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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. The Paraclinoid Region: Fundamentals for Every Surgeon.

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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
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
the anatomic facts rhoton s canon
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

the anatomic facts rhoton s canon4
The Anatomic Facts: Rhoton’s Canon
  • Segments of the ICA
    • Fisher
    • Berenstein and Lasjaunias
    • Bouthillier and van Loveren
the anatomic facts rhoton s canon5
The Anatomic Facts: Rhoton’s Canon
  • Unique anatomic features of the C5-6 segments of ICA
the anatomic facts rhoton s canon6
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
the anatomic facts rhoton s canon7
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
the anatomic facts rhoton s canon8
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
imaging the paraclinoid region
Imaging The Paraclinoid Region

Kobayashi: Cisternographic Guidance

Gonzales, Zabramski and Spetzler: Optic Strut as Reference

the anatomic facts rhoton s canon10
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
the anatomic facts rhoton s canon11
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
the anatomic facts rhoton s canon12
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
the anatomic facts rhoton s canon13
The Anatomic Facts: Rhoton’s Canon
  • Anatomy as the surgeon’s safeguard
    • Ease of approach
    • Vascular control
    • Maximize safety
    • Maximize exposure, maneuverability
    • Maximize effectiveness
implications for paraclinoid aneurysms
Implications for Paraclinoid Aneurysms
  • The ophthalmic aneurysm
  • The superior hypophyseal aneurysm (extradural versus carotid cave)
  • The ventral paraclinoid aneurysm (transitional versus intradural)
ophthalmic aneurysm
Ophthalmic Aneurysm
  • Optic nerve canal decompression + clinoidectomy
  • Endovascular adjuncts
    • Proximal control
    • Suction decompression
    • Intraoperative angiography
ophthalmic aneurysm17
Ophthalmic Aneurysm

IO Angio

IO Angio

ventral paraclinoid aneurysm20
Ventral Paraclinoid Aneurysm

Clip Intradural Portion,

Coil Extradural Portion

maximalist vs minimalist strategies
Maximalist vs. Minimalist Strategies
  • Adaptation of conventional approaches
  • Maximalist skull base approaches
  • Minimalist (keyhole, endoscopic assisted or controlled)
  • Focused strategies
a personal philosphy balancing what is safe and what is feasible
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