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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 QuickTime™ and a Graphics decompressor are needed to see this picture.
  • 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 QuickTime™ and a MPEG-4 Video decompressor are needed to see this picture.
  • 17. Ophthalmic Aneurysm IO Angio IO Angio QuickTime™ and a DV - NTSC decompressor are needed to see this picture.
  • 18. Superior Hypophyseal Aneurysm
  • 19. Ventral Paraclinoid Aneurysm QuickTime™ and a H.263 decompressor are needed to see this picture.
  • 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