scholarly journals Optic Foraminotomy for Clipping of Superior Carotid-Ophthalmic Aneurysms

2021 ◽  
Vol 8 ◽  
Author(s):  
Matias Baldoncini ◽  
Sabino Luzzi ◽  
Alice Giotta Lucifero ◽  
Ana Flores-Justa ◽  
Pablo González-López ◽  
...  
Keyword(s):  
Optic Nerve ◽  
Carotid Artery ◽  
Surgical Techniques ◽  
Visual Outcome ◽  
Current Approach ◽  
Direct Access ◽  
Anterior Clinoid Process ◽  
Anterior Clinoidectomy ◽  
Transsylvian Approach ◽  
Secondary Objective

Background: Carotid-ophthalmic aneurysms usually cause visual problems. Its surgical treatment is challenging because of its anatomically close relations to the optic nerve, carotid artery, ophthalmic artery, anterior clinoid process, and cavernous sinus, which hinder direct access. Despite recent technical advancements enabling risk reduction of this complication, postoperative deterioration of visual function remains a significant problem. Therefore, the goal of preserving and/or improving the visual outcome persists as a paramount concern.Objective: We propose optic foraminotomy as an alternative microsurgical technique for dorsal carotid-ophthalmic aneurysms clipping. As a secondary objective, the step by step of that technique and its benefits are compared to the current approach of anterior clinoidectomy.Methods: We present as an example two patients with superior carotid-ophthalmic aneurysms in which the standard pterional craniotomy, transsylvian approach, and optic foraminotomy were performed. Surgical techniques are presented and discussed in detail with the use of skull base dissections, microsurgical images, and original drawings.Results: Extensive opening of the optic canal and optic nerve sheath was successfully achieved in all patients allowing a working angle with the carotid artery for correct visualization of the aneurysm and further clipping. Significant visual acuity improvement occurred in both patients because of decompression of the optic nerve.Conclusion: Optic foraminotomy is an easy and recommended technique for exposing and treating superior carotid-ophthalmic aneurysms and allowing optic nerve decompression during the first stages of the procedure. It shows several advantages over the current anterior clinoidectomy technique regarding surgical exposure and facilitating visual improvement.

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.

Ultrasonic bone curettage for optic canal unroofing and anterior clinoidectomy

2006 ◽  
Vol 104 (4) ◽  
pp. 621-624 ◽  
Author(s):  
Han Soo Chang ◽  
Masahiro Joko ◽  
Joon Suk Song ◽  
Kiyoshi Ito ◽  
Tatsushi Inoue ◽  
...  
Keyword(s):  
Optic Nerve ◽  
Visual Outcome ◽  
Optic Canal ◽  
Internal Auditory Meatus ◽  
Major Morbidity ◽  
Anterior Clinoidectomy ◽  
Optic Nerve Damage ◽  
Bone Removal ◽  
Visual Status ◽  
Optic Canal Unroofing

✓Extradural unroofing of the optic canal and subsequent mobilization of the optic nerve is a useful technique in the surgical treatment of parasellar tumors; however, the drilling procedure itself is associated with the risk of optic nerve damage. A safer technique would certainly be beneficial. The ultrasonic bone curette is a device developed in Japan for safer bone removal. Its use in intradural anterior clinoidectomy and opening of the internal auditory meatus has been reported before. In this article the authors describe their experience in using this device for extradural unroofing of the optic canal in patients with parasellar tumors. Between March 2002 and November 2004, the aforementioned technique was used in the treatment of eight patients with parasellar tumors. After undertaking a frontotemporal craniotomy and orbital osteotomy, an ultrasonic bone curette was used to unroof the optic canal via an epidural approach; in five cases anterior clinoidectomy was added subsequently. Using an ultrasonic bone curette, unroofing of the optic canal was completed safely and required much less expertise than that required for standard drilling. The mortality and major morbidity rates were 0%. The visual function outcome was satisfactory, with the overall visual status improving in all seven patients in whom this symptom was present preoperatively. The ultrasonic bone curette makes the unroofing of the optic canal safer and easier, possibly improving the visual outcome of patients undergoing surgery for parasellar tumors.

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.

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.

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.

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.

Selective extradural anterior clinoidectomy for supra- and parasellar processes

1997 ◽  
Vol 3 (2) ◽  
pp. E2 ◽  
Author(s):  
Yasuhiro Yonekawa ◽  
Nobuyoshi Ogata ◽  
Hans-Georg Imhof ◽  
Magnus Olivecrona ◽  
Kevin Strommer ◽  
...  
Keyword(s):  
Optic Nerve ◽  
Basilar Artery ◽  
Pituitary Tumors ◽  
Artery Aneurysm ◽  
Anterior Clinoid Process ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Anterior Clinoidectomy ◽  
Basilar Artery Aneurysm ◽  
Brain Retraction ◽  
Sphenoid Ridge

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.

