Surgical and Radiologic Anatomy

https://doi.org/10.1007/s00276-021-02681-1

REVIEW

Intra‑ and extradural anterior clinoidectomy: anatomy review

and surgical technique step by step
Federico Carlos Gallardo1   · Jorge Luis Bustamante1 · Clara Martin1 · Aylen Andrea Targa Garcia1 ·
Santiago Enrique Feldman1 · Felix Pastor2 · Marcelo Cristian Orellana1 · Pablo Augusto Rubino1 ·
Vicent Quilis Quesada2,3,4

Received: 1 September 2020 / Accepted: 7 January 2021

© The Author(s), under exclusive licence to Springer-Verlag France SAS part of Springer Nature 2021

Abstract
Purpose  The complex relations of the paraclinoid area make the surgical management of the pathology of this region a chal-
lenge. The anterior clinoid process (ACP) is an anatomical landmark that hinders the visualization and manipulation of the
surrounding neurovascular structures, hence in certain surgical interventions might be necessary to remove it. We reviewed
the anatomical relationships that involve the paraclinoid area and detailed the step-by-step techniques of intra and extradural
clinoidectomy in cadaveric specimens.
Materials and methods  A literature review was done describing the most relevant anatomic relationships regarding the
anterior clinoid process. Extradural and intradural clinoidectomy techniques were performed in six dry bone heads and in ten
previously injected cadaverous specimens with colored latex (Sanan et al. in Neurosurgery 45:1267–1274, 1999) and each
step of the procedure was recorded using photographic material. Finally, an analysis of the anatomical exposure achieved in
each of the techniques used was performed.
Results  The main advantage of the intradural clinoidectomy technique is the direct visualization of the neurovascular struc-
tures adjacent to the ACP when drilling, at the same time, opening the Sylvian fissure will allow the direct visualization of the
ACP variants. The main advantage offered by the extradural technique is that the dura protects adjacent eloquent structures
while drilling. Among the disadvantages, it is noted that the same dura that would protect the underlying structures also
prevents the direct visualization of these neurovascular structures adjacent to the ACP.
Conclusion  We reviewed the anatomy of the paraclinoid area and made a step-by-step description of the technique of the
anterior clinoidectomy in its intra- and extradural variants in cadaveric preparations for a better understanding.

Keywords  Anterior clinoidectomy · Intradural clinoidectomy · Extradural clinoidectomy · Anatomy · Paraclinoid ·

Microsurgery

Background

The complex bone and neurovascular relations of the para-

clinoid area make the surgical management of vascular and
* Federico Carlos Gallardo tumor pathology of this region a real challenge. The ante-
federicogallardo89@gmail.com rior clinoid process (ACP) is an anatomical landmark that
hinders or prevents the visualization and manipulation of
1
Department of Neurosurgery, Hospital de Alta Complejidad the surrounding neurovascular structures, hence in certain
El Cruce, Buenos Aires, Argentina
surgical interventions might be necessary to remove it. This
2
Department of Neurosurgery, Hospital Clínic Universitari de technique is called anterior clinoidectomy and the different
València, Valencia, Spain
microsurgical techniques to perform it are classified into
3
College of Medicine and Science, Mayo Clinic, Rochester, two large groups, extradural and intradural, each one with
USA
respective advantages and disadvantages.
4
Department of Human Anatomy and Embryology, Faculty
of Medicine, University of Valencia, Valencia, Spain

