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Carotid 360°
1. The Queen of skull base
Carotid 360°
21-1-2016
11.14pm
The Queen Padmini, Rajasthan, India
https://www.flickr.com/photos/bikashputatunda/
5360119800/
2. Great teachers – All this is their work .
I am just the reader of their books .
Prof. Paolo castelnuovo
Prof. Aldo Stamm Prof. Mario Sanna
Prof. Magnan
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10. Internal carotid artery going medial & posterior to medial pterygoid muscle into
Parapharyngeal space & becoming Parapharyngeal carotid
12th nerve bissecting internal &
external carotid
11. Internal carotid artery going medial & posterior
to medial pterygoid muscle into Parapharyngeal
space & becoming Parapharyngeal carotid
12. After removing the LPM you will see Tensor veli palatini muscle (TVPM) coming
vertically downwards from anterior surface of ET , protecting parapharyngeal carotid
& after TVPM , thick Stylopharyngeal apneurosis (SPHA ) present ANTERIOR to
Parapharyngeal carotid [ So 2 structures ( TVPM & SPHA ) protecting parapharyngeal
carotid ]
13. Hand model --
left hand = medial & lateral pterygoid
right hand = index is parapharyngeal
carotid , middle is IJV , ring is styloid &
stylopharyngeal muscles , thumb is
horizontal carotid
14. Great vessels , last 4 cranial nerves & sympathetic
plexus present in Post-styloid compartment.
17. Transoral approach to SUPERO-MEDIAL Parapharyngeal
tumors – incision anterior to anterior pillar of tonsil
18.
19.
20. In infrapetrous approach there are chances of injury to 6th nerve [ in dorello’s
canal medial to paraclival carotid ] & 12th nerve
21. The hypoglossal nerve exits from the hypoglossal canal medial to the ICAp. It lies posteriorly to
the vagus nerve and passes laterally between the internal jugular vein and ICAp.
The hypoglossal nerve is usually accompained, within the hypoglossal canal, by an emissary vein and arterial
branches from ascending pharyngeal artery and occipital artery.
C1 atlas, Cl clivus, CS cavernous sinus, CV condylar vein, FCB fi brocartilago basalis, HC hypoglossal canal,
ICAc cavernous portion of the internal carotid artery, ICAp parapharyngeal portion of the internal carotid
artery, JT jugular tubercle, OC occipital condyle, XIIcn hypoglossal nerve, violet arrow atlanto-occipital
joint
22.
23. Posterior boarder of Lateral Pterygoid bone leads to Foramen
Ovale [ FO ] – Dr.Kuriakose
24. Endoscopically [ Anterior skull base ] if we follow upper end of LPT posteriorly we can
reach V3 [ Posterior boarder of Lateral Pterygoid bone leads to Foramen Ovale –
Dr.Kuriakose ]
25. Yellow arrow - Bony-cartilagenous junction of ET tube is
at posterior genu of carotid - ET is pointing like an
ARROW the posterior genu of internal carotid
26. V 3 is anteriror to all the 3 structures - Petrous carotid
& ET & Parapharyngeal carotid [ very imp ]
28. KISSING CAROTIDS
1. http://radiopaedia.org/articles/kissing-carotids
2. http://www.ncbi.nlm.nih.gov/pubmed/17607445
• The term kissing carotids refers to
tortuous and elongated vessels which
touch in the midline. They can be be
found in:
• retropharynx 2
• intra-sphenoid 1
– within the pituitary fossa
– within sphenoid sinuses
– within sphenoid bones
• The significance of kissing carotids is
two-fold:
– may mimic intra-sellar pathology
– catastrophic if unknown or
unreported before
transsphenoidal / retropharyngeal
surgery
29. Cervical kissing carotids – here also papaphayrngela kinking
present http://www.radrounds.com/photo/cervical-kissing-
carotids-1
Coronal MIP of aberrant medial course
of the carotids arteries showing the
internal carotids arteries nearly
touching at the C2 level.
30. kinking or looping of the ICAp - when looping present para-pharyngeal carotid
comes to pre-styloid compartment – previously thought that para-pharyngeal
carotid never comes anterior to styloid mucles – which is UNTRUE
31. The stylopharyngeus and styloglossus muscles are critical landmarks, being
usually placed anterior to the great vessels (Dallan et al. 2011 ).
Note that the presence of kinking or looping of the ICAp could make this
statement untrue.
32. The stylopharyngeus and styloglossus muscles are critical landmarks, being
usually placed anterior to the great vessels (Dallan et al. 2011 ).
Note that the presence of kinking or looping of the ICAp could make this
statement untrue.
33. Cervical kissing carotids – here also papaphayrngeal kinking
present http://www.radrounds.com/photo/cervical-kissing-
carotids-1
Coronal MIP of aberrant medial course
of the carotids arteries showing the
internal carotids arteries nearly
touching at the C2 level.
34. An Aberrant Cervical Internal Carotid Artery in the Mouth – we
have to be very careful even in adenoidectomy also.
http://amjmed.org/an-aberrant-internal-carotid-artery-in-the-mouth/
35.
36. In this kinking of ICA also Prof.Mario
Sanna uses very flexible ICA stents
37. Relation of Eustachian tube & looping of parapharyngeal carotid
& styloid process – loop of paraphyrngeal carotid came anterior
to ET & styloid process – which means when loop present , it
comes to pre-styloid compartment
40. The external carotid artery passes deeply to the digastric and stylohyoid
muscles, but superficially to the stylopharyngeus and styloglossal muscle
when running toward the parotid gland (Janfaza et al. 2001 ) .
41. From Aldostamm - Fig. 42.10 - When there is loop of parapharyngeal
carotid , it goes nearer to the RCLM or anterior arch of atlas
Anterior view. The right longus capitis muscle has been
removed. 1, clivus; 2, anterior arch of the atlas; 3, atlantoaxial joint;
4, left longus capitis muscle; 5, longus colli muscle; 6, rectus capitis
anterior muscle; 7, carotid artery.
43. Infra-temporal fossa approach
The rest of the anterior canal wall has been drilled away, and
the internal carotid artery is better skeletonized. C Basal turn of the
cochlea (promontory), ET Eustachian tube, FN(m) Mastoid segment of
the facial nerve. G Genu of the internal carotid artery, ICA(v) Vertical
segment of the internal carotid artery
44. To obtain control of the horizontal
segment of the internal
carotid artery, the eustachian tube
(ET), glenoid fossa bone (GF), and the
anterior zygomatic tubercle (AZT)
have to be carefully drilled away.
