Anterior clinoidectomy

Anterior clinoidectomy

The optic nerve within the optic canal, the parophthalmic segment of the internal carotid artery, and the oculomotor nerve in the superior orbital fissure all lay against the anterior clinoid process. Bone resection uncovers these structures.

Indications

Removal of the anterior clinoid process(ACP) facilitates radical removal of tumors or radical neck clipping of aneurysms in the suprasellar region and parasellar regions by providing a wide operative exposure of the internal carotid artery (ICA) and the optic nerve and by reducing the need for brain retraction.

Preoperative imaging of anterior clinoid region meningioma can accurately predict the presence or absence of tumor involvement of the clinoid in only approximately 75% of cases. In light of the fact that a quarter of patients with radiographically negative clinoids will have tumor present on pathological analysis, Copeland et al. recommend a clinoidectomy for all anterior clinoid region meningioma1).


Initially developed intradurally 2) 3) , later extradural 4).

Technique

A high-speed power-drilling technique of anterior clinoidectomy has been advocated in all publications on paraclinoid region surgery. The entire shaft of the power drill is exposed in the operative field; thus, all neurovascular structures in proximity to any portion of the full length of the rotating drill bit are at risk for direct mechanical and/or thermal injury. Ultrasonic bone removal has recently been developed to mitigate the potential complications of the traditional power-drilling technique of anterior clinoidectomy. However, ultrasound-related cranial neuropathies are recognized complications of its use, as well as the increased cost of device acquisition and maintenance.

see Endoscopic extradural anterior clinoidectomy.

Extradural clinoidectomy

Extradural removal of the anterior clinoid process (ACP) is a crucial step in the proper surgical exposure of various pathologies in and around the central skull base. Since the pioneering description by Vinko Dolenc, the technique of extradural clinoidectomy has undergone several refinements in the light of improved understanding of microsurgical anatomy and maturation of neurosurgical techniques 5).

Noguchi et al., in 2005 compared the original Dolenc procedure and its subsequent derivatives with their own simpler and less laborious technique. Different clinical situations in which to use the procedure were described based on the authors’ experience from 60 cases (40 aneurysm cases and 20 tumor cases) during a 4-year period 6).


For extradural resection of the anterior clinoid process and surrounding bone, two key steps are recommended: bony opening of the superior orbital fissure, and transection of the orbitotemporal periosteal fold.

Key Points: Pterional craniotomy • Complete extradural anterior clinoidectomy • Slit dura (3 mm) to drain cerebrospinal fluid • Peel dura from orbital roof and lateral wall • Bony opening of superior orbital fissure to use it as surgical corridor • Drilling of optic canal • Transection of orbitotemporal periosteal fold • Hollow anterior clinoid process and piece-meal resection • Transection of falciforme ligament to free optic nerve • Replace falciforme ligament by extradural free pericranial flap 7).

Hybrid technique

It is important to note that the surgeon should prefer the method he or she feels most comfortable with. This preference is often affected by the surgeon’s training. Extradural clinoidectomy is advantageous during removal of the medial sphenoid wing meningiomas as aggressive bony removal facilitates extradural devascularization of the tumor and may enhance gross tumor removal, especially if the clinoid is infiltrated with tumor. The intradural technique may be preferred for clipping of ophthalmic aneurysms as bony removal can be tailored based on the pathology at hand and clinoidectomy can be done under careful monitoring of the aneurysm to prevent manipulations that would place the aneurysm at risk of intraoperative rupture.

The hybrid method theoretically can be used as a versatile method under both circumstances mentioned above. Cutting the dura along the sphenoid wing will prevent the dural layers from obscuring the clinoid and offers intradural visualization to monitor the lesion and potentially tailor bony removal. 8).


In a study, Tayebi Meybodi et al., sought to develop a hybrid technique based on localization of the optic strut (OS) to combine the advantages and avoid the disadvantages of both techniques. Ten cadaveric specimens were prepared for surgical simulation. After a standard pterional craniotomy, the anterior clinoid process (ACP) was resected in 2 steps. The segment anterior to the OS was resected extradurally, while the segment posterior to the OS was resected intradurally. The proposed technique was performed in 6 clinical cases to evaluate its safety and efficiency. Anterior clinoidectomy was successfully performed in all cadaveric specimens and all 6 patients by using the proposed technique. The extradural phase enabled early decompression of the optic nerve while avoiding the adjacent internal carotid artery. The OS was drilled intradurally under direct visualization of the adjacent neurovascular structures. The described landmarks were easily identifiable and applicable in the surgically treated patients. No operative complication was encountered. A proposed 2-step hybrid technique combines the advantages of the extradural and intradural techniques while avoiding their disadvantages. This technique allows reduced intradural drilling and subarachnoid bone dust deposition. Moreover, the most critical part of the clinoidectomy-that is, drilling of the OS and removal of the body of the ACP-is left for the intradural phase, when critical neurovascular structures can be directly viewed 9).

