Peer-Review Reports
Surgical Microanatomy of the Anterior Clinoid Process for Paraclinoid Aneurysm
Surgery and Efficient Modification of Extradural Anterior Clinoidectomy
Nakao Ota, Rokuya Tanikawa, Takanori Miyazaki, Shiro Miyata, Jumpei Oda, Kosumo Noda, Toshiyuki Tsuboi,
Rihei Takeda, Hiroyasu Kamiyama, Sadahisa Tokuda
Key words
- Anatomic variation of the anterior clinoid process
- Caroticoclinoid foramen
- Extradural anterior clinoidectomy
- Interclinoid osseous bridge
- Paraclinoid aneurysms
- Pneumatization of the anterior clinoid process
Abbreviations and Acronyms
ACP: Anterior clinoid process
AR: Anterior root
CCF: Caroticoclinoid foramen
CT: Computed tomography
EAC: Extradural anterior clinoidectomy
ICA: Internal carotid artery
IOB: Interclinoid osseous bridge
OS: Optic strut
Department of Neurosurgery, Stroke Center, Teishinkai
Hospital, Hokkaido, Japan
To whom correspondence should be addressed:
Nakao Ota, M.D.
[E-mail: nakao1980@gmail.com]
Citation: World Neurosurg. (2015).
http://dx.doi.org/10.1016/j.wneu.2014.12.014
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2015 Elsevier Inc.
All rights reserved.
INTRODUCTION
Extradural anterior clinoidectomy (EAC),
first reported by Dolenc (4), facilitates
complete neck clipping of aneurysms in
the paraclinoid region or radical removal
of tumors by providing wide operative
exposure of the internal carotid artery (ICA)
and superior surface of the cavernous sinus
with minimal brain retraction. However,
some anatomic variations of the anterior
clinoid process (ACP) have been reported,
such as a caroticoclinoid foramen (CCF),
interclinoid osseous bridge (IOB) (3, 5-7,
10-12), and pneumatization of the ACP
(2, 9, 13).
CCF was first described by Henle (6) as an
osseous bridge between the tip of the middle
clinoid process and ACP. According to
Williams et al. (15) and Lang (12), this
bony structure is formed by ossification
of the caroticoclinoid ligament in early
WORLD NEUROSURGERY - [-]: ---, MONTH 2015
- BACKGROUND: Anatomic variations of the anterior clinoid process (ACP)
should be recognized before clinoidectomy to ensure a safe approach. This study
describes the incidence of caroticoclinoid foramen (CCF), interclinoid osseous
bridge, and pneumatization of the ACP during extradural anterior clinoidectomy.
The problems and technical issues encountered in such cases are described.
- METHODS: Using multidetector-row computed tomography, 144 sides in 72
cases of paraclinoid aneurysm treated by extradural anterior clinoidectomy
were analyzed preoperatively.
- RESULTS:
CCF, interclinoid osseous bridge, and pneumatization of the ACP
were observed in 16.6%, 2.77%, and 27.7% of cases. Pneumatized patterns were
divided into 3 groups according to route: pneumatization via the optic strut (in
74.1%), pneumatization via the anterior root (in 14.8%), and pneumatization via
optic strut and anterior root (in 11.1%). CCF and interclinoid osseous bridge
represent obstacles to complete extradural removal of the ACP. The ACP should
not be moved even after drilling the lateral wall of the ACP, orbital roof, and
optic strut, so an intradural approach is sometimes needed. A CCF warrants
careful removal to open the distal dural ring. Awareness of the routes of
pneumatization for the ACP should reduce the risk of tears in the paranasal
mucosa. If tears arise in the mucosa, suturing and closure are needed to prevent
liquorrhea.
- CONCLUSIONS: Preoperative computed tomography is useful to detect vari-
ations in the anatomy around the ACP. When performing extradural anterior
clinoidectomy in such anomalous cases, appropriate modifications are needed
to ensure a safe approach.
childhood. An IOB is an osseous bridge This study describes the incidence of
between the tip of the ACP and posterior CCF, IOB, and pneumatization of the ACP
clinoid process. This structure also involves during EAC and intraoperative findings,
ossification of the interclinoid ligament along with technical perspectives on these
during development (15). The existence of anatomic variants. To our knowledge, this
these bony structures is an important is the first report to correlate preoperative
problem for neurosurgeons, complicating anatomic variation of the ACP with intra-
removal of the ACP (8, 14). Even after operative findings.
release of the distal dural ring, these
structures encumber mobilization of the
ICA (4). MATERIALS AND METHODS
Pneumatization of the ACP involves During the period April 2012eDecember
extending a paranasal sinus such as the 2013, we examined 144 sides in 72 cases of
sphenoid or ethmoid sinus into the ACP paraclinoid aneurysm treated by clipping or
through the optic strut (OS) or anterior trapping with bypass using EAC. Surgical
root (AR). Tearing these paranasal sinuses indications were determined with reference
can cause pneumocephalus or liquorrhea to the 2009 Japanese guidelines for the
(1, 7, 9, 13). management of stroke. All 144 sides were
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NAKAO OTA ET AL. ANATOMIC VARIATIONS OF ACP AND CLINOIDECTOMY

