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Chapter 30
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30.1 Indications 316
Anterior Transpetrosal
Approach versus EEA
Transclival Approach
30.2 Surgical Steps 316
30.3 Complications 318
30.4 Tips and Tricks 319
30.5 Case Example 320
Anterior Transpetrosal Approach versus EEA Transclival Approach
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30 Anterior Transpetrosal Approach versus EEA
Transclival Approach
Jun Muto, Leo F. S. Ditzel Filho, Bradley A. Otto, Ricardo L. Carrau, Daniel M. Prevedello
Introduction
In pathologies involving the petroclival and petrous apex
regions, the approach used is based on lesion extension,
histologic origin, and involvement with the epidural
or subdural space. The anterior transpetrosal approach
(ATPA) is an established technique to access the upper
and middle petroclival lesion and petrous apex. The
endoscopic endonasal approach (EEA) offers direct access
to clival lesions (i.e., median) with or without lateral
expansion and shows the greatest benefits and least
morbidity for tumors that are medial or caudal to the
abducens nerve, such as chordoma and chondrosarcoma,
and median midclivus lesions. Both the anterior
transpetrosal and the endoscopic endonasal approaches
are feasible techniques, which lead to adequate resection
rates and outcomes when used in appropriately selected
patients by experienced surgeons.
30.1 Indications
30.1.1 Endoscopic Endonasal
Approach (EEA)—Transclival
Approach
• Extradural: Lesions involving the clivus and petrous
apex, such as chordomas, chondrosarcomas and cholesterol granulomas.
• Intradural: Lesions located medial to the VI cranial nerve,
such as meningiomas, chordomas, neuroenteric cysts.
30.1.2 Anterior Transpetrosal
Approach (ATPA)
• Extradural: Posterior and/or lateral to paraclival ICA
segment and lesions with extension to middle fossa
and/or infratemporal fossa, such as chondrosarcomas,
some chordomas and invasive meningiomas.
• Intradural: Lesions located between the cranial nerve
III and VII, VIII, such as meningiomas, trigeminal
schwannomas.
30.2 Surgical Steps
to the facial, cochlear, and vestibular nerves. Potential
advantages of the ATPA for the treatment of petroclival
meningiomas include the following:
• Tumor feeding arteries (i.e., the tentorial and middle
• No retraction injury on cerebellum.
• Low incidence of manipulation injury to cranial nerves
• Single-stage surgery is possible for tumors invading
geal arteries) can be accessed before resecting
menin
the tumor and coagulated before the dura is opened.
VII–XI.
Meckel’s cave and the middle cranial fossa.
1
Technique
Previous reports
Here, we offer a stepwise depiction of the technique. The
head is secured in a lateral supine position. A “U”-shaped
incision is made above the ear (Fig. 30.1a) and a temporalis fascia flap is raised to facilitate wound closure at the
end of the procedure. The temporal fascia is dissected from
the temporal muscle and is transposed caudally, while the
temporal muscle is transposed anteriorly (Fig. 30.1b). A
craniotomy is performed with its base parallel to the zygomatic arch and the floor of the middle fossa, just above
the root of the zygoma and the mastoid crest (Fig. 30.1c).
The periosteal dura is carefully dissected from the temporal bone. The foramen spinosum is identified and the
middle meningeal artery is located, coagulated, and cut
with microscissors (Fig. 30.1d). Next, the foramen ovale
is seen anteriorly. The bony depression, along with the
greater superficial petrosal nerve (GSPN), marks the anterolateral boundary of the drilling area, which is further
bound by the arcuate eminence posterolaterally, the internal auditory canal (IAC) inferolaterally, the carotid canal
inferiorly, and the trigeminal impression anteromedially
(Fig. 30.1e). After drilling the petrous pyramid (Fig. 30.1f),
the dura of the posterior fossa is opened, finding the lateral aspect of the pons and the root of the trigeminal nerve
(Fig. 30.1g). A T-shaped cut is made over the dura of the
temporal lobe and along the superior petrosal sinus (SPS),
showing the edge of the tentorium. The SPS is coagulated,
cut with microscissors, and sutured at both ends. The tentorium itself is then cut until the tentorial notch is open.
