How I do it : Anterior clinoidectomy and optic canal unroofing for microneurosurgical management of ophthalmic segment aneurysms
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Power drilling commonly used for anterior clinoidectomy and optic canal unroofing can result in thermal injury to the optic nerve.
The authors describe an intradural “limited drill” technique of anterior clinoidectomy and optic canal unroofing for microneurosurgical management of ophthalmic segment aneurysms, where optic canal unroofing is done with 1 mm Kerrison punch and the use of the power drill is restricted to anterior clinoidectomy to avoid thermal injury to the optic nerve. The optic nerve, internal carotid artery (ICA), and aneurysm are covered with wet gelfoam pieces to prevent any inadvertent contact with the drill.
“Limited drill technique” is a safe and effective technique of anterior clinoidectomy and optic canal unroofing.
• Anterior clinoidectomy and optic canal unroofing is an important skull base technique required for safe clipping of the majority of ophthalmic segment aneurysms
• Power drilling commonly used for optic canal unroofing can cause thermal injury to optic nerve
• More than 2 mm free space is available around the optic nerve in the optic canal
• Foot plate of 1 mm Kerrison punch can be safely introduced within a normal optic canal without causing mechanical injury to the optic nerve
• Reflection of posteriorly based dural flap acts as a dural barrier, preventing direct contact of drill bit to optic nerve, internal carotid artery and aneurysm during drilling
• Entanglement of cottonoids to rotating drill bit is a major problem in intradural anterior clinoidectomy
• Wet gelfoam pieces do not get entangled to the rotating drill bit
• Structures surrounding the area of drilling can be covered with wet gel foam pieces to prevent direct contact of the drill to neurovascular structures
• Opened cisterns can be covered with wet gelfoam pieces during drilling to prevent deposition of bone dust in the subarachnoid space
• “Limited drill technique” of anterior clinoidectomy and optic canal unroofing is a safe and effective technique for the exposure of ophthalmic segment aneurysms
KeywordsAnterior clinoidectomy Ophthalmic segment aneurysms Optic canal unroofing Optic nerve Optic strut Power drill
We thank Anjali K (student of anaesthesia technology) and Dr. Swathi G (anaesthesia resident) for providing the schematic line diagrams from operative images.
Conflicts of interest
Video (Illustrative case 1) that demonstrates the clipping of a medially directed right ophthalmic segment aneurysm. (WMV 45764 kb)
Video (Illustrative case 2) that demonstrates the clipping of a large superiorly directed right ophthalmic segment aneurysm closely related to ACP. (WMV 29756 kb)