Anterior clinoidectomy using an extradural and intradural 2-step hybrid technique

2018 ◽  
Vol 130 (1) ◽  
pp. 238-247 ◽  
Author(s):  
Ali Tayebi Meybodi ◽  
Michael T. Lawton ◽  
Sonia Yousef ◽  
Xiaoming Guo ◽  
Jose Juan González Sánchez ◽  
...  
Keyword(s):  
Internal Carotid ◽  
Surgical Simulation ◽  
Skull Base Surgery ◽  
The Body ◽  
Hybrid Technique ◽  
Dust Deposition ◽  
Anterior Clinoid Process ◽  
Anterior Clinoidectomy ◽  
Optic Strut ◽  
Neurovascular Structures

Anterior clinoidectomy is a difficult yet essential technique in skull base surgery. Two main techniques (extradural and intradural) with multiple modifications have been proposed to increase efficiency and avoid complications. In this study, the authors sought to develop a hybrid technique based on localization of the optic strut (OS) to combine the advantages and avoid the disadvantages of both techniques.Ten cadaveric specimens were prepared for surgical simulation. After a standard pterional craniotomy, the anterior clinoid process (ACP) was resected in 2 steps. The segment anterior to the OS was resected extradurally, while the segment posterior to the OS was resected intradurally. The proposed technique was performed in 6 clinical cases to evaluate its safety and efficiency.Anterior clinoidectomy was successfully performed in all cadaveric specimens and all 6 patients by using the proposed technique. The extradural phase enabled early decompression of the optic nerve while avoiding the adjacent internal carotid artery. The OS was drilled intradurally under direct visualization of the adjacent neurovascular structures. The described landmarks were easily identifiable and applicable in the surgically treated patients. No operative complication was encountered.A proposed 2-step hybrid technique combines the advantages of the extradural and intradural techniques while avoiding their disadvantages. This technique allows reduced intradural drilling and subarachnoid bone dust deposition. Moreover, the most critical part of the clinoidectomy—that is, drilling of the OS and removal of the body of the ACP—is left for the intradural phase, when critical neurovascular structures can be directly viewed.

The “No-drill” Technique of Anterior Clinoidectomy: A Cranial Base Approach To The Paraclinoid And Parasellar Region

2009 ◽  
Vol 64 (suppl_1) ◽  
pp. ONS96-ONS106 ◽  
Author(s):  
Dongwoo John Chang
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Cranial Base ◽  
Optic Canal ◽  
Anterior Clinoid Process ◽  
Anterior Clinoidectomy ◽  
Computed Tomographic ◽  
Optic Strut ◽  
Neurovascular Structures