ICA Vertical segment of the internal
carotid artery
In live surgery, the middle meningeal
artery (MMA) should be
coagulated to prevent bleeding. ICA
Internal carotid artery, MFP Middle
fossa plate
45. The middle meningeal artery
(MMA) is being sharply cut.
ET Eustachian tube, ICA
Internal carotid artery, MFP
Middle fossa plate
Further anterior drilling uncovers the
mandibular nerve (MN).
This nerve also has to be coagulated in
live surgery before it is cut.
ET Eustachian tube, ICA Internal
carotid artery, MFP Middle fossa plate
46. Sharply cutting the mandibular
nerve (MN). ET Eustachian
tube, ICA Internal carotid
artery, MFP Middle fossa plate
The stumps of the mandibular
nerve (*). ET Eustachian tube,
ICA Internal carotid artery,
MFP Middle fossa plate
47.
48. Endoscopic view of the eustachian tube orifice
(arrow).- Note Internal carotid artery
50. The tensor tympani muscle has
been dissected away from its
canal (TTC). ET Medial wall of the
eustachian tube, ICA Internal
carotid
artery, MFP Middle fossa plate
A large diamond burr is used to remove the
remaining bone
overlying the horizontal segment of the internal
carotid artery. C Basal
turn of the cochlea (promontory), ICA Vertical
segment of the internal
carotid artery, MFP Middle fossa plate, MMA
Stump of the middle
meningeal artery, MN Stump of the mandibular
nerve
51. In Infra-temporal fossa approach
The full course of the intratemporal internal carotid artery has
been freed. AFL Anterior foramen lacerum, CF Carotid foramen, CL
Dura
overlying the clivus area, ICA(h) Horizontal segment of the
internal
carotid artery, ICA(v) Vertical segment of the internal carotid
artery,
MN Stump of the mandibular nerve
Drilling of the clivus has been completed. C Basal
turn of the
cochlea (promontory), FN(m) Mastoid segment
of the facial nerve,
FN(t) Tympanic segment of the facial nerve, GG
Geniculate ganglion,
GPN Greater petrosal nerve, ICA Internal carotid
artery, RW Round window
52. Pterygoid trigone – just anterior to foramen lacerum in
both photos is Pterygoid trigone
55. Note that the basal turn of the cochlea (BT) starts to curve
superiorly near the internal carotid artery (ICA), a short distance
from the level of the round window.
56. In most cases, the medial aspect of the horizontal
portion of the internal carotid
artery is not covered by bone, but simply by dura.
57. GSPN bisects the Petrous carotid & V3 and
Vertical part of Facial nerve bisects Jugular bulb
GSPN bisects V3
58. In most cases, the medial aspect of the horizontal
portion of the internal carotid
artery is not covered by bone, but simply by dura.
62. Paraclival carotid
1. Lower half of paraclival
carotid - caudal part, the
lacerum segment of the
artery corresponding to the
extracavernous portion of
the vessel, and
2. Upper half of paraclival
carotid - rostral part, the
trigeminal, intracavernous
portion of the artery, so-
called because the Gasserian
ganglion is posterior to it and
the trigeminal divisions are
lateral to it.
63. Pontomedullary junction = Vertebro-basillar junction =
Junction of Mid clivus & Lower clivus = foramen lacerum area
The pontomedullary junction. The vertebral artery junction is at the level of the
junction of the inferior and midclivus. The basilar artery runs in a straight line on the
surface of the pons. The exit zones of the hypoglossal and abducent nerves are at the
same level. The abducent nerve exits from the pontomedullary junction, and ascends
in a rostral and lateral direction toward the clivus.
64. Lower half of paraclival carotid - caudal part, the lacerum segment of
the paraclival carotid
”The unsolved surgical problem remains the medial wall of the ICA at the level of the
anterior foramen lacerum, until now unreachable with the available surgical
approaches." - In lateral skull base by Prof. Mario sanna – this unreachable is Carotid-
Clival window which is accessable in Anterior skull base
Infrapetrous Approach
Carotid-Clival window – Mid clivus
a. Petrosal face
b.Clival face
65. Upper half of paraclival carotid – rostral part, the trigeminal
segment of the paraclival carotid
TG ( Trigeminal ganglion ) is lateral to upper half [ rostral part ]
of Paraclival carotid
Anterior skull base Lateral skull base
66. “Front door” to Meckel’s cave
PLL - It can be considered
the border between the horizontal and cavernous portions of the
internal carotid artery.
67. 1. 6th N. crossing carotid at Petro-clival junction when viewing in lateral skull base - The
lateral aspect of the parasellar & paraclival carotid junction is crossed by the
abducent nerve (VI) at the entrance of both [ 6th nerve & carotid ] structures into the
cavernous sinus.
2. The gulfar segment can be identified at the intersection of the sellar floor and the
proximal parasellar internal carotid artery (ICA) (Barges-Coll et al. 2010 ).
68. After drilling the carotid canal what we see is endosteal layer /
periosteum, not directly the ICA
Subperiosteal/Subadventitial Dissection
Subperiosteal/subadventitial dissection is accomplished for tumors that involve the ICA to a greater extent,
such as C2 glomus tumors and meningiomas (Fig. 15.24a, b). In general, dissection of the tumor from the
artery is relatively easier and safer in the vertical intrapetrous segment, which is thicker and more accessible
than the horizontal intrapetrous segment. A plane of cleavage between the tumor and the artery should be
found first. In most cases, the tumor is attached to the periosteumsurrounding the artery. Dissection
is better started at an area immediately free of tumor. Aggressive tumors may, however, extend even to the
adventitia of the artery and subadventitial dissection may be needed. This should be done very carefully in
order to avoid any tear to the arterial wall, which can become weakened (Fig. 15.25), with the risk of
subsequent blowout.
69. A case of left glomus jugulare tumor in our early experience. ubadventitial dissection has been
performed because the artery had been so weakened after the tumor removal. Although the
patient had no relevant complications postoperatively, such excessive manipulation is better
avoided and permanent balloon occlusion or stenting are preferably tried preoperatively.
81. Foramen lacerum - The petrous ICA then curves upward above the
foramen lacerum (FL), thus giving the anterior genu. The segment above the FL is not
truly intrapetrous, and it has been called the lacerum segment by some authors
(Bouthillier et al. 1996 ) . These segments, the anterior genu and the anterior vertical
segment, are placed above the FL, and the artery does not cross the foramen. In this
sense, it is better called the supralacerum segment (Herzallah and Casiano 2007 ) .
