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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
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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
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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
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The Anatomic Facts: Rhoton’s Canon Segments of the ICA Fisher Berenstein and Lasjaunias Bouthillier and van Loveren
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The Anatomic Facts: Rhoton’s Canon Unique anatomic features of the C5-6 segments of ICA
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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
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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
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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
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Imaging The Paraclinoid Region Kobayashi: Cisternographic Guidance Gonzales, Zabramski and Spetzler: Optic Strut as Reference
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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
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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
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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
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The Anatomic Facts: Rhoton’s Canon Anatomy as the surgeon’s safeguard Ease of approach Vascular control Maximize safety Maximize exposure, maneuverability Maximize effectiveness
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Implications for Paraclinoid Aneurysms The ophthalmic aneurysm The superior hypophyseal aneurysm (extradural versus carotid cave) The ventral paraclinoid aneurysm (transitional versus intradural)
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Ophthalmic Aneurysm Optic nerve canal decompression + clinoidectomy Endovascular adjuncts Proximal control Suction decompression Intraoperative angiography
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Ophthalmic Aneurysm
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IO Angio
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Superior Hypophyseal Aneurysm
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Ventral Paraclinoid Aneurysm
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Clip Intradural Portion, Coil Extradural Portion
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Maximalist vs. Minimalist Strategies Adaptation of conventional approaches Maximalist skull base approaches Minimalist (keyhole, endoscopic assisted or controlled) Focused strategies
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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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