13
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There are multiple articles that describe these techniques
[1, 6–8, 10–12, 16–18, 23, 24, 26, 29, 36, 42], however, the
clinoidectomy remains a challenge for neurosurgeons, thus
making essential a thorough knowledge of the anatomy of
the paraclinoid area to perform a stepwise description of
both procedures.
We reviewed the anatomical relationships that involve the
paraclinoid area and detailed the step-by-step techniques of
intra- and extradural clinoidectomy in cadaveric specimens.
Materials and methods
In the first place, a literature review was done describing the
most relevant anatomic relationships regarding the anterior
clinoid process. Through Pubmed, we used the following
terms: “anterior clinoid process”, “cavernous sinus”, “inter-
nal carotid artery”, “optic nerve”, “orbit”, “optic roof”,
“anterior and middle fossa” and “anterior clinoidectomy”.
Extradural and intradural clinoidectomy techniques
were performed in six dry bone heads and in ten previously
injected cadaverous specimens with colored latex [35] and
each step of the procedure was recorded using photographic
material. Finally, an analysis of the anatomical exposure
achieved in each of the techniques used was performed.
Results
Anterior clinoid process
The anterior clinoid process, which is the posterior and
medial projection of the lesser sphenoid wing, has in its
medial portion two roots, the upper one and lower one. The
upper root will be part of the roof of the optic canal and con-
tinues medially with the planum sphenoidale. The lower root
is also called optic strut [21, 39] and forms the lateral and
inferior wall of the optic canal, connecting the lesser wing
with the body of the sphenoid bone (Fig. 1).
We can recognize three attachments of the anterior cli-
noid process to the sphenoid bone: lateral and superior, the
most medial portion of the lesser wing of the sphenoid,
medial and superior constituted by the roof of the optic
canal, and the third anchor point is the optic strut, which is
directed inferior and medial towards the body of the sphe-
noid. This pillar separates the optic canal medially and supe-
riorly (through which the optic nerve and the ophthalmic
artery make their way to the orbit) from the superior orbital
fissure (SOF) lateral and inferiorly.
The SOF limits are: superiorly the lesser wing of the
sphenoid; inferolaterally, the greater wing of the sphenoid
and medially, the optic strut and the body of the sphenoid.
Through the SOF run from the cavernous sinus to the orbit,
13
Surgical and Radiologic Anatomy
the oculomotor nerves trochlear, abducens and the first
trigeminal division, sympathetic branches of the carotid
plexus. From the orbit to the cavernous sinus run the supe-
rior and inferior ophthalmic veins.
Therefore, the anterior clinoid process and its attachments
are the key bone structures to understand the communica-
tion between the neurovascular elements of the skull base
and the orbit and the complex neurovascular relationship in
this region (Table 1).
There are dural folds between the anterior clinoid, the
middle clinoid and posterior clinoid processes [2, 13, 21].
These dural folds are sometimes calcified constituting ana-
tomical variants that we must know, because if we have to
deal with these variations, the removal of the ACP could be
more difficult. For example, we can identify the presence of
a bone bridge between the anterior clinoid and the posterior
clinoid, or the presence of a carotid-clinoid foramen, that is,
a bone bridge connecting the ACP with the middle clinoid
process [13, 24, 32, 39].
The anterior clinoid process is mainly formed by corti-
cal bone on its outer surface and cancellous bone inside. It
can be pneumatized and thus, in communication with the
sphenoid sinus or posterior ethmoid air cells (according to
previous descriptions, it can summarize up to 10% of the
cases) [24, 39]. Occasionally, it is crossed by small venous
channels that connect the cavernous sinus and diploic veins
of the orbital roof [25, 38, 43].
Dural relationships
The tentorium at the level of the petrous apex offers dural
projections towards the anterior and posterior clinoid pro-
cesses, and between the former two, forming the anterior
petroclinoid fold (from the petrous apex to the anterior
clinoid process), the posterior petroclinoid fold (from the