Anatomically, the FL is an opening in the dry skull that in life is fi lled by fi
brocartilagineous tissue (fi brocartilago basalis).
AFL = Anterior foramen
lacerum
* [ black asterisk ] = foramen
lacerum
Petrolingual area = foramen
lacerum
83. 1. The foramen lacerum (FL) is located lateral to the floor of the sphenoid sinus at the
level of the spheno-petro-clival confuence.
2. In respect to the FL, the JT is postero-medially located. Therefore to
access the jugular tubercle from anteriorly a complete exposure of the foramen
lacerum is needed.
black asterisk foramen lacerum , JT jugular tubercle, HC hypoglossal canal
85. Parasellar carotid – shrimp shaped
It covers four segments of the ICA: (1) the hidden segment; (2) the inferior horizontal segment;
(3) the anterior vertical segment, and (4) the superior horizontal segment. The hidden segment is
located at the level of the posterior sellar floor and includes the posterior bend of the ICA. The
inferior horizontal segment appears short due to the perspective view, but is the longest segment
of the intracavernous ICA. It courses along the sellar floor. The anterior vertical segment
corresponds to the convexity of the C- shaped parasellar protuberance. The superior horizontal
segment includes the clinoidal segment which courses medially to the optic strut, is anchored by
the proximal and distal dural ring and continues in the subarachnoid portion of the vessel.
86. Parasellar carotid
It covers four segments of the
ICA:
1. the hidden segment =
Posterior Genu– most common
injure area .
2. the inferior horizontal
segment – The inferior horizontal
segment appears short due to the
perspective view, but is the longest
segment of the intracavernous ICA.
3. the anterior vertical
segment, and
4. the superior horizontal
segment ( = Clinioidal segment )
Or in another way
1. Retrosellar prominance
2. Infrasellar prominance
3. Presellar prominance
87. Cadaveric dissection image demonstrating the close anatomical relationship
of the posterior clinoid (PC) with both the intracranial carotid artery (ICCA)
and the posterior genu of the intracavernous carotid artery (P. CCA). AL,
anterior lobe of the pituitary gland; PL, posterior lobe of the pituitary gland;
BA, basilar artery.
90. A) Cadaveric dissection image taken within the sphenoid sinus, with removal of bone over the lateral sphenoid wall.
The paraclival carotid artery (PCA) enters the base of the sphenoid sinus and runs in a vertical direction. At
approximately the level of the V2 (maxillary division of trigeminal nerve) the carotid artery then enters the cavernous
sinus and becomes the intracavernous carotid artery (CCA). Once the artery enters the cavernous sinus it continues to
ascend for a short distance, called the vertical portion of the CCA (V. CCA), before turning anteriorly at the posterior
genu of the CCA (P. Genu CCA). This posterior genu corresponds to the floor of the sella. The artery then runs
horizontally as the horizontal portion of the CCA (H. CCA), before reaching the anterior
91. Intrasellar kissing carotid arteries -This anomaly is particularly
important since it may cause or mimic pituitary disease and also may complicate transsphenoidal
surgery.http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-
282X2007000200034&lng=en&nrm=iso&tlng=en
92.
93.
94.
95.
96. http://www.slideshare.net/INUB/endoscopic-anatomy-and-approaches-of-the-cavernous-sinus-
cadaver-study - Endoscopic view of the right cavernous sinus and neurovascular relations,
demonstrating the ‘S’ shaped configuration formed by the oculomotor, the
abducens , carotid nerve ( paraclival carotid ) and the vidian nerves.
III oculomotor nerve, V1 ophthalmic nerve, V2 maxillary nerve, V3 mandibular nerve, VI abducens
nerve, C clivus, ICA-Sa anterior bend of the internal carotid artery–parasellar segment, ICA-Sp posterior
bend of the internal carotid artery–parasellar segment, ICA-C paraclival segment of the internal carotid
artery, ICA-L lacerum segment of the internal carotid artery, ICA-P petrous segment of the internal
carotid artery, PG pituitary gland, VC vidian canal, VN vidian nerve
VI nerve is parallel & medial to V1 –
in the same direction of V1 [
Mneumonic – VI & V1 in same
direction ]
97. 1. 6th N. crossing carotid at Petro-clival junction when viewing in lateral skull base - The
lateral aspect of the parasellar & paraclival carotid junction is crossed by the
abducent nerve (VI) at the entrance of both [ 6th nerve & carotid ] structures into the
cavernous sinus.
2. The gulfar segment can be identified at the intersection of the sellar floor and the
proximal parasellar internal carotid artery (ICA) (Barges-Coll et al. 2010 ).
98. Carotid nerve –
part of S’ shaped configuration formed by the
oculomotor, the abducens , carotid nerve (
paraclival carotid ) and the vidian nerves.
99. VI nerve is parallel & medial to V1 – in the same direction of V1 [ Mneumonic – VI &
V1 in same direction ]
100. STA is devided into 1. Supra-Trochlear triangle
2. Infra-Trochlear triangle
101. STA is devided into 1. Supra-Trochlear triangle
2. Infra-Trochlear triangle
1.Supra Trochanteric & Infratrochanteric Triangles
2. Upper & lower dural rings
3. lower dural ring is COM ( Carotico-Oculomotor Membrane )
In the below picture superior
cerebellar artery mislabelled as
meningohypophyseal trunk .
102. STA is devided into 1. Supra-Trochlear triangle
2. Infra-Trochlear triangle
1.Supra Trochanteric & Infratrochanteric Triangles
2. Upper & lower dural rings
3. lower dural ring is COM ( Carotico-Oculomotor Membrane )
Right lateral view of the inferolateral trunk or artery of the inferior
cavernous sinus, a branch of the horizontal part of the internal carotid
artery (ICA) that provides blood to the dura of the lateral wall of the
cavernous sinus as well as to the cranial nerves running along the lateral
wall of the cavernous sinus. The trochlear nerve has been displaced
inferiorly and the oculomotor nerve has been displaced superiorly. A
recurrent branch from the inferolateral trunk is observed in this specimen.
This branch heads back toward the tentorium cerebelli forming the so-
called marginal tentorial artery. 1=horizontal segment of cavernous ICA,
2=clinoid segment of ICA, 3=supraclinoid ICA, 4=inferolateral trunk or
artery of the inferior cavernous sinus, 5=marginal tentorial artery, 6=optic
nerve, 7=oculomotor nerve, 8=trochlear nerve, 9=ophthalmic nerve,
10=abducent nerve, and 11=sphenoid sinus.
