Paraclinoid Region - Surgical Anatomy of the Paraclinoid Region ...
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Surgical Anatomy of the Paraclinoid Region: Lessons From Many Masters
Issam A. Awad, MD, MSc, FACS, MA (hon)Professor of Neurosurgery
Northwestern University
Evanston Northwestern Health
Evanston, Illinois
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The Paraclinoid Region:Fundamentals for Every Surgeon
The anatomic facts: Rhoton’s Canon Implications for paraclinoid aneurysms
Implications for surgical approach Maximalist versus minimalist strategies
A personal philosophy
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The Anatomic Facts: Rhoton’s Canon
Segments of the internal carotid artery (ICA) Unique anatomic features of the C5-6
segments of the ICA The oculomotor triangle
Relations to the optic nerve Anatomy as
the surgeon’s safeguard
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The Anatomic Facts: Rhoton’s Canon
Segments of the ICA Fisher Berenstein and
Lasjaunias Bouthillier and van
Loveren
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The Anatomic Facts: Rhoton’s Canon
Unique anatomic features of the C5-6 segments of ICA
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The Anatomic Facts: Rhoton’s Canon
Unique anatomic features of the C5-6 segments of ICA Hemodynamic
stresses Imaging limitations Dural relationships Bony relationships The subarachnoid
space
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The Anatomic Facts: Rhoton’s Canon
Unique anatomic features of the C5-6 segments of ICA Hemodynamic
stresses Imaging limitations Dural relationships Bony relationships The subarachnoid
space
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The Anatomic Facts: Rhoton’s Canon
Unique anatomic features of the C5-6 segments of ICA Hemodynamic
stresses Imaging limitations Dural relationships Bony relationships The subarachnoid
space
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Imaging The Paraclinoid Region
Kobayashi: Cisternographic Guidance
Gonzales, Zabramski and Spetzler: Optic Strut as Reference
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The Anatomic Facts: Rhoton’s Canon
The oculomotor triangle The interclinoid
ligament The tentorial edge
(anterior petroclinoid ligament)
The posterior petroclinoid ligament
Relations to Cr. Ns. III, IV and VI
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The Anatomic Facts: Rhoton’s Canon
The oculomotor triangle The interclinoid
ligament The tentorial edge
(anterior petroclinoid ligament)
The posterior petroclinoid ligament
Relations to Cr. Ns. III, IV and VI
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The Anatomic Facts: Rhoton’s Canon
Relations to the optic nerve The anterior clinoid
process The falciform
ligament The optic strut The distal ring The proximal ring
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The Anatomic Facts: Rhoton’s Canon
Anatomy as the surgeon’s safeguard Ease of approach Vascular control Maximize safety Maximize exposure,
maneuverability Maximize
effectiveness
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Implications for Paraclinoid Aneurysms
The ophthalmic aneurysm
The superior hypophyseal aneurysm (extradural versus carotid cave)
The ventral paraclinoid aneurysm (transitional versus intradural)
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Ophthalmic Aneurysm
Optic nerve canal decompression + clinoidectomy
Endovascular adjuncts Proximal control Suction
decompression Intraoperative
angiography
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Ophthalmic Aneurysm
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Ophthalmic Aneurysm
IO Angio
IO Angio
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Superior Hypophyseal Aneurysm
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Ventral Paraclinoid Aneurysm
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Ventral Paraclinoid Aneurysm
Clip Intradural Portion, Coil Extradural Portion
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Maximalist vs. Minimalist Strategies
Adaptation of conventional approaches Maximalist skull base approaches
Minimalist (keyhole, endoscopic assisted or controlled)
Focused strategies
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A Personal Philosphy: Balancing What is “Safe” and What is “Feasible”
Proximal control Intradural versus extradural
consideration Endovascular adjuncts
Endovascular treatments Future challenges and opportunities
-- surgical, endovascular