Endonasal endoscopic exposure of the internal carotid artery: An anatomical study

Fortes, Felipe; Pinheiro‐Neto, Carlos D.; Carrau, Ricardo L.; Brito, Rubens de; Prevedello, Daniel M.; Sennes, Luiz Ubirajara

doi:10.1002/lary.22395

Cited by 40 publications

(40 citation statements)

References 31 publications

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“…In this study, the authors observed some variations in the course of the ICA. Others have reported these variations previously; nonetheless, their correlations with the quadrangular space were never established. Specifically, it was noted that the ICA can present anatomic variations, mainly at the transition between the paraclival and parasellar segments; when lateral, this portion of the ICA partially obscured the course of the abducens nerve, and, thus, significantly reduced the window provided by the quadrangular space.…”

Section: Discussionmentioning

confidence: 97%

“…In this study, the authors observed some variations in the course of the ICA. Others 31,39,40 have reported these variations previously; nonetheless, their correlations Abbreviations: AM, anteromedial triangle; AL, anterolateral triangle; IT, infratrochlear triangle. Surface areas (mm 2 ) of the bilateral anteromedial, anterolateral, and infratrochlear triangles and of the bilateral quadrangular spaces in 10 specimens.…”

Section: Discussionmentioning

confidence: 98%

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Endoscopic endonasal study of the cavernous sinus and quadrangular space: Anatomic relationships

et al. 2016

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Section: Discussionmentioning

confidence: 97%

Section: Discussionmentioning

confidence: 98%

Endoscopic endonasal study of the cavernous sinus and quadrangular space: Anatomic relationships

et al. 2016

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“…There are variations in the course of the vidian canal in relation to the sphenoid sinus. [1130313233] From the microsurgical prospective, this segment is important during surgery of Meckel's cave, and our results showed that the sleeve of the gasserian ganglia may cover the lateral surface of this ICA segment. Therefore, from a lateral microsurgical perspective, the surgery of Meckel's cave may be associated with injury of the gasserian segment of the ICA [Table 3].…”

Section: Discussionmentioning

confidence: 71%

“…provided the results of anatomic dissections that exposed the ICA through an endoscopic transpterygoid approach. [11] In 2013, Wang et al . used CTA and subclassified the cavernous ICA for endoscopic approaches.…”

Section: Discussionmentioning

confidence: 99%

Proposed clinical internal carotid artery classification system

Abdulrauf

Ashour

Marvin

et al. 2016

J Craniovert Jun Spine

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Introduction:Numerical classification systems for the internal carotid artery (ICA) are available, but modifications have added confusion to the numerical systems. Furthermore, previous classifications may not be applicable uniformly to microsurgical and endoscopic procedures. The purpose of this study was to develop a clinically useful classification system.Materials and Methods:We performed cadaver dissections of the ICA in 5 heads (10 sides) and evaluated 648 internal carotid arteries with computed tomography angiography. We identified specific anatomic landmarks to define the beginning and end of each ICA segment.Results:The ICA was classified into eight segments based on the cadaver and imaging findings: (1) Cervical segment; (2) cochlear segment (ascending segment of the ICA in the temporal bone) (relation of the start of this segment to the base of the styloid process: Above, 425 sides [80%]; below, 2 sides [0.4%]; at same level, 107 sides [20%]; P < 0.0001) (relation of cochlea to ICA: Posterior, 501 sides [85%]; posteromedial, 84 sides [14%]; P < 0.0001); (3) petrous segment (horizontal segment of ICA in the temporal bone) starting at the crossing of the eustachian tube superolateral to the ICA turn in all 10 samples; (4) Gasserian-Clival segment (ascending segment of ICA in the cavernous sinus) starting at the petrolingual ligament (PLL) (relation to vidian canal on imaging: At same level, 360 sides [63%]; below, 154 sides [27%]; above, 53 sides [9%]; P < 0.0001); in this segment, the ICA projected medially toward the clivus in 275 sides (52%) or parallel to the clivus with no deviation in 256 sides (48%; P < 0.0001); (5) sellar segment (medial loop of ICA in the cavernous sinus) starting at the takeoff of the meningeal hypophyseal trunk (ICA was medial into the sella in 271 cases [46%], lateral without touching the sella in 127 cases [23%], and abutting the sella in 182 cases [31%]; P < 0.0001); (6) sphenoid segment (lateral loop of ICA within the cavernous sinus) starting at the crossing of the fourth cranial nerve on the lateral aspect of the cavernous ICA and located directly lateral to the sphenoid sinus; (7) ring segment (ICA between the 2 dural rings) starting at the crossing of the third cranial nerve on the lateral aspect of the ICA; (8) cisternal segment starting at the distal dural ring.Conclusions:The classification may be applied uniformly to all skull base surgical approaches including lateral microsurgical and ventral endoscopic approaches, obviating the need for 2 separate classification systems. The classification allows extrapolation of relevant clinical information because each named segment may indicate potential surgical risk to specific structures.