Abstract Introduction: A high-speed power-drilling technique of anterior clinoidectomy has been advocated in all publications on paraclinoid region surgery. The entire shaft of the power drill is exposed in the operative field; thus, all neurovascular structures in proximity to any portion of the full length of the rotating drill bit are at risk for direct mechanical and/or thermal injury. Ultrasonic bone removal has recently been developed to mitigate the potential complications of the traditional power-drilling technique of anterior clinoidectomy. However, ultrasound-related cranial neuropathies are recognized complications of its use, as well as the increased cost of device acquisition and maintenance. Methods: A retrospective review of a cerebrovascular/cranial base fellowship-trained neurosurgeon's 45 consecutive cases of anterior clinoidectomy using the “no-drill” technique is presented. Clinical indications have been primarily small to giant aneurysms of the proximal internal carotid artery; however, in addition to ophthalmic segment aneurysms, selected internal carotid artery-posterior communicating artery aneurysms and internal carotid artery bifurcation aneurysms, and other large/giant/complex anterior circulation aneurysms, this surgical series of “no-drill” anterior clinoidectomy includes tuberculum sellae meningiomas, clinoidal meningiomas, cavernous sinus lesions, pituitary macroadenomas with significant suprasellar extension, other perichiasmal lesions (sarcoid), and fibrous dysplasia. A bony opening is made in the mid- to posterior orbital roof after the initial pterional craniotomy. Periorbita is dissected off the bone from inside the orbital compartment. Subsequent piecemeal resection of the medial sphenoid wing, anterior clinoid process, optic canal roof, and optic strut is performed with bone rongeurs of various sizes via the bony window made in the orbital roof. Results: No power drilling was used in this surgical series of anterior clinoidectomies. Optimal microsurgical exposure was obtained in all cases to facilitate complete aneurysm clippings and lesionectomies. There were no cases of direct injury to surrounding neurovascular structures from the use of the “no-drill” technique. The surgical technique is presented with illustrative clinical cases and intraoperative photographs, demonstrating the range of applications in anterior and central cranial base neurosurgery. Conclusion: Power drilling is generally not necessary for removal of the anterior clinoid process, optic canal roof, and optic strut. Rigorous study of preoperative computed tomographic scans/computed tomographic angiography scans, magnetic resonance imaging scans, and angiograms is essential to identify important anatomic relationships between the anterior clinoid process, optic strut, optic canal roof, and neighboring neurovascular structures. The “no-drill” technique eliminates the risks of direct power-drilling mechanical/ thermal injury and the risks of ultrasound-associated cranial neuropathies. The “no-drill” technique provides a direct, time-efficient, and efficacious approach to the paraclinoid/ parasellar/pericavernous area, using a simplified mechanical route.This technique is applicable to any neurosurgical diagnosis and approach in which anterior clinoidectomy is necessary. It is arguably the gentlest and most efficient method for exposing the paracli-noid/parasellar/pericavernous region.

The “Yo-Yo” Technique to Prevent Cerebrospinal Fluid Rhinorrhea after Anterior Clinoidectomy for Proximal Internal Carotid Artery Aneurysms

2006 ◽  
Vol 59 (suppl_1) ◽  
pp. ONS-101-ONS-107 ◽  
Author(s):  
John H. Chi ◽  
Michael Sughrue ◽  
Sandeep Kunwar ◽  
Michael T. Lawton
Keyword(s):  
Cerebrospinal Fluid ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Sphenoid Sinus ◽  
Internal Carotid ◽  
Anterior Clinoid Process ◽  
Csf Rhinorrhea ◽  
Anterior Clinoidectomy ◽  
Optic Strut ◽  
Proximal Internal Carotid Artery

Abstract OBJECTIVE: Resection of the anterior clinoid process is important for the exposure of aneurysms on clinoidal and supraclinoidal segments of the internal carotid artery. Cerebrospinal fluid (CSF) rhinorrhea can complicate anterior clinoidectomy when the optic strut is pneumatized and its removal communicates the subarachnoid space with the sphenoid sinus. We present a technique for repairing this defect and preventing CSF rhinorrhea. METHODS: A suture is secured around a strip of temporalis muscle, which is then pushed through the opening in the optic strut completely into the sphenoid sinus. The ends of suture that trail the muscle are used to retract the muscle from the sphenoid sinus back into the optic strut. The suture is trimmed and the repair is covered with sealant or fibrin glue. RESULTS: During an 8-year period in which 127 patients with proximal internal carotid artery aneurysms that required anterior clinoidectomy were treated, pneumatized optic struts were encountered in 14 patients (11%). Four patients were treated with the “yo-yo” technique, none of whom experienced CSF rhinorrhea. Before using this technique, 10 patients were managed with standard packing techniques (wax, muscle, and gel foam) and four of these patients subsequently experienced CSF rhinorrhea (40%). In these four patients, all required reoperation with either craniotomy and packing with pericranium (one patient), Couldwell-Luc procedure (one patient), or endoscopic transnasal obliteration of the sphenoid sinus with fat (two patients). CONCLUSION: The “yo-yo” technique of tightly wedging a muscle plug into the optic strut proved to be simple, fast, and effective, preventing CSF rhinorrhea in all patients in whom it was applied. Although experience with this technique is limited, reversing the direction of packing and pulling muscle from the sphenoid sinus into the optic strut eliminated a complication that occurred in 40% of patients with standard packing techniques.

