Embed Size (px)
DESCRIPTION
Citation preview
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
QuickTime™ and aGraphics decompressor
are needed to see this picture.
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
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 Canon
Segments of the ICA Fisher Berenstein and
Lasjaunias Bouthillier and van
Loveren
The Anatomic Facts: Rhoton’s Canon
Unique anatomic features of the C5-6 segments of ICA
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 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 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
Kobayashi: Cisternographic Guidance
Gonzales, Zabramski and Spetzler: Optic Strut as Reference
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 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 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 Canon
Anatomy as the surgeon’s safeguard Ease of approach Vascular control Maximize safety Maximize exposure,
maneuverability Maximize
effectiveness
Implications for Paraclinoid Aneurysms
The ophthalmic aneurysm
The superior hypophyseal aneurysm (extradural versus carotid cave)
The ventral paraclinoid aneurysm (transitional versus intradural)
Ophthalmic Aneurysm
Optic nerve canal decompression + clinoidectomy
Endovascular adjuncts Proximal control Suction
decompression Intraoperative
angiography
Ophthalmic Aneurysm
QuickTime™ and aMPEG-4 Video decompressor
are needed to see this picture.
Ophthalmic Aneurysm
IO Angio
IO Angio
QuickTime™ and aDV - NTSC decompressor
are needed to see this picture.
Superior Hypophyseal Aneurysm
Ventral Paraclinoid Aneurysm
QuickTime™ and aH.263 decompressor
are needed to see this picture.
Ventral Paraclinoid Aneurysm
Clip Intradural Portion, Coil Extradural Portion
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”
Proximal control Intradural versus extradural
consideration Endovascular adjuncts
Endovascular treatments Future challenges and opportunities
-- surgical, endovascular
