Anatomical nuances of the internal carotid artery in relation to the quadrangular space

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OBJECTIVE

The aim of this study was to evaluate the anatomical variations of the internal carotid artery (ICA) in relation to the quadrangular space (QS) and to propose a classification system based on the results.

METHODS

A total of 44 human cadaveric specimens were dissected endonasally under direct endoscopic visualization. During the dissection, the anatomical variations of the ICA and their relationship with the QS were noted.

RESULTS

The space between the paraclival ICAs (i.e., intercarotid space) can be classified as 1 of 3 different shapes (i.e., trapezoid, square, or hourglass) based on the trajectory of the ICAs. The ICA trajectories also directly influence the volumetric area of the QS. Based on its geometry, the QS was classified as one of the following: 1) Type A has the smallest QS area and is associated with a trapezoid intercarotid space, 2) Type B corresponds to the expected QS area (not minimized or enlarged) and is associated with a square intercarotid space, and 3) Type C has the largest QS area and is associated with an hourglass intercarotid space.

CONCLUSIONS

The different trajectories of the ICAs can modify the area of the QS and may be an essential parameter to consider for preoperative planning and defining the most appropriate corridor to reach Meckel's cave. In addition, ICA trajectories should be considered prior to surgery to avoid injuring the vessels.

ABBREVIATIONS CN = cranial nerve; CSF = cerebrospinal fluid; EEA = endoscopic endonasal approach; ICA = internal carotid artery; QS = quadrangular space.

Article Information

Correspondence Daniel M. Prevedello, Department of Neurosurgery, Wexner Medical Center at The Ohio State University, N-1049 Doan Hall, 410 West 10th Ave., Columbus, OH 43210. email: daniel.prevedello@osumc.edu.

INCLUDE WHEN CITING Published online February 24, 2017; DOI: 10.3171/2016.10.JNS16381.

Disclosures The authors report no conflict of interest concerning the materials and methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    EEA with a 0° endoscope (A, B, and C) and 30° endoscope (D, E, and F) showing the stepwise cadaveric dissection of the pterygopalatine fossa and cavernous sinus. A: Essential landmarks in an endoscopic endonasal skull base surgery are identified. This dissection was performed through a wide antrostomy exposing the posterior wall of the maxillary sinus; behind the bone it is possible to visualize the right infraorbital artery and its corresponding nerve going upward toward the right orbit. Superiorly and posteriorly, the lamina papyracea can be identified. Medially and superiorly to the lamina papyracea, located in the midline, is the cribriform plate, a critical structure in the surgical dissection to reach the anterior fossa. Inferiorly and posteriorly to the cribriform plate, also in the midline, 2 essential landmarks can be visualized: the sella and the clivus. B: Using a ball probe, we performed a dissection between the mucosa and the bone to expose the sphenopalatine foramen; this is a key landmark to identify since it contains the nasoseptal artery that provides blood supply to the nasoseptal flap, which has revolutionized endoscopic endonasal skull base surgery. Inferiorly and medially to the sphenopalatine foramen, the eustachian tube is located. C: A closer view of the sphenopalatine foramen and infraorbital nerve and its corresponding artery in the posterior wall of the maxillary sinus. D: The bone from the posterior wall of the maxillary sinus was removed to give access to the pterygopalatine fossa. The first identifiable layer is the periosteum. E: The bone and periosteum were removed to visualize some branches of the maxillary artery located in the pterygopalatine fossa. Lateral to the pterygopalatine fossa is the infratemporal fossa. The major terminal branch of the external carotid arteries is the maxillary artery that will give several branches; the most important one for skull base surgeons is the sphenopalatine artery. Other branches that can be visualized are the descending palatine artery and the posterior superior alveolar artery. Lateral to these structures is the temporal muscle in the infratemporal fossa. In the first plane it is possible to identify the arteries and the nerves behind it. In this figure panel we can also see the infraorbital nerve, which is an extension of the maxillary nerve after it crosses the foramen rotundum. F: The last step in the dissection of the lateral wall of the cavernous sinus and the QS. The vidian nerve was dissected in its entire pathway, starting from the pterygopalatine ganglion, which was removed, and ending in the foramen lacerum. On the lateral wall of the cavernous sinus are cranial nerve (CN) III, CNV1, CNV2, and the entire course of CNVI. The ICA was exposed from the foramen lacerum to the intracranial segment; therefore, after this dissection we can observe all the structures that compose the QS borders. AM = anteromedial; CNIII = oculomotor nerve; CNV1 = ophthalmic nerve; CNV2 = maxillary nerve; CNV3 = mandibular nerve; CNVI = abducens nerve; CP = cribriform plate; DPA = descending palatine artery; ET = eustachian tube; FR = foramen rotundum; Imax = internal maxillary artery; IOA = infraorbital artery; ION = infraorbital nerve; LP = lamina papyracea; pcICA = paraclival segment of ICA; PP = pterygoid process; PS = planum sphenoidale; PSAA = posterior superior alveolar artery; psICA = parasellar segment of ICA; PwMS = posterior wall of maxillary sinus; SPA = sphenopalatine artery; SPF = sphenopalatine foramen; TM = temporal muscle; VN = vidian nerve.

