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Serioli S, Plou P, Donato G, Graepel S, Ajler P, De Bonis A, Pinheiro-Neto CD, Leonel LCPC, Peris-Celda M. The Coexistence of Carotico-Clinoid Foramen and Interclinoidal Osseous Bridge: An Anatomo-Radiological Study With Surgical Implications. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01239. [PMID: 38968000 DOI: 10.1227/ons.0000000000001258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/03/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The coexistence of complete carotico-clinoid bridge (CCB), an ossification between the anterior (ACP) and the middle clinoid (MCP), and an interclinoidal osseous bridge (ICB), between the ACP and the posterior clinoid (PCP), represents an uncommonly reported anatomic variant. If not adequately recognized, osseous bridges may complicate open or endoscopic surgery, along with the pneumatization of the ACP, especially when performing anterior or middle clinoidectomies. METHODS According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines, a systematic scoping review was conducted up to June 5, 2023. PubMed, Scopus, Web of Science databases, and additional citations were searched. Two hundred high-resolution noncontrast computed tomography (CT) scans (400 sides) and 41 dry skulls (82 sides) were analyzed to identify the different morphology of sellar bridges, focusing on the coexistence of complete CCF and ICB. Two embalmed latex-injected heads with coexisting CCF and ICB were dissected step-by-step to show the anatomic relationship with the surrounding structures from an endoscopic and microscopic perspective. RESULTS A total of 19 articles were included. The review identified a complete CCF and ICB rate ranging from 4.92% to 6.3%. The analysis of 200 CT scans revealed a rate of coexistence in 4% of the cases, all encountered in White women. Two different types of interclinoid bridges were identified based on the degree of bone mineralization. Both endoscopic and macroscopic step-by-step dissections highlighted variability in morphology and consistency of the sellar bridges and the close relationship with the cavernous sinus neurovascular structures. CONCLUSION The coexistence of CCF and ICB is an anatomic variation found in 4% of cases. Preoperative knowledge of the degree of mineralization and its relationship with surrounding structures is essential to performing safe surgery and minimizing cranial nerve and vascular injuries. Preoperative high-resolution CT scans can adequately identify these anatomic variations.
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Affiliation(s)
- Simona Serioli
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Pedro Plou
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Neurosurgery, Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Glaudir Donato
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Medical Sciences Center, Federal University of Paraiba, João Pessoa, Brazil
| | - Stephen Graepel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Pablo Ajler
- Neurosurgery, Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Alessandro De Bonis
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Carlos D Pinheiro-Neto
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Luciano C P C Leonel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria Peris-Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Wu Y, Wu X, Zhang YZ, Wu YX, Zhu G, Li ZH, Luo JN, Xue YF, Cheng HB, Lv ZQ, Gao GD, Qu Y, Zhao TZ. A Six-Surface System to Describe Anatomy of Anterior Clinoid Process and Its Application in Anterior Clinoidectomy and Resection of Paraclinoid Meningioma. World Neurosurg 2023; 178:e777-e790. [PMID: 37562682 DOI: 10.1016/j.wneu.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE The anterior clinoid process (ACP) is surrounded by nerves and vessels that, together, constitute an intricate anatomical structure with variations that challenges the performance of individualized anterior clinoidectomy in treating lesions with different extents of invasion. In the present study, we established a 6-surface system for the ACP based on anatomical landmarks and analyzed its value in guiding ACP drilling and resection of paraclinoid meningiomas. METHODS Using the anatomical characteristics of 10 dry skull specimens, we set 9 anatomical landmarks to delineate the ACP into 6 surfaces. Guided by our 6-surface system and eggshell technique, 5 colored silicone-injected anatomical specimens were dissected via a frontotemporal craniotomy to perform anterior clinoidectomy. Next, 3 typical cases of paraclinoid meningioma were selected to determine the value of using our 6-surface system in tumor resection. RESULTS Nine points (A-H and T) were proposed to delineate the ACP surface into frontal, temporal, optic nerve, internal carotid artery, cranial nerve III, and optic strut surfaces according to the adjacent tissues. Either intradurally or extradurally, the frontal and temporal surfaces could be identified and drilled into depth, followed by skeletonization of the optic nerve, cranial nerve III, internal carotid artery, and optic strut surfaces. After the residual bone was removed, the ACP was drilled off. In surgery of paraclinoid meningiomas, our 6-surface system provided great benefit in locating the dura, nerves, and vessels, thus, increasing the safety of opening the optic canal and relaxing the oculomotor or optic nerves and allowing for individualized ACP drilling for meningioma removal. CONCLUSIONS Our 6-surface system adds much anatomical information to the classic Dolenc triangle and can help neurosurgeons, especially junior ones, to increase their understanding of the paraclinoid spatial structure and accomplish individualized surgical procedures with high safety and minimal invasiveness.