scholarly journals The Microsurgical Relationships between Internal Carotid-Posterior Communicating Artery Aneurysms and the Skull Base

2017 ◽  
Vol 79 (05) ◽  
pp. 427-436 ◽  
Author(s):  
Noritaka Komune ◽  
Ryosuke Tsuchimochi ◽  
Yasutoshi Kai ◽  
Kenichi Matsumoto ◽  
Sei Haga ◽  
...  
Keyword(s):  
Skull Base ◽  
Clinical Characteristics ◽  
Internal Carotid ◽  
Posterior Communicating Artery ◽  
Microsurgical Anatomy ◽  
Anterior Clinoid Process ◽  
Anterior Clinoidectomy ◽  
Close Relationship ◽  
Anatomical Relationship ◽  
Formalin Fixed

Objective This study aimed to review the anatomical and clinical characteristics of internal carotid-posterior communicating artery (IC-PC) aneurysms, especially those located close to the skull base. Methods The microsurgical anatomy around the posterior communicating artery (PComA) was examined in a dry skull and five formalin-fixed human cadaveric heads. The clinical characteristics of 37 patients with 39 IC-PC aneurysms, who were treated microsurgically between April 2008 and July 2016, were retrospectively reviewed. Results The anterior clinoid process (ACP), as well as the anterior petroclinoidal dural fold (APF), which forms part of the oculomotor triangle, are closely related to the origin of the PComA. Among the 39 IC-PC aneurysms, anterior clinoidectomy was performed on 4 (10.3%) and a partial resection of the APF was performed on 2 (5.1%). Both of these aneurysms projected inferior to the tentorium, or at least part of the aneurysm's dome was inferior to the tentorium. Conclusion Proximally located IC-PC aneurysms have an especially close relationship with the ACP and APF. We should be familiar with the anatomical relationship between IC-PC aneurysms and the structures of the skull base to avoid hazardous complications.

scholarly journals Variations in the Anatomy of Sphenoid Sinus: A Computed Tomography Investigation

2019 ◽  
pp. 1-7
Author(s):  
Mohammad Taghi Joghataei ◽  
Amir Hosseini ◽  
Javad Mohajer Ansari ◽  
Ehsan Golchini ◽  
Zeinab Namjoo ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Retrospective Study ◽  
Sphenoid Sinus ◽  
Internal Carotid ◽  
Anterior Clinoid Process ◽  
3D Images ◽  
Maxillary Nerve ◽  
Adjacent Structures ◽  
Neurovascular Structures ◽  
Greater Wing

Aims: The sphenoid sinus is surrounded by many neurovascular structures which are very vulnerable to intrasphenoid sinus surgeries. The purpose of this study is to investigate the variation of sphenoid sinus structure by CT scan imaging. Methodology: This is a retrospective study of 3D images of a paranasal sinus in 129 cases. In this study, three-way metering of the sphenoid sinus, additional septum, pneumatization of the period process (PP), anterior clinoid process (ACP) and greater wing of sphenoid and protrusion and dehiscence of adjacent structures will be assessed. Results: Protrusion of internal carotid artery (ICA), a vidian nerve, maxillary nerve (V2) and optical canal were seen respectively 50.4%, 57.36%, 62.5% and 54.3% but dehiscence of this structure was seen 8.5%, 7%, 3.9% and 6.2%. penumtazition of PP, ACP and greater wing of sphenoid were seen 96.87%, 43.9% and 41.1%. Additional septum also is seen in 76% of the population. Conclusion: This study demonstrates numerous variations in sphenoid sinus structure. Some of the variations cause many problems during intrasphenoidal surgery. Therefore, physicians should evaluate patients completely before surgery.

scholarly journals Morphology of the anterior clinoid process in a select Kenyan population