analyzed preoperatively for the presence or
absence of CCF, IOB, or pneumatization of
ACP using 320-row multidetector computed
tomography (CT). Although Keyes (11)
classified CCFs into 3 groups of complete
type, incomplete type, and contact type,
preoperative CT and intraoperative
findings made it difficult to distinguish
between complete and contact types, and
so we classified CCFs into 2 groups:
complete type (including contact type) and
incomplete type (Figure 1A and B).
An IOB was defined as a bony structure
bridging between the apex of the ACP and
the posterior clinoid process (Figure 1C).
Pneumatization of the ACP was defined
as a paranasal sinus extending into the
ACP (even if only slightly) through the AR
or OS (Figure 1D and E).
In each of the patients, helical CT of the
head was performed using a 320-row CT
scanner (Aquilion ONE ViSION Edition;
Toshiba Medical Systems, Tochigi, Japan).
Scanning was performed with a collima-
tion of 0.5 mm and 0.25-mm slice recon-
struction. Digital CT data were transferred
to the Ziostation 2 version 2.1.x (Qi Im-
aging, Redwood City, California, USA)
for review, axial reconstruction, and three-
dimensional analysis.
RESULTS
The 72 cases comprised 64 women and 8
men with a mean age of 57.3 years (range,
31e78 years). In terms of treatment, 68 an-
eurysms were treated by direct clipping, and
4 aneurysms were treated by trapping with
external carotid artery-to-middle cerebral
artery anastomosis. A CCF was observed in
12 of 72 cases (16.6%): unilaterally in 6 cases
(8.3%) and bilaterally in 6 cases (8.3%). Of
the 18 sides showing a CCF, complete type
was observed in 9 sides (50.0%), and
incomplete type was observed in 9 sides
(50.0%). An IOB was seen in 2 cases (2.8%):
unilaterally in 1 case (1.4%) and bilaterally in
1 case (1.4%). Pneumatization of the ACP
was observed in 20 cases (27.7%): unilater-
ally in 13 cases (18.0%) and bilaterally in 7
cases (9.7%). Patterns of pneumatization
were divided into 3 groups according to the
route: pneumatization via the OS in 74.1%;
via the AR in 14.8%; and via the OS and AR
in 11.1% (Table 1). No discrepancies were
seen between preoperative CT findings
and intraoperative anatomic findings.

Figure 1. Thin-slice computed tomography images of 2 types of
caroticoclinoid foramen (CCF) (A, B), interclinoid osseous bridge (C), and
pneumatization of the anterior clinoid process (D, E). (A) Complete-type
CCF. The foramen and bridge show the normal anatomy (arrowhead). (B)
Incomplete-type CCF. Spicules of bone extend medially from the anterior
and middle clinoid processes but do not touch (arrowhead). (C) Interclinoid
osseous bridge. Spicules of bone extend posteriorly from the anterior and
posterior clinoid processes. (D) Pneumatization of the anterior clinoid
process is observed via the optic strut (arrowhead). (E) Pneumatization is
observed via the anterior root (arrowhead).

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NAKAO OTA ET AL. ANATOMIC VARIATIONS OF ACP AND CLINOIDECTOMY

Table 1. Incidence of Caroticoclinoid

Foramen, Interclinoid Osseous Bridge,
and Pneumatization of Anterior Clinoid
Process According to Preoperative
Computed Tomography
Factor Number (%)