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Affiliation(s)
- Yang Wu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China; Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Xun Wu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Yun-Ze Zhang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Ying-Xi Wu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Gang Zhu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Zhi-Hong Li
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Jia-Ning Luo
- Department of Neurosurgery, West Theater General Hospital, Chengdu, Sichuan Province, China
| | - Ya-Fei Xue
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Hong-Bo Cheng
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Zhong-Qiang Lv
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Guo-Dong Gao
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Tian-Zhi Zhao
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China.
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Badran KH, Tarifi A, Shatarat A, Badran D. Frontal sinus pneumatisation: an isolated finding or a sign of concomitant anatomical variation? J Laryngol Otol 2023; 137:1097-1101. [PMID: 35522072 DOI: 10.1017/s0022215122000548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine the association between frontal sinus pneumatisation and concomitant anatomical variations in paranasal sinuses as seen on computed tomography. METHODS A total of 403 patients who underwent paranasal sinus computed tomography were allocated to three groups according to the degree of frontal sinus pneumatisation (type 1 - hypoplasia; type 2 - medium size; and type 3 - hyperplasia). In this unique model, the prevalence of ipsilateral variations on paranasal sinuses on each side of the head were analysed separately within each pneumatisation group. RESULTS The type 3 frontal sinus pneumatisation group showed a greater association with ipsilateral variations of the sphenoid bone. Variations included pneumatisation of the anterior clinoid process, lateral sphenoid recess, pterygoid process and greater wing, and exposure of Vidian canal. This group also showed significant associations with male gender, and the presence of frontal and Onodi cells. CONCLUSION Interpretation of the paranasal sinus variations is imperative for pre-operative evaluation in functional endoscopic sinus surgery, particularly in patients with frontal sinus hyperplasia. Attention to variation on the ipsilateral side is informative.
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Affiliation(s)
- K H Badran
- Department of Otolaryngology Head and Neck Surgery, Hashemite University, Zarqa, Jordan
| | - A Tarifi
- Department of Otolaryngology Head and Neck Surgery, Hashemite University, Zarqa, Jordan
| | - A Shatarat
- Department of Anatomy and Histology, University of Jordan, Amman, Jordan
| | - D Badran
- Department of Anatomy and Histology, University of Jordan, Amman, Jordan
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Lim J, Sung KS, Yoo J, Oh J, Moon JH. Endoscopic transorbital extradural anterior clinoidectomy: A stepwise surgical technique and case series study [SevEN-013]. Front Oncol 2022; 12:991065. [PMID: 36106107 PMCID: PMC9465428 DOI: 10.3389/fonc.2022.991065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/08/2022] [Indexed: 11/29/2022] Open
Abstract
Background Anterior clinoidectomy is an important procedure for approaching the central skull base lesions. However, anterior clinoidectomy through the endoscopic transorbital approach (ETOA) still has limitations due to technical difficulties and the structural complexity of the anterior clinoid process (ACP). Therefore, the authors designed a stepwise surgical technique of extradural anterior clinoidectomy through the ETOA. The purpose of this study was to evaluate the feasibility of this technique. Methods Anatomical dissections were performed in 6 cadaveric specimens using a neuroendoscope and neuro-navigation system. The extradural anterior clinoidectomy through the ETOA was performed stepwise, and based on the results, this surgical technique was performed in the 7 clinical cases to evaluate its safety and efficiency. Results Endoscopic extradural anterior clinoidectomy was successfully performed in all cadaveric specimens and patients using the proposed technique. This 5-step technique enabled detachment of the lesser wing of sphenoid bone from the ACP, safe unroofing of the optic canal, and resection of the optic strut without injuring the optic nerve and internal carotid artery. Since the sequential resection of the 3 supporting roots of the ACP was accomplished safely, anterior clinoidectomy was then successfully performed in all clinical cases. Furthermore, no complications related to the anterior clinoidectomy occurred in any clinical case. Conclusion We designed a stepwise surgical technique that allows safe and efficient anterior clinoidectomy through the ETOA. Using this technique, extradural anterior clinoidectomy can be accomplished under direct endoscopic visualization with low morbidity. Since this technique is applicable to the central skull base surgery where anterior clinoidectomy is necessary, it expands the application of the ETOA.
