Abstract
Background
When performing a transplanum transtuberculum approach, dealing with the anterior communicating artery (ACoA) complex is inevitable. The aim of this study is to provide quantitative anatomical information regarding the ACoA complex and its bony and neural relationships, when exposed through this approach.
Method
The endoscopic endonasal transplanum transtuberculum approach was performed on ten human cadaver heads. In each specimen, radiological studies were performed. A three-dimensional model of the approach was reconstructed. Measured parameters were: exposure of the vessels; distance between the proximal anterior cerebral artery (A1) and the optic chiasm; dimension of the bone opening. The feasibility to perform clip placement was graded as “possible” or “not possible”.
Results
Dimension of bone opening varied from 88 to 53 mm2. The ACoA was exposed for 3 mm ± 2 mm, A1 for 17 mm ± 9 mm, the distal anterior cerebral artery (A2) for 12 mm ± 3 mm, the recurrent artery of Heubner (RAH) for 16 mm ± 4 mm. Clip placement was possible on the ACoA, A2, and distal segment of A1 in all cases, and on the proximal segment of A1 in one instance. The distance between A1 and the optic chiasm measured 9 mm ± 2 mm.
Conclusions
The ACoA, A2, and the distal segment of A1 can be visualized and controlled through the transplanum transtuberculum approach. The relationship between A1, gyrus rectus, and optic chiasm is the main determinant for the exposure and control of the vessel. The olfactory nerve can represent a surgical landmark for the identification of the A1 origin. The whole course of the RAH can be visualized trough this approach.
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Comment
The authors provide a quantitative anatomical information of the Acom complex through an endoscopic endonasal transtuberculum approach. As expected, the access to distal A1, Acom, and Proximal A2, and visualization of the recurrent artery of Heubner is relatively easily obtained through this approach but access to the proximal A1 is difficult and most often impossible. A midline transtuberculum approach without opening of the optic canal and/or removal of the medial orbital wall is often enough to safely expose the Acom complex. The advantage of this approach compared to mini craniotomy and a retractorless microscopic exposure of the Acom aneurysm is, however debatable, and although I am an avid advocate for expanded transtubercular approaches, I am not yet convinced that Acom aneurysm surgery should be done through endoscopic transsphenoidal approach. However, this study enhances our understanding of the limitations of this technique in dealing with vascular structures.
Amir Dehdashti
NY, USA
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d’Avella, E., De Notaris, M., Enseñat, J. et al. The extended endoscopic endonasal transplanum transtuberculum approach to the anterior communicating artery complex: anatomic study. Acta Neurochir 157, 1495–1503 (2015). https://doi.org/10.1007/s00701-015-2497-2
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DOI: https://doi.org/10.1007/s00701-015-2497-2