Number of cases 72
Sex
Female 64
Male 8
Patient age (years)
Mean 57.3
Range 31e78
Caroticoclinoid foramen 12 (16.6%)
Bilateral cases 6 (8.3%)
Figure 2. Computed tomography (CT) results. (A) CT angiography shows an unruptured aneurysm
Complete type 9 sides (50%) arising from the C2 portion of the internal carotid artery (arrowhead). (BeD) Three-dimensional
Incomplete type 9 sides (50%) reconstruction of CT images reveals complete-type caroticoclinoid foramen on the left side
(arrowhead) and incomplete-type on the right.
Interclinoid osseous bridge 2 (2.8%)
Bilateral cases 1 (1.4%)
Unilateral cases 1 (1.4%) After removal of this bony structure, the
ICA achieved sufficient mobility.
Pneumatization of ACP 20 (27.7%)
Bilateral cases 7 (9.7%) Case 2: Pneumatization of ACP via OS. A
Via OS 20 sides (74.1%) 60-year-old woman presented with a right-
side ICA aneurysm proximal to the poste-
Via AR 4 sides (14.8%)
rior communicating artery (Figure 4A). To
Via OS and AR 3 sides (11.1%) secure the proximal ICA, clinoidectomy
ACP, anterior clinoid process; AR, anterior root; OS, was needed because the aneurysm arose
optic strut. immediately after perforating the distal
dural ring (Figure 4B). Preoperative CT
revealed a pneumatized ACP via the OS
(Figure 4CeE). Aneurysm clipping with
Illustrative Cases EAC was performed. After drilling the
Case 1: Complete-Type CCF. A 44-year-old cancellous bone of the ACP (Figure 5A), a
woman presented with a left-side anterior thin bulkhead of compact bone appeared
wall aneurysm of the ICA (Figure 2A). (Figure 5B). Paranasal mucosa via the OS
Preoperative CT and three-dimensional to the sphenoid sinus appeared under
reconstruction imaging showed a left-side this compact bone (Figure 5C). Using a
complete-type CCF and a right-side incom- microdissector, the mucous membrane
plete-type CCF (Figure 2BeD). Clipping with was pushed anteromedially toward the ICA
EAC was performed. The ACP could not be (Figure 5D). Careful drilling of compact
moved even after skeletonization by drilling bone covering the C3 portion of the ICA
the lateral wall of the ACP, orbital roof, was performed (Figure 5E), and the ACP
and OS (Figure 3A). The intradural was removed. After opening the dura
approach was added by drilling to mater, the distal dural ring (Figure 5F) and
determine the apex of the ACP (Figure 3B) aneurysm were identified. After opening
and investigate bony structures continuing the distal dural ring inferiorly to preserve
to the medial clinoid process (Figure 3C). the neck of the aneurysm (Figure 5G), neck
The CCF was covered by the distal dural clipping was performed (Figure 5H).
ring. After careful drilling of the ACP, a
bony structure continuing to the middle Case 3: Pneumatization of ACP via AR. A
clinoid process was observed (Figure 3D). 45-year-old woman presented with a right-
side ICAeposterior communicating artery
aneurysm. Preoperative CT angiography
revealed that EAC was needed to secure the
ICA because the aneurysm and posterior
communicating artery existed close to the
distal dural ring. Preoperative CT revealed
pneumatization of the ACP via the AR
(Figure 6). Aneurysm clipping with EAC was
performed. Immediately after drilling of the
compact bone of the lateral margin of the
ACP (Figure 7A), the paranasal mucous
membrane was identified via the AR
(Figure 7B). The mucosal tissue was
pushed superomedially in the direction
of the optic canal (Figure 7C). The thin
compact bone covering the optic canal was
identified under the mucous membrane
(Figure 7D). After skeletonization by
drilling of the lateral wall of the ACP,
orbital roof, and OS, the ACP was removed
extradurally.
Case 4: Pneumatization of ACP via OS and
AR. A 78-year-old woman presented with a
right-side ICAesuperior hypophyseal artery
aneurysm. Preoperative CT revealed com-
plete alteration of the cancellous bone of
the ACP to the paranasal sinus (Figure 8).
Aneurysm clipping with EAC was
performed. Immediately after drilling the
lateral wall of the lesser wing of the
sphenoid bone, the mucosa of the
paranasal sinus was identified under the