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Affiliation(s)
- Jaejoon Lim
- Department of Neurosurgery, Bundang CHA Medical Center, CHA University College of Medicine, Seongnam, South Korea
| | - Kyoung Su Sung
- Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, South Korea
| | - Jihwan Yoo
- Department of Neurosurgery, Brain Tumor Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jiwoong Oh
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Ju Hyung Moon
- Department of Neurosurgery, Endoscopic Skull Base Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
- *Correspondence: Ju Hyung Moon,
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Change in the Location of the Optic Strut Relative to the Anterior Clinoid Process Pneumatization. J Craniofac Surg 2022; 33:1924-1928. [PMID: 35905388 DOI: 10.1097/scs.0000000000008707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE This study aimed to peruse the alteration of the position of the optic strut (OS) according to the anterior clinoid process (ACP) pneumatization. METHODS This retrospective study conducted on cone-beam computed tomography images of 400 patients with a mean age of 36.49±15.91 years. RESULTS Anterior clinoid process length, width, and angle were measured as 10.56±2.42 mm, 5.46±1.31 mm, and 42.56±14.68 degrees, respectively. The tip of ACP was measured as 6.60±1.50 mm away from the posterior rim of OS. In the 631 sides (78.87%) did not have ACP pneumatization. In the cases with ACP pneumatization, three different configurations were identified as follows: Type 1 in 71 sides (8.87%), Type 2 in 56 sides (7%), and Type 3 in 42 sides (5.23%). Relative to ACP, the location of OS was determined as follows: Type A in 29 sides (3.64%), Type B in 105 sides (13.12%), Type C in 344 sides (43%), Type D in 289 sides (36.12%), and Type E in 33 sides (4.12%). The spread of data related to the attachment site of OS according to the presence or absence of ACP pneumatization showed that the location of OS was affected by ACP pneumatization (P<0.001). In ACPs with pneumatization, the frequency of OS position relative to ACP was found as follows: Type A in none of sides (0%), Type B in 8 sides (7.6%), Type C in 53 sides (15.4%), Type D in 88 sides (30.4%), and Type E in 20 sides (60.6%). CONCLUSIONS The main finding of this study was that the location of OS relative to ACP was affected by ACP pneumatization. In ACPs with pneumatization, OS was located more posteriorly compared with ACPs without pneumatization.
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Modified intradural anterior clinoidectomy to protect the paraclinoid neurovascular structures: a technical note. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Sella turcica bridging: a systematic review. Surg Radiol Anat 2022; 44:381-389. [PMID: 35091766 DOI: 10.1007/s00276-021-02873-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/16/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE Sella turcica bridging (STB) has significant implications during neurosurgery, since it alters regional anatomy; however, no studies have investigated the global prevalence of STB. Our systematic review aimed to establish the global prevalence of STB, in specimens/individuals with and without comorbidities, in males and females, and of partial, complete, unilateral, and bilateral bridging. METHODS A literature search was conducted in MEDLINE/PubMed, ScienceDirect, and Google Scholar with various key words relating to Sella turcica bridging. Quantitative data were extracted and statistically analysed. RESULTS Eighty-two studies satisfied our inclusion criteria. The mean prevalence of STB was 26.54%, and most prevalent in Europe. STB was detected more frequently using radiological investigations. STB was less prevalent in healthy individuals (21.12%) when compared to individuals with comorbidities (33.31%). Partial STB was found to be the more prevalent in both individuals with (41.06%) and without (21.55%) comorbidities. The prevalence of unilateral and bilateral STB was only studied in healthy individuals, with unilateral bridging being the more prevalent (6.26% vs 3.84%). CONCLUSION The global overall prevalence of Sella turcica bridging in the general population was found to be higher than previously thought. Anatomical and embryological textbooks should consider including information on STB in their texts, due to its considerable prevalence and effects to the regional anatomy.
