysm neck; 5) Parameter E, the direction of the aneurysm from the ICA wall on the anteroposterior angiogram; and 6) Parameter F, the distance from the medial side of the estimated distal dural ring to the proximal aneurysm neck on the lateral angiogram. RESULTS Parameters A to F were 8.8 mm (range, 5.4–11.1 mm), 14.5 mm (range, 10.4–22.2 mm), 0.9 mm (range, 0.6–1.3 mm), and 3.0 mm (range, 2.3–4.7 mm), 5 to 160 degrees, and 1.3 mm (range, 0.3–2.4 mm), respectively. All patients had excellent operative outcomes without visual dysfunction. Three patients required drilling of the bone around the optic canal on the craniotomy side; bone drilling was not required when Parameter E was between 30 and 160 degrees and Parameter F was more than 1 mm. CONCLUSION Parameters A to D are important for assessing the feasibility of the contralateral approach to ICA-ophthalmic segment aneurysms, and Parameters E and F are most useful for calculating the difficulty of this approach.

scholarly journals Morphometric Comparison of the Pterional Trans-sylvian and the Pretemporal Transclinoidal Approaches to Posterior Communicating Artery Aneurysms: Anatomical Study

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Jaafar Basma ◽  
Kenneth Moore ◽  
Tarek Abuelem ◽  
Khaled Krisht ◽  
L Madison Michael ◽  
...  
Keyword(s):  
Clinical Case ◽  
Internal Carotid ◽  
Focal Point ◽  
Anatomical Study ◽  
Pterional Approach ◽  
Case Examples ◽  
Pterional Craniotomy ◽  
Working Space ◽  
Area 5 ◽  
Ischemic Complications

Abstract INTRODUCTION Due to the advent of endovascular techniques, modern series of surgically treated posterior communicating (Pcom) aneurysms have shown a tendency towards higher complexity and more technical difficulties. The pretemporal approach was described as a valuable extension to the pterional approach in treating basilar apex aneurysms. Its use for clipping of ruptured Pcom aneurysms was associated with decreased ischemic complications. However, its anatomical advantages for Pcom aneurysm surgery have not been previously analyzed. METHODS Six cadaveric heads (12 sides) underwent a sequential dissection, starting with a pterional craniotomy, and then extended to a pretemporal transclinoidal approach. In each step, the following variables were measured, taking the origin of Pcom as a focal point: (1) exposed length of the internal carotid artery (ICA) proximal to the Pcom artery, (2) exposed angular circumference of ICA at the origin of Pcom, (3) deep working area between the optic nerve and tentorium/oculomotor nerve, (4) superficial working area, (5) depth of the exposure and the (6) fronto-temporal (superior posterolateral), and (7) orbito-sphenoidal (inferior anterolateral) angles of exposure. Clinical case examples are used to illustrate the advantages of the pretemporal approach. RESULTS Compared to the pterional craniotomy, the pretemporal transclinoidal approach increased the exposed length of the proximal ICA from 3.3 to 11.7 mm (P = .0001), and its circumference from 5.1 to 7.8 mm (P = .0003), allowing a 210-degree view of the ICA (vs 137.9). The deep and superficial working areas also significantly widened from 53.7 to 92.4 mm2 (P = .0048) and 252.8 to 418.2 mm2 (P = .0001), respectively; while the depth of the exposure was equivalent. The frontotemporal and the sphenosylvian angles increased on average by 17 (P = .0006) and 10 (P = .0037) degrees, respectively. The clinical case examples demonstrate the visual, technical and strategic advantages of the pretemporal approach as a consequence of its anatomical exposure. CONCLUSION The pretemporal approach can be useful for complex Pcom aneurysms by providing easier proximal control, wider working space, aneurysm visualization, and more versatile clipping angles. The enhanced exposure potentially results in a higher rate of complete aneurysm obliteration and complication avoidance.

A Surgical Technique for the Removal of Clinoidal Meningiomas

2006 ◽  
Vol 59 (suppl_1) ◽  
pp. ONS-108-ONS-114 ◽  
Author(s):  
Joung H. Lee ◽  
Burak Sade ◽  
Bong J. Park
Keyword(s):  
Optic Nerve ◽  
Surgical Technique ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Oculomotor Nerve ◽  
Tumor Removal ◽  
The Past ◽  
Aggressive Tumor ◽  
Neurovascular Structures

