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Agosti E, Alexander AY, Leonel LC, Van Gompel JJ, Link MJ, Pinheiro-Neto CD, Peris-Celda M. Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal Approach to the Sellar and Parasellar Regions. J Neurol Surg B Skull Base 2023; 84:361-374. [PMID: 37405244 PMCID: PMC10317571 DOI: 10.1055/a-1869-7532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 06/01/2022] [Indexed: 10/18/2022] Open
Abstract
Introduction Surgery of the sellar and parasellar regions can be challenging due to the complexity of neurovascular relationships. The main goal of this study is to develop an educational resource to help trainees understand the pertinent anatomy and procedural steps of the endoscopic endonasal approaches (EEAs) to the sellar and parasellar regions. Methods Ten formalin-fixed latex-injected specimens were dissected. Endoscopic endonasal transsphenoidal transsellar, transtuberculum-transplanum, and transcavernous approaches were performed by a neurosurgery trainee, under supervision from the senior authors and a PhD in anatomy with advanced neuroanatomy experience. Dissections were supplemented with representative case applications. Results Endoscopic endonasal transsphenoidal approaches afford excellent direct access to sellar and parasellar regions. After a wide sphenoidotomy, a limited sellar osteotomy opens the space to sellar region and medial portion of the cavernous sinus. To reach the suprasellar space (infrachiasmatic and suprachiasmatic corridors), a transplanum-prechiasmatic sulcus-transtuberculum adjunct is needed. The transcavernous approach gains access to the contents of the cavernous sinus and both medial (posterior clinoid and interpeduncular cistern) and lateral structures of the retrosellar region. Conclusion The anatomical understanding and technical skills required to confidently remove skull base lesions with EEAs are traditionally gained after years of specialized training. We comprehensively describe EEAs to sellar and parasellar regions for trainees to build knowledge and improve familiarity with these approaches and facilitate comprehension and learning in both the surgical anatomy laboratory and the operating room.
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Affiliation(s)
- Edoardo Agosti
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - A. Yohan Alexander
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Luciano C.P.C. Leonel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Jamie J. Van Gompel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael J. Link
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Carlos D. Pinheiro-Neto
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Maria Peris-Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
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Endoscopic Endonasal Approach for Clipping Anterior Communicating Artery Aneurysms From Cadaver Studies and Three-Dimensional Printed Models to a Clinical Case. J Craniofac Surg 2021; 32:2854-2858. [PMID: 34238881 DOI: 10.1097/scs.0000000000007848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Anterior communicating artery (ACoA) aneurysm is one of the most common intracranial aneurysms, and it is also the aneurysm with the highest rupture rate. With the improvement of endoscopic techniques, it is possible to use an endoscopic endonasal approach (EEA) to clip ACoA aneurysms. For further analysis of the EEA for clipping ACoA aneurysms, we used cadaver heads and three-dimensional (3D)-printed models to finish the anatomical study, and we finally selected 1 clinical case to complete the clipping through the EEA. MATERIALS AND METHODS We first collected 3 cadaver heads to simulate the EEA. Then, the imaging data of 29 real cases of ACoA aneurysm were collected, and the model of an aneurysm was prepared by 3D printing technology; then, the EEA was used to simulate the clipping of the aneurysm model. Finally, a clinical case with 2 ACoA aneurysms was selected to adopt the EEA for clipping. RESULTS Both the cadaver head and 3D-printed aneurysm model could simulate aneurysm clipping with the EEA. The clinical case of the selected ACoA aneurysm can successfully complete the clipping through the EEA. CONCLUSIONS 3D-printed models are a good method to study the anatomical characteristics of a surgical approach. For specially selected ACoA aneurysms, the EEA is relatively simple method that can be used to clip the aneurysm successfully. The EEA for clipping ACoA aneurysms is a useful complement to the current traditional craniotomy approaches and endovascular embolization.