This step is performed with care to avoid injury to the
trochlear nerve, which runs beneath the medial edge of
the tentorium (Fig. 30.1h), and completes the exposure.
(Fig. 30.1j)
2–4
have described this procedure in detail.
30.2.1 Anterior Transpetrosal
Approach
The ATPA is an established procedure indicated for lesions of the upper and middle petroclival and petrous
apex regions. This approach offers a wide working angle
of up to 90 degrees, exposing a surgical field that consists
of the area superior to the abducens nerve and anterior
316
30.2.2 Endoscopic Endonasal
Transclival Approach
Previous reports have described the use of the transclival
endonasal approach to access petroclival and petrous
apex lesions.
proach to access lesions in the sagittal plane.
5
This method is the basic endonasal ap-
Anterior Transpetrosal Approach versus EEA Transclival Approach
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a b c
FS
MMA
Ant.
d
FO
ICA
f
Fig. 30.1 Stepwise cadaveric depiction of a right anterior transpetrosal approach as visualized directly with the naked eye (a–c),
microscope (d–g), and endoscope (h–j). (a) The head is placed in a lateral supine position. (b) A “U”-shaped skin incision is made above
the ear. A temporalis fascial fl ap is raised for closure of the dural defect and displaced caudally; the temporalis muscle is retracted
anteriorly. (c) The squamous suture, the mastoid superior crest, and the zygomatic arch are the landmarks for the craniotomy. The
craniotomy basal edges are drilled fl ush with the fl oor of the middle fossa to allow visualization of the superior portion of the tumor.
(d) The petrous pyramid is exposed epidurally until the petrous rim is identifi ed along the SPS. The foramen spinosum is the initial
landmark; the MMA is coagulated with bipolar electrocautery and cut with microscissors. Next, the dura is peeled off epidurally and the
foramen ovale, the second key landmark, can be identifi ed anterior to the foramen spinosum. (e) The white dotted area corresponds
to the petrous apex section to be drilled down. The greater and lesser superfi cial petrosal nerves (GSPN, LSPN), which can be identifi ed
by their dural adhesion, following the bony groove, are located within the periosteal dura. Note that if the periosteal dura at the lateral
rim of the greater petrosal groove is incised and dissected at the same layer, this will cause the surgeon to enter the interdural space.
Hence, the medial rim of the greater petrosal groove should be incised once again and the epidural dissection should be held to the rim
of the petrosal bone.7 The drilling area is outlined by the trigeminal impression anteriorly, the arcuate eminence posteriorly, the greater
superior petrosal groove laterally, the carotid canal inferiorly, and the internal auditory canal inferoposteriorly. (Continued)
Med.
GSPN
Inf.
Sup.
T
T
Lat.
Post.
AE
FO
TI
T
e
FO
Cv
T
g
GSPN
IAC
GSPN
VI
V
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Anterior Transpetrosal Approach versus EEA Transclival Approach
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V
TE
III
h
Fig. 30.1 (Continued) (f) After the petrous apex is drilled, the periosteal dura of the posterior fossa is encountered. (g) The tentorium
is incised and the dura of the posterior fossa is opened, revealing the trigeminal nerve and the lateral aspect of the pons. The abducens
nerve can be seen medial to the trigeminal nerve, passing into Dorello’s canal. (h) Cranial aspect of the surgical fi eld. The posterior
opening of Meckel’s cave is covered by two thick dural folds: the petroclival and the petroclinoidal (tentorial) folds; the trochlear nerve
is seen inferior to the medial edge of the tentorium. The oculomotor nerve can be seen above the tentorium, which is the cranial limit
of the ATPA. (i) Caudal aspect of the surgical fi eld. The intradural part of the abducens nerve enters Dorello’s canal. (j) A posterior
endoscopic view of the surgical fi eld shows the facial and vestibulocochlear nerve complex en route to the internal auditory canal (IAC).
