Pterional craniotomy via a transcavernous approach for the treatment of low-lying distal basilar artery aneurysms

1998 ◽  
Vol 89 (6) ◽  
pp. 921-926 ◽  
Author(s):  
Stephen L. Nutik
Keyword(s):  
Cavernous Sinus ◽  
Basilar Artery ◽  
Anterior Clinoid Process ◽  
Technical Problems ◽  
Content Type ◽  
Pterional Craniotomy ◽  
Transsylvian Approach ◽  
Posterior Clinoid Process ◽  
Additional Exposure ◽  
Fine Print

Object. The author describes a surgical procedure in which pterional craniotomy is performed via a transcavernous approach to treat low-lying distal basilar artery (BA) aneurysms. This intradural procedure is compared with the extradural procedure described by Dolenc, et al. Methods. The addition of a transcavernous exposure to the standard pterional intradural transsylvian approach allows a lower exposure of the distal BA behind the dorsum sellae. The technical steps involved in this procedure are as follows: 1) removal of the anterior clinoid process: 2) entry into the cavernous sinus medial to the third nerve; 3) packing of the venous channels of the cavernous sinus lying between the carotid artery and the pituitary gland to open this space; 4) removal of the posterior clinoid process and the portion of the dorsum sellae that is exposed from within the cavernous sinus; and 5) removal of the exposed dura mater to obtain additional exposure of the perimesencephalic cistern. Eight cases of aneurysms of the distal BA are presented to illustrate how this approach can help in their surgical treatment. Conclusions. Using the standard pterional approach, these distal BA aneurysms were found to be either too low relative to the posterior clinoid process for adequate exposure or there was insufficient room for temporary clipping of the BA proximal to the lesion. The addition of a transcavernous exposure eliminated these technical problems and aneurysm clipping could be accomplished in each case.

scholarly journals Pterional craniotomy via a transcavernous approach for the treatment of low-lying distal basilar artery aneurysms

1998 ◽  
Vol 5 (4) ◽  
pp. E2
Author(s):  
Stephen L. Nutik
Keyword(s):  
Cavernous Sinus ◽  
Basilar Artery ◽  
Pterional Approach ◽  
Anterior Clinoid Process ◽  
Technical Problems ◽  
Pterional Craniotomy ◽  
Transsylvian Approach ◽  
Posterior Clinoid Process ◽  
Temporary Clipping ◽  
Additional Exposure

Object The author describes a surgical procedure in which pterional craniotomy is performed via a transcavernous approach to treat low-lying distal basilar artery (BA) aneurysms. This intradural procedure is compared with the extradural procedure described by Dolenc, et al. Methods The addition of a transcavernous exposure to the standard pterional intradural transsylvian approach allows a lower exposure of the distal BA behind the dorsum sellae. The technical steps involved in this procedure are as follows: 1) removal of the anterior clinoid process; 2) entry into the cavernous sinus medial to the third nerve; 3) packing of the venous channels of the cavernous sinus lying between the carotid artery and the pituitary gland to open this space; 4) removal of the posterior clinoid process and the portion of the dorsum sellae that is exposed from within the cavernous sinus; and 5) removal of the exposed dura mater to obtain additional exposure of the perimesencephalic cistern. Eight cases of aneurysms of the distal BA are presented to illustrate how this approach can help in their surgical treatment. Conclusions Using the standard pterional approach, these distal BA aneurysms were found to be either too low relative to the posterior clinoid process for adequate exposure or there was insufficient room for temporary clipping of the BA proximal to the lesion. The addition of a transcavernous exposure eliminated these technical problems and aneurysm clipping could be accomplished in each case.