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NAKAO OTA ET AL.
compact bone. The first mucosal tissue
obtained was parallel to the AR and
pushed superomedially toward the optic
Figure 4. Computed tomography (CT) results for case 2. (A) CT angiography reveals the right-side
internal carotid artery aneurysm proximal to the posterior communicating artery. (B) To secure the
proximal internal carotid artery, clinoidectomy is needed because the aneurysm arises immediately
after perforating the distal dural ring. (CeE) Thin-slice CT reveals a pneumatized anterior clinoid
process via the optic strut.
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ANATOMIC VARIATIONS OF ACP AND CLINOIDECTOMY
Figure 3. Intraoperative findings in case 1. The
anterior clinoid process (ACP) (arrowhead) should
not be moved even after drilling the lateral wall of
the ACP, orbital roof, and optic strut (A). The apex
of the ACP is determined after opening the dura
mater (arrowhead) (B). After careful drilling of the
ACP (arrowhead) (C, D), the bony structure
continues medially to the middle clinoid process
(arrowhead) (E). ON, optic nerve; OS, optic strut;
C3, C3 portion of the internal carotid artery; C2, C2
portion of the internal carotid artery; D, dura
matter.
canal (Figure 9A). After pushing up the paranasal sinus via the OS (Figure 9A).
mucosa, a thin bulkhead of compact bone After careful drilling of the thin compact
was found and separated from the bone, the mucosa along the OS was
observed (Figure 9B). The mucosa was
tucked into the OS. Below the mucosa,
the C3 portion of the ICA was seen to be
covered by thin compact bone (Figure 9C).
The apex of the ACP was removed
extradurally (Figure 9D).
Case 5: IOB. A 69-year-old woman pre-
sented with a left-side aneurysm of
the anterior wall of the C2 portion of
the ICA. Preoperative thin-slice CT and
three-dimensional reconstruction imaging
revealed a right-side IOB and an incom-
plete form of IOB on the left side
(Figure 10). EAC and clipping were
performed. In this case, the ACP did not
continue to the posterior clinoid process.
Even after drilling the lateral wall of the
ACP, the OS, and the orbital roof,
movement of the apex was restricted.
After removing the ACP, a hole
continuing to the posterior clinoid
process was observed (Figure 11).
Case 6: All Anatomic Variations—Complete-
Type CCF, IOB, and Pneumatization of ACP
via OS and AR. A 63-year-old woman pre-
sented with a left-side ICAeophthalmic
artery aneurysm. Preoperative CT and
three-dimensional reconstruction imaging
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toward the optic canal. Under the mucous

membrane, compact bone of the optic
canal and a thin bulkhead of compact
bone were found and separated from the
paranasal sinus via the OS. After careful
drilling of the thin compact bone, the
mucosa along the OS was observed. The
mucosa was tucked into the OS. Below
the mucosa, the C3 portion of the ICA
that had been covered by thin compact
bone was observed. Drilling of the
cancellous bone of the apex of the ACP
was performed. A bony structure along
the medial clinoid process and posterior
clinoid process was revealed. Almost the
entire apex of the ACP was drilled out
intradurally because the apex of the ACP
was completely identified extradurally;
this was because sufficient elevation of the
dura propria was able to be performed.
The bony structure was retained largely
without drilling because the C3 portion of
the ICA was easily secured in this case,
and the aneurysm projection was medial
to the ICA, so there was no need to open
the lateral and posterior margins of the
distal dural ring. Nevertheless, despite the
lack of need to open the distal dural ring
fully, the CCF restricted cutting this
structure.

DISCUSSION
EAC is an established and safe approach
that allows extensive removal of the ACP
and creation of a wide operative field
(4, 16), but anatomic variations of the ACP
and ophthalmic artery must be kept in
mind to ensure a safe, less invasive
approach. The present study emphasizes
the anatomic importance of the CCF, IOB,
and pneumatization of the ACP.
The sphenoid bone receives attachments
from 3 ligaments: the pterygospinous liga-
Figure 5. Intraoperative findings in case 2. After drilling away the cancellous bone of the anterior
clinoid process (arrowhead) (A), thin compact bone is seen (arrowhead) (B). Paranasal mucosa via the ment between the spine and upper part
optic strut to the sphenoid sinus is seen under this compact bone (arrowhead) (C). Using the of the lateral pterygoid plate, the interclinoid
microdissector, the mucous membrane is pushed inferomedially toward the internal carotid artery ligament between the anterior and posterior
(ICA) (D). Careful drilling of the compact bone covering the C3 portion of the ICA is performed (E), and
the ACP is removed. After opening the dura mater, the distal dural ring (arrowhead) (F) and aneurysm
clinoid processes, and the caroticoclinoid
are identified. After opening the distal dural ring inferiorly (arrowhead) to preserve the neck of the ligament between the anterior and middle
aneurysm (G), neck clipping is performed (H). ON, optic nerve; C3, C3 portion of the internal carotid clinoid processes (15). Some of these
artery; C2, C2 portion of the internal carotid artery; An, aneurysm.
ligaments may ossify, resulting in
alteration of the interrelationships in
anatomic configurations. The latter 2
showed complete-type CCFs, IOBs, and Immediately after drilling the cancellous ligaments are the CCF and IOB. Fibrous
pneumatization of the ACP via the OS and bone of the lesser wing, the compact bone ossification of ligaments is considered a
AR on both sides (Figure 12). Aneurysm covered by mucous membrane via the AR normal physiologic process that occurs
clipping with EAC was performed. was revealed and pushed superomedially with aging, but these ligaments represent