103. 1. In the posterior part of the CS the trochlear nerve is below the oculomotor nerve, while
anteriorly it turns upward and becomes the most superior structure of the CS (at the level of
the optic strut) (Iaconetta et al. 2012 ) .
2. Trochlear nerve is always superior to V1.
104. The abducens nerve in most case is a single trunk throughout its entire course (Zhang et al. 2012 ) . There
are some variants, and one should be aware that the nerve can fuse with the oculomotor nerve for all its
course (Zhang et al. 2012 ) . The surgeon must be prepared to face other rare variations, such as different
fasciculi within the CS. Globally, the incidence of a duplicated abducens nerve has been reported, ranging
from 8 % to 18 % (Nathan et al. 1974 ; Iaconetta et al. 2001 ; Ozveren et al. 2003 ) . In the prepontine cistern,
when the duplication is present, AICA passes through the bundles. Furthermore, the incidence of a
bilaterally duplicated nerve has been reported as frequently as 8 % of the time (Nathan et al. 1974 ; Ozveren
et al. 2003 ) . The abducens nerve can pass above the Gruber’s ligament in 12 % of cases (Lang 1995 ) .
Endoscopic vision of the cavernous sinus. Vision obtained through a right supraorbital
approach with a 30° down-facing lens focusing on the cavernous sinus
ICAc cavernous portion of the internal carotid artery, lwCS lateral wall of the cavernous sinus, SCA
superior cerebellar artery, IIIcn oculomotor nerve, IVcn trochlear nerve, Vcn root of the trigeminal nerve,
VIcn abducens nerve, blue arrow Gruber’s ligament, white asterisk Dorello’s canal.
105. Blue arrow in Left picture ; * in Right
picture - Gruber’s ligament
106. http://www.slideshare.net/INUB/endoscopic-anatomy-and-approaches-of-the-
cavernous-sinus-cadaver-study- Endoscopic view of the right cavernous sinus and its
neurovascular relations, demonstrating the triangular area formed by the medial
pterygoid process laterally, the parasellar ICA medially and the vidian nerve inferiorly
at the base. III oculomotor nerve, V1 ophthalmic nerve, V2 maxillary nerve, V3
mandibular nerve, VI abducens nerve, C clivus, ICA-Sa anterior bend of the internal
carotid artery–parasellar segment, ICA-Sp posterior bend of the internal carotid
artery–parasellar segment, ICA-C paraclival segment of the internal carotid artery, ICA-
L lacerum segment of the internal carotid artery, ICA-P petrous segment of the
internal carotid artery, PG pituitary gland, VC vidian canal, VN vidian nerve
107. http://www.slideshare.net/INUB/endoscopic-anatomy-and-approaches-of-the-cavernous-
sinus-cadaver-study -Endoscopic view of the right cavernous sinus showing its neurovascular
relations and the main anatomic areas. III oculomotor nerve, V1 ophthalmic nerve, V2
maxillary nerve, V3 mandibular nerve, VI abducens nerve, C clivus, ICA-Sa anterior bend of
the internal carotid artery–parasellar segment, ICA Sp posterior bend of the internal carotid
artery–parasellar segment, ICA-C paraclival segment of the internal carotid artery, ICA-L
lacerum segment of the internal carotid artery, ICA-P petrous segment of the internal carotid
artery, PG pituitary gland, VC vidian canal, VN vidian nerve, STA superior triangular area, SQA
superior quadrangular area, IQA inferior quadrangular area
1.Supra Trochanteric & Infratrochanteric Triangles
2. Upper & lower dural rings
108.
109.
110. Branches of cavernous carotid
1. Meningohypophyseal trunk
2. Inferolateral trunk
The anterior lobe of the pituitary gland is mainly fed by the superior hypophyseal
arteries while the posterior lobe is fed mainly by the inferior hypophyseal artery.
Branches of Intracranial carotid
1. Superior hypophyseal Artery
2. Retrograde branch – Opthalmic artery
3. Anterior choroidal artery
4. Pcom
5. MCA
6. ACA
112. The MHT is traditionally described as having three branches:
1. the inferior hypophyseal artery, IHA
2. the dorsal meningeal artery (also called the dorsal clival artery) DMA, and
3. the tentorial artery (also called the Bernasconi-Cassinari artery) BCA .
113.
114. Cadaveric dissection image of the right side of the pituitary gland. Dissection has occurred
between the periosteal layer of dura and the meningeal layer of dura (MD) as far posteriorly as
the dorsum sella. The inferior hypophyseal artery (IHA) is visualized as
the base of the posterior clinoid (PC).
Cadaveric dissection image of the pituitary gland tethered from its
transposed position by the inferior hypophyseal artery
(IHA). In this image the meningeal and periosteal layers of dura have
been removed. The IHA needs to be ligated and cut to allow
complete transposition between the carotid arteries. The dorsum
sella (DS) can be visualized. P, pituitary gland; CS, cavernous sinus.
115. At superior part of Siphon carotid , SHA arises where as
inferior part of Siphon carotid MHT [ Inferior
hypophyseal artery ] arises
116. DMA main feeder of dorellos
segement of 6th nerve
DMA main feeder of dorellos
segement of 6th nerve
124. The anterior lobe of the pituitary gland is mainly fed by the superior
hypophyseal arteries while the posterior lobe is fed mainly by the inferior
hypophyseal artery.
125. Cadaveric dissection allowing visualization into the subchiasmatic cistern. The superior
hypophyseal artery (SHA) can be seen g iving off its chiasmatic (C) and infundibular (I)
branches. ON, optic nerve; OC, optic chiasm; CCA, cavernous carotid artery.
Cadaveric dissection image demonstrating the
incised diaphragma (D) to the pituitary stalk (PS).
ON, optic nerve; OC, optic chiasm; CCA,
cavernous carotid artery.
126. Superior Hypophyseal Arteries [ SHAs ]
- more commonly arise from the paraclinoid ICA - In rare cases SHAs originate
from the intracavernous segment of the ICA
130. classification of the ophthalmic artery types
http://www.springerimages.com/Images/MedicineAndPublicHealth/1-
10.1007_s10143-006-0028-6-1
a = intradural type,
b = extradural supra-optic strut type [ Optic strut = L-OCR ]
c = extradural trans-optic strut type
on optic nerve, pr proximal ring, cdr carotid dural
ring= upper dural ring , ica internal carotid artery
I think this variation is type c
131. In both type a = intradural type,
b = extradural supra-optic strut types Opthalmic
foramen is in Optic canal
132. In Type c = extradural trans-optic strut type , the Opthalmic
foramen in Optic strut
134. Origin and intracranial and
intracanalicular course of
the ophthalmic artery and its
subdivisions, as seen on opening
the optic canal (reproduced from
Hayreh67).
