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Extradural anterior clinoidectomy versus endoscopic transplanum-transcavernous approach to the paraclinoid region: quantitative anatomical exposure analysis

  • Original Article - Vascular Neurosurgery - Aneurysm
  • Published:
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Abstract

Background

Transcranial anterior clinoidectomy is a conventional microsurgical approach for treatment of paraclinoid aneurysms. The endoscopic endonasal approach (EEA) is an alternative method for clipping intracranial aneurysms. No analysis has been conducted to anatomically compare approaches with respect to treating paraclinoid aneurysms. The surgical anatomical exposures of the paraclinoid region during transcranial extradural anterior clinoidectomy (EAC) and the endoscopic endonasal transplanum-cavernous approach (EETC) are described and quantitatively assessed.

Method

Seven cadaveric heads underwent EAC and EETC. Measurements included the area of exposure, volume of surgical freedom, angle of attack, ophthalmic artery (OphA) origin, and coronal exposure angle of the internal carotid artery (ICA).

Results

The EETC provided a larger area of exposure than the EAC (100.1±24.9 vs 76.1±12.9 mm2, p = 0.04). The EAC provided a higher volume of surgical freedom and greater angle of attack than the EETC in all neurovascular parameters, including the OphA, superior hypophyseal artery (SHA), distal ICA, and distal dural ring (all p < 0.001). The OphA origin was intradural in 85.7% and extradural in 14.3% of specimens. With regard to the coronal angle of exposure, the EAC exposed the OphA and SHA in the upper lateral quadrant (67.9±7.8° and 80.6±4.5°, respectively) and the distal ICA in the upper medial and upper lateral quadrants (92±7.5°). The EEA exposed the OphA, SHA, and distal ICA in the upper medial and lower medial quadrants (130.4±10.7°, 68.4±10.8°, and 58±11.4°, respectively).

Conclusions

The EAC and EETC each offer specific advantages for paraclinoid region exposure. The EAC is appropriate for paraclinoid aneurysms that occur at the dorsolateral surface of the paraclinoid ICA. The EETC is an alternative approach for aneurysms that occur along medial surface of the paraclinoid ICA (e.g., carotid cave and SHA aneurysms). The EETC provides greater surgical exposure to the medial aspect of the paraclinoid ICA.

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Data availability

The data supporting this study are available on request.

Code availability

N/A.

Abbreviations

CSF:

Cerebrospinal fluid

DDR:

Distal dural ring

EAC:

Extradural anterior clinoidectomy

EEA:

Endoscopic endonasal approach

EETC:

Endoscopic endonasal transplanum-cavernous approach

ICA:

Internal carotid artery

IHA:

Inferior hypophyseal artery

OphA:

Ophthalmic artery

PCoA:

Posterior communicating artery

SHA:

Superior hypophyseal artery

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Acknowledgements

We thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript preparation and David Naughton for the volume of surgical freedom calculation software.

Funding

This study was supported by funds from the Newsome Chair in Neurosurgery Research held by Dr. Preul at Barrow Neurological Institute and from the Barrow Neurological Foundation.

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Authors and Affiliations

  1. Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA

    Thanapong Loymak, Irakliy Abramov, Lena Mary Houlihan & Mark C. Preul

  2. Division of Nephrology, Department of Internal Medicine, Chulalongkorn University, Bangkok, Thailand

    Somkanya Tungsanga

  3. University of Arizona College of Medicine, Phoenix, AZ, USA

    Jubran H. Jubran

  4. Neuroscience Publications, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA

    Mark C. Preul

Authors
  1. Thanapong Loymak
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  4. Jubran H. Jubran
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  5. Lena Mary Houlihan
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Contributions

TL, ST, IA, and MCP contributed to the study conception and design. Material preparation, data collection, and analysis were performed by TL, ST, IA, JHJ, and LMH. The first draft of the manuscript was written by TL and MCP. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Mark C. Preul.

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This was a laboratory study. There is no research ethics committee involvement.

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The manuscript does not contain clinical studies or patient data.

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The manuscript does not contain clinical studies or patient data.

Conflict of interest

The authors declare no competing interests. This research was presented in part as an e-poster at the American Association of Neurological Surgeons 2021 virtual meeting, August 21–25, 2021.

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Loymak, T., Tungsanga, S., Abramov, I. et al. Extradural anterior clinoidectomy versus endoscopic transplanum-transcavernous approach to the paraclinoid region: quantitative anatomical exposure analysis. Acta Neurochir 164, 1055–1067 (2022). https://doi.org/10.1007/s00701-022-05172-3

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  • DOI: https://doi.org/10.1007/s00701-022-05172-3

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