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Surgical Anatomy of the Paraclinoid Region: Lessons From Many

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Surgical Anatomy of the
Paraclinoid Region: Lessons
From Many Masters
Issam A. Awad, MD, MSc, FACS, MA (hon)
Professor of Neurosurgery
Northwestern University
Evanston Northwestern Health
Evanston, Illinois
QuickTimeв„ў and a
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The Paraclinoid Region:
Fundamentals for Every Surgeon
The anatomic facts: Rhoton’s Canon
пЃ® Implications for paraclinoid aneurysms
пЃ® Implications for surgical approach
пЃ® Maximalist versus minimalist strategies
пЃ® A personal philosophy
пЃ®
The Anatomic Facts:
Rhoton’s Canon
пЃ®
Segments of the internal carotid artery (ICA)
пЃ® Unique anatomic features of the C5-6
segments of the ICA
пЃ® The oculomotor triangle
пЃ® Relations to the optic nerve
пЃ® Anatomy as
the surgeon’s safeguard
The Anatomic Facts:
Rhoton’s Canon
пЃ®
Segments of the ICA
пЃ®
пЃ®
пЃ®
Fisher
Berenstein and
Lasjaunias
Bouthillier and van
Loveren
The Anatomic Facts:
Rhoton’s Canon
пЃ®
Unique anatomic
features of the C5-6
segments of ICA
The Anatomic Facts:
Rhoton’s Canon
пЃ®
Unique anatomic
features of the C5-6
segments of ICA
пЃ®
пЃ®
пЃ®
пЃ®
пЃ®
Hemodynamic
stresses
Imaging limitations
Dural relationships
Bony relationships
The subarachnoid
space
The Anatomic Facts:
Rhoton’s Canon
пЃ®
Unique anatomic
features of the C5-6
segments of ICA
пЃ®
пЃ®
пЃ®
пЃ®
пЃ®
Hemodynamic
stresses
Imaging limitations
Dural relationships
Bony relationships
The subarachnoid
space
The Anatomic Facts:
Rhoton’s Canon
пЃ®
Unique anatomic
features of the C5-6
segments of ICA
пЃ®
пЃ®
пЃ®
пЃ®
пЃ®
Hemodynamic
stresses
Imaging limitations
Dural relationships
Bony relationships
The subarachnoid
space
Imaging The Paraclinoid Region
Kobayashi:
Cisternographic
Guidance
Gonzales,
Zabramski
and Spetzler:
Optic Strut as
Reference
The Anatomic Facts:
Rhoton’s Canon
пЃ®
The oculomotor
triangle
пЃ®
пЃ®
пЃ®
пЃ®
The interclinoid
ligament
The tentorial edge
(anterior petroclinoid
ligament)
The posterior
petroclinoid ligament
Relations to Cr. Ns.
III, IV and VI
The Anatomic Facts:
Rhoton’s Canon
пЃ®
The oculomotor
triangle
пЃ®
пЃ®
пЃ®
пЃ®
The interclinoid
ligament
The tentorial edge
(anterior petroclinoid
ligament)
The posterior
petroclinoid ligament
Relations to Cr. Ns.
III, IV and VI
The Anatomic Facts:
Rhoton’s Canon
пЃ®
Relations to the
optic nerve
пЃ®
пЃ®
пЃ®
пЃ®
пЃ®
The anterior clinoid
process
The falciform
ligament
The optic strut
The distal ring
The proximal ring
The Anatomic Facts:
Rhoton’s Canon
пЃ®
Anatomy as the
surgeon’s safeguard
пЃ®
пЃ®
пЃ®
пЃ®
пЃ®
Ease of approach
Vascular control
Maximize safety
Maximize exposure,
maneuverability
Maximize
effectiveness
Implications for Paraclinoid
Aneurysms
пЃ®
пЃ®
пЃ®
The ophthalmic
aneurysm
The superior
hypophyseal aneurysm
(extradural versus
carotid cave)
The ventral paraclinoid
aneurysm (transitional
versus intradural)
Ophthalmic Aneurysm
пЃ®
пЃ®
Optic nerve canal
decompression +
clinoidectomy
Endovascular
adjuncts
пЃ®
пЃ®
пЃ®
Proximal control
Suction
decompression
Intraoperative
angiography
Ophthalmic Aneurysm
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Ophthalmic Aneurysm
IO Angio
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IO Angio
Superior Hypophyseal
Aneurysm
Ventral Paraclinoid
Aneurysm
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Ventral Paraclinoid
Aneurysm
Clip Intradural Portion,
Coil Extradural Portion
Maximalist vs. Minimalist
Strategies
пЃ®
Adaptation of conventional approaches
пЃ® Maximalist skull base approaches
пЃ® Minimalist (keyhole, endoscopic
assisted or controlled)
пЃ® Focused strategies
A Personal Philosphy: Balancing
What is “Safe” and What is “Feasible”
Proximal control
пЃ® Intradural versus extradural
consideration
пЃ® Endovascular adjuncts
пЃ® Endovascular treatments
Future challenges and opportunities
-- surgical, endovascular
пЃ®
пЃ®
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