petrous apex to the posterior clinoid process) and the inter-
clinoid fold (between the anterior and posterior clinoid pro-
cesses) [21, 25, 38].
A triangle, known as the oculomotor triangle, is located
at the posterior half of the roof of the cavernous sinus [21,
38], and is formed by these folds, through where the third
cranial nerve enters into the cavernous sinus.
The anterior half of the roof of the cavernous sinus will
be covered by the anterior clinoid process and dura mater.
When the ACP is removed, a triangular area is delimited
medially by the optic nerve, laterally by the oculomo-
tor nerve and posteriorly by a ring of dura. Inside we can
observe the so-called clinoid segment of the internal carotid
artery (ICA), a transition between the cavernous segment
and the subarachnoid segment [21, 38, 41, 43].
The dura that covers the ACP extends medially towards
the planum sphenoidale partially covering the entrance of
Surgical and Radiologic Anatomy
Fig. 1  a Endocranial view of the skull base. The lesser wing of the
sphenoid when directed medially is divided into two branches or
roots called, upper and lower, respectively. The upper root it is part
of the roof of the optic canal and will continue medially with the
planum sphenoidale. The inferior root, also called optic strut, forms
the inferolateral wall of the optic canal and connects the lesser wing
of the sphenoid with the body of the sphenoid. From the origin of
these two roots, towards posterior and medial, is located the ante-
rior clinoid process, the posterior extension of the lesser wing of the
sphenoid bone. b Posterior view of the anterior clinoid process. Its
three anchorages are observed, superomedial, the roof of the optical
canal, superolateral, the most medial portion of the lesser wing of
the sphenoid and the third anchorage point, a bone pillar called the
optic strut, which is directed inferiorly and medially towards the body
of the sphenoid. The optic strut separates the optical canal medially
and superiorly from the superior orbital fissure laterally and inferi-
orly. c Extracranial view of the orbit, note the optic canal separated
from the superior orbital fissure by the optic strut, the lesser wing of
the sphenoid that forms the posterior portion of the orbital roof, and
the greater wing of the sphenoid which constitutes the posterior two-
the optic nerve into the optic canal, constituting a dural fold
called the falciform ligament [38, 41].
From the apex of the ACP and its medial border, the dura
mater folds and surrounds the carotid artery in the roof of the
cavernous sinus forming a ring; the distal dural ring which
thirds of the lateral wall of the orbit. d Endocranial view of the skull
base. The tentorium is inserted into the anterior and posterior clinoid
process through dural folds that extend from the petrous apex. These
are the anterior petroclinoid, posterior petroclinoid, and interclinoid
dural folds, which constitutes the boundaries of the oculomotor tri-
angle, through which the third cranial nerve enters to the cavernous
sinus. From the posterior wall of the cavernous sinus, below Gruber’s
ligament, the dural perforation of the sixth cranial nerve is observed.
The dura that covers the superior aspect of the anterior clinoid pro-
cess extends medially towards the planum sphenoidale partially
covering the entrance of the optic nerve into the optic canal, form-
ing the so-called falciform ligament. Medial to the clinoid process is
the ophthalmic segment of the internal carotid artery, superomedial
to the ICA is located the optic nerve (sectioned), allowing to iden-
tify the origin of the ophthalmic artery on the superomedial aspect of
the internal carotid artery. Op.Canal optical canal. Planum Sp planum
sphenoidale. Falc. Lig falciform ligament. Oph. Ar ophthalmic artery.
Op. N optic nerve. IC. Dural fold interclinoid dural fold. PCP: poste-
rior clinoid process. P.P.C posterior petroclinoid dural fold, III N third
nerve. IV N: fourth nerve. APC anterior petroclinoid dural fold
is intimately attached to the artery, except in certain cases in
its medial and superior face, forming a potential space, like
a pouch, called the carotid cave [19, 38].
From the inferolateral surface of the ACP, another dural
fold in intimate relation to the third cranial nerve (III CN) is
13