Abstract CLINOIDAL MENINGIOMAS, ALSO referred to as medial or inner sphenoid wing meningiomas, are often difficult and challenging to remove completely and safely, especially when they become large enough to encircle, compress, or displace the adjacent critical neurovascular structures such as the optic nerve, the internal carotid artery and its branches, and the oculomotor nerve. In this article, the authors describe the detailed surgical technique used in their practice in addition to subtle nuances learned from their experience of operating on more than 40 patients with clinoidal meningiomas over the past several years. The primary goals of surgery are to achieve aggressive tumor removal with avoidance of intraoperative morbidity and, in addition, for those with preoperative compromised vision, to provide improvement in their visual function after surgery.

scholarly journals Isolated oculomotor nerve palsy inspontaneous internal carotid artery dissection: case report

2003 ◽  
Vol 61 (3A) ◽  
pp. 668-670 ◽  
Author(s):  
Cynthia Resende Campos ◽  
Ayrton Roberto Massaro ◽  
Milberto Scaff
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Nerve Palsy ◽  
Internal Carotid ◽  
Carotid Artery Dissection ◽  
Oculomotor Nerve ◽  
Oculomotor Nerve Palsy ◽  
Artery Dissection ◽  
Internal Carotid Artery Dissection ◽  
The Third

Partial oculosympathetic palsy followed by ischemic manifestations in brain or retina are the main symptoms of extracranial internal carotid artery (ICA) dissection. Unusually, cranial nerves may be affected. Isolated oculomotor nerve palsy is found only rarely. CASE: We present a 50-year-old nondiabetic man who experienced acute onset of right occipital headache which spread to the right retro-orbital region. Five days later he noticed diplopia and right blurred vision sensation. Neurologic examination disclosed only impaired adduction and upward gaze of right eye, slight ipsilateral pupillary dilatation, without ptosis. Brain MRI was normal. Angiography showed right internal carotid artery dissection with forward occlusion to the base of the skull. Intravenous heparin followed by warfarin was prescribed. The headache and the oculomotor nerve deficit gradually resolved in the next three weeks. DISCUSSION: Isolated oculomotor nerve palsy is underrecognized as a clinical presentation of extracranial ICA dissection. If the angiographic evaluation is incomplete without careful study of extracranial arteries, misdiagnosis may lead to failure to initiate early treatment to prevent thromboembolic complications. For this reason we draw attention to the need for careful evaluation of cervical arteries in patients with oculomotor nerve palsy. Mechanical compression or stretching of the third nerve are possible mechanisms, but the direct impairment of the blood supply to the third nerve seems to be the most plausible explanation.

Retinal and Optic Nerve Ischemia due to an Internal Carotid Artery Dissection: The “Cup of Wine” Sign

2020 ◽  
Vol 83 (3) ◽  
pp. 325-326
Author(s):  
Jordi Sarto ◽  
Gerard Mayà-Casalprim ◽  
Álvaro Carbayo ◽  
Daniel Santana ◽  
Xabier Urra
Keyword(s):  
Optic Nerve ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Carotid Artery Dissection ◽  
Artery Dissection ◽  
Internal Carotid Artery Dissection

Compressive optic nerve atrophy resulting from a distorted internal carotid artery

2000 ◽  
Vol 22 (4) ◽  
pp. 322-324 ◽  
Author(s):  
Tatsuya Ishikawa ◽  
Tatsuhiko Ito ◽  
Eiichi Shoji ◽  
Kazuhisa Inukai
Keyword(s):  
Optic Nerve ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Optic Nerve Atrophy

An Operative Complication in a Patient with a True Posterior Communicating Artery Aneurysm: Case report and Review of the Literature

Neurosurgery ◽  
1990 ◽  
Vol 27 (4) ◽  
pp. 650-653 ◽  
Author(s):  
Tadashi Kudo
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Artery Aneurysm ◽  
Oculomotor Nerve ◽  
Posterior Communicating Artery ◽  
Review Of The Literature ◽  
Operative Complications ◽  
Posterior Communicating Artery Aneurysm ◽  
Aneurysmal Neck

Abstract Intraoperative oculomotor nerve injury in a patient with a true posterior communicating artery aneurysm is reported in detail. A comparison of internal carotid artery aneurysms at the posterior communicating artery junction with true posterior communicating artery aneurysms deserves special attention, because the vascular relationships of the aneurysm are more complex. A clip along the internal carotid artery does not occlude blood flow to the aneurysm, and the aneurysmal neck and the distal posterior communicating artery are closer to the oculomotor nerve. This is the 27th reported case of a true posterior communicating artery aneurysm. The incidence of true posterior communicating artery aneurysms ranges from 0.1 to 2.8% of all aneurysm patients. Such aneurysms constitute 4.6 and 11% of so-called posterior communicating aneurysms in two series. Difficulty associated with a preoperative diagnosis has been documented in at least 4 cases. An awareness of this rare aneurysm is stressed in order to avoid operative complications.

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