2018 ◽  
Vol 7 (1) ◽  
pp. 1132-1137
Author(s):  
William Sibuor ◽  
Isaac Cheruiyot ◽  
Jeremiah Munguti ◽  
James Kigera ◽  
Gichambira Gikenye
Keyword(s):  
Skull Base ◽  
Human Anatomy ◽  
Average Thickness ◽  
Anterior Clinoid Process ◽  
Morphological Variations ◽  
Anterior Clinoidectomy ◽  
Mean Width ◽  
The Mean ◽  
Caroticoclinoid Foramen ◽  
Neurovascular Structures

Knowledge of the morphological variations of the anterior clinoid process is pertinent during anterior clinoidectomy to prevent injury to the adjacent neurovascular structures as well as in the interpretation of skull base radiographs. Fifty-one open crania (102 anterior clinoid processes) were obtained from the Departments of Human Anatomy in three Kenyan Universities. Caroticoclinoid foramen was present in nine (17.6%) out of the 51 skulls studied. Of the 9 skulls, 2 had bilateral complete foramina while the remaining 7 had unilateral foramina, all on the left side. The mean length of the anterior clinoid process ranged between 5.0 and 18.8mm with a mean of 10.92±2.79 mm. The mean width was found to be 10.43±2.67 mm (range: 5.3-18.0mm) while the average thickness was 5.43±2.02mm (range: 1.3-11.9mm). There were no statistically significant side differences in the dimensions of the anterior clinoid process. Type IIIb anterior clinoid process was the commonest (47.1%) while type IIIa was the least common (7.8%). Compared to other populations, the anterior clinoid process in our setting shows some differences involving its type and the caroticoclinoid foramen. These features should be taken into account when interpreting skull base radiographs and planning for anterior clinoidectomies.Keywords: Clinoid Process, Kenya, Morphology

Exposure of the Intracavernous Carotid Artery in Aneurysm Surgery

Neurosurgery ◽  
1991 ◽  
Vol 28 (2) ◽  
pp. 317-324 ◽  
Author(s):  
Takashi Ohmoto ◽  
Seigo Nagao ◽  
Shogo Mino ◽  
Terukazu Ito ◽  
Yutaka Honma ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid ◽  
Lateral Wall ◽  
Easy Access ◽  
Anterior Clinoid Process ◽  
Ocular Movements ◽  
Intracavernous Aneurysm ◽  
Optic Strut ◽  
Posterior Clinoid Process ◽  
Horizontal Portion

Abstract The pterional intradural approach was used in five cases of large and giant carotid-ophthalmic aneurysms and in two cases of intracavernous aneurysms that arose from the anterior siphon knee in the cavernous sinus (CS) and extended into the carotid cistern. In four cases of large carotid-ophthalmic aneurysms removal of the anterior clinoid process and the roof of the optic canal gave easy access to the pericarotid ring. The anteromedial part of the pericarotid ring was dissected to expose the extradural portion of the internal carotid artery (ICA) proximal to the neck and to make enough room between the wall of the CS and the extradural portion of the ICA, thus allowing easy clipping of the neck. In one case of a giant carotid-ophthalmic aneurysm extending into the CS with an extradural origin of the ophthalmic artery and in two cases of an intracavernous aneurysm arising from the siphon knee, neck clipping was performed by opening the lateral wall and roof of the CS after removal of the optic strut. The opening of the lateral wall anterior to the 3rd nerve facilitated wide exposure of the anterior siphon knee. The horizontal portion of the intracavernous ICA as well as the whole aspect of the aneurysm could be exposed as a result of the extended opening of the cavernous roof anterior to the posterior clinoid process. Successful operative results were obtained in all seven patients. A visual field detect as an operative complication was noted in one patient. No disturbance of ocular movements was noted.

scholarly journals The caroticoclinoid foramen in fetal and infantile orbitosphenoid, presphenoid, and sphenoid bones: developmental and neurosurgical considerations

2019 ◽  
Vol 23 (3) ◽  
pp. 390-396 ◽  
Author(s):  
Matthew J. Zdilla
Keyword(s):  
Carotid Artery ◽  
Early Life ◽  
Internal Carotid ◽  
Clinical Importance ◽  
Common Finding ◽  
Anterior Clinoid Process ◽  
Black And White ◽  
Risk Of Injury ◽  
Caroticoclinoid Foramen ◽  
Neurovascular Structures