Table 1  Bone relationships of the anterior clinoid process
Superior and anterior Orbital roof
Superior and medial Optic canal
roof and
planum
sphenoidale
Superior and lateral Lesser wing
of the sphe-
noid bone
Inferior and medial Optic strut
found, the carotid-oculomotor membrane. It surrounds the
internal carotid artery forming the proximal dural ring. The
dura that extends from the proximal dural ring to the distal
dural ring loosely envelops the internal carotid artery con-
stituting the so-called carotid collar [38, 43]. The proximal
dural ring and the distal dural ring form the boundaries of
the clinoid segment of the ICA [2, 17]. Both the proximal
and the distal ring join superiorly and posteriorly in proxim-
ity to the ACP apex, giving the clinoid segment a wedge-
shaped continent.
The proximal dural ring attaches to the carotid more
loosely than the distal ring, allowing the circulation of
venous blood through the anterior part of the cavernous
sinus, between the ICA and the carotid collar, forming the
clinoid venous plexus. Therefore, many authors consider the
clinoid segment to be a part of the cavernous sinus [25, 34,
38, 43].
The petroclinoidal dural folds continue medially with the
sellar diaphragm [44], anteriorly with the dura that covers
the orbital portion of the frontal bone, posteriorly with the
dura of the basilar plexus and laterally and inferiorly with
the lateral wall of the cavernous sinus [40].
Neurovascular relations
Carotid artery
The internal carotid artery enters the cavernous sinus after
passing medially to the petrolingual ligament, describing an
“S”-shaped path. It is divided into its posterior ascending
segments, posterior knee, horizontal segment, anterior knee
and anterior ascending segment.
The ACP is located lateral and superior to the anterior
ascending segment, which courses along its inferomedial
surface. Folds of dura mater extend medially from the top of
the anterior clinoid process, forming the proximal and distal
dural rings around the ICA. The segment of the ICA cours-
ing along the inferomedial margin of the clinoid process and
between both dural rings is known as the clinoid segment
[2, 21, 22, 27, 31–33].
13
Surgical and Radiologic Anatomy
After passing through the distal dural ring, the carotid
becomes intradural and enters the subarachnoid space. It
courses in a posterior and superior direction, passing below
and lateral to the optic nerve initially, and giving rise to the
ophthalmic artery (92% of cases) [34]; perforating branches
to the chiasm, infundibulum and optic nerve. The ophthal-
mic segment, which extends from the origin of the oph-
thalmic artery to the origin of the posterior communicating
artery, gives rise to the superior hypophyseal artery in its
medial aspect (Fig. 2).
Cavernous sinus
The cavernous sinus is a venous vascular structure contained
between the leaves of the dura of the middle fossa floor. For
its study, it is classically described as a ship, with a roof, a
lateral and medial wall, and with anterior and a posterior
limits [20, 21, 28, 30, 34, 37, 38, 40, 41, 43, 44].
The roof of the cavernous sinus is divided into two tri-
angles: posteriorly, the oculomotor triangle where the third
cranial nerve (III CN) enters the cavernous sinus. Anteriorly,
we find the ACP covering the clinoidal segment of the ICA,
and the III CN runs laterally, in close relation to the trochlear
nerve (IV CN). The roof is delimited laterally by the anterior
petroclinoid fold, posteriorly by the posterior petroclinoid
fold and medially by the interclinoid fold [7, 20, 28, 34, 37,
38, 41, 43].
The anterior clinoid process covers the anterior triangle,
therefore, known as anteromedial or clinoidal. Removing
the ACP exposes the internal carotid artery passing through
the distal dural ring, giving rise to the ophthalmic artery on
the middle third of the superior aspect of the ICA [28, 34,
37, 38, 41].
The anterior aspect of the cavernous sinus is constituted
medially by the inferior surface of the anterior clinoid pro-
cess and by the optic strut; and laterally by the superior
orbital fissure, through which the oculomotor, trochlear,
ophthalmic and abducens nerves pass towards the orbit; the
latter accompanied by sympathetic branches of the carotid
sympathetic plexus. The superior and inferior ophthalmic
veins enter the superior orbital fissure to reach and drain into
the cavernous sinus [30, 34, 38] (Table 2).
The lateral wall of the cavernous sinus is intimately