The anterior inferior cerebellar artery can be seen surrounding the IAC. AICA, anterior inferior cerebellar artery; AE, arcuate eminence,
BA: basilar artery; Cv: clivus; FO, foramen ovale; FS, foramen spinosum; GSPN, greater superfi cial petrosal nerve; ICA, internal carotid
artery; IAC, internal auditory canal; LSPN, lesser superfi cial petrosal nerve; MMA, middle meningeal artery; MC, Meckel’s cave; SCA,
superior cerebellar artery; SPS, superior petrosal sinus; T, temporal lobe; TE, tentorium; TI, trigeminal impression; III, oculomotor nerve;
IV, trochlear nerve; V, trigeminal nerve; VI, abducens nerve; VII, facial nerve; VIII, vestibulocochlear nerves.
SCA
IV
MC
PCA
i
Techinque
The head is secured in the supine position with a three-pin
head holder. The approach is initiated with a right middle
turbinectomy to provide space for the endoscope and any
instrument that will be introduced from this side. The left
middle turbinate is not resected but out-fractured. The
sphenoid ostium is enlarged, and a nasoseptal flap pedicled
on the sphenopalatine artery contralateral to the lesion is
elevated to construct the skull base and dura at the end of
the procedure. A wide sphenoidotomy and right total and
left posterior partial ethmoidectomies are performed,
the mucosa on the sphenoid sinus is stripped, and the
exposure in nasal cavity is completed with a posterior
septectomy (Fig. 30.2a). The mucosa of the contralateral side in relation to the flap is then transferred back to
cover the denuded anterial septal area where the flap
was elevated completing what we call “reverse flap”. The
pharyngobasilar fascia is bluntly dissected from the roof
of the choana. The palatovaginal artery and nerve are coagulated and cut, and the vidian nerve and canal are identified. The vidian nerve is located lateral to the floor of
the sphenoid sinus and is a good landmark to identify the
anterior genu of the ICA at the lacerum foramen. A small
VI
Pons
V
IV
SCA
j
Cv
AICA
V
SCA
Next, the clivus itself is thinned with the drill.
The substantial bleeding may be encountered on entry to
the cancellous portion of the clivus. To avoid injury to the
dura, the inner cortex is carefully removed using Kerrison
rongeurs in combination with drilling, and elevation with
a Cottle dissector (Fig. 30.2d). Any bleeding in this phase
of the dissection is controlled with hemostatic foam.
The clival dura can be exposed completely between
the paraclival segments of the ICA to maximize the operative space, and the initial dural incision should be made
at the midline to avoid injury to the abducens nerve that
runs in the interdural space at the level of the pons. Intraoperative navigation is used to determine the location of
the vertebrobasilar junction, as the abducens nerves rise
bilaterally from the pontomedullary junction and above
the vertebral arteries; this maneuver prevents damage to
the nerves by placing the initial dural incision below the
vertebrao-basilar junction level (Fig. 30.2e). Finally, the
dura is resected with sharp 90-degree Kerrison rongeurs
to complete the exposure (Fig. 30.2 f, g). The amount
of lateral access is determined by the size of the tumor;
typically, large lesions create a wide corridor and require
less manipulation of neurovascular structures located at
their edges.
IAC
VII, VIII
Pons
window is created in the posterior wall of maxillary sinus
to gain access to the pterygopalatine fossa (Fig. 30.2b). To
access petroclival and petrous apex lesions via an endonasal transclival approach, the vidian nerve is skeletonized and followed posteriorly until the cartilages of the
foramen lacerum are found. The bone over the paraclival
ICA is thinned with the drill and removed using Kerrison
rongeurs to expose the periosteal dura. The floor of the
sphenoid sinus is drilled flush with the clivus. The inferior clival bone is the place of attachment of the longus
capitis and the rectus capitis anterior. There are two defined attachment lines at the inferior clivus: the superior
clival line (for the longus capitis) and the inferior clival
line (for the rectus capitis anterior). The inferior clival
line offers a reliable landmark for the hypoglossal canal.