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Castle-Kirszbaum M, Uren B, Goldschlager T. Anatomic Variation for the Endoscopic Endonasal Transsphenoidal Approach. World Neurosurg 2021; 156:111-119. [PMID: 34610448 DOI: 10.1016/j.wneu.2021.09.103] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 10/20/2022]
Abstract
Knowledge of anatomy and its variations is the key to safe and efficient surgery. The endoscopic endonasal route to the sella has evolved to become the preferred route to access a wide variety of diseases. We describe the skeletal, vascular, and neural anatomic variations that could be encountered from the nasal phase, through the sphenoid phase, to the sellar phase of the operative exposure. A preoperative checklist is also provided.
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Affiliation(s)
| | - Brent Uren
- Department of Ear, Nose and Throat Surgery, Monash Health, Melbourne, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Health, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
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López CB, Di Somma A, Cepeda S, Arrese I, Sarabia R, Agustín JH, Topczewski TE, Enseñat J, Prats-Galino A. Extradural anterior clinoidectomy through endoscopic transorbital approach: laboratory investigation for surgical perspective. Acta Neurochir (Wien) 2021; 163:2177-2188. [PMID: 34110491 DOI: 10.1007/s00701-021-04896-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 05/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The endoscopic transorbital approach (eTOA) is a new mini-invasive procedure used to explore different areas of the skull base. Authors propose an extradural anterior clinoidectomy (AC) through this corridor, defining the anatomical landmarks of the anterior clinoid process (ACP) projection onto the posterior orbit wall and the technical feasibility of this approach. We describe the exposure of the opticocarotid region and the surgical freedom and the angles of attack obtained with this novel approach. METHODS Five cadaver heads underwent an eTOA at the Laboratory of Surgical Neuroanatomy of the University of Barcelona. A step-by-step description of the extradural endoscopic transorbital clinoidectomy was provided. A volumetric analysis of the morphometrics characteristics of the sphenoid wings was evaluated before and after dissection using CT scans. Pterional approach was performed to ascertain ACP removal. RESULTS In all the specimens, it was possible to resect the ACP endo-orbitally aiming an optimal optic canal (OC) unroofing. The surface of the triangle corresponding to the ACP projection onto the posterior orbit wall was 0.42 ± 0.20 cm2. The drilled area to perform the extradural clinoidectomy via eTOA was 3.11 ± 2.27 cm2, and the volume of bone removal corresponding to the greater sphenoid wing (GSW) and lesser sphenoid wing (LSW) was 2.55 ± 1.41 and 0.26 ± 0.18 cm3 respectively. The area of surgical freedom provided by the eTOA was (3.11 ± 2.27cm2), and the angles of attack were 21.39 ± 9.13° in the horizontal axel and 30.63 ± 18.51° in the vertical. CONCLUSIONS The described extradural anterior clinoidectomy by eTOA uses specific landmarks to localize the ACP on the posterior orbit wall. Resection of the ACP is a technically feasible approach, achieving the main goals of any clinoidectomy.
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Affiliation(s)
| | - Alberto Di Somma
- Department of Neurosurgery, Hospital Clinic, Barcelona, Spain.
- Laboratory of Surgical Neuroanatomy, Faculty of Medicine, University of Barcelona, Barcelona, Spain.