Videos

Extradural anterior clinoidectomy is a versatile technique to increase exposure of the sellar and parasellar region. It is of particular use in the resection of clinoidal meningiomas, as sphenoidal and clinoidal hyperostosis can cause compression of the optic nerve. Extradural clinoidectomy follows a series of steps, consisting of (1) unroofing of the superior orbital fissure, (2) unroofing of the optic canal, (3) removal of the optic strut, and (4) removal of the anterior clinoid process. The authors show these steps in detail, as well as their application to the resection of a large clinoidal meningioma. The video can be found here: https://youtu.be/O1Fcef29ETg 10).

Case series

2012

Between June 2007 and January 2011, a total of 82 patients with neoplastic and vascular lesions underwent anterior clinoidectomy by the senior author (J.H.) through the LSO approach. They analyzed the operative videos paying particular attention to the surgical technique used for removal of the anterior clinoid process (ACP) and compared the microsurgical nuances to postoperative complications related to anterior clinoidectomy.

Forty-five patients were treated for aneurysms; 35 patients for intraorbital, parasellar, and suprasellar tumors; and 2 patients for carotid-cavernous fistulas. Intradural anterior clinoidectomy was performed in 67 (82%) cases; in 15 (18%) cases an extradural approach was used. In 51 (62%) cases, ACP was removed completely, whereas in the remaining 31 (38%) a tailored anterior clinoidectomy was performed. Four (5%) patients had new postoperative visual deficits and 3 (4%) experienced a worsening of preoperative visual deficits. Twelve (15%) patients improved their preoperative visual deficits after intradural anterior clinoidectomy. Ultrasonic bone device is a useful tool but may damage the optic nerve when performing anterior clinoidectomy. There was no mortality in our series.

Anterior clinoidectomy can be performed through an LSO approach with a safety profile that is comparable to other approaches. Ultrasonic bone dissector is a useful tool but may lead to injury of the optic nerve and should be used very carefully in its vicinity 11).

2009

A retrospective review of a cerebrovascular/cranial base fellowship-trained neurosurgeon’s 45 consecutive cases of anterior clinoidectomy using the “no-drill” technique is presented. Clinical indications have been primarily small to giant aneurysms of the proximal internal carotid artery; however, in addition to ophthalmic segment aneurysms, selected internal carotid artery-posterior communicating artery aneurysms and internal carotid artery bifurcation aneurysms, and other large/giant/complex anterior circulation aneurysms, this surgical series of “no-drill” anterior clinoidectomy includes tuberculum sellae meningiomas, clinoidal meningiomas, cavernous sinus lesions, pituitary macroadenomas with significant suprasellar extension, other perichiasmal lesions (sarcoid), and fibrous dysplasia. A bony opening is made in the mid-to posterior orbital roof after the initial pterional craniotomy. Periorbita is dissected off the bone from inside the orbital compartment. Subsequent piecemeal resection of the medial sphenoid wing, anterior clinoid process, optic canal roof, and optic strut is performed with bone rongeurs of various sizes via the bony window made in the orbital roof. RESULTS: No power drilling was used in this surgical series of anterior clinoidectomies. Optimal microsurgical exposure was obtained in all cases to facilitate complete aneurysm clippings and lesionectomies. There were no cases of direct injury to surrounding neurovascular structures from the use of the “no-drill” technique. The surgical technique is presented with illustrative clinical cases and intraoperative photographs, demonstrating the range of applications in anterior and central cranial base neurosurgery. CONCLUSION: Power drilling is generally not necessary for removal of the anterior clinoid process, optic canal roof, and optic strut. Rigorous study of preoperative computed tomographic scans/computed tomographic angiography scans, magnetic resonance imaging scans, and angiograms is essential to identify important anatomic relationships between the anterior clinoid process, optic strut, optic canal roof, and neighboring neurovascular structures. The “no-drill” technique eliminates the risks of direct power-drilling mechanical/ thermal injury and the risks of ultrasound-associated cranial neuropathies. The “no-drill” technique provides a direct, time-efficient, and efficacious approach to the paraclinoid/ parasellar/pericavernous area, using a simplified mechanical route. This technique is applicable to any neurosurgical diagnosis and approach in which anterior clinoidectomy is necessary. It is arguably the gentlest and most efficient method for exposing the paraclinoid/parasellar/pericavernous region 12).