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Najera E, Truong HQ, Belo JTA, Borghei-Razavi H, Gardner PA, Fernandez-Miranda J. Proximal Branches of the Anterior Cerebral Artery: Anatomic Study and Applications to Endoscopic Endonasal Surgery. Oper Neurosurg (Hagerstown) 2020; 16:734-742. [PMID: 30649510 DOI: 10.1093/ons/opy308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/03/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The endoscopic endonasal approach is a surgical alternative for midline anterior skull base tumors. A detailed understanding of the proximal anterior cerebral artery (ACA) branches' anatomy from an endonasal perspective is essential for avoiding vascular complications. OBJECTIVE To evaluate, from an endonasal perspective, the anatomic variations of the ACA and its proximal branches, specifically the recurrent artery of Heubner (RAH), and the fronto-orbital (FOA) and frontopolar (FPA) arteries. METHODS We study the origin, course, branching pattern, diameter, and relationship between the proximal ACA branches and the optic apparatus and olfactory tract in 25 head specimens. RESULTS The RAH was present in all hemispheres and originated within 3 ± 1.5 mm of the AcomA, with a 0.4 ± 0.1 mm diameter. Based on its relationship with the A1 segment, we observed three RAH courses: anterior (40%), superior (22%), and posterior (38%). The FOA was present in all cases, a mean of 6 ± 4 mm from the AcomA, with a 0.7 ± 0.4 mm diameter. The FOA arose mainly from the A2 (70%), with three courses in relation to the olfactory tract: crossing its proximal third (54%), crossing its middle third (31%), and running parallel to it along the gyrus rectus (15%). The FPA was present in 92% of the hemispheres, a mean of 10 ± 5 mm from the AcomA, always arising from the A2 and coursing anteriorly within the interhemispheric fissure towards the frontal pole. CONCLUSION The RAH, FOA, and FPA can be differentiated by origin, course, and destination using the A1 segment, olfactory tract, and interhemispheric fissure, respectively, as surgical landmarks.
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Affiliation(s)
- Edinson Najera
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Huy Q Truong
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joao T Alves Belo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hamid Borghei-Razavi
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Juan Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
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Zhu H, Vigo V, Ahluwalia A, Chae R, El-Sayed I, Abla AA, Rubio RR. Comparative Analysis of Pterional, Supraorbital, Extended Supraorbital, and Transtubercular-Transplanum Approaches for Exposing the Anterior Communicating Artery Complex: A Cadaveric Study. World Neurosurg 2020; 141:e576-e588. [PMID: 32522638 DOI: 10.1016/j.wneu.2020.05.244] [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: 04/07/2020] [Accepted: 05/27/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We aimed to quantify and compare surgical exposure and freedom at the anterior communicating artery (ACoA) complex using pterional (PT), supraorbital (SO), extended supraorbital withorbital osteotomy (SOO), and endonasal endoscopic transtubercular-transplanum (EEATT) approaches. METHODS Right-sided PT, SO, SOO, and EEATT approaches were performed using 10 cadaveric heads. Surgical exposure and freedom (horizontal and vertical attack angle) at the ACoA complex were measured. The farthest clipping distance from ACoA to A1 (precommunicating segment of the anterior cerebral artery)/A2 (postcommunicating segment of the anterior cerebral artery) was also quantified. RESULTS There was a significantly greater exposure length of right A1 in the PT approach (12.20 ± 2.48 mm) compared with the EEATT approach (9.52 ± 2.09 mm; P = 0.029). Among the 4 approaches, EEATT provided the shortest clipping distance for right A1 (6.56 ± 1.33 mm; P = 0.001) and the longest clipping distance for right A2 (3.36 ± 1.24 mm; P = 0.003). SO, SOO, and PT approaches (2.9 ± 0.9) had more observations on perforators from ACoA than did the EEATT approach (2.0 ± 0.66; P = 0.029). The EEATT approach (50.90 ± 17.45 mm2) provided better exposure of the superior part of the ACoA complex compared with the SO approach (29.37 ± 17.27 mm2; P = 0.05). PT and SOO approaches provided the greatest horizontal (36.88° ± 5.85°) and vertical (19.37° ± 4.70°) attack angle, respectively. CONCLUSIONS The SO, SOO, and PT approaches provided a better hemilateral view of the ACoA complex and similar surgical exposure, whereas the EEATT approach offered greater exposure in the upper part of the ACoA complex, with relatively limited exposure of perforators from ACoA and surgical freedom. The EEATT approach can play a role in exposure of lesion involving the ACoA complex.
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Affiliation(s)
- Hongwei Zhu
- Department of Neurological Surgery, First Affiliated Hospital of Xiamen University, Xiamen, Fujian Province, China; Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Vera Vigo
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Amandeep Ahluwalia
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Ricky Chae
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Ivan El-Sayed
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurological Surgery, First Affiliated Hospital of Xiamen University, Xiamen, Fujian Province, China; Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Roberto Rodriguez Rubio
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA.