Both from one specimen. (a) The extradural
origin of the right ophthalmic artery, so that
no ophthalmic artery is seen even on
opening theoptic canal; a thinning of the
dural sheath is seen at 'X', indicating the
position of the artery. (b) The ophthalmic
artery is seen after removing the dural
sheath covering it (reproduced from Hayreh
and Dass2).
135. Schematic drawing origin (a medial, b central, c lateral) and exit
(d lateral, emedial) of superior wall of the ophthalmic artery
136. A diagrammatic representation of variations in origin and intraorbital course of ophthalmic artery.
(a) Normal pattern. (b–e) The ophthalmic artery arises from the internal carotid artery as usual,
but the major contribution comes from the middle meningeal artery. (f and g) The only source of
blood supply to the ophthalmic artery is the middle meningeal artery, as the connection with the
internal carotid artery is either absent (f) or obliterated (g) (reproduced from Hayreh and Dass3).
137. Origin, course, and branches of the ophthalmic artery in two adult specimens. Segment Y
disappeared in (a) and segment Z disappeared in (b), resulting in the ophthalmic artery crossing
under the optic nerve in both. In (b) an anastomosis is seen in lateral wall of the cavernous sinus
between the part of the internal carotid artery lying in proximal part of the cavernous sinus and a
branch from the ophthalmic artery passing through the superior orbital fissure (reproduced from
Hayreh67).
138.
139. Various relations of OA [ Opthalmic artery ] to ON
left figure when it crosses under the optic
nerve (in 17.4%) and right figure when it
crosses over the optic nerve (in 82.6%).
141. ACA anterior cerebral artery, AchA anterior choroidal artery, BA basilar artery, Cl clivus, DS diaphragma
sellae, ICAi intracranial portion of the internal carotid artery, OA ophthalmic artery, ON optic nerve,
PcomAf posterior communicating artery (fetal con fi guration), PcomAn posterior communicating artery
(normal con fi guration), PG pituitary gland, PS pituitary stalk, P1 fi rst segment of the posterior cerebral
artery, SCA superior cerebellar artery, SHAs superior hypophyseal arteries, TS tuberculum sellae, IIIcn
oculomotor nerve
The PcomA is the most variable vessel of Willis’s circle. If PcomA is wider than P1, it is
said to be of the fetal type. This happens in about 20 % of cases. In 1 % of cases, it is
absent (Lang 1995 ) .
148. Endoscopic third ventricle from
posteriorly -- a. Infundibular
recess b. tuber cinereum c.
mammillary bodies
left posterior communicating artery (a),
mammillary body (b), and right posterior
hypoplasic communicating artery (c) ---
measurement performed between the
posterior communicating arteries using
Geogebra software (a-b = 11.3 mm),
149. In the descriptive analysis of the 20 specimens, the PCoAs
distance was 9 to 18.9 mm, mean of 12.5 mm, median of 12.2
mm, standard deviation of 2.3 mm.
150. AchA anterior choroidal artery
Usually, the AchA arises from the ICA as a single artery, in most
cases close to the PcomA. In rare cases (2 %), it arises from the
PcomA or the MCA (Lang 1995 ; Rhoton 2003 ) . In the great
majority of cases, it arises from the cisternal segment of the ICA
lateral to the optic tract and passes below or along the optic tract
(usually medially to it) to get the lateral surface of the cerebral
peduncle.
151.
152. ACA anterior cerebral artery, AchA anterior choroidal artery, BA basilar artery, Cl clivus, DS diaphragma
sellae, ICAi intracranial portion of the internal carotid artery, OA ophthalmic artery, ON optic nerve,
PcomAf posterior communicating artery (fetal con fi guration), PcomAn posterior communicating artery
(normal con fi guration), PG pituitary gland, PS pituitary stalk, P1 fi rst segment of the posterior cerebral
artery, SCA superior cerebellar artery, SHAs superior hypophyseal arteries, TS tuberculum sellae, IIIcn
oculomotor nerve
The PcomA is the most variable vessel of Willis’s circle. If PcomA is wider than P1, it is
said to be of the fetal type. This happens in about 20 % of cases. In 1 % of cases, it is
absent (Lang 1995 ) .
153.
154. In the great majority of cases, it arises from the cisternal segment of the ICA
lateral to the optic tract and passes below or along the optic tract (usually
medially to it) to get the lateral surface of the cerebral peduncle.
161. Dural rings – the ICA between upper
& lower dural ring is Clinoidal ICA
162. Cl clivus, ICAc cavernous portion of the internal carotid artery, ON optic nerve, PG pituitary
gland, PS planum sphenoidale, TS tuberculum sellae, yellow asterisks upper dural ring, blue
arrowheads lower dural ring, white asterisk lateral optico-carotid recess, white circle medial
optico-carotid recess, white arrow ophthalmic artery, black arrows middle clinoid process, red
arrows lateral tubercular crest, yellow arrows endocranial region corresponding to MCP
163.
164. Anatomically speaking, the paraclinoid segment of the internal carotid artery is not fully
intracavernous, and it is separated from the cavernous sinus by the extension of the dura
covering the inferior surface of the anterior clinoid process (Reisch et al. 2002 ) .
Note carotid cave , cavernous
sinus , upper & lower dural rings
165. Upper [ green bangle ] & lower dural [ red bangle ] rings
166.
167. Lower dural ring is nothing but COM [ Carotico-occulomotor membrane ] - The dura
lining the inferior aspect of the anterior clinoid process forms the lower
dural ring. This ring is often incomplete on the medial side and often a venous channel
can follow the paraclinoidal ICA to the upper dural ring.
By Fronto temporal approach
168. lower dural ring - This ring is often incomplete on the medial side and often
a venous channel can follow the paraclinoidal ICA to the upper dural ring.
169. Clinoid has three roots of attachment
1. Anteriror root = Anterior Clinoid process attachemnt to planum
2. Posterior root = Optic struct = L-OCR
3. 3rd root = Anterior Clinoid process attachment to Lesser wing of sphenoid
170. Three surgical attachments of the right anterior clinoid process.
(a, sphenoid ridge; b, roof of optic canal; c, optic strut.)
