Intradural “limited drill” technique of anterior clinoidectomy and optic canal unroofing for microneurosurgical management of ophthalmic segment and PCOM aneurysms—review of surgical results

Endoscopic Endonasal Transsphenoidal Approach to Repair Cerebrospinal Fluid Rhinorrhea After an Anterior Clinoidectomy for Aneurysm Clipping: Series of 4 Cases

BACKGROUND

Cerebrospinal fluid (CSF) rhinorrhea through a pneumatized optic strut is a known potential complication after an anterior clinoidectomy that is used to microsurgically clip a proximal internal carotid artery aneurysm. The original craniotomy site can be reopened to repair the skull base defect, but this technique has disadvantages.

OBJECTIVE

To avoid a repeat craniotomy and address the limitations of a transcranial approach, a straightforward alternative was used for skull base repair-the binostril endoscopic endonasal transsphenoidal approach.

METHODS

This retrospective case series describes the use of endoscopic transsphenoidal repair and outcomes for patients with CSF leaks after anterior clinoidectomy for aneurysm repair between January 1, 2015, and December 31, 2019.

RESULTS

Four adult patients (3 women and 1 man) with a mean age of 59.5 years were reviewed. Skull base repair occurred on average 24 days (range, 4-75 days) after the index operation. After demucosalization of the parasellar sphenoid sinus, the fistula in the pneumatized optic strut was reconstructed with a free nasal mucosal graft with or without an autologous muscle graft. None of the patients developed a recurrent CSF leak at a mean follow-up of 12.5 months (range, 8-22 months), and none experienced complications.

CONCLUSION

The endoscopic endonasal transsphenoidal approach was safe and effective for skull base repair in 4 patients with CSF rhinorrhea after an anterior clinoidectomy for aneurysm clipping.

Intradural Clinoidectomy: A Tailored Osteotomy for Approaching the Paraclinoid Carotid Artery and Interpeduncular Cisterns

Anterior clinoidectomy is an important tool for neurovascular and skull base surgeons. This technique is cardinal for expanding access to the sella, proximal carotid artery, and central skull base. The goal of anterior clinoidectomy is to reveal the more proximal ophthalmic and clinoidal segments of the internal carotid artery while unroofing the optic canal and skeletonizing the proximal optic nerve. This maneuver expands the opticocarotid and carotid-oculomotor access windows and therefore the operative corridor to the interpeduncular cisterns.

Visual Outcomes after Surgery for Paraclinoid Aneurysms: A Fujita Experience

INTRODUCTION

The surgical strategies for clipping of paraclinoid aneurysms are diverse. These aneurysms are unique in their location, as they closely abut the anterior clinoid process (ACP) and the optic nerve. The ultimate goal of clipping encompasses the exposure of neck of the aneurysm which is seldom complete without the manipulation of optic nerve and the ACP. This manipulation may result in disturbances of vision postoperatively. We analyze our results of visual outcomes in the surgery for paraclinoid aneurysms in this retrospective study.

MATERIALS AND METHODS

All patients with paraclinoid aneurysms who underwent surgery from June 2014 to June 2019 were included in the study. Surgical procedure was uniform in all patients which included anterior clinoidectomy and clipping of aneurysms as per the Bantane protocol. Glasgow Outcome Scale as well as vision was assessed at discharge and at 1 month and 6 months.

RESULTS

There were 77 cases of paraclinoid aneurysms operated during the abovementioned period. All patients had no symptoms related to vision preoperatively. Visual deterioration was noted in two patients. All patients were discharged with a good outcome on the Glasgow Outcome Scale.

CONCLUSION

Paraclinoid aneurysm has a good outcome when treated with surgery. The visual deterioration following surgery can be minimized with extradural anterior clinoidectomy and careful handling of the vessels and nerve.