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, Carrer de Villaroel, 170, 08036, Barcelona, Spain.
| | - Santiago Cepeda
- Department of Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Ignacio Arrese
- Department of Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Rosario Sarabia
- Department of Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Javier Herrero Agustín
- Department of Otolaryngology-Head and Neck Surgery, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Thomaz E Topczewski
- Department of Neurosurgery, Hospital Clinic, Barcelona, Spain
- Laboratory of Surgical Neuroanatomy, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clinic, Barcelona, Spain
| | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy, Faculty of Medicine, University of Barcelona, Barcelona, Spain
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Rennert RC, Brandel MG, Steinberg JA, Martin JR, Gonda DD, Fukushima T, Day JD, Khalessi AA, Levy ML. Surgical Relevance of Pediatric Anterior Clinoid Process Maturation for Anterior Skull Base Approaches. Oper Neurosurg (Hagerstown) 2021; 20:E200-E207. [PMID: 33372959 DOI: 10.1093/ons/opaa374] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/06/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Removal of the anterior clinoid process (ACP) can expand anterior skull base surgical corridors. ACP development and anatomical variations are poorly defined in children. OBJECTIVE To perform a morphometric analysis of the ACP during pediatric maturation. METHODS Measurements of ACP base thickness (ACP-BT), midpoint thickness (ACP-MT), length (ACP-L), length from optic strut to ACP tip (ACP-OS), pneumatization (ACP-pneumo), and the presence of an ossified carotico-clinoid ligament (OCCL) or interclinoid ligament (OIL) were made from high-resolution computed-tomography scans from 60 patients (ages 0-3, 4-7, 8-11 12-15, 16-18, and >18 yr). Data were analyzed by laterality, sex, and age groups using t-tests and linear regression. RESULTS There were no significant differences in ACP parameters by laterality or sex, and no significant growth in ACP-BT or ACP-MT during development. From ages 0-3 yr to adult, mean ACP-L increased 49%, from 7.7 to 11.5 mm. The majority of ACP-L growth occurred in 2 phases between ages 0-3 to 8-11 and ages 16-18 to adult. Conversely, ACP-OS was stable from ages 0-3 to 8-11 but increased by 63% between ages 8-11 to adult. Variations in ACP morphology (OCCL/OIL/ACP-pneumo) were found in 15% (9/60) of scans. OCCL and OIL occurred in patients as young as 3 yrs, whereas ACP-pneumo was not seen in patients younger than 11 yrs. CONCLUSION The ACP demonstrates stable thickness and a complex triphasic elongation and remodeling pattern with development, the understanding of which may facilitate removal in patients <12. Clinically relevant ACP anatomic variations can occur at any age.
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Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Michael G Brandel
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Jeffrey A Steinberg
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Joel R Martin
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - David D Gonda
- Department of Neurosciences and Pediatrics, University of California, San Diego, San Diego, California
| | | | - John D Day
- Department of Neurosurgery, University of Arkansas, Little Rock, Arkansas
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Michael L Levy
- Department of Neurosciences and Pediatrics, University of California, San Diego, San Diego, California
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Alejandro SA, Carrasco-Hernández JP, da Costa MDS, Ferreira DS, Lima JVF, de Amorim BL, Paz-Archila JA, Chaddad-Neto F. Anterior Clinoidectomy: Intradural Step-by-Step En Bloc Removal Technique. World Neurosurg 2020; 146:217-231. [PMID: 33248309 DOI: 10.1016/j.wneu.2020.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Anterior clinoidectomy is an important and essential skill for skull base and cerebrovascular neurosurgeons. We present a 1-piece intradural anterior clinoidectomy, providing a step-by-step description of the technique, independently of anatomic variations. METHODS Between 2014 and 2020, 128 patients (119 women and 9 men; average age, 54.6 years) underwent intradural anterior clinoidectomy during microsurgical clipping of carotid-ophthalmic aneurysms. RESULTS The anterior clinoid process continues medially with the planum sphenoidale, over the optic nerve, laterally with the lesser wing of the sphenoid bone, and inferiorly with the optic strut, which is always found anteriorly to the clinoid segment of the internal carotid artery, and separates the optic canal from the superior orbital fissure. The proposed anterior clinoidectomy followed, one after the other, these 3 fixation points for the detachment of the anterior clinoid process. The main indication for intradural anterior clinoidectomy was the management of vascular lesions around paraclinoid (clinoidal and ophthalmic) segments of the internal carotid artery. Complications of the procedure included injury to the internal carotid artery or the ophthalmic artery, thermal damage to the optic nerve, and invasion of the sphenoid sinus or a pneumatized anterior clinoid process, which could lead to postoperative cerebrospinal fluid leakage. CONCLUSIONS The anterior clinoidectomy technique described here minimizes the drilling surface for detachment of the anterior clinoid process and reduces operative time as well as the amount of bone dust produced by drilling. It also precisely delineates the localization of the optic strut, preventing carotid or optic nerve damage.