1997

Over a period of 3 years, anterior clinoidectomy was performed in 40 patients, 30 of whom harbored aneurysms (18 of the ICA and 13 of the basilar artery [one patient had two aneurysms]) and 10 of whom had tumors (four large pituitary tumors, four craniopharyngiomas, and two sphenoid ridge meningiomas). The ACP was removed extradurally in 31 cases and intradurally in nine cases. Extradural clinoidectomy was performed in all cases of pituitary adenoma and craniopharyngioma and in most cases of basilar artery aneurysm. Intradural clinoidectomy was performed in two cases of ICA-ophthalmic artery aneurysm, two cases of ICA-posterior communicating artery aneurysm, two cases of ICA cavernous aneurysm, one case of basilar artery aneurysm, and two cases of sphenoid ridge meningioma. The outcome was satisfactory in all patients, except for one patient who underwent clipping of a basilar tip aneurysm and suffered a thalamic and midbrain infarction. Three patients who underwent extradural clinoidectomy suffered a postoperative diminution of visual acuity or a visual field defect on the side of the clinoidectomy. These deficits may have been caused either by drilling of the ACP or by other operative manipulation of the optic nerve. Cerebrospinal fluid rhinorrhea, which required reoperation, occurred in one patient. The authors’ experience suggests that the extradural technique of ACP removal is easier and less time consuming than the intradural one and provides better operative exposure. It can be used routinely in treating lesions in the supra- and parasellar region 13).

References

1)

Copeland WR, Van Gompel JJ, Giannini C, Eckel LJ, Koeller KK, Link MJ. Can Preoperative Imaging Predict Tumor Involvement of the Anterior Clinoid in Clinoid Region Meningiomas? Neurosurgery. 2015 Oct;77(4):525-30. doi: 10.1227/NEU.0000000000000873. PubMed PMID: 26120799.
2)

Drake CG, Vanderlinden RG, Amacher AL. Carotid-ophthalmic aneurysms. J Neurosurg. 1968;29:24–31.
3)

Hauser MJ, Gass H. Optic nerve pressure by aneurysm relieved by decompression of optic nerve; report of a case. AMA Arch Ophthalmol. 1952;48:627–31.
4)

Dolenc VV. A combined epi- and subdural direct approach to carotid-ophthalmic artery aneurysms. J Neurosurg. 1985;62:667–72.
5)

Mishra S, Leão B, Rosito DM. Extradural anterior clinoidectomy: Technical nuances from a learner’s perspective. Asian J Neurosurg. 2017 Apr-Jun;12(2):189-193. doi: 10.4103/1793-5482.145544. PubMed PMID: 28484528; PubMed Central PMCID: PMC5409364.
6)

Noguchi A, Balasingam V, Shiokawa Y, McMenomey SO, Delashaw JB Jr. Extradural anterior clinoidectomy. Technical note. J Neurosurg. 2005 May;102(5):945-50. PubMed PMID: 15926728.
7)

Lehmberg J, Krieg SM, Meyer B. Anterior clinoidectomy. Acta Neurochir (Wien). 2014 Feb;156(2):415-9; discussion 419. doi: 10.1007/s00701-013-1960-1. Epub 2013 Dec 10. Review. PubMed PMID: 24322583.
8)

Kulwin C, Tubbs RS, Cohen-Gadol AA. Anterior clinoidectomy: Description of an alternative hybrid method and a review of the current techniques with an emphasis on complication avoidance. Surg Neurol Int. 2011;2:140. doi: 10.4103/2152-7806.85981. Epub 2011 Oct 12. PubMed PMID: 22059135; PubMed Central PMCID: PMC3205487.
9)

Tayebi Meybodi A, Lawton MT, Yousef S, Guo X, González Sánchez JJ, Tabani H, García S, Burkhardt JK, Benet A. Anterior clinoidectomy using an extradural and intradural 2-step hybrid technique. J Neurosurg. 2018 Feb 23:1-10. doi: 10.3171/2017.8.JNS171522. [Epub ahead of print] PubMed PMID: 29473783.
10)

Buttrick S, Morcos JJ, Elhammady MS, Wang AC. Extradural clinoidectomy for resection of clinoidal meningioma. Neurosurg Focus. 2017 Oct;43(VideoSuppl2):V10. doi: 10.3171/2017.10.FocusVid.17363. PubMed PMID: 28967317.
11)

Romani R, Elsharkawy A, Laakso A, Kangasniemi M, Hernesniemi J. Complications of anterior clinoidectomy through lateral supraorbital approach. World Neurosurg. 2012 May-Jun;77(5-6):698-703. doi: 10.1016/j.wneu.2011.08.014. Epub 2011 Nov 7. PubMed PMID: 22120307.
12)

Chang DJ. The “no-drill” technique of anterior clinoidectomy: a cranial base approach to the paraclinoid and parasellar region. Neurosurgery. 2009 Mar;64(3 Suppl):ons96-105; discussion ons105-6. doi: 10.1227/01.NEU.0000335172.68267.01. PubMed PMID: 19240577.
13)

Yonekawa Y, Ogata N, Imhof HG, Olivecrona M, Strommer K, Kwak TE, Roth P, Groscurth P. Selective extradural anterior clinoidectomy for supra- and parasellar processes. Technical note. J Neurosurg. 1997 Oct;87(4):636-42. PubMed PMID: 9322855.

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