Extradural temporopolar approach to lesions of the upper basilar artery and infrachiasmatic region

1994 ◽  
Vol 81 (2) ◽  
pp. 230-235 ◽  
Author(s):  
J. Diaz Day ◽  
Steven L. Giannotta ◽  
Takanori Fukushima
Keyword(s):  
Basilar Artery ◽  
Cranial Nerve ◽  
Pathological Process ◽  
Total Resection ◽  
Anterior Clinoid Process ◽  
Content Type ◽  
Surgical Access ◽  
Complete Obliteration ◽  
Brain Retraction ◽  
Fine Print

✓ Surgical access to the parasellar, infrachiasmatic, and posterior clinoid regions has traditionally been accomplished through an intradural pterional or subtemporal approach. However, for large or complex lesions in these locations, such traditional trajectories may not afford sufficient exposure for complete obliteration of the pathological process. The authors describe an anterolateral transcavernous approach to this region that includes the following components: 1) extradural removal of the sphenoid wing and exposure of the superior orbital fissure and foramen rotundum; 2) removal of the anterior clinoid process via the anterolateral route; 3) decompression of the optic canal; 4) extradural retraction of the temporal tip; 5) transcavernous mobilization of the carotid artery and third cranial nerve; and 6) removal of the posterior clinoid process. This method results in enhanced exposure with minimal brain retraction and preservation of the temporal tip bridging veins. This approach has been used in 22 patients: 10 with basilar top aneurysms, eight with craniopharyngiomas, one with a tuberculum sellae meningioma, and two with trigeminal neuromas; the last patient had a carotidcavernous fistula and a concomitant pituitary adenoma. Complete clip ligation was performed for all 10 basilar artery aneurysms, and gross total resection was achieved with preservation of the pituitary stalk in all tumor cases. Microscopic total resection was not possible in two cases of craniopharyngioma due to hypothalamic invasion. Two patients suffered transient postoperative hemiparesis, and one patient has persisting weakness; however, no patient followed for more than 6 months suffered any persistent cranial nerve morbidity. It is concluded that this procedure can serve as an alternative to either the transsylvian or subtemporal approaches when cranial base pathologies are large or complex.

Selective extradural anterior clinoidectomy for supra- and parasellar processes

1997 ◽  
Vol 87 (4) ◽  
pp. 636-642 ◽  
Author(s):  
Yasuhiro Yonekawa ◽  
Nobuyoshi Ogata ◽  
Hans-Georg Imhof ◽  
Magnus Olivecrona ◽  
Kevin Strommer ◽  
...  
Keyword(s):  
Optic Nerve ◽  
Basilar Artery ◽  
Artery Aneurysm ◽  
Anterior Clinoid Process ◽  
Content Type ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Anterior Clinoidectomy ◽  
Basilar Artery Aneurysm ◽  
Sphenoid Ridge ◽  
Fine Print

✓ Removal of the anterior clinoid process (ACP) facilitates radical removal of tumors or radical neck clipping of aneurysms in the supra- and parasellar regions by providing a wide operative exposure of the internal carotid artery (ICA) and the optic nerve and by reducing the need for brain retraction. Over a period of 3 years, anterior clinoidectomy was performed in 40 patients, 30 of whom harbored aneurysms (18 of the ICA and 13 of the basilar artery [one patient had two aneurysms]) and 10 of whom had tumors (four large pituitary tumors, four craniopharyngiomas, and two sphenoid ridge meningiomas). The ACP was removed extradurally in 31 cases and intradurally in nine cases. Extradural clinoidectomy was performed in all cases of pituitary adenoma and craniopharyngioma and in most cases of basilar artery aneurysm. Intradural clinoidectomy was performed in two cases of ICA—ophthalmic artery aneurysm, two cases of ICA—posterior communicating artery aneurysm, two cases of ICA cavernous aneurysm, one case of basilar artery aneurysm, and two cases of sphenoid ridge meningioma. The outcome was satisfactory in all patients, except for one patient who underwent clipping of a basilar tip aneurysm and suffered a thalamic and midbrain infarction. Three patients who underwent extradural clinoidectomy suffered a postoperative diminution of visual acuity or a visual field defect on the side of the clinoidectomy. These deficits may have been caused either by drilling of the ACP or by other operative manipulation of the optic nerve. Cerebrospinal fluid rhinorrhea, which required reoperation, occurred in one patient. The authors' experience suggests that the extradural technique of ACP removal is easier and less time consuming than the intradural one and provides better operative exposure. It can be used routinely in treating lesions in the supra- and parasellar regions.

