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Amin B. Kassam, Allan D. Vescan, Ricardo L. Carrau, Daniel M. Prevedello, Paul Gardner, Arlan H. Mintz, Carl H. Snyderman, and Albert L. Rhoton Jr.

the medial to lateral path on the axial image. Ant = anterior. An “H” is formed, with the superior vertical limb represented by the paraclival ascending carotid artery and the descending vertical limb represented by the descending portion of the paired medial pterygoid plates in the depth ( Fig. 5 ). The horizontal portion is represented by the floor of the sphenoid sinus as it spans between the bases of the pterygoid processes. Once the vidian canal is identified, drilling can then proceed cautiously along its inferior and medial aspect. This point cannot be

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Ricardo L. L. Dolci, Leo F. S. Ditzel Filho, Carlos R. Goulart, Smita Upadhyay, Lamia Buohliqah, Paulo R. Lazarini, Daniel M. Prevedello, and Ricardo L. Carrau

satisfactorily low. Access is achieved through the quadrangular space (QS), which was named the “front door of Meckel's cave.” 25 Entry into this space is limited medially and inferiorly by the internal carotid artery (ICA). Therefore, this technique, in combination with transcranial approaches, gives the skull base surgeon the potential to access 360° of Meckel's cave. Injury to the ICA is one of the most disastrous complications that can occur during microscopic transsphenoidal surgery or EEAs. 12 , 16 An ICA injury can lead to death, postoperative pseudoaneurysm or

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Hae-Dong Jho and Ricardo L. Carrau

surgeon can recognize the bony structures covering the carotid arteries and optic nerves. 14 Although the incidence of injury to the hypothalamus, the carotid artery, and the optic system is low with the conventional microscopic technique, 2, 22 direct endoscopic visualization of those structures may further reduce the risk of injury. The disadvantage of an endoscopic technique compared to the conventional microscopic surgery is that a surgeon has to operate in a two-dimensional view. Endoscopic images are still less clear and less sharp than the three

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Marc R. Mayberg

the lesion to critical neurovascular structures, especially the internal carotid artery. Although arbitrary, these categories and surgical modules were derived from the incremental experience of the authors and provided a good correlation to complication risk (see below). Complexity Level I (endoscopic sinus surgery) was not analyzed in this report. Level II (the transsellar approach) is familiar to most neurosurgeons who perform transsphenoidal surgery. Levels III–V represent case complexity that extends the scope of neurosurgical treatment to greater rostral

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Jun Muto, Daniel M. Prevedello, and Ricardo L. Carrau

TO THE EDITOR: We read the article by Freeman et al. 1 with interest ( Freeman JL, Sampath R, Quattlebaum SC, et al: Expanding the endoscopic transpterygoid corridor to the petroclival region: anatomical study and volumetric comparative analysis. J Neurosurg [epub ahead of print July 21, 2017. DOI: 10.3171/2017.1.JNS161788] ). The authors discussed how removal of the cartilaginous eustachian tube (ET) and mobilization of the paraclival internal carotid artery (ICA) can expand the transpterygoid corridor leading to the petroclival region 6 times its original

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André Beer-Furlan, Diego A. Servián, Ricardo L. Carrau, and Daniel M. Prevedello

TO THE EDITOR: The recently published article by Tayebi Meybodi et al. 3 has drawn our attention, as it described a new landmark for the lacerum segment of the ICA ( Tayebi Meybodi A, Little AS, Vigo V, et al: The pterygoclival ligament: a novel landmark for localization of the internal carotid artery during the endoscopic endonasal approach. J Neurosurg [epub ahead of print May 18, 2018. DOI: 10.3171/2017.12.JNS172435] ). Their cadaveric study provided an interesting morphometric analysis of the “pterygoclival ligament.” Based on our experience, the most

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Mostafa Shahein, Thiago Albonette-Felicio, Giuliano Silveira-Bertazzo, Rafael Martinez-Perez, Marcus Zachariah, Ricardo L. Carrau, and Daniel M. Prevedello

performed exposure of the dura of the sella with extension of the clivectomy inferiorly. Identifying and skeletonizing the carotid artery superiorly near the sella was essential for us to optimize the corridor drilling from internal carotid artery to internal carotid artery. 1:07 Elevation of right nasoseptal flap. 1:15 Posterior nasal septectomy. 1:17 Reverse flap. 1:21 Wide anterior sphenoidectomy. 1:22 Drilling of the sella and clivus. 1:32 Dissection of the tumor. 1:45 We then used a 45° endoscope and removed the epidural component of the tumor, dissecting

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Rafael Martínez-Pérez, Marcus Zachariah, Ruychen Li, Giuliano Silveira-Bertazzo, Ricardo L. Carrau, and Daniel M. Prevedello

artery, and in the infratemporal component of the tumor, located below the petrous carotid artery. 1:39 Left middle turbinectomy We then defined those landmarks, and proceeded to perform the surgery. An EEA was started regularly initially through the left nostril and a middle turbinectomy was accomplished. We exposed the bulla ethomoidalis as well as the uncinate process. 1:58 Left ethmoidectomy and uncinectomy We removed the bulla ethmoidalis in order to access the maxillary sinus. We removed the uncinate process, performed a left-side uncinectomy, accessing then the

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Amin B. Kassam, Paul A. Gardner, Arlan Mintz, Carl H. Snyderman, Ricardo L. Carrau, and Michael Horowitz

clip access to the proximal ICA was confirmed ( Fig. 5 ). A transplanum exposure of the paraclinoidal carotid artery in the opticocarotid cistern provided distal control ( Fig. 6 ). F ig . 3. Endoscopic view of the initial exposure after a wide sphenoidotomy was performed. PCP = paraclival carotid protuberance; pl = planum sphenoidale; tub = tuberculum sellae. F ig . 4. Endoscopic view of the left paraclival segment of the ICA exposed to obtain proximal control. CR = clival recess. F ig . 5. Endoscopic view of proximal control. Potential

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Ricky Madhok, Daniel M. Prevedello, Paul Gardner, Ricardo L. Carrau, Carl H. Snyderman, and Amin B. Kassam

—both internal carotid arteries, the optic nerves, the medial and lateral opticocarotid recesses, and the clival recess—were identified ( Fig. 1 ). For purely sellar tumors, the sellar face was drilled “eggshell thin” and removed with a Kerrison rongeur until the “blue” of the cavernous sinus was identified laterally, and the superior and inferior intercavernous sinuses were identified superiorly and inferiorly, respectively. Most importantly, the floor of the sella turcica was carefully removed using the same technique. Removing the entire anterior face of the sphenoid sinus