The longus capitis is removed and the inferior clivus is
exposed (Fig. 30.2c).
30.3 Complications
Potential complications in the EEA to petroclival lesions
are ICA injury, sixth nerve injury, vidian nerve injury, and
injury to the maxillary and mandibular nerves and basilar artery, as mentioned previously in Chapter 18.
The possible complications in the ATPA are temporal
lobe swelling, contusion, and complications due to venous return disturbance in temporal lobe due to brain
retraction, such as aphasia, consciousness disturbance,
convulsion, etc. Injury to the greater superior petrosal
nerve causing dry eye or facial palsy; and cerebral spinal
6
fluid leakage are the other complications of the ATPA.
This approach requires technical training to drill near the
ICA at the petrosal part.
1,2
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Anterior Transpetrosal Approach versus EEA Transclival Approach
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30.4 Tips and Tricks
Surgical tips about approaches are mentioned as before.
In this chapter, we would like to discuss the preferred
approach route to petrosal apex lesions.
On On
LOCR
S
Post.
C
The floor of
sphenoid sinus
ab
PG
Vn
cdf
D
V
ET
Med.
Sup.
(Rost)
Int.
(Caus.)
Lat.
Ant.
ICA
Vn
The EEA is more appropriate for accessing lesions medial or caudal to the abducens nerve, such as chordomas,
chondrosarcomas, and midclival meningiomas compared
with the ATPA. The ATPA is more appropriate for lesions
located lateral and/or posterior to the paraclival ICA seg-
ICA
PG
PG
D
Vn
Vn
ET
C
PF
ET
ICA
VI
Sn
DS
P-com
IPS
SHA
III
SCA
VI
St
PG
BA
PICA
ALCA
Pons
VI
VA
Sup.
(Rost)
Rt
Ant.
Inf.
(Caud.)
eg
Fig. 30.2 Stepwise cadaveric depiction of an endoscopic endonasal transclival approach to the right petroclival region, performed
with 0-degree (a–d) and 30-degree (e–g) endoscopes. (a) Wide bilateral sphenoidotomy and ethmoidectomies with posterior
septectomy create a single posterior nasal cavity. (b) Removal of the sellar face and fl oor. (c) After removal of the pharyngobasilar
fascia and longus capitis muscle, the inferior clivus and the rectus capitis anterior muscle are exposed. The inferior clival line off ers a
reliable landmark for the hypoglossal canal. (d) A pan clivectomy is performed to expose the clival dura. (e) Intradural ventral view
of the right petroclival region. A white dotted circle shows the abducens nerve piercing the periosteal dura behind the petrosal apex
bone. (f) General view of the region exposed in (e). (g) Intradural view of the upper clivus region/interpeduncular fossa. AICA, anterior
inferior cerebellar artery; BA, basilar artery; DS, diaphragma sellae; ICA, internal carotid artery; Med, medulla; PF, pharyngobasilar
fascia; ET, eustachian tube; V, vomer bone; P-com: posterior communicating artery; PG: pituitary gland; SHA: superior hypophyseal
artery; Sn, sympathetic nerve; St, pituitary stalk; VA: vertebral artery; III, oculomotor nerve; VI, abducens nerve.
Post.
Lt
III
PG
VI
ICA
PA
VI
D
ICA
III
VI
BA
PG
M
PCA
SCA
ALCA
IV
VI
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Fig. 30.3 A case of trigeminal
schwannoma in petroclival lesion.
Axial (a) and sagittal (b) contrastenhanced magnetic resonance
imaging (MRI) demonstrated
the dumbbell-type trigeminal
schwannoma located in Meckel’s
cave and petroclival lesion. The tumor
was enhanced heterogeneously. (c)
Postoperative axial contrast-enhanced
MRI showed the total removal of
the tumor without any damage of
temporal lobe. (d) Postoperative
computed tomography scans of the
bone showed the resection area of
petrosal apex that was the working
window in the anterior transpetrosal
approach (white arrow).
ment and lesions extending to the middle fossa and/or infratemporal fossa. Both the EEA and the ATPA are complementary approaches and can be utilized independently
or in combination with each other to approach complex
petroclival lesions.