Giant anterior clinoidal meningiomas: surgical technique and outcomes

2012 ◽  
Vol 117 (4) ◽  
pp. 654-665 ◽  
Author(s):  
Moshe Attia ◽  
Felix Umansky ◽  
Iddo Paldor ◽  
Shlomo Dotan ◽  
Yigal Shoshan ◽  
...  
Keyword(s):  
Optic Nerve ◽  
Skull Base ◽  
Cavernous Sinus ◽  
Visual Outcome ◽  
Optic Canal ◽  
Maximum Diameter ◽  
Tumor Diameter ◽  
Anterior Clinoid Process ◽  
The Mean ◽  
Neurovascular Structures

Object Surgery for giant anterior clinoidal meningiomas that invade vital neurovascular structures surrounding the anterior clinoid process is challenging. The authors present their skull base technique for the treatment of giant anterior clinoidal meningiomas, defined here as globular tumors with a maximum diameter of 5 cm or larger, centered around the anterior clinoid process, which is usually hyperostotic. Methods Between 2000 and 2010, the authors performed 23 surgeries in 22 patients with giant anterior clinoidal meningiomas. They used a skull base approach with extradural unroofing of the optic canal, extradural clinoidectomy (Dolenc technique), transdural debulking of the tumor, early optic nerve decompression, and early identification and control of key neurovascular structures. Results The mean age at surgery was 53.8 years. The mean tumor diameter was 59.2 mm (range 50–85 mm) with cavernous sinus involvement in 59.1% (13 of 22 patients). The tumor involved the prechiasmatic segment of the optic nerve in all patients, invaded the optic canal in 77.3% (17 of 22 patients), and caused visual impairment in 86.4% (19 of 22 patients). Total resection (Simpson Grade I or II) was achieved in 30.4% of surgeries (7 of 23); subtotal and partial resections were each achieved in 34.8% of surgeries (8 of 23). The main factor precluding total removal was cavernous sinus involvement. There were no deaths. The mean Glasgow Outcome Scale score was 4.8 (median 5) at a mean of 56 months of follow-up. Vision improved in 66.7% (12 of 18 patients) with consecutive neuroophthalmological examinations, was stable in 22.2% (4 of 18), and deteriorated in 11.1% (2 of 18). New deficits in cranial nerve III or IV remained after 8.7% of surgeries (2 of 23). Conclusions This modified surgical protocol has provided both a good extent of resection and a good neurological and visual outcome in patients with giant anterior clinoidal meningiomas.

Large and Giant Paraclinoid Aneurysms: Surgical Techniques, Complications, and Results

Neurosurgery ◽  
1983 ◽  
Vol 12 (2) ◽  
pp. 153-163 ◽  
Author(s):  
Roberto C. Heros ◽  
Paul B. Nelson ◽  
Robert G. Ojemann ◽  
Robert M. Crowell ◽  
Gerard DeBrun
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Bypass Graft ◽  
Surgical Techniques ◽  
The Other ◽  
Carotid Occlusion ◽  
Anterior Clinoid Process ◽  
Carotid Ligation ◽  
Paraclinoid Aneurysms

Abstract Twenty-five patients with giant (>25 mm in diameter) and 9 patients with large (15 to 25 mm in diameter) aneurysms of the internal carotid artery in the ophthalmic or paraophthalmic region are reviewed. In 23 of these patients the aneurysm was clipped directly. There was 1 death in this group, and none of the survivors had disabling neurological complications outside the visual system. The other 11 patients were treated by a trapping procedure or by either common carotid ligation or internal carotid ligation in the neck. Of the 5 patients treated by internal carotid ligation preceded by an extracranial to intracranial bypass graft, 3 developed embolic complications, which in 1 patient resulted in death. One of the 4 patients treated by ligation of the common carotid artery died 1 year later from a recurrent subarachnoid hemorrhage. Of the total group, 18 patients had visual loss preoperatively as a result of aneurysmal compression; in 10 the vision was improved by operation, in 3 it was made worse, and in 2 it was unchanged. In another patient the vision continued to deteriorate slowly after common carotid occlusion, and the other 2 patients died postoperatively before vision could be assessed. The complications in the patients are described and analyzed in detail. Maneuvers found to be of value in the direct approach to these lesions are described. Of these, exposure of the internal carotid artery in the neck for temporary occlusion during clipping and thorough drilling of the anterior clinoid process and unroofing of the optic canal were particularly helpful. The literature on indirect methods of treatment by carotid occlusion with and without bypass graft is reviewed with special reference to the complications and effectiveness of each alternative. Based on this review of the literature and our experience, a treatment scheme is suggested for these aneurysms depending on their mode of presentation.

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