Anatomical assessment of the endoscopic endonasal approach for the treatment of paraclinoid aneurysms

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OBJECTIVE

Endoscopic endonasal approaches (EEAs) are increasingly being incorporated into the neurosurgeon’s armamentarium for treatment of various pathologies, including paraclinoid aneurysms. However, few anatomical assessments have been performed on the use of EEA for this purpose. The aim of the present study was to provide a comprehensive anatomical assessment of the EEA for the treatment of paraclinoid aneurysms.

METHODS

Five cadaveric heads underwent an endonasal transplanum-transtuberculum approach to expose the paraclinoid area. The feasibility of obtaining proximal and distal internal carotid artery (ICA) control as well as the topographic location of the origin of the ophthalmic artery (OphA) relative to dural landmarks were assessed. Limitations of the EEA in exposing the supraclinoid ICA were also recorded to identify favorable paraclinoid ICA aneurysm projections for EEA.

RESULTS

The extracavernous paraclival and clinoidal ICAs were favorable segments for establishing proximal control. Clipping the extracavernous ICA risked injury to the trigeminal and abducens nerves, whereas clipping the clinoidal segment put the oculomotor nerve at risk. The OphA origin was found within 4 mm of the medial opticocarotid point on a line connecting the midtubercular recess point to the medial vertex of the lateral opticocarotid recess. An average 7.2-mm length of the supraclinoid ICA could be safely clipped for distal control. Assessments showed that small superiorly or medially projecting aneurysms were favorable candidates for clipping via EEA.

CONCLUSIONS

When used for paraclinoid aneurysms, the EEA carries certain risks to adjacent neurovascular structures during proximal control, dural opening, and distal control. While some authors have promoted this approach as feasible, this work demonstrates that it has significant limitations and may only be appropriate in highly selected cases that are not amenable to coiling or clipping. Further clinical experience with this approach helps to delineate its risks and benefits.

ABBREVIATIONS DDR = distal dural ring; EEA = endoscopic endonasal approach; ICA = internal carotid artery; LOCR = lateral opticocarotid recess; OphA = ophthalmic artery; PDR = proximal dural ring; SHA = superior hypophyseal artery.

Article Information

Correspondence Mark C. Preul: Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ. mpreul@dignityhealth.org; neuropub@barrowneuro.org.

INCLUDE WHEN CITING Published online December 21, 2018; DOI: 10.3171/2018.6.JNS18800.

Disclosures Dr. Little: ownership in SPIWay and Kogent.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Stepwise depiction of the EEA for exposure of the paraclinoid region. A: Exposure of the left paraclival ICA using the vidian nerve (n.) and the pterygoclival ligament (PCL) as anatomical landmarks. The pterygoclival ligament is a thick, fibrous tissue running between the body of the sphenoid bone and medial pterygoid process to reach the medial aspect of the lacerum segment of the ICA. The ICA is prepared for proximal clipping by drilling bone on its lateral, anterior, and medial aspects. On the lateral aspect of the ICA, there is a quadrangular space (i.e., the lingular recess), drilling of which leads to Meckel’s cave (MC). In order to protect the abducens nerve running on the superior aspect of this space, drilling should be limited superiorly to the level of the maxillary division (V2) of the trigeminal nerve. B: Dural exposure extending from the planum sphenoidale to the anterior sellar region in the sagittal plane and extending laterally to the optic canals and parasellar carotid arteries. Dashed lines designate the approximate course of the paraclival (including the extracavernous [ex.] and intracavernous [in.] parts), parasellar (PS), and paraclinoid (PC) segments of the ICA separated by solid white lines. The lateral tubercular recess (TR) is a triangle-shaped area on the lateral end of the tubercular recess reaching medial to the optic nerve and ICA (shown on the right side). The corner of this triangular area faces medially; the upper arm (white arrow) reaches the medial opticocarotid point (point 2), and the lower arm (double black arrow) reaches the caroticosellar point (point 3). C: Dural reference points: 1 = midtubercular recess point; 2 = medial opticocarotid point; 3 = caroticosellar point; 4 = medial vertex of the LOCR. The white dashed line shows the approximate level of the DDR, and the yellow dashed double-arrowed line shows the approximate level of the PDR. D: Proximal control obtained on the extracavernous paraclival ICA. E: Exposure of the clinoidal ICA using 3 consecutive dural cuts (black arrows) starting from the caroticosellar point reaching the medial opticocarotid point, and then continuing inferior to the DDR to reach the medial vertex of the lateral opticocarotid recess, and finally descending on the lateral aspect of the clinoidal ICA. F: Proximal control on the clinoidal ICA. G: Dural incision to expose the supraclinoid ICA. The dural incision could be started either on the lateral tubercular recess or in the midline (dashed arrows—both crossing the superior intercavernous sinus [red arrowhead]) to reach the tubercular recess. Next, the dural incision is continued in the midline to reach planum sphenoidale and then turns laterally to reach the region of the optic canal. Small black arrows show the interfalciform ligament (interfalc. lig.). H: The supraclinoid ICA is exposed by reflecting the dural flap. All views were obtained using a 0° endoscope. cav. sin. = cavernous sinus; CP = carotid protuberance; CR = clival recess; ON = optic nerve. Copyright Mark Preul. Published with permission. Figure is available in color online only.

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    A and B: Enhancing exposure of the supraclinoid ICA by cutting the superior intercavernous sinus (small black arrow) and the diaphragma sellae (red dashed line). This cut (red dashed lines in B) could reach the posterior clinoid process (PCP) posteriorly to allow medial mobilization of the pituitary. C and D: Distal control of the supraclinoid ICA after incising the diaphragma sellae. Note the superior retraction of the optic nerve (ON) necessary to apply the clip. The white arrow (D) indicates the origin of the OphA. All views were obtained using a 30° endoscope. Copyright Mark Preul. Published with permission. Figure is available in color online only.

  • View in gallery

    Opticotubercular line shown on the right parasellar area. Left: The opticotubercular line runs from the midtubercular recess point (point 1) to the medial vertex of the LOCR (point 2). The OphA origin was found on this line (or close to it) within 4 mm of the medial opticocarotid point (point 3; yellow shaded area). Right: The dura is opened and the origin of the OphA (white arrow) is found. The opticotubercular line is drawn, and the OphA origin is shown to be very close to this line near the medial opticocarotid point (white dot). All views were taken with a 30° endoscope. Copyright Mark Preul. Published with permission. Figure is available in color online only.

  • View in gallery

    Close relationship between the oculomotor nerve and the clinoidal ICA. Left: Endoscopic endonasal view of the left parasellar area (30° endoscope) shows that violation of the PDR is easily possible; hence clipping the clinoidal ICA may pose risk to the adjacent oculomotor nerve running immediately inferior to the PDR. Right: Cavernous sinus dissection on the right side showing the close relationship between the PDR (black arrowheads) and the underlying oculomotor nerve. The dashed line shows the DDR. The yellow star designates the clinoidal ICA. Note that the anterior clinoid process has been removed. CN = cranial nerve; GG = Gasserian ganglion; OS = optic strut; PCA = posterior cerebral artery. Copyright Mark Preul. Published with permission. Figure is available in color online only.

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