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Affiliation(s)
| | | | | | - Danilo Santos Ferreira
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, São Paulo, Brazil
| | | | - Bruno Loof de Amorim
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, São Paulo, Brazil
| | | | - Feres Chaddad-Neto
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, São Paulo, Brazil; Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
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Chaddad-Neto F, da Costa MDS, Santos B, Caramanti RL, Costa BL, Doria-Netto HL, Figueiredo EG. Reproducibility of a new classification of the anterior clinoid process of the sphenoid bone. Surg Neurol Int 2020; 11:281. [PMID: 33033643 PMCID: PMC7538961 DOI: 10.25259/sni_133_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 07/08/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pneumatization of the anterior clinoid process (ACP) affects paraclinoid region surgery, this anatomical variation occurs in 6.6-27.7% of individuals, making its preoperative recognition essential given the need for correction based on the anatomy of the pneumatized process. This study was conducted to evaluate the reproducibility of an optic strut-based ACP pneumatization classification by presenting radiological examinations to a group of surgeons. METHODS Thirty cranial computer tomography (CT) scans performed from 2013 to 2014 were selected for analysis by neurosurgery residents and neurosurgeons. The evaluators received Google Forms with questionnaires on each scan, DICOM files to be manipulated in the Horos software for multiplanar reconstruction, and a collection of slides demonstrating the steps for classifying each type of ACP pneumatization. Interobserver agreement was calculated by the Fleiss kappa test. RESULTS Thirty CT scans were analyzed by 37 evaluators, of whom 20 were neurosurgery residents and 17 were neurosurgeons. The overall reproducibility of the ACP pneumatization classification showed a Fleiss kappa index of 0.49 (95% confidence interval: 0.49-0.50). The interobserver agreement indices for the residents and neurosurgeons were 0.52 (0.51-0.53) and 0.49 (0.48-0.50), respectively, and the difference was statistically significant (P < 0.00001). CONCLUSION The optic strut-based classification of ACP pneumatization showed acceptable concordance. Minor differences were observed in the agreement between the residents and neurosurgeons. These differences could be explained by the residents' presumably higher familiarity with multiplanar reconstruction software.
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Affiliation(s)
| | | | - Bruno Santos
- Department of Neurosurgery, Universidade Federal de São Paulo
| | | | - Bruno Lourenco Costa
- Department of Neurosurgery, Centro Hospitalar Tondela-Viseu, EPE, Viseu, Portugal
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Xiao L, Xie S, Tang B, Hu J, Hong T. Endoscopic endonasal anterior clinoidectomy: surgical anatomy, technique nuance, and case series. J Neurosurg 2020; 133:451-461. [PMID: 31277066 DOI: 10.3171/2019.4.jns183213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 04/08/2019] [Indexed: 11/06/2022]
Abstract
Advances in endoscopic technique allow for resection of the anterior clinoid process (ACP) via an endoscopic endonasal approach. The authors discuss the endoscopic endonasal anterior clinoidectomy (EEAC) and demonstrate the relevant surgical anatomy and technical nuances. The approach was simulated in 6 cadaveric heads. From a technical point of view, the lateral optic carotid recess was used as the landmark in the proposed technique. The superomedial, superolateral, and inferior vertices of this recess are the main operative points. The EEAC approach was achieved by disconnecting the ACP tip from the base by drilling the 3 vertices. The proposed approach was successfully performed in all cadaveric specimens. Then, in a case series involving 6 patients in whom the EEAC approach was used, there were no vascular injuries; 2 patients had postoperative oculomotor nerve palsy, which improved in one and resolved in the other by 1 month.The EEAC approach for tumors and vascular lesions in the parasellar region is technically feasible. The surgical corridor is increased by ACP resection, although to a lesser extent than the transcranial anterior clinoidectomy. Based on the authors' initial anatomical and surgical results, resection of the ACP via the endonasal endoscopic approach is a novel technique worth exploring in suitable cases.