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    Detailed 0° (A, B, and F) and 30° (C, D, and E) endoscopic views of the QS and surrounding structures. A: The bone on the right and left side of the lateral wall of the sphenoid sinus was removed. The dura was removed on the right side, allowing visualization of CNVI and the paraclival and parasellar segments of the ICA. On the left side, the dura was kept intact, and the lateral opticocarotid recess is visible superiorly; this is a critical landmark to recognize between the optic nerve and ICA; inferiorly, from lateral to medial, it is visualized by the impression of the maxillary strut and the maxillary nerve behind the dura. The portion of bone that was preserved in front of the QS, working like a shield to protect it, we named the “QS strut.” B: The QS strut was removed. C: With a 30° endoscope, the entire course of the vidian nerve can be seen along the vidian canal. It is possible to visualize the lateral recess of the sphenoid sinus, a space between the vidian nerve and the maxillary nerve. The dura around the lateral opticocarotid recess was removed to show the relationship between the parasellar segment of the ICA and the optic nerve. D: With the 30° endoscope, more details of the impression of the QS strut in the dura are visible. E: The dura around the paraclival segment of the ICA was removed, allowing a closer view of the vidian canal, lateral recess of the sphenoid sinus, and the impression of the maxillary nerve. F: The area around the QS in more detail; the sympathetic nerve fibers running with the paraclival segment of the ICA are visible, leaving it to join to the abducens nerve. CNII = optic nerve; iMS = impression of maxillary strut; iQSS = impression of QS strut; LOCR = lateral opticocarotid recess; LRSS = lateral recess of sphenoid sinus; QSS = QS strut; SF = sympathetic fibers; SS = sphenoid sinus; TS = tuberculum sellae; VC = vidian canal.

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    Illustrations and anatomical dissection demonstrating the different ICA angles, their relation with the QS, and our proposed QS classification scheme. A: Illustration depicting a ventral perspective of an EEA. On the left, note the shadow of the right sphenoid bone and its corresponding superior orbital fissure and nerves; the nerves passing through the superior orbital fissure from superior to inferior are (in order) the lacrimal nerve, frontal nerve (a branch of the ophthalmic nerve), trochlear nerve (CNIV), superior division of the oculomotor nerve (CNIII), nasociliary nerve (a branch of the ophthalmic nerve), inferior division of the oculomotor nerve (CNIII), and the abducens nerve (CNVI). Superior to the superior orbital fissure, it is possible to identify the optic nerve and ophthalmic artery entering the optic canal. In addition, several anatomical structures and their relations are illustrated (superior to inferior); the optic chiasm is located superiorly, and lateral to it is CNII. Inferior to the chiasm is the pituitary stalk, which connects to the hypophysis. In the background, inferior to the pituitary gland, the vertebral arteries join themselves to form the basilar artery. The petrous, paraclival, parasellar, paraclinoid, and intradural segments of the left ICA are exposed. Lateral to the left ICA (superior to inferior) are CNII, CNIII, CNIV, CNV1, CNVI, CNV2, and CNV3. The QS is highlighted in blue. This is an area limited medially by the paraclival ICA, inferiorly by the horizontal petrous ICA, laterally by CNV2, and superiorly and obliquely by CNVI. B: Illustrations depicting the different types of ICA angle measurements on the right ICA. This classification scheme, proposed by Cebula et al., 2014, categorizes the angle between the parasellar and paraclival ICA segments into 1 of 4 types: < 80° (Type I), 80°–100° (Type II), > 100° (Type III), and asymmetrical (Type IV). The intercarotid space classification is highlighted in green. The intercarotid space is located between the parasellar and paraclival segments of both ICAs and is categorized based on its shape. The trapezoid shape is created when the course of the parasellar to paraclival segments of the ICA runs medial to lateral. With this type of intercarotid space, the distance between the ICAs in this trajectory (superior to inferior) widens. The square shape is created when the course of the parasellar to paraclival segments of the ICA is straight. The distance between the ICAs in this trajectory (superior to inferior) remains the same. The hourglass shape is created when the course of the parasellar to paraclival segments of the ICA is lateral to medial. The distance between the ICAs in this trajectory (superior to inferior) narrows. Our proposed QS classification is highlighted in blue. The QS is considered to be Type A when the shape of the intercarotid space (green) is trapezoid; the area and shape of the QS becomes narrower and shorter. The QS is considered to be Type B when the shape of the intercarotid space is square; the shape and area of the QS does not significantly alter. The QS is considered to be Type C when the intercarotid space has an hourglass shape; the area and shape of the QS becomes wider and longer. Images of cadaveric dissection of the left ICA, performed through an EEA using a 0° endoscope, mimic the illustrations. CNIV = trochlear nerve. Illustrations by Anthony Baker. Copyright The Ohio State University. Published with permission.

  • View in gallery

    Illustration depicting the distribution of ICA angle types in 44 cadaveric specimens (88 sides). The classification scheme developed by Cebula et al., based on the angle between the paraclival and parasellar segments of the ICA, was used. Twelve cadaveric specimens (27%) displayed a Type I angle, in which the angle between the paraclival and parasellar segments of the ICA is < 80° bilaterally. Three specimens (7%) displayed a Type II angle, in which the angle between the paraclival and parasellar segments of the ICA is 80°–100° bilaterally. Twenty specimens (46%) displayed a Type III angle, in which the angle between the paraclival and parasellar segments of the ICA is > 100° bilaterally. Nine specimens (20%) displayed a Type IV angle, in which the angle between the paraclival and parasellar segments of the ICA has a different type on each side.

  • View in gallery

    Graph depicting the relationship between ICA angle type and shape of the intercarotid space. A Type I angle (< 80°) was most commonly found in the 15 cadaveric specimens (34%) with a trapezoid-shaped intercarotid space. A Type III angle (> 100°) was most frequently found in the 16 cadaveric specimens (36%) with a square (straight)–shaped intercarotid space. A Type III angle (> 100°) was most commonly found in 13 cadaveric specimens (30%) with an hourglass-shaped intercarotid space. No Type I angles were observed with this conformation.

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