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Montaser AS, Prevedello DM, Gomez M, Lima L, Beer-Furlan A, Servian D, Otto BA, Carrau RL. Extended Endoscopic Endonasal Clipping of Intracranial Aneurysms: An Anatomic Feasibility Study. World Neurosurg 2019; 133:e356-e368. [PMID: 31521759 DOI: 10.1016/j.wneu.2019.09.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 09/03/2019] [Accepted: 09/05/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Intracranial aneurysms (IAs) located in the midline region represent formidable challenge owing to their deep location. The objective of this study was to assess feasibility and identify the limitations of endoscopic endonasal clipping of IAs. We further aimed to describe the locations and characteristics of aneurysms that may be amenable for endoscopic endonasal clipping; thus outlining the indications of these approaches. METHODS Fifteen latex-injected cadaveric heads were used for endoscopic endonasal exposure of anterior and posterior cerebral circulations. An aneurysm simulator model with 2 different sizes was used at the common sites for IAs to emulate a real surgery. Key measured parameters included "exposure of vessels and their respective perforators," "ability to gain proximal/distal control," and "possibility of clip placement" according to the size, direction, and location of the aneurysm model. Maneuverability of instruments and the need for pituitary gland transposition were assessed and recorded as well. RESULTS Exposure of the anterior communicating artery complex and the common sites of posterior circulation aneurysms were feasible. The size, location, and direction of the aneurysm model had an impact on obtaining proximal and/or distal control, and the ability of clip placement. CONCLUSIONS Clipping of midline aneurysms of the posterior circulation is feasible via endoscopic endonasal approach. Small-sized ventrally and medially directed aneurysm models carried a better probability of getting proximal and/or distal control, as well as better overall ability to place a clip. The endonasal route seems to provide a limited condition for proper management of anterior circulation aneurysms.
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Affiliation(s)
- Alaa S Montaser
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA; Department of Neurological Surgery, Ain Shams University, Cairo, Egypt
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
| | - Matias Gomez
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Lucas Lima
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - André Beer-Furlan
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Diego Servian
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bradley A Otto
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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de Divitiis O, d’Avella E, de Notaris M, Di Somma A, De Rosa A, Solari D, Cappabianca P. The (R)evolution of Anatomy. World Neurosurg 2019; 127:710-735. [DOI: 10.1016/j.wneu.2019.03.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/05/2019] [Indexed: 11/28/2022]
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Review of the main surgical and angiographic-oriented classifications of the course of the internal carotid artery through a novel interactive 3D model. Neurosurg Rev 2018; 43:473-482. [PMID: 30051302 DOI: 10.1007/s10143-018-1012-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 05/31/2018] [Accepted: 07/10/2018] [Indexed: 12/24/2022]
Abstract
The course of the internal carotid artery (ICA) and its segment classifications were reviewed by means of a new and freely available 3D interactive model of the artery and the skull base, based on human neuroimages, that can be freely downloaded at the Public Repository of the University of Barcelona (http://diposit.ub.edu/dspace/handle/2445/112442) and runs under Acrobat Reader in Mac and Windows computers and Windows 10 tablets. The 3D-PDF allows zoom, rotation, selective visualization of structures, and a predefined sequence view. Illustrative images of the different classifications were obtained. Fischer (Zentralbl Neurochir 3:300-313, 1938) described five segments in the opposite direction to the blood flow. Gibo-Rothon (J Neurosurg 55:560-574, 1981) follow the blood flow, incorporated the cervical and petrous portions, and divided the subarachnoid course-supraclinoid-in ophthalmic, communicating, and choroidal segments, enhancing transcranial microscopic approaches. Bouthillier (Neurosurgery 38:425-433, 1996) divided the petrous portion describing the lacerum segment (exposed in transfacial procedures and exploration of Meckel's cave) and added the clinoid segment between the proximal and distal dural rings, of interest in cavernous sinus surgery. The Kassam's group (2014), with an endoscopic endonasal perspective, introduces the "paraclival segment," including the "lacerum segment" and part of the intracavernous ICA, and details surgical landmarks to minimize the risk of injury. Other classifications are also analyzed. This review through an interactive 3D tool provides virtual views of the ICA and becomes an innovative perspective to the segment classifications and neuroanatomy of the ICA and surrounding structures.
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Valera-Melé M, Puigdellívol-Sánchez A, Mavar-Haramija M, Juanes-Méndez JA, San-Román L, de Notaris M, Prats-Galino A. A Novel and Freely Available Interactive 3d Model of the Internal Carotid Artery. J Med Syst 2018; 42:72. [DOI: 10.1007/s10916-018-0919-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/19/2018] [Indexed: 10/17/2022]
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Tayebi Meybodi A, Benet A. Letter to the Editor: Endoscopic endonasal approach for clip ligation of cerebral aneurysms. J Neurosurg 2016; 125:780-2. [PMID: 27315023 DOI: 10.3171/2016.3.jns16582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ali Tayebi Meybodi
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, CA
| | - Arnau Benet
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, CA
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