173. The lower dural ring is given by the COM [ Carotid-oculomotor
membrane ] , that lines the inferior surface of the ACP. It can be visible, through a
transcranial route, only by removing the ACP. The lower dural ring is also called
Perneczky’s ring. Medially the COM blends with the dura that lines the carotid sulcus
(Yasuda et al. 2005 )
Endoscopic supraorbital view with a 30°
down-facing lens -The right portion of the
planum sphenoidale is seen from above.
Right side
176. ICAcl clinoidal portion of the
internal carotid artery , The
clinoidal segment of the internal
carotid artery faces the posterior
aspect of the optic strut.
white arrowhead - paraclinoid
portion of the internal carotid
artery – after removal of
anterior clinoidal process
177. ICA Clin.: clinoid, clinoidal [ Observe here also – posterior border of Optico-
carotid recess is Clinoidal ICA ]
183. The mOCR is located just medial to the paraclinoidal-supraclinoidal ICA
transition and inferior to the distal cisternal segment of the ON(Labib et al. 2013 ).
Cl clivus, ICAc cavernous portion of the internal carotid artery, ON optic nerve, PG pituitary
gland, PS planum sphenoidale, TS tuberculum sellae, yellow asterisks upper dural ring, blue
arrowheads lower dural ring, white asterisk lateral optico-carotid recess, white circle medial
optico-carotid recess, white arrow ophthalmic artery, black arrows middle clinoid process, red
arrows lateral tubercular crest, yellow arrows endocranial region corresponding to MCP
184. Cadaveric dissection image demonstrating the close anatomical relationship
of the posterior clinoid (PC) with both the intracranial carotid artery (ICCA)
and the posterior genu of the intracavernous carotid artery (P. CCA). AL,
anterior lobe of the pituitary gland; PL, posterior lobe of the pituitary gland;
BA, basilar artery.
186. Opthalmic artery – Retrograde branch of Intracranial carotid
Branches of the cavernous internal
carotid artery ( ICA ), a rare
variation: ophthalmic
artery passing through the superior
orbital fissure
187. In the lateral border of the chiasmatic cistern the first part of
the ICAi is visible.
Note Optic tract here which is above
Posterior clinoid process [ PCP ]
188. First part of intracranial carotid & paraclinoidal
carotid present in infra-chiasmatic cistern
189. In the lateral border of the chiasmatic cistern the first part of
the ICAi is visible.
Note the first part of ICAi in
chiasmatic cistern in bifrontal
craniotomy approach & note
the optico-carotid recess on
both sides .
Endoscopic anterior skull base
approach
214. https://www.scienceopen.com/document_file/84699ab2-4980-4f70-a5b0-
c8d95a1fb6a2/PubMedCentral/84699ab2-4980-4f70-a5b0-c8d95a1fb6a2.pdf
FIGURE 4. The capsule of the cystic craniopharyngioma was firmly attached to the left
hypothalamus, the stalk was dislocated to the right side (Patient 6). The outgrowth of the
craniopharyngioma from proximal stalk is recognizable A. Complete removal of the capsule was
possible, but produced subpial blood injection over the left hypothalamic surface B. MRI scan
revealed a small ischemic injury in the left hypothalamus C. This patient had transient sleep
disorder, moderate hyperphagia and memory problems (see also a supplemented video
material 1).
215. FIGURE 2. In this cystic craniopharyngioma (Patient 5), the stalk was centrally
infiltrated close to the pituitary and could not be preserved A. The incipient third
ventricle entrance is seen from intracavitary view. The slit into the third ventricle is
still covered with tumour capsule B. Complete removal of the capsule opened the
third ventricle C. Petehiae in the hypothalamus bilaterally resulted from apparently
gentle traction and blunt dissection of the capsule away from the hypothalamus
D. Psychoorganic change, disorientation and memory deficits were noticed in less
than a week after surgery, the transient sleep disorder become apparent in the
second week postoperatively (see also a supplemented video material 2).
216. FIGURE 3. Large craniopharyngioma (Patient 3) produced unilateral hydrocephalus
by obstructing the right formen of Monro A. The dome was filled with soft
cholesterine cristals B, which were easily removed. Lower limbus of the right foramen
of Monro is seen through the empty third ventricle D. Despite bilateral preservation
of anteromedial hypothalamus C and stalk preservation E, the patient developed
panhypopituitarism and diabetes insipidus with long lasting psychoorganic change
218. Surpra petrous window [ see the GSPN groove here ]
ET eustachian tube, GPN greater petrosal nerve, MCFd dura of the middle cranial fossa, MMA
middle meningeal artery, SPS superior petrosal surface, TI trigeminal impression, V3 third
branch of the trigeminal nerve, yellow arrow accessory middle meningeal artery, white
asterisks greater petrosal nerve groove
220. Inferior petrosal sinus is superior to jugular tubercle &
hypoglossal canal is inferior to jugular tubercle
Infratemporal fossa [=intact cochlear
approach – Dr.Morwani ] type B approach
221. The pontomedullary junction.
1. The exit zones of the hypoglossal and abducent nerves are at
the same level [ same vertical line when view from Transclival
approah ( through lower clivus ) ]
2. The abducent nerve exits from the pontomedullary junction, and ascends
in a rostral and lateral direction toward the clivus.
222.
223. In infrapetrous approach there are chances of injury to 6th nerve [ in dorello’s
canal medial to paraclival carotid ] & 12th nerve
224. When we are drilling lower clivus – lateral to
hypoglossal canal we get Jugular fossa
225. Adenoid cycstic carcinoma clivus -- Just look at the carotid. .The paraclival both sides
360 degree encased..look at the mass eroding Petros apex going above horizontal
carotid above the meckels cave..we need a trans cavernous..trans supra Petros. .infra
Petros. . App..
227. Fig. 2.1 Drawing showing the skin incision (red line), the craniotomy
and the microsurgical intraoperative view of the subfrontal unilateral approach. This approach provides a
wide intracranial exposure of the frontal lobe and easy access to the optic nerves, the chiasm, the carotid
arteries and the anterior communicating complex
228. Fig. 2.4 Intraoperative microsurgical photograph showing contralateral
extension of the tumor (T) dissected via a unilateral subfrontal
approach. Note on the left side the falx cerebri (F) and
the mesial surface of the left frontal lobe (FL)
229. Fig. 2.5 Drawing showing the skin incision (red line), the craniotomy
and the microsurgical anatomic view of the subfrontal bilateral
route. This approach provides a wide symmetrical anterior
cranial fossa exposure and easy access to the optic nerves, the
chiasm, the carotid arteries and the anterior communicating arteries
complex
230. In the lateral border of the chiasmatic cistern the first part of
the ICAi is visible.
