Combining Cavernous-Petrous Drilling with Intradural Posterior Clinoidectomy Enhances the Maneuverability Inside the Interpeduncular Cistern

Objective: To emphasize the importance of adding cavernous-petrous drilling to reach the interpeduncular cistern (IPC).

Background: Cadaveric simulation for IPC surgery is an indispensable prerequisite.

Methods: Following completion of preparatory surgical steps (orbitozygomatic craniotomies, extradural anterior-clinoidectomies, cavernous sinus unlocking, releasing the oculomotor and trochlear nerves via opening the porous oculomotorius and detaching tentorial ligaments, respectively” and sylvian fissure dissections), 6 colored-injected formalin-fixed heads (12 sides) were dissected to review the benefit of adding cavernous-petrous (cavernous part of the petrous apex) drilling with intradural posterior clinoidectomy to expose to the IPC. Anatomical IPC-targets (n = 10) were elected to understand the accessibility and maneuverability from the open microscopic surgical perspective. We did not cut the PcomA to reduce miscalculation errors. The data were collected and analyzed.

Results: Adding cavernous-petrous drilling to expose to the IPC allows reasonable visual validation and maneuverability for all (n = 60 (10 x 6 heads)) targets (Basilar apex/trunk, 2 (ipsilateral/contralateral) posterior communicating arteries (PcomA), 2 posterior cerebral arteries, 2 superior cerebellar arteries, 2 oculomotor nerves, and mamillary bodies). It gives better proximal control for both low-seated/high riding basilar apices and overcomes the tunnel-like corridor for such deep targets. However, inevitable trigeminal nerve controlled-retraction was done to ensure safe drilling for the cavernous-petrous apex (ophthalmic division at risk). Besides, for right-handed surgeons, the right sided posterior clinoidectomy and temporary aneurysm clipping to the basilar trunk were done without handshaking (contrary, specific maneuvers with the nondominant hands caries potential risk). Trochlear nerve injuries (n = 3) were encountered during our initial IPC manipulations on the left side [25% (3/12) of all trochlear nerves = 5% of all targets (3/60)]. All other targets were anatomically preserved.

Conclusion: Adding cavernous-petrous drilling for IPC approaches is promising. It provides additional workspace. Clarifying the surgical targets and structures-at-risk benefits to the realization of limitations and providing prospective feedback for operative theatres.

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Artikel online veröffentlicht:
05. Februar 2024