30.5 Case Example
A 52-year-old female presented with a 4-month
history of diplopia. Examination revealed hypesthesia in the first and second divisions of the right
trigeminal nerve and left abducent palsy, and no
other neurologic deficits. Magnetic resonance
imaging revealed a large tumor in the left parasellar lesion, with heterogeneous enhancement. The
tumor extended into the middle and posterior fossae. The patient underwent tumor resection via ATPA
(Fig. 30.3). The tumor was totally resected with preser-
vation of the root of the fifth cranial nerve. On the basis
of pathologic examination of the obtained sample, the
lesion was diagnosed as a schwannoma. Postoperative
complications included mild facial hypesthesia of the
first and second divisions of trigeminal nerve, but no
oculomotor disturbance.
References
1. Kawase T, Shiobara R, Toya S. Middle fossa transpetrosal-transtentorial approaches for petroclival meningiomas. Selective pyramid resection and radicality. Acta Neurochir (Wien) 1994;
129(3–4):113–120
2. Kawase T, Shiobara R, Toya S. Anterior transpetrosal-transtentorial approach for sphenopetroclival meningiomas: surgical method
and results in 10 patients. Neurosurgery 1991;28(6):869–875,
discussion 875–876
3. Kawase T, Toya S, Shiobara R, Mine T. Transpetrosal approach for
aneurysms of the lower basilar artery. J Neurosurg 1985;63(6):
857–861
4. Muto J, Kawase T, Yoshida K. Meckel’s cave tumors: relation to
the meninges and minimally invasive approaches for surgery:
anatomic and clinical studies. Neurosurgery 2010; 67(3, Suppl
Operative):291–298, discussion 298–299
5. Muto J, Prevedello DM, Ditzel Filho LF, et al. Comparative analysis of the anterior transpetrosal approach with the endoscopic endonasal approach to the petroclival region. J Neurosurg
2016;125(5):1-16
6. Morera VA, Fernandez-Miranda JC, Prevedello DM, et al. “Farmedial” expanded endonasal approach to the inferior third of the
clivus: the transcondylar and transjugular tubercle approaches.
Neurosurgery 2010; 66(6, Suppl Operative):211–219, discussion
219–220
7. Jittapiromsak P, Sabuncuoglu H, Deshmukh P, Nakaji P, Spetzler
RF, Preul MC. Greater superficial petrosal nerve dissection: back
to front or front to back? Neurosurgery 2009; 64(5, Suppl 2):
253–258, discussion 258–259
320
V
I
Section 8
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31 Intracranial vascular anatomy 323
Basic Landmarks in
Expanded Endoscopic
Skull Base Surgery
32 Cranial nerves 347
33 Bony Landmarks 359
II
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Chapter 31
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31.1 Internal Carotid Artery 324
Intracranial Vascular
Anatomy
31.2 Superior and Inferior
Intercavernous Sinuses
(and Cavernous Sinuses) 335
31.3 Superior and Inferior
Petrosal Sinuses 338
31.4 Basilar Artery (and
Vertebrobasilar System
including Vertebral Arteries) 339
1
Intracranial Vascular Anatomy
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31 Intracranial Vascular Anatomy
Paolo Castelnuovo, Apostolos Karligkiotis, Iacopo Dallan
Introduction
Describing the intracranial vascular anatomy is a complex
and challenging task, particularly if the anatomy has to be
depicted from an endoscopic surgical perspective. For this
reason, we have decided to use the concept of corridors as
a teaching tool in this chapter. By creating one corridor, it
is possible to see what lies behind and this model can be
reproduced endlessly during dissection. In this sense, the
paranasal sinuses (especially the ethmoid and sphenoid
sinuses) can be considered the endoscopic gateway to the
ventral and lateral skull base. Obviously, knowledge of the
surgical landmarks is mandatory to safely perform every
single approach to the skull base. However, the endoscopic
corridors are followed by a description of the gross anatomy of each vascular structure described in this chapter.