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Figure 6. Computed tomography (CT) findings for case 3. (A) CT angiography reveals the aneurysm
arising from the bifurcation of the internal carotid artery and posterior communicating artery. (B) The
aneurysm exists very close to the anterior clinoid process (arrowhead). (CeD) Thin-slice CT shows
bilateral anterior clinoid process pneumatization via the anterior root. An, aneurysm.

Figure 8. Computed tomography (CT)

findings for case 4. (A) CT angiography
shows the aneurysm arising from the
right-side internal carotid artery (ICA). (BeD)
Thin-slice CT reveals pneumatization of the
anterior clinoid process via the optic strut
(B, C) and anterior root (D). A thin bulkhead
of compact bone separate from the
paranasal sinus is observed between the
pneumatization via the optic strut and via the
anterior root (arrowhead) (D).

an exception because of the possibility of

ossification in fetuses and children (12, 15).
The incidence of CCF has been investi-
gated by various authors in different pop-
ulations (5, 8, 11, 12). Keyes (11) reported
on 2187 human dry skulls, with complete-
type CCF in 7.1%, incomplete-type CCF
Figure 7. Intraoperative findings in case 3. Drilling of the compact bone of the lateral margin of the
in 19.2%, and contact-type CCF in 1.2%.
anterior clinoid process (A). Immediately after drilling of the compact bone, the paranasal mucous Our series showed very similar frequencies
membrane is identified (arrowhead) (B). The mucosal tissue is pushed superomedially (arrowhead) for CCF (14.2%) indicating that CCF is
(C) toward the optic canal (arrowhead). Thin compact bone covering the optic canal is seen under the
commonly encountered when neurosur-
mucous membrane (D). ON, optic nerve.
geons perform clinoidectomy.

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Figure 9. Intraoperative findings in case 4, from the right-side approach. (A)
Immediately after drilling the lateral wall of the anterior clinoid process, the
mucosa of the paranasal sinus is identified under the compact bone
(arrowhead). (B) The paranasal sinus is tucked into the anterior root. Thin
compact bone covers the mucosa of the sphenoid sinus (arrowhead). (C)
After careful drilling of the thin compact bone, the mucosa of the sphenoid
sinus is seen. (D) The mucosa of the sphenoid sinus is tucked into the optic
strut. Below the mucosa, the C3 portion of the internal carotid artery
covered in thin compact bone is seen. (E) The apex of the anterior clinoid
process is removed extradurally. (F) After opening the dura mater and distal
dural ring, the aneurysm is shown in the carotid cave. ON, optic nerve; m,
mucosa of the paranasal sinus; C3, C3 portion of the internal carotid artery.