OBJECTIVEThe presence of a caroticoclinoid foramen may increase the likelihood of adverse neurosurgical events. Despite the clinical importance of the caroticoclinoid foramen, its study has been mostly limited to adult populations. Therefore, the object of this study was to describe the prevalence, morphology, and development of the caroticoclinoid foramen among varied sexes and races in early life.METHODSThe study analyzed caroticoclinoid foramina in dry orbitosphenoid, presphenoid, and sphenoid bones from a population of 101 fetal and infantile crania of varied sex and race.RESULTSA caroticoclinoid foramen, whether complete, near complete, or partial, was found in 36 of 199 sides (18.1%). Of the 98 crania with bilaterally intact sides, 21 (21.4%) had the presence of at least one caroticoclinoid foramen. Caroticoclinoid foramina were found unilaterally and bilaterally, in both female and male crania (9/41, 22.0%; 12/57, 21.1%, respectively) and, likewise, in crania of both black and white races (9/54, 16.7%; 12/44, 27.3%, respectively). Caroticoclinoid foramina were formed from cornuate bony projections from the anterior clinoid process, middle clinoid process, or both anterior and middle clinoid processes. Caroticoclinoid foramina were also found in isolated orbitosphenoid bones from individuals as young as 4 months’ fetal age.CONCLUSIONSThe caroticoclinoid foramen occurs in approximately one of every 5 sides and in one in every 5 individuals of perinatal age and should, therefore, be considered a common finding in both fetuses and infants. It is common in both females and males as well as in both black and white races, alike. Furthermore, the caroticoclinoid foramen can be found in individuals as young as 4 months of fetal age. Failure to anticipate the presence of a caroticoclinoid foramen will place important neurovascular structures, including the internal carotid artery, at risk of injury. Neurosurgeons should, therefore, anticipate the caroticoclinoid foramen even in their youngest patients.

scholarly journals Extradural clinoidectomy for resection of clinoidal meningioma

2017 ◽  
Vol 43 (videosuppl2) ◽  
pp. V10 ◽  
Author(s):  
Simon Buttrick ◽  
Jacques J. Morcos ◽  
Mohamed S. Elhammady ◽  
Anthony C. Wang
Keyword(s):  
Optic Nerve ◽  
Optic Canal ◽  
Superior Orbital Fissure ◽  
Anterior Clinoid Process ◽  
Anterior Clinoidectomy ◽  
Link Type ◽  
Optic Strut ◽  
Parasellar Region ◽  
Versatile Technique

Extradural anterior clinoidectomy is a versatile technique to increase exposure of the sellar and parasellar region. It is of particular use in the resection of clinoidal meningiomas, as sphenoidal and clinoidal hyperostosis can cause compression of the optic nerve. Extradural clinoidectomy follows a series of steps, consisting of (1) unroofing of the superior orbital fissure, (2) unroofing of the optic canal, (3) removal of the optic strut, and (4) removal of the anterior clinoid process. The authors show these steps in detail, as well as their application to the resection of a large clinoidal meningioma.The video can be found here: https://youtu.be/O1Fcef29ETg.

Quantitative Analysis of Variable Extent of Anterior Clinoidectomy With Intradural and Extradural Approaches

2015 ◽  
Vol 11 (1) ◽  
pp. 147-161 ◽  
Author(s):  
Manjul Tripathi ◽  
Rama Chandra Deo ◽  
Natesan Damodaran ◽  
Ashish Suri ◽  
Vinkle Srivastav ◽  
...  
Keyword(s):  
Optic Nerve ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Laser Scanning ◽  
Internal Carotid ◽  
Volumetric Analysis ◽  
Surgical Approaches ◽  
Anterior Clinoid Process ◽  
Anterior Clinoidectomy ◽  
Bony Landmarks