Simulation of the surgical manipulation involved in clipping a basilar artery aneurysm: concepts of virtual clipping

2000 ◽  
Vol 93 (2) ◽  
pp. 355-360 ◽  
Author(s):  
Toru Koyama ◽  
Kazuhiro Hongo ◽  
Yuichiro Tanaka ◽  
Shigeaki Kobayashi
Keyword(s):  
Cerebral Aneurysm ◽  
Basilar Artery ◽  
Morphological Changes ◽  
Three Dimensional ◽  
Artery Aneurysm ◽  
Content Type ◽  
Aneurysm Clip ◽  
Transsylvian Approach ◽  
Surgical Manipulation ◽  
Fine Print

✓ Despite recent advances in three-dimensional imaging based on a voxel-rendering method, these techniques do not simulate the morphological changes that occur during surgery. The authors' goal was to develop a computer-graphics model to simulate the manipulation that occurs during surgery when clipping a cerebral aneurysm.The authors developed an application program to interpolate the contours of models of an artery and an aneurysm clip. The center of displacement was determined inside the arterial model. The directions of displacement were changed to simulate saccular and broad-neck aneurysms, and the intensity of displacement was calculated by using a cosine-based formula. The morphological changes in a saccular aneurysm that may occur during clipping were calculated in x, y, and z coordinates by using sine- and cosine-based formulas. Clip movement was integrated with the aneurysm model, thus simulating the manipulation used during clipping of a cerebral aneurysm. Surgery performed to clip a basilar artery (BA) aneurysm via the transsylvian approach was simulated, in which displacement of the internal carotid artery and clipping of the BA aneurysm were necessary. The movements of an aneurysm clip and clip applicator were designed to represent those occurring when a surgeon actually manipulates a BA aneurysm.The authors have named this methodological tool “virtual clipping.” Use of this tool would assist the preoperative choice of clipping style and selection of the best clip.

Computer-generated microsurgical anatomy of the basilar artery bifurcation

1999 ◽  
Vol 91 (1) ◽  
pp. 145-152 ◽  
Author(s):  
Toru Koyama ◽  
Hiroshi Okudera ◽  
Hirohiko Gibo ◽  
Shigeaki Kobayashi
Keyword(s):  
Computer Graphics ◽  
Basilar Artery ◽  
Surgical Simulation ◽  
Critical Path ◽  
Cranial Nerves ◽  
Microsurgical Anatomy ◽  
Content Type ◽  
Transsylvian Approach ◽  
Bifurcation Aneurysm ◽  
Fine Print

✓ The authors' goal was to develop a computer graphics model to represent the microsurgical anatomy of the basilar artery (BA) bifurcation and surrounding structures to simulate surgery of a BA bifurcation aneurysm performed via the transsylvian approach.The source of the input data was a variety of publications that showed detailed anatomy of the area. A computer graphics model of the area near the BA bifurcation including relevant structures, such as perforating branches or cranial nerves, was depicted in detail. A BA bifurcation aneurysm was added to the computer graphics model and it was rotated to simulate the transsylvian approach. After the internal carotid artery was displaced using a virtual retractor, the aneurysm was exposed, thus providing an understanding of the three-dimensional surgical orientation of the area.Designing a standard anatomical model on the basis of data culled from a variety of publications and adding morphological changes by using a virtual retractor to displace structures that obstruct the view along a critical path at the base of the brain are useful strategies of computer manipulation for surgical simulation in open microneurosurgery. This methodological tool would be useful in teaching surgical microanatomy and in introducing a new navigational system for virtual reality. Both concept and technical details are discussed.