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Raseman J, Guryildirim M, Beer-Furlan A, Jhaveri M, Tajudeen BA, Byrne RW, Batra PS. Preoperative Computed Tomography Imaging of the Sphenoid Sinus: Striving Towards Safe Transsphenoidal Surgery. J Neurol Surg B Skull Base 2020; 81:251-262. [PMID: 32499999 DOI: 10.1055/s-0039-1691831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 04/04/2019] [Indexed: 10/26/2022] Open
Abstract
Introduction Preoperative high-resolution computed tomography (HRCT) is essential in patients undergoing transsphenoidal surgery to identify potential high-risk anatomic variations. There is no consensus in the literature, as to which grading system to use to describe these variants, leading to inconsistent terminology between studies. In addition, substantial variability exists in the reported incidence of anatomic variants. In this study, we performed an institutional imaging analysis and literature review with the objective of consolidating and clearly defining these sphenoid sinus anatomical variations. In addition, we highlighted their surgical implications and propose a checklist for a systematic assessment of the sphenoid sinus on preoperative CT. Methods Review of the literature and retrospective analysis assessing several imaging parameters in 81 patients who underwent preoperative HRCT imaging for endoscopic transsphenoidal tumor resection from January 2008 through July 2015 at Rush University Medical Center. Results The most common sphenoid pneumatization patterns were sellar (45%) and postsellar (49%) types. Anterior clinoid process (ACP) pneumatization was seen in 17% of patients with high concordance of ipsilateral optic nerve (ON) protrusion. ON protrusion and dehiscence was present in 17 and 6% of patients, respectively. Internal carotid artery (ICA) protrusion and dehiscence was present in 30 and 5% of patients, respectively. Dehiscence rates from local bone invasion overlying the ICA and ON occurred in 17 and 4% of cases, respectively. Conclusions Our study highlights and reviews the key variants that have potential to impact surgical complications and outcomes in a heterogeneous patient population. The proposed preoperative CT checklist for patients, undergoing transsphenoidal surgery, consistently identifies these higher risk anatomical variants.
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Affiliation(s)
- John Raseman
- Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, St. Louis, Missouri, United States
| | - Melike Guryildirim
- Department of Diagnostic Radiology, Rush University Medical Center, Chicago, Illinois, United States
| | - André Beer-Furlan
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, United States
| | - Miral Jhaveri
- Department of Diagnostic Radiology, Rush University Medical Center, Chicago, Illinois, United States
| | - Bobby A Tajudeen
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, United States
| | - Richard W Byrne
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, United States
| | - Pete S Batra
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, United States
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Devaraja K, Doreswamy SM, Pujary K, Ramaswamy B, Pillai S. Anatomical Variations of the Nose and Paranasal Sinuses: A Computed Tomographic Study. Indian J Otolaryngol Head Neck Surg 2019; 71:2231-2240. [PMID: 31763326 PMCID: PMC6848411 DOI: 10.1007/s12070-019-01716-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/11/2019] [Indexed: 11/27/2022] Open
Abstract
To evaluate the anatomical variations in computed tomographic (CT) images of paranasal sinuses and to investigate association between them. DESIGN Retrospective study. SETTING Tertiary care center in the southern part of India. SUBJECTS Radiological images of paranasal sinuses belonging to chronic rhinosinusitis patients managed between June 2016 and November 2018. METHODS The studied characteristics in the CT images included the deviated nasal septum (DNS), concha bullosa (CB), Haller cell (HC), Onodi cell (OC), pneumatization of anterior clinoid process (ACP), pterygoid base (PB), superior turbinate, inferior turbinate, crista galli (CG), and nasal septum. The height of the lateral lamella of the cribriform plate, the sphenoid pneumatization pattern, and the optic nerve relationship with sphenoid sinus were studied separately. The associations between these factors, and with maxillary sinus opacifications were also investigated. A total of 151 adult patients' CT images were analyzed. The most common manifestations noted were DNS, CB and pneumatized PB, seen in 83.4%, 49% and 47% of the patients respectively. The rates of HC, OC, pneumatized septum, pneumatized CG, and pneumatized ACP were 39%, 23%, 27%, 43% and 27% in that order. Rates of most of these variations were within the range reported in the literature. Chi square test revealed that the OC was independently associated with pneumatized CG and pneumatized septum. The maxillary sinus opacification was related to DNS and CB, but not with protrusion of tooth root into the sinus. Most of the anatomical variations were comparable with the reports across the globe, however, the associations between these variations weren't common in our cohort.