Abstract BACKGROUND Drilling of the anterior clinoid process (ACP) is an integral component of surgical approaches for central and paracentral skull base lesions. The technique to drill ACP has evolved from pure intradural to extradural and combined techniques. OBJECTIVE To describe the computerized morphometric evaluation of exposure of optic nerve and internal carotid artery with proposed tailored intradural (IDAC) and complete extradural (EDAC) anterior clinoidectomy. METHODS We describe a morphometric subdivision of ACP into 4 quadrangles and 1 triangle on the basis of fixed bony landmarks. Computerized volumetric analysis with 3-dimensional laser scanning of dry-drilled bones for respective tailored IDAC and EDAC was performed. Both approaches were compared for the area and length of the optic nerve and internal carotid artery. Five cadaver heads were dissected on alternate sides with intradural and extradural techniques to evaluate exposure, surgical freedom, and angulation of approach. RESULTS Complete anterior clinoidectomy provides a 2.5-times larger area and 2.7-times larger volume of ACP. Complete clinoidectomy deroofed the optic nerve to an equal extent as by proposed the partial tailored clinoidectomy approach. Tailored IDAC exposes only the distal dural ring, whereas complete EDAC exposes both the proximal and distal dural rings with complete exposure of the carotid cave. CONCLUSION Quantitative comparative evaluation provides details of exposure and surgical ease with both techniques. We promote hybrid/EDAC technique for vascular pathologies because of better anatomic orientation. Extradural clinoidectomy is the preferred technique for midline cranial neoplasia. An awareness of different variations of clinoidectomy can prevent dependency on any particular approach and facilitate flexibility.

Sphenoid Sinus: Pneumatization and Septation Patterns in a Hispanic Population

ORL ◽  
2021 ◽  
pp. 1-10
Author(s):  
José Luis Treviño-Gonzalez ◽  
Félix Maldonado-Chapa ◽  
Joel Adrián Becerra-Jimenez ◽  
Germán Armando Soto-Galindo ◽  
Josefina Alejandra Morales-del Angel
Keyword(s):  
Ethnic Groups ◽  
Sphenoid Sinus ◽  
Internal Carotid ◽  
Preoperative Assessment ◽  
Hispanic Population ◽  
Anterior Clinoid Process ◽  
Anatomical Variants ◽  
Iatrogenic Injuries ◽  
Gender And Age ◽  
Neurovascular Structures

<b><i>Introduction:</i></b> Pneumatization of the sphenoid sinus (SS) varies widely among different ethnic groups. Information regarding the prevalence and significance of SS variants among Hispanic groups is limited. This study aims to describe and analyze pneumatization and septation patterns of the SS in a Hispanic population. <b><i>Methods:</i></b> A total of 160 paranasal sinus computed tomographies were reviewed by a head and neck-specialized radiologist and 2 otolaryngologists. <b><i>Results:</i></b> The postsellar and sellar types were the most frequent patterns of pneumatization observed, with a prevalence of 52.5 and 40%, respectively. Accessory septations were present in 59.4% of the patients. Septa were inserting over the internal carotid artery (ICA) in 43.8% and over the optic nerve in 17.5% of the population. No significant association (<i>p</i> &#x3e; 0.05) was observed when comparing the different accessory septation patterns among the types of the SS. The frequency of septa inserting on the ICA was significantly higher in postsellar types (<i>p</i> &#x3c; 0.001). Pneumatization of the anterior clinoid process, pterygoid processes, and greater wing was present in 20, 17.5, and 45.9% of the sinuses, respectively. Onodi cells were encountered in 40% of the sinuses. There were no significant differences in any of the pneumatization and septation variables when compared by gender and age (<i>p</i> &#x3e; 0.05). <b><i>Discussion/Conclusion:</i></b> Differences regarding anatomical variants and septations of the SS were observed in our study when compared with findings reported in other ethnic groups. Preoperative assessment of the anatomical variants of the SS in Mexican patients is imperative to select the most optimal surgical approach and prevent iatrogenic injuries to related neurovascular structures.

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