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Xiaochun Zhao, Ali Tayebi Meybodi, Mohamed A. Labib, Sirin Gandhi, Evgenii Belykh, Komal Naeem, Mark C. Preul, Peter Nakaji, and Michael T. Lawton

OBJECTIVE

Aneurysms that arise on the medial surface of the paraclinoid segment of the internal carotid artery (ICA) are surgically challenging. The contralateral interoptic trajectory, which uses the space between the optic nerves, can partially expose the medial surface of the paraclinoid ICA. In this study, the authors quantitatively measure the area of the medial ICA accessible through the interoptic triangle and propose a potential patient-selection algorithm that is based on preoperative measurements on angiographic imaging.

METHODS

The contralateral interoptic trajectory was studied on 10 sides of 5 cadaveric heads, through which the medial paraclinoid ICA was identified. The falciform ligament medial to the contralateral optic canal was incised, the contralateral optic nerve was gently elevated, and the medial surface of the paraclinoid ICA was inspected via different viewing angles to obtain maximal exposure. The accessible area on the carotid artery was outlined. The distance from the distal dural ring (DDR) to the proximal and distal borders of this accessible area was measured. The superior and inferior borders were measured using the clockface method relative to a vertical line on the coronal plane. To validate these parameters, preoperative measurements and intraoperative findings were reviewed in 8 clinical cases.

RESULTS

In the sagittal plane, the mean (SD) distances from the DDR to the proximal and distal ends of the accessible area on the paraclinoid ICA were 2.5 (1.52) mm and 8.4 (2.32) mm, respectively. In the coronal plane, the mean (SD) angles of the superior and inferior ends of the accessible area relative to a vertical line were 21.7° (14.84°) and 130.9° (12.75°), respectively. Six (75%) of 8 clinical cases were consistent with the proposed patient-selection algorithm.

CONCLUSIONS

The contralateral interoptic approach is a feasible route to access aneurysms that arise from the medial paraclinoid ICA. An aneurysm can be safely clipped via the contralateral interoptic trajectory if 1) both proximal and distal borders of the aneurysm neck are 2.5–8.4 mm distal to the DDR, and 2) at least one border of the aneurysm neck on the coronal clockface is 21.7°–130.9° medial to the vertical line.

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Mohamed A. Labib, Leandro Borba Moreira, Xiaochun Zhao, Sirin Gandhi, Claudio Cavallo, Ali Tayebi Meybodi, A. Samy Youssef, Andrew S. Little, Peter Nakaji, Mark C. Preul, and Michael T. Lawton

OBJECTIVE

The pretemporal transcavernous approach (PTA) and the endoscopic endonasal transcavernous approach (EETA) are both used to access the retroclival region. A direct quantitative comparison of both approaches has not been made. The authors compared the technical nuances of, and surgical exposure afforded by, each approach and identified the key elements of the approach selection process.

METHODS

Fourteen cadaveric specimens underwent either PTA (group A) or EETA with unilateral (group B) followed by bilateral (group C) interdural pituitary gland transposition. The percentage of drilled clivus; length of exposed oculomotor nerve (cranial nerve [CN] III), posterior cerebral artery (PCA), and superior cerebellar artery (SCA); and surgical area of exposure of both cerebral peduncles and the pons for the 3 groups were measured and compared.

RESULTS

Group A had a significantly lower percentage of drilled area than group B (mean [SD], 35.6% [11.2%] vs 91.3% [4.9%], p < 0.01). In group C, 100% of the upper third of the clivus was drilled in all specimens. Significantly longer segments of the ipsilateral PCA (p < 0.01) and SCA (p < 0.01) were exposed in group A than in group B. There was no significant difference in the length of the ipsilateral CN III exposed among the 3 groups. There was also no significant difference between group A and either group B or group C for the contralateral CN III or PCA exposure. However, longer segments of the contralateral SCA were exposed in group C than in group A (p = 0.02). Furthermore, longer segments of CN III (p < 0.01), PCA (p < 0.01), and SCA (p < 0.01) were exposed in group C than in group B. For brainstem exposure, there was greater exposure of the pons in group C than in group A (mean [SD], 211.4 [19.5] mm2 vs 157.7 [25.3] mm2, p < 0.01) and group B (211.4 [19.5] mm2 vs 153.9 [34.1] mm2, p < 0.01). However, significantly greater exposure of the ipsilateral peduncle was observed in group A (mean [SD], 125.6 [43.1] mm2) than in groups B and C (56.3 [6.0] mm2, p < 0.01). Group C had significantly greater exposure of the contralateral peduncle than group B (p = 0.02).

CONCLUSIONS

This study is the first to quantitatively identify the advantages and limitations of the PTA and EETA from an anatomical perspective. Understanding these data may help the skull base surgeon design a maximally effective yet minimally invasive approach to individual lesions.