31.1 Internal Carotid Artery
From an endoscopic point of view the internal carotid
artery (ICA) can be divided in five segments: (1) parapharyngeal or cervical segment, (2) petrous segment, (3)
supralacerum segment, (4) cavernous segment [(a) paraclival and (b) parasellar], and (5) supracavernous segment
[(a) clinoidal and (b) cisternal]. In this chapter, only the
intracranial segments (3–5) (Fig. 31.1) will be described
in detail, while the parapharyngeal and petrous segments
will only be mentioned.
OC
ON
PS
PG
Fig. 31.1 Endoscopic view of the intracranial segments
of the internal carotid artery and its relationship with the
pituitary gland, the cavernous sinus, and the suprasellar
region. C, clivus; cpcICA, cavernous paraclival internal carotid
artery; cpsICA, cavernous parasellar internal carotid artery;
CS, cavernous sinus; iDR, inferior dural ring; IHA, inferior
hypophyseal artery; OC, optic chiasma; ON, optic nerve; PG,
pituitary gland; PS, pituitary stalk; sccICA, supracavernous
clinoidal internal carotid artery; uDR, upper dural ring; V2,
maxillary branch of trigeminal nerve; VIcn, abducens nerve.
1
ON
uDR
sccICA
iDR
cpsICA
IHA
cpcICA
C
VIcn
CS
V2
31.1.1 Parapharyngeal and Petrous
Segments
The ICA starts at the common carotid artery bifurcation
and runs toward the skull base, to enter the external orifice
of the carotid canal of the petrous bone. The ICA is seated
anteromedial to the vagus nerve and medial to the internal jugular vein inside the carotid sheath. The endoscopic
corridor to reach the parapharyngeal or cervical segment
of the ICA is the infratemporal one and the anatomic dissection as well as anatomy are described in more detail in
Chapter 25. Once in the skull base, the ICA enters the carotid canal and turns from vertical to horizontal inside the
petrous bone. Then, the ICA follows a posterior-to-anterior
and lateral-to-medial trajectory toward the foramen lacerum (FL). The petrous segment of the ICA and its exposure
are described in more detail in Chapter 17.
31.1.2 Supralacerum Segment
Supralacerum Segment of ICA via the
Transpterygoidal Corridor
The key structure to reach endoscopically the anterior
genu and supralacerum segment of the ICA is the pterygoid or vidian canal. The pterygoid bone lies posterior to the palatine bone. By drilling in a lateral direction
where the pterygoid plate joins the basisphenoid, the
pterygoid (vidian) canal can be identified.
points toward the ICA, at the level of the supralacerum
portion (anterior genu) (Fig. 31.2). The vidian nerve passes through the pterygoid canal running from the anterior
genu of the ICA to reach the pterygopalatine ganglion in
the upper portion of the pterygopalatine fossa (Fig. 31.3).
The artery of the pterygoid canal (vidian artery) is not always present. From an anatomic point of view, there is
an anterior (from external carotid artery [ECA] system)
and a posterior (from ICA system) vidian artery. However,
it is possible that there is no counterpart from the maxillary artery. In this case, the artery (~0.5 mm) has been
described to transverse the cartilage-filled FL to enter the
pterygoid canal.
Anatomy
Once the ICA exits the petrous bone, it curves upward
above the FL, thus giving the anterior genu that is not truly intrapetrous. Anatomically, the FL is an opening in the
dry skull that in life is filled by fibrocartilaginous tissue
(fibrocartilago basalis) that is firmly attached to the ICA,
eustachian tube, clivus, and petrous portion of the temporal bone.
of the sphenoid, and medially the occipital bone. Tiny
periosteal branches of the petrous ICA, the meningeal
branches of the ascending pharyngeal artery, and small
veins pass it.
origin to the vidian artery that enters and courses into
the pterygoid canal to anastomose with the same-named
branch of the maxillary artery (Fig. 31.3).
4
Its borders are the petrous apex, the body
5
The supralacerum segment of the ICA gives
2,3
This canal
6
324
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