Note the first part of ICAi in
chiasmatic cistern in bifrontal
craniotomy approach & note
the optico-carotid recess on
both sides .
Endoscopic anterior skull base
approach
231. Supraorbital approach - Fig. 3.2 Illustrations comparing the incision and
bony exposure in a supraorbital craniotomy with those in a pterional craniotomy. a
The supraorbital craniotomy utilizes the subfrontal corridor and involves a frontobasal
burr hole and removal of a small window in the frontal bone. b The pterional
craniotomy utilizes a frontotemporal incision and removal of the frontal and temporal
bones andsphenoid wing. The pterional craniotomy primarily exploits the sylvian
fissure
233. Fig. 4.6 a Craniotomy. b When the flap has been removed the
lesser wing of the sphenoid is drilled down to optimize the most
basal trajectory to the skull base. c Dural opening. DM dura
mater, FL frontal lobe, MMA middle meningeal artery, LWSB
lesser wing of the sphenoid bone, SF sylvian fissure, TL temporal
lobe, TM temporal muscle, ZPFB zygomatic process of the frontal bone
234. Fig. 4.8 Intradural exposure; right approach. Before (a) and after (b) opening of the
Sylvian fissure. A1 first segment of the anterior cerebral artery, AC anterior clinoid, FL
frontal lobe, HA Heubner’s artery, I olfactory tract, III oculomotor nerve, ICA internal
carotid artery, LT lamina terminalis, M1 first segment of the middle cerebral artery,
MPAs perforating arteries, ON optic nerve, P2 second segment of the posterior
cerebral artery, PC posterior clinoid, PcoA posterior communicating artery, SF sylvian
fissure, TL temporal lobe, TS tuberculum sellae
235. Fig. 4.9 Intradural exposure; right approach. a Instruments enlarging the optocarotid
area. b Displacing medially the posterior communicating artery, exposing the
contents of the interpeduncular cistern. AC anterior clinoid, AchA anterior choroidal
artery, BA basilar artery, FL frontal lobe, ICA internal carotid artery, III oculomotor
nerve, OA left ophthalmic artery, ON optic nerve, OT optic tract, P2 second segment of
the posterior cerebral artery, PC posterior clinoid, PcoA posterior communicating
artery, Ps pituitary stalk, SCA superior cerebellar artery, SHA superior hypophyseal
artery, TE tentorial edge, TL temporal lobe
236. Fig. 4.10 Intradural exposure; right approach; enlarged view. A1 first segment of the anterior
cerebral artery, A2 second segment of the anterior cerebral artery, AC anterior clinoid, AcoA
anterior communicating artery, BA basilar artery, FL frontal lobe, HA Heubner’s artery, ICA
internal carotid artery, III oculomotor nerve, LT lamina terminalis, M1 first segment of the middle
cerebral artery, OA left ophthalmic artery, ON optic nerve, P2 second segment of the posterior
cerebral artery, PC posterior clinoid, PcoA posterior communicating artery, SCA superior cerebellar
artery, SHA superior hypophyseal artery, TE tentorial edge, TL temporal lobe, TS tuberculum sellae
237. Fig. 4.11 Intradural exposure; right approach; close-up view ofthe interpeduncular fossa. AchA
anterior choroidal artery, BAbasilar artery, DS dorsum sellae, III oculomotor nerve, IV
trochlear nerve, P1 first segment of the posterior cerebral artery,P2 second segment of the
posterior cerebral artery, PC posteriorclinoid, PcoA posterior communicating artery, Ps pituitary
stalk, SCA superior cerebellar artery, TE tentorial edge
238. Endoscope-assisted microsurgery [ 45° endoscope in a corridor
between the carotid artery and the oculomotor nerve ]-- Fig. 4.12
Intradural exposure; right approach; microsurgical (a) and endoscopic (b–d) views. AchA
anterior choroidal artery, BA basilar artery, C clivus, FL frontal lobe, ICA internal carotid artery, III
oculomotor nerve, ON optic nerve, P1 first segment of the posterior cerebral artery, P2 second
segment of the posterior cerebral artery, PC posterior clinoid, PCA posterior cerebral artery, PcoA
posterior communicating artery, SCA superior cerebellar artery, TE tentorial edge, TL temporal
lobe, Tu thalamoperforating artery; green dotted triangle area for entry of the endoscope into
the interpeduncular fossa
239. Fig. 4.12 Intradural exposure; right approach; microsurgical (a) and endoscopic (b–d) views.
AchA anterior choroidal artery, BA basilar artery, C clivus, FL frontal lobe, ICA internal carotid
artery, III oculomotor nerve, ON optic nerve, P1 first segment of the posterior cerebral artery, P2
second segment of the posterior cerebral artery, PC posterior clinoid, PCA posterior cerebral
artery, PcoA posterior communicating artery, SCA superior cerebellar artery, TE tentorial edge, TL
temporal lobe, Tu thalamoperforating artery; green dotted triangle area for entry of the
endoscope into the interpeduncular fossa
240. Fig. 4.13 Intradural exposure; right approach; microsurgical (a)
and endoscopic omolateral (b) and contralateral (c) views. A1 first segment of the anterior
cerebral artery, AC anterior clinoid, ICA internal carotid artery, FL frontal lobe, III oculomotor
nerve, LT lamina terminalis, M1 first segment of the middle cerebral artery, OA left ophthalmic
artery, ON optic nerve, PcoA posterior communicating artery, SHA superior hypophyseal artery, TE
tentorial edge, TS tuberculum sellae
241. Fig. 4.13 Intradural exposure; right approach; microsurgical (a)
and endoscopic omolateral (b) and contralateral (c) views. A1 first segment of the anterior
cerebral artery, AC anterior clinoid, ICA internal carotid artery, FL frontal lobe, III oculomotor
nerve, LT lamina terminalis, M1 first segment of the middle cerebral artery, OA left ophthalmic
artery, ON optic nerve, PcoA posterior communicating artery, SHA superior hypophyseal artery, TE
tentorial edge, TS tuberculum sellae
246. Fig. 4.15 Microsurgical view; extradural anterior
clinoidectomy. a Exposure and drilling of the anterior clinoid process
and optic canal under microscope magnification. b Widened space after complete removal of
the AC. AC anterior clinoid, eON extracranial intracanalar optic nerve, FD frontal dura, ICA
internal carotid artery, iON intraorbital optic nerve, LWSB lesser wing of sphenoid bone, OC optic
canal, OR orbit roof, SOF superior orbital fissure, TD temporal dura
247. Fig. 4.16 Microsurgical view; intradural anterior clinoidectomy. a, b After the dura above the
anterior clinoid process has been transected in a “T” shape (a), we usually drill always parallel
