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Surgical Anatomy of the Paraclinoid Region: Lessons From Many Masters

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. The Paraclinoid Region: Fundamentals for Every Surgeon.

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Surgical Anatomy of the Paraclinoid Region: Lessons From Many Masters

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  1. 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

  2. The Paraclinoid Region:Fundamentals for Every Surgeon • The anatomic facts: Rhoton’s Canon • Implications for paraclinoid aneurysms • Implications for surgical approach • Maximalist versus minimalist strategies • A personal philosophy

  3. The Anatomic Facts: Rhoton’s Canon • Segments of the internal carotid artery (ICA) • Unique anatomic features of the C5-6 segments of the ICA • The oculomotor triangle • Relations to the optic nerve • Anatomy as the surgeon’s safeguard

  4. The Anatomic Facts: Rhoton’s Canon • Segments of the ICA • Fisher • Berenstein and Lasjaunias • Bouthillier and van Loveren

  5. The Anatomic Facts: Rhoton’s Canon • Unique anatomic features of the C5-6 segments of ICA

  6. The Anatomic Facts: Rhoton’s Canon • Unique anatomic features of the C5-6 segments of ICA • Hemodynamic stresses • Imaging limitations • Dural relationships • Bony relationships • The subarachnoid space

  7. The Anatomic Facts: Rhoton’s Canon • Unique anatomic features of the C5-6 segments of ICA • Hemodynamic stresses • Imaging limitations • Dural relationships • Bony relationships • The subarachnoid space

  8. The Anatomic Facts: Rhoton’s Canon • Unique anatomic features of the C5-6 segments of ICA • Hemodynamic stresses • Imaging limitations • Dural relationships • Bony relationships • The subarachnoid space

  9. Imaging The Paraclinoid Region Kobayashi: Cisternographic Guidance Gonzales, Zabramski and Spetzler: Optic Strut as Reference

  10. The Anatomic Facts: Rhoton’s Canon • The oculomotor triangle • The interclinoid ligament • The tentorial edge (anterior petroclinoid ligament) • The posterior petroclinoid ligament • Relations to Cr. Ns. III, IV and VI

  11. The Anatomic Facts: Rhoton’s Canon • The oculomotor triangle • The interclinoid ligament • The tentorial edge (anterior petroclinoid ligament) • The posterior petroclinoid ligament • Relations to Cr. Ns. III, IV and VI

  12. The Anatomic Facts: Rhoton’s Canon • Relations to the optic nerve • The anterior clinoid process • The falciform ligament • The optic strut • The distal ring • The proximal ring

  13. The Anatomic Facts: Rhoton’s Canon • Anatomy as the surgeon’s safeguard • Ease of approach • Vascular control • Maximize safety • Maximize exposure, maneuverability • Maximize effectiveness

  14. Implications for Paraclinoid Aneurysms • The ophthalmic aneurysm • The superior hypophyseal aneurysm (extradural versus carotid cave) • The ventral paraclinoid aneurysm (transitional versus intradural)

  15. Ophthalmic Aneurysm • Optic nerve canal decompression + clinoidectomy • Endovascular adjuncts • Proximal control • Suction decompression • Intraoperative angiography

  16. Ophthalmic Aneurysm

  17. Ophthalmic Aneurysm IO Angio IO Angio

  18. Superior Hypophyseal Aneurysm

  19. Ventral Paraclinoid Aneurysm

  20. Ventral Paraclinoid Aneurysm Clip Intradural Portion, Coil Extradural Portion

  21. Maximalist vs. Minimalist Strategies • Adaptation of conventional approaches • Maximalist skull base approaches • Minimalist (keyhole, endoscopic assisted or controlled) • Focused strategies

  22. A Personal Philosphy: Balancing What is “Safe”and What is “Feasible” • Proximal control • Intradural versus extradural consideration • Endovascular adjuncts • Endovascular treatments • Future challenges and opportunities -- surgical, endovascular

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