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“…10 Many publications focus on different anatomical landmarks of the anterior end of the VC and how the endonasal transpterygoid approach may be performed safely. [3][4][5]16,17,19,23 However, the literature is lacking a thorough anatomical description of the posterior and inferior limits of the endonasal transpterygoid avenue. Although the identification of the VN in the proximal aspect of its canal may permit us to safely identify the anterior genu of the ICA, the endoscopic anatomy of the most inferior and posterior area surrounding the ICA in this region-that is, the deepest and most posterior limit of the endoscopic endonasal transpterygoid route-has not been well documented.…”

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confidence: 99%

Refining the anatomic boundaries of the endoscopic endonasal transpterygoid approach: the “VELPPHA area” concept

Kaen¹,

Ruiz‐Valdepeñas²,

Somma

et al. 2019

Journal of Neurosurgery

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T he endoscopic endonasal transpterygoid approach is a lateral extension of the midline endonasal route; although it was initially described to access only the lateral recess of the sphenoid sinus, currently this route is used to reach the most lateral aspect of the skull base. In this surgical scenario, injury to the internal carotid artery (ICA) is one of the most feared complications.The vidian nerve (VN) has been clearly described as a critical landmark for the safe identification of the petrous ICA in the foramen lacerum (FL) during the endoscopic ABBREVIATIONS ET = eustachian tube; FL = foramen lacerum; ICA = internal carotid artery; VC = vidian canal; VELPPHA = vidian nerve, eustachian tube, foramen lacerum, petroclival fissure, and pharyngobasilar fascia; VN = vidian nerve. OBJECTIVEThe endoscopic endonasal transpterygoid route has been widely evaluated in cadavers, and it is currently used during surgery for specific diseases involving the lateral skull base. Identification of the petrous segment of the internal carotid artery (ICA) is a key step during this approach, and the vidian nerve (VN) has been described as a principal landmark for safe endonasal localization of the petrous ICA at the level of the foramen lacerum. However, the relationship of the VN to the ICA at this level is complex as well as variable and has not been described in the pertinent literature. Accordingly, the authors undertook this purely anatomical study to detail and quantify the peri-lacerum anatomy as seen via an endoscopic endonasal transpterygoid pathway. METHODS Eight human anatomical specimens (16 sides) were dissected endonasally under direct endoscopic visualization. Anatomical landmarks of the VN and the posterior end of the vidian canal (VC) during the endoscopic endonasal transpterygoid approach were described, quantitative anatomical data were compiled, and a schematic classification of the most relevant structures encountered was proposed. RESULTS The endoscopic endonasal transpterygoid approach was used to describe the different anatomical structures surrounding the anterior genu of the petrous ICA. Five key anatomical structures were identified and described: the VN, the eustachian tube, the foramen lacerum, the petroclival fissure, and the pharyngobasilar fascia. These structures were specifically quantified and summarized in a schematic acronym-VELPPHA-to describe the area. The VELPPHA area is a dense fibrocartilaginous space around the inferior compartment of the foramen lacerum that can be reached by following the VC posteriorly; this area represents the posterior limits of the transpterygoid approach and, of utmost importance, no neurovascular structures were observed through the VELPPHA area in this study, indicating that it should be a safe zone for surgery in the posterior end of the endoscopic endonasal transpterygoid approach. CONCLUSIONS The VELPPHA area represents the posterior limits of the endoscopic endonasal transpterygoid approach. Early identification of this area can enhance the safety of the e...

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Endonasal endoscopic exposure of the internal carotid artery: An anatomical study

Cited by 40 publications

References 31 publications

Endoscopic endonasal study of the cavernous sinus and quadrangular space: Anatomic relationships

Endoscopic endonasal study of the cavernous sinus and quadrangular space: Anatomic relationships

Proposed clinical internal carotid artery classification system

Refining the anatomic boundaries of the endoscopic endonasal transpterygoid approach: the “VELPPHA area” concept

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