tothe optic nerve and to the carotid artery (b). c The distal ring is finally exposed. A1
precommunicating anterior cerebral artery, AC anterior clinoid, AchA anterior choroid artery, Ch
optic chiasm, DR distal ring, fl falciform ligament, FL frontal lobe, ICA internal carotid artery, M1
first tract of the middle cerebral artery, ON optic nerve, PC posterior clinoid, PCOA posterior
communicating artery, TS tuberculum sellae
248. Fig. 4.16 Microsurgical view; intradural anterior clinoidectomy. a, b After the dura above the
anterior clinoid process has been transected in a “T” shape (a), we usually drill always parallel
tothe optic nerve and to the carotid artery (b). c The distal ring is finally exposed. A1
precommunicating anterior cerebral artery, AC anterior clinoid, AchA anterior choroid artery, Ch
optic chiasm, DR distal ring, fl falciform ligament, FL frontal lobe, ICA internal carotid artery, M1
first tract of the middle cerebral artery, ON optic nerve, PC posterior clinoid, PCOA posterior
communicating artery, TS tuberculum sellae
253. Fig. 7.13 a Intraoperative photograph shows good exposure of the left tentorial anterior and middle incisura
obtained through the pretemporal and subtemporal corridors. In this patient the
basilar apex is well above the superior margin of the dorsum sellae. b Same patient. A more lateral exposure
showing the pontomesencephalic junction surface and the neurovascular structures in the ambient cistern. c
Intraoperative photograph of another patient showing structures in the left lateral incisural space from the
subtemporal corridor. d Same patient. More lateral view. e Same patient. More posterior exposure. The lifting
of the free edge of the tentorium shows the trochlear nerve entering the tentorium. The junction between the
P2a and P2p segments (P2a, P2p) of the posterior cerebral artery is shown. ACA anterior cerebral artery, AChA
anterior choroidal artery and tiny perforating vessels, BA basilar artery, DS dorsum sellae, FET free edge of
tentorium, ICA internal carotid artery, LM Liliequist’s membrane, LON left optic nerve, ON oculomotor nerve, OT
optic tract, PCA posterior cerebral artery, PComA posterior communicating artery, PLChA posterolateral
choroidal artery arising from the P2a–P2p junction, PS pituitary stalk, RON right optic nerve, SCA superior
cerebellar artery, TN trochlear nerve in the arachnoidal covering
254. Fig. 7.13 a Intraoperative photograph shows good exposure of the left tentorial anterior and middle incisura
obtained through the pretemporal and subtemporal corridors. In this patient the
basilar apex is well above the superior margin of the dorsum sellae. b Same patient. A more lateral exposure
showing the pontomesencephalic junction surface and the neurovascular structures in the ambient cistern. c
Intraoperative photograph of another patient showing structures in the left lateral incisural space from the
subtemporal corridor. d Same patient. More lateral view. e Same patient. More posterior exposure. The lifting
of the free edge of the tentorium shows the trochlear nerve entering the tentorium. The junction between the
P2a and P2p segments (P2a, P2p) of the posterior cerebral artery is shown. ACA anterior cerebral artery, AChA
anterior choroidal artery and tiny perforating vessels, BA basilar artery, DS dorsum sellae, FET free edge of
tentorium, ICA internal carotid artery, LM Liliequist’s membrane, LON left optic nerve, ON oculomotor nerve, OT
optic tract, PCA posterior cerebral artery, PComA posterior communicating artery, PLChA posterolateral
choroidal artery arising from the P2a–P2p junction, PS pituitary stalk, RON right optic nerve, SCA superior
cerebellar artery, TN trochlear nerve in the arachnoidal covering
255. Fig. 7.13 a Intraoperative photograph shows good exposure of the left tentorial anterior and middle incisura
obtained through the pretemporal and subtemporal corridors. In this patient the
basilar apex is well above the superior margin of the dorsum sellae. b Same patient. A more lateral exposure
showing the pontomesencephalic junction surface and the neurovascular structures in the ambient cistern. c
Intraoperative photograph of another patient showing structures in the left lateral incisural space from the
subtemporal corridor. d Same patient. More lateral view. e Same patient. More posterior exposure. The lifting
of the free edge of the tentorium shows the trochlear nerve entering the tentorium. The junction between the
P2a and P2p segments (P2a, P2p) of the posterior cerebral artery is shown. ACA anterior cerebral artery, AChA
anterior choroidal artery and tiny perforating vessels, BA basilar artery, DS dorsum sellae, FET free edge of
tentorium, ICA internal carotid artery, LM Liliequist’s membrane, LON left optic nerve, ON oculomotor nerve, OT
optic tract, PCA posterior cerebral artery, PComA posterior communicating artery, PLChA posterolateral
choroidal artery arising from the P2a–P2p junction, PS pituitary stalk, RON right optic nerve, SCA superior
cerebellar artery, TN trochlear nerve in the arachnoidal covering
256. THE FULLY ENDOSCOPIC SUBTEMPORAL APPROACH [ from
Shahanian book ] - The traditional middle fossa subtemporal approach requires long-
standing placement of retractors on the temporal lobe; therefore, potential injury to the
temporal lobe can occur
(e.g., hematoma and edema resulting in aphasia, hemiparesis, or seizures). This concern should
not be a problem with the described approach because temporal lobe retractors are not used.
(L) a Epidermoid tumor. b Atraumatic
suction. c Brainstem. d Occulomotor (III)
nerve. e Posterior cerebral artery (PCA).
f Superior cerebellar artery (SCA). g
Trochlear (IV) nerve.
(N) a Epidermoid tumor. b Atraumatic suction. c
Left-curved tumor forceps. d Occulomotor (III)
nerve. e Posterior cerebral artery (PCA). f
Posterior communicating (PCOM) artery. g
Superior cerebellar artery (SCA).
h Brainstem. i Trochlear (IV) nerve.
257. Q) a Occulomotor (III) nerve. b
Internal carotid artery (ICA). c
Posterior cerebral artery (PCA).
d Superior cerebellar artery
(SCA).
(P) a Ipsilateral optic (II) nerve. b
Internal carotid artery (ICA). c
Occulomotor (III) nerve.
d Dura overlying anterior clinoid
process.
259. Various forceps designed to
control internal carotid artery
bleeding – designed by Prof. PJ
wormald
260.
261. For Other powerpoint presentatioins
of
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