How I do it: microsurgical clipping of carotid-ophthalmic aneurysms through minipterional approach with extradural resection of the anterior clinoid process

Abstract

Background. In modern neurosurgery, preference is given to less invasive procedures. A classic example is switching from standard surgical approaches to keyhole approaches, in particular transition from pterional to minipterional approach. In turn, addition of extradural resection of the anterior clinoid process to the minipterional approach significantly expands the range of its indications.Method. The paper analyses the stages and main features of microsurgical clipping of carotid-ophthalmic aneurysms through the minipterional approach with extradural anterior clinoidectomy in patients operated in the Federal Centre of Neurosurgery (Tyumen, Russia) by professor Sufianov.Conclusion. The technique described in this research is a safe surgical approach, which demonstrates the efficacy of adding some skull base surgery elements to keyhole approaches. This type of craniotomy could become a method of choice for many neurosurgical conditions.

Anatomical Justification of Extradural Resection of the Anterior Clinoid Process

“… 20 21 In our previous study, we proposed our own method of removing the ACP by drilling the lateral, medial pillar with sequential removal of the inferior pillar. 1 We offer a method of removal of OS (inferior pillar) using a special technique described in this article. In our opinion, a thorough study of the anatomy of the ACP with CT will allow to choose the optimal access for sequential removal of ACP, which contributes to performing a gentle surgery without intraoperative complications.…”

“…Anatomically, the ACP is attached to the wing of the sphenoid bone by three bony structures (pillars): a lateral pillar, which is formed by a wedge-shaped ridge and is bounded from below by the superior orbital fissure, the medial pillar that forms the roof of the optic canal, and the inferior pillar (or optic strut [OS]), which separates the supraclinoid portion of the internal carotid artery (ICA) inferolaterally from the superior medial optic nerve. 1 As ACP covers the roof of the cavernous sinus and the paraclinoidal segment of the ICA, anterior clinoidectomy becomes mandatory in approaching cavernous sinus, and in optic canal decompression. 2 Thus, ACP is a key access to the sellar/parasellar area, anterior and anterolateral circle of Willis, middle cerebral artery, upper basilar artery, and anterior cranial fossa.…”

“…Anatomically, the ACP is attached to the wing of the sphenoid bone by three bony structures (pillars): a lateral pillar, which is formed by a wedge-shaped ridge and is bounded from below by the superior orbital fissure, the medial pillar that forms the roof of the optic canal, and the inferior pillar (or optic strut [OS]), which separates the supraclinoid portion of the internal carotid artery (ICA) inferolaterally from the superior medial optic nerve. 1 …”

“…The option of removing the OS depends on its morphometric parameters. 1 Therefore, in this article, we decided to carry out a morphometry of ACP and OS and offer our own surgical classification of the OS to choose the appropriate method for removing it, and evaluate the percentage of the expansion of the volume of the WOF after the ACP removal.…”