Anatomical study of the orbitozygomatic transsellar—transcavernous—transclinoidal approach to the basilar artery bifurcation

2002 ◽  
Vol 97 (1) ◽  
pp. 151-160 ◽  
Author(s):  
Amitabha Chanda ◽  
Anil Nanda
Keyword(s):  
Carotid Artery ◽  
Basilar Artery ◽  
Sella Turcica ◽  
Anatomical Study ◽  
Content Type ◽  
Prepontine Cistern ◽  
Interpeduncular Cistern ◽  
Posterior Clinoid Process ◽  
Temporary Clip ◽  
Fine Print

Object. An anatomical study in which measurements were obtained was undertaken to demonstrate that the orbitozygomatic transcavernous—transclinoidal approach provides excellent exposure of the trunk of the basilar artery (BA) and its bifurcation. Methods. Bilateral stepwise dissections were performed on 10 fixed cadaver heads with the aid of × 3 to × 40 magnifications. A frontotemporal craniotomy was made, followed by an orbitozygomatic osteotomy. After the dura mater had been opened, the sylvian fissure was widely separated. The anteromedial triangle of the cavernous sinus was opened to mobilize the internal carotid artery medially. The sella turcica and the dorsum sellae were exposed. The posterior clinoid process and the dorsum sellae were drilled to expose a length of BA that included its bifurcation. Measurements were obtained following the frontotemporal craniotomy, orbitozygomatic osteotomy, and drilling of the posterior clinoid process to quantify the exposures provided by these procedures. Excellent exposure of the trunk of the BA and its bifurcation was achieved. The structures in the interpeduncular cistern and the prepontine cistern were also exposed. There was an average gain of a 13.4-mm-long segment of the BA, which in some surgeries can be invaluable. The angle of exposure that was achieved with the BA bifurcation located at the apex increased markedly. Moreover, this method widened the oculomotor nerve—carotid artery corridor for easier access to the BA bifurcation region. Conclusions. This approach combines the advantages granted by most conventional approaches to aneurysms of the BA bifurcation. The approach is suitable for aneurysms situated at a high, normal, or low position on the BA bifurcation. It exposes a sufficient length of the BA trunk to place a temporary clip.

Extradural anterior clinoidectomy

2005 ◽  
Vol 102 (5) ◽  
pp. 945-950 ◽  
Author(s):  
Akio Noguchi ◽  
Vijayabalan Balasingam ◽  
Yoshiaki Shiokawa ◽  
Sean O. McMenomey ◽  
Johnny B. Delashaw
Keyword(s):  
Skull Base ◽  
Basilar Artery ◽  
Anatomical Variations ◽  
Anterior Clinoid Process ◽  
Content Type ◽  
Anterior Clinoidectomy ◽  
Small Structure ◽  
Surgical Field ◽  
The Brain ◽  
Fine Print

✓ The anterior clinoid process (ACP), located on the skull base, is a relatively small structure, although its removal provides enormous gain in facilitating the management of lesions—either tumors or aneurysms—in the paraclinoid region and upper basilar artery. The extensive surgical field gained contributes to safer exposure of the neurovascular elements in the vicinity while avoiding excessive and hazardous retraction of the brain. In this report the authors present a technically simpler avenue for performing an extradural anterior clinoidectomy after reviewing the anatomy of the ACP and its anatomical variations. Additionally, the original Dolenc procedure and its subsequent derivatives are compared and contrasted to the authors' simpler and less laborious technique. Different clinical situations in which to use the procedure are described based on the authors' experience from 60 cases (40 aneurysm cases and 20 tumor cases) during a 4-year period.

The superior wall of the cavernous sinus: a microanatomical study

1994 ◽  
Vol 81 (6) ◽  
pp. 914-920 ◽  
Author(s):  
Felix Umansky ◽  
Alberto Valarezo ◽  
Josef Elidan
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cavernous Sinus ◽  
Internal Carotid ◽  
Deep Layer ◽  
Lateral Wall ◽  
Anterior Clinoid Process ◽  
Content Type ◽  
Carotid Canal ◽  
Fine Print