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Affiliation(s)
- K. Devaraja
- Department of Otorhinolaryngology and Head and Neck Surgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Udupi, Karnataka 576104 India
| | - Shreyanka M. Doreswamy
- Department of Otorhinolaryngology and Head and Neck Surgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Udupi, Karnataka 576104 India
| | - Kailesh Pujary
- Department of Otorhinolaryngology and Head and Neck Surgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Udupi, Karnataka 576104 India
| | - Balakrishnan Ramaswamy
- Department of Otorhinolaryngology and Head and Neck Surgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Udupi, Karnataka 576104 India
| | - Suresh Pillai
- Department of Otorhinolaryngology and Head and Neck Surgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Udupi, Karnataka 576104 India
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Yazici D. The effect of frontal sinus pneumatization on anatomic variants of paranasal sinuses. Eur Arch Otorhinolaryngol 2019; 276:1049-1056. [PMID: 30607558 DOI: 10.1007/s00405-018-5259-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 12/17/2018] [Indexed: 01/26/2023]
Abstract
PURPOSE The aim of this study is to determine the effect of frontal sinus pneumatization on various variations of paranasal sinuses on maxillofacial CT. MATERIALS AND METHODS A total number of 120 patients (62 females, 58 males) were included in this study. Patients were divided into three groups regarding their frontal sinus pneumatization extent on paranasal sinus CT as Type 1 pneumatization (aplasia and hypoplasia), Type 2 pneumatization (medium) and Type 3 pneumatization (hyperplasia). The prevalence of various variations on paranasal sinus CT like pneumatization of upper and middle concha, presence of agger nasi, Haller and Onodi cell, maxillary sinus and sphenoid sinus hypoplasia, pneumatization of anterior clinoid process, pterygoid process and greater wing of sphenoid sinus, dehiscence and protrusion of internal carotid artery and optic nerve and vidian canal types were ascertained and compared within each group. RESULTS The prevalence of upper and middle concha pneumatization, Haller cell, pneumatization of anterior clinoid process, pterygoid process and greater wing of sphenoid and internal carotid artery dehiscence and protrusion was higher in Type 3 group compared with other groups. CONCLUSION Excessive pneumatization of frontal sinus has various effects on paranasal sinus variations at maxillofacial CT. Surgeons dealing with endoscopic sinus surgery, maxillofacial and skull base surgery must be vigilant of association between certain variations when analyzing CT scan preoperatively for avoiding complications.
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Affiliation(s)
- Demet Yazici
- ENT Department, Adana City Training and Research Hospital, Dr. Mithat Özsan Bulvarı Kışla Mah. 4522 Sok. No: 1 Yüreğir, Adana, Turkey.
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Tayebi Meybodi A, Lawton MT, Yousef S, Guo X, González Sánchez JJ, Tabani H, García S, Burkhardt JK, Benet A. Anterior clinoidectomy using an extradural and intradural 2-step hybrid technique. J Neurosurg 2019; 130:238-247. [PMID: 29473783 DOI: 10.3171/2017.8.jns171522] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/28/2017] [Indexed: 11/06/2022]
Abstract
In Brief: The authors found a practical intraoperative landmark to localize the optic strut during anterior clinoidectomy and used it as the basis for performing anterior clinoidectomy in two steps: extradural phase and intradural phase. This anatomically based technique can increase the safety of anterior clinoidectomy by providing easily identifiable landmarks and reducing intradural bone drilling, which could put the adjacent neurovauscular structures at risk.
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Affiliation(s)
- Ali Tayebi Meybodi
- 1Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael T Lawton
- 1Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Sonia Yousef
- 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California; and
| | - Xiaoming Guo
- 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California; and
- 3Department of Neurosurgery, First Affiliated Hospital of Chinese PLA General Hospital, Beijing, People's Republic of China
| | | | - Halima Tabani
- 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California; and
| | - Sergio García
- 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California; and
| | - Jan-Karl Burkhardt
- 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California; and
| | - Arnau Benet
- 1Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
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