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The extended endoscopic endonasal transplanum transtuberculum approach to the anterior communicating artery complex: anatomic study

  • Experimental Research - Neurosurgical Anatomy
  • Published:
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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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Conflicts of interest

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Author information

Authors and Affiliations

  1. Laboratory of Surgical NeuroAnatomy (LSNA), Human Anatomy and Embryology Unit, Faculty of Medicine, Universitat de Barcelona, C/ Casanova 143, 08036, Barcelona, Spain

    Elena d’Avella, Marija Mavar & Alberto Prats-Galino

  2. Department of Neuroscience, Neurosurgery, University of Padua, Padua, Italy

    Elena d’Avella

  3. Neurosurgical Department, “G. Rummo” Hospital of Benevento, Benevento, Italy

    Matteo De Notaris

  4. Department of Neurosurgery, Hospital Clinic, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain

    Joaquim Enseñat & Enrique Ferrer

  5. Department of Radiology, Hospital Clinic, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain

    Joan Berenguer

  6. Macquarie Neurosurgery, Australian School of Advanced Medicine, Macquarie University, Sydney, Australia

    Cristian Gragnaniello

Authors
  1. Elena d’Avella
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  2. Matteo De Notaris
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  3. Joaquim Enseñat
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  4. Joan Berenguer
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  5. Cristian Gragnaniello
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  6. Marija Mavar
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  7. Enrique Ferrer
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  8. Alberto Prats-Galino
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Corresponding author

Correspondence to Elena d’Avella.

Additional information

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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Supplemental PDF

Interactive PDF of the 3D reconstruction of the transplanum transtuberculum approach for the exposure of the anterior communicating artery complex and its bony and neural relationships. The file should be opened by Acrobat Reader XI or superior. (PDF 5283 kb)

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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

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