Abstract
PurposePenetration of the clivus is required for surgical access of the brain stem. The endoscopic transclivus approach is a difficult procedure with high risk of injury to important neurovascular structures. We undertook a novel anatomical and radiological investigation to understand the structure of the clivus and neurovascular structures relevant to the extended trans-nasal trans-sphenoid procedure and determine a safe corridor for the penetration of the clivus.MethodWe examined the clivus region in the computed tomographic angiography (CTA) images of 220 adults, magnetic resonance (MR) images of 50 adults, and dry skull specimens of 10 adults. Multiplanar reconstruction (MPR) of the CT images was performed, and the anatomical features of the clivus were studied in the coronal, sagittal, and axial planes. The data from the images were used to determine the anatomical parameters of the clivus and neurovascular structures, such as the internal carotid artery and inferior petrosal sinus.ResultsThe examination of the CTA and MR images of the enrolled subjects revealed that the thickness of the clivus helped determine the depth of the penetration, while the distance from the sagittal midline to the important neurovascular structures determined the width of the penetration. Further, data from the CTA and MR images were consistent with those retrieved from the examination of the cadaveric specimens.ConclusionOur findings provided certain pointers that may be useful in guiding the surgery such that inadvertent injury to vital structures is avoided and also provided supportive information for the choice of the appropriate endoscopic equipment.
Highlights
The clivus is a region of the skull base extending from the posterior clinoid process (PCP) to the foramina magnum
The examination of the computed tomographic angiography (CTA) and magnetic resonance (MR) images of the enrolled subjects revealed that the thickness of the clivus helped determine the depth of the penetration, while the distance from the sagittal midline to the important neurovascular structures determined the width of the penetration
Data from the CTA and MR images were consistent with those retrieved from the examination of the cadaveric specimens
Summary
The clivus is a region of the skull base extending from the posterior clinoid process (PCP) to the foramina magnum It is formed by the corpora ossis sphenoidalis and the basilar part of the occipital bone and is closely associated with tumors originating from the ventral aspect of the brain stem [1]. The rapid technological advances in endoscopic surgery have led to the introduction of the extended trans-nasal trans-sphenoidal approach for the effective surgical removal of tumors in the sellar region and the ventral aspect of the brain stem [3,4] This surgical approach is made complex by the requirement of comprehensive anatomical understanding of the area to accurately identify the site of surgical resection and avoid the complications of injury to the adjacent neurovascular structures. We sought to undertake a novel radiological and anatomical study of the clivus and important adjacent neurovascular structures that are relevant to the extended trans-nasal trans-sphenoidal approach
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