✓ The superior wall of the cavernous sinus was studied in 30 specimens obtained from 15 cadaver heads fixed in formalin. Trapezoidal in shape, the superior wall of cavernous sinus is limited laterally by the anterior petroclinoid ligament, medially by the dura of the diaphragma sellae, anteriorly by the endosteal dura of the carotid canal, and posteriorly by the posterior petroclinoid ligament. An interclinoid ligament bisects the wall, dividing it into two triangles: the carotid trigone anteromedially and the oculomotor trigone posterolaterally. Similar to the lateral wall of the cavernous sinus, the superior wall is formed by two layers: a smooth superficial dural layer and a thin, less defined deep layer. In the area of the carotid trigone, both layers separate to wrap the anterior clinoid process. The removal of this process will reveal a “clinoid space” medial to which the internal carotid artery can be identified. This clinoid segment of the artery, still extracavernous, is surrounded by two fibrous rings: a distal ring formed by fibers of the superficial dural layer and a proximal ring related to the deep dural layer. Below the proximal ring, the internal carotid artery becomes intracavernous; above the distal ring, the artery is continuous with its supraclinoid segment. The complex dural anatomy of the superior wall, its fibrous rings, and the clinoid space in relation to a superior surgical approach to the cavernous sinus are discussed.

Association between an aplastic basilar artery, unaccompanied by a primitive carotid—vertebrobasilar anastomosis, and multiple aneurysms on the dominant posterior communicating artery

2004 ◽  
Vol 100 (5) ◽  
pp. 946-949 ◽  
Author(s):  
Sanjay Behari ◽  
Himanshu Krishna ◽  
Marakani V. Kiran Kumar ◽  
Vijay Sawlani ◽  
Rajendra V. Phadke ◽  
...  
Keyword(s):  
Basilar Artery ◽  
Posterior Communicating Artery ◽  
Cerebral Vasculature ◽  
Hemodynamic Changes ◽  
Meningeal Irritation ◽  
Content Type ◽  
Third Nerve Palsy ◽  
Transsylvian Approach ◽  
The Right ◽  
Fine Print

✓ Basilar artery (BA) aplasia when unaccompanied by a primitive carotid—vertebrobasilar anastomosis is exceedingly rare. The association of BA aplasia with two aneurysms on the dominant posterior communicating artery (PCoA) has not been previously reported. This 40-year-old man presented in a state of drowsiness and responded to simple commands only after being coaxed. He had complete left cranial third nerve palsy, right hemiparesis, and persisting signs of meningeal irritation. A computerized tomography (CT) scan revealed subarachnoid and intraventricular hemorrhage. An angiogram revealed BA aplasia. The right PCoA followed a sinuous course with multiple loops and provided the dominant supply to the posterior circulation. This vessel harbored two aneurysms, one at the origin of the PCoA from the internal carotid artery and the other at the looping segment just proximal to the brainstem. The left PCoA was extremely thin. The pterional transsylvian approach was used to clip the two aneurysms on the PCoA. The hemodynamic changes produced by the BA aplasia may have produced alterations in the cerebral vasculature leading to aneurysm formation and consequent subarachnoid hemorrhage.

Aneurysms of the basilar artery trunk

1987 ◽  
Vol 66 (4) ◽  
pp. 500-505 ◽  
Author(s):  
Kenichiro Sugita ◽  
Shigeaki Kobayashi ◽  
Toshiki Takemae ◽  
Tsuyoshi Tada ◽  
Yuichiro Tanaka
Keyword(s):  
Trigeminal Nerve ◽  
Basilar Artery ◽  
Surgical Results ◽  
Content Type ◽  
Subtemporal Approach ◽  
Vertebral Arteries ◽  
Posterior Clinoid Process ◽  
Fine Print

✓ Ten cases of basilar artery trunk aneurysms are reported; nine were operated on by a middle subtemporal approach and one by a pterional transsylvian technique. The middle subtemporal approach facilitated clipping of aneurysms located as deep as 25 mm below the posterior clinoid process as seen on the lateral views of the angiogram, such that the junction of the vertebral arteries was visible in most cases. The authors emphasize the usefulness of direct retraction of the trigeminal nerve, the pons, and the aneurysm itself; occasionally, drilling off the pyrimidal edge is also valuable. Surgical results were satisfactory in seven cases and poor in one; two patients died.

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