The presence of CCF makes it difficult to
remove the ACP purely extradurally
because detachment of the apex of the ACP
from the bony structures of the CCF re-
quires drilling under the siphon of the ICA.
Intradural drilling out can be performed in
cases in which full elevation of the dura
propria from the cavernous membrane and
apex is confirmed. However, to ensure a
safe approach, we recommend extradural
and intradural removal because the bony
structures of the CCF and apex of the ACP
can be confirmed from a broader space
than with an extradural-only approach
(Figure 11). The neurosurgeon should
be aware of the presence of a CCF
preoperatively to avoid excessive or
unsuitable manipulation of surrounding
tissues, which may result in injury of
the ICA, optic nerve, or oculomotor
nerve. Even after removal of the ACP, as
presented in case 1, bony structures to
the medial clinoid process prevent
mobility of the ICA. This structure must
be removed to the fullest extent possible.
As evidenced by the intraoperative
findings, the CCF is covered by the distal
dural ring. The CCF can be understood as
a kind of bony distal dural ring.
IOB was reported in 8.68% of cases in
the series described by Keyes (11). In our
study, the incidence of this finding was
1.58%. IOB is less frequent than CCF.
This anomaly should also be confirmed
preoperatively because the bony bridge
continues to the posterior clinoid process
and can be drilled deeply to the posterior
clinoid process. En bloc removal of the
ACP is impossible, and careful drilling
and detachment of 4 parts (lateral wall of
the ACP, OS, orbital roof, and IOB) is
required. In cases requiring aneurysm
clipping, careful extradural drilling is
needed until sufficient exposure of the
distal dural ring and good mobility of the
ICA can be achieved. If space for drilling
is insufficient, an intradural approach is
also needed.
Mikami et al. (13) reported 600 sides in
300 consecutive patients using
multidetector-row CT. Pneumatization of
the ACP was found in 55 sides (9.2%), and
pneumatized patterns were divided into 3
groups according to the route: pneumati-
zation occurred via the OS in 41 sides
(74.5%), via the AR in 8 sides (14.8%), and
via OS and AR in 6 sides (10.9%). The
incidence of ACP pneumatization in our
series was 27.7%, representing the most
frequent variation when performing ante-
rior clinoidectomy. As in case 2, cases of
pneumatization of the ACP via OS and AR
appeared to involve mucous membrane via
OS and AR distinguishable by thin
compact bone. This is an important point
when performing clinoidectomy because
the direction in which the mucous mem-
brane of the paranasal sinus needs to be
pushed can be predicted preoperatively.
Involvement of mucous membrane via the
OS is pushed inferomedially toward the
ICA, whereas involvement of mucous
membrane via the AR is pushed super-
omedially toward the optic canal. The
neurosurgeon should be familiar with the
bony anatomy when performing drilling of
the ACP so that the cancellous bone of the
ACP replaces the paranasal sinus, which is

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NAKAO OTA ET AL.
Figure 10. Computed tomography (CT) findings in case 5. (A) CT angiography reveals an unruptured
aneurysm arising from the C2 portion of the internal carotid artery. (BeD) Three-dimensional CT
reconstruction and thin-slice CT shows an interclinoid osseous bridge on the right side (arrowhead)
and incomplete-form interclinoid osseous bridge on the left side.
Figure 11. Extradural anterior clinoidectomy
from the left side. (A) Even after drilling the
lateral wall of the anterior clinoid process,
optic strut, and orbital roof, movement of
the apex is restricted (arrowhead). (B) After
removing the anterior clinoid process, a hole
continuing to the posterior clinoid process is
observed (arrowhead). ON, optic nerve; OS,
optic strut.
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ANATOMIC VARIATIONS OF ACP AND CLINOIDECTOMY
invariably covered by compact bone. A tear
in the paranasal mucosa can cause rhinor-
rhea or postoperative infection (1, 7, 9, 13).
Preoperative evaluation by CT is the most
important and effective means to avoid
tearing the paranasal mucosa. Particularly
in cases of small pneumatization via the
OS, meticulous preoperative evaluation is
needed because the operative field is deep
and narrow, the mucosa is difficult to
repair, and tearing may pass unnoticed—
this represents the worst-case scenario. In
cases occurring via the AR, we identified
the paranasal mucosa immediately after
drilling away the compact bone of the
lesser wing of the sphenoid bone and
pushed the mucosa superomedially toward
the optic canal. In cases occurring via the
OS, we found the paranasal mucosa after
drilling away the cancellous bone of the
ACP. The advent of compact bone is a good
bellwether of the mucosa. The key point
when drilling near the mucosa is to use the
dissector to push the mucosa toward the
paranasal sinus and cover it with bone wax.
If the mucosa tears, the neurosurgeon
should suture and close the mucosa and
provide coverage with an abdominal fat
graft.
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PEER-REVIEW REPORTS
Figure 12. Computed tomography (CT)
findings in case 6. Preoperative CT
angiography reveals a left-side internal
carotid arteryeophthalmic artery aneurysm.
Thin-slice CT reveals anterior clinoid process
pneumatization via the anterior root
(arrowhead) (A, B), interclinoid osseous
bridge (arrowhead) (C), anterior clinoid
process pneumatization via the optic strut
(arrowhead) (D), and caroticoclinoid foramen
(arrowhead) (E).
CONCLUSIONS
Preoperative CT is useful for detecting
anatomic variants of the ACP, such as CCF,
IOB, and pneumatization of the ACP as well
as determining the route of pneumatization.
When performing EAC in such anomalous
cases, appropriate modifications are
needed to ensure a safe approach.
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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 11 July 2014; accepted 10 December 2014
Citation: World Neurosurg. (2015).
http://dx.doi.org/10.1016/j.wneu.2014.12.014
Journal homepage: www.WORLDNEUROSURGERY.org
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