related to the uncus of the temporal lobe, in the middle fossa
floor. It is covered by two sheets of dura mater [20, 34, 37,
38, 40] (meningeal and endosteal layers). It is within this
envelope, that the trochlear, oculomotor and ophthalmic
nerves course. The inferior limit of the cavernous sinus is
constituted by the upper border of the maxillary nerve (V2),
which exits the cranium through the foramen rotundum. The
third division of the trigeminal nerve (V3), or mandibular
nerve, is located inferolateral to the maxillary nerve, directed
Surgical and Radiologic Anatomy
Fig. 2  a Lateral view of the right cavernous sinus after resecting
the dura of its lateral wall. Notice how the anterior clinoid process
obstructs the view of the clinoidal segment and the initial portion of
the ophthalmic segment of the internal carotid artery. Inferior to the
anterior clinoid process, in the lateral wall of the cavernous sinus,
the oculomotor, trochlear nerves and the V1 trigeminal branch on
their way to the superior orbital fissure. Inferiorly, the trigeminal
V2 trigeminal branch is observed on the floor of the middle fossa.
Between the III and IV nerves the horizontal segment of the cavern-
ous internal carotid artery. b After performing the anterior clinoid-
ectomy, the clinoid segment of the internal carotid artery is exposed,
limited superiorly by the distal dural ring and inferiorly by the proxi-
mal dural ring, note the wedge-shaped continent given between the
rings and where the clinoid segment runs. The optic nerve was sec-
tioned to observe the origin and direction of the ophthalmic artery.
The Gasser’s ganglion and the V1 and V2 branches of the fifth nerve
were also sectioned to expose the cavernous carotid artery. The origin
of the meningohypophyseal trunk was observed in the posterior knee
of the cavernous carotid. The middle fossa floor was drilled exposing
the transition from the petrous carotid to the cavernous carotid artery.
towards the foramen oval, and it is not part of the cavernous
sinus (Fig. 2).
The pterygoid plexus, which communicates with the
cavernous sinus, passes through the foramen rotundum
c V1 and IV nerves were sectioned exposing the cavernous carotid,
note its sinuous shape, describing a posterior ascending segment,
posterior knee, the horizontal segment (descending), anterior knee,
and anterior ascending segment. It is in the anterior ascending seg-
ment where the carotid is related to the anterior clinoid process and
is enveloped by the dural rings constituting the clinoid segment. Lat-
eral to the cavernous carotid, after crossing through Dorello’s canal,
the VI cranial nerve describes its intracavernous course. d Magni-
fied view of the clinoid segment of the internal carotid artery, note
the close relationship between the distal dural ring and the origin of
the ophthalmic artery, which is why this artery must be first visual-
ized prior to section the distal dural ring. When refuting anteriorly the
optic nerve an arterial branch from the ophthalmic artery supplying it
is observed. Op. N optic nerve. Op. Seg. ICA ophthalmic segment of
the internal carotid artery. Falc. Lig falciform ligament. ACP anterior
clinoid process. III N third nerve. IV N fourth nerve. VI N sixth nerve.
V1 and V2 first and second divisions of the trigeminal nerve. Oph. Ar
ophthalmic artery. D.D.R distal dural ring. Clin. Seg. ICA clinoid seg-
ment of the internal carotid artery. P. Lig petrolingual ligament. ICA
internal carotid artery. APC anterior petroclinoid dural fold
surrounding the second division of the trigeminal nerve
[25, 34, 38].
The medial wall of the cavernous sinus is formed infe-
riorly by the carotid sulcus of the sphenoidal body and
13
 Surgical and Radiologic Anatomy

superiorly by a sheet of dura mater. The sella turcica and its

oculomotor nerve pierces

the roof of the cavernous

nerve into the cavernous

sinus. It gives rise to the
content, the hypophysis, is located medial to it [44].

Oculomotor triangle and

meningohypophyseal
entry point of the 6th
Basilar plexus and the
The medial and lateral aspects of the cavernous sinus

the place where the

communicate inferiorly, giving it the shape of a ship’s keel.
In proximity to the union between the lateral and medial

Optic chiasm
walls of the cavernous sinus, the ICA carves out the carotid
Posterior

trunk
sinus
sulcus on the sphenoidal body.
The posterior wall of the cavernous sinus is formed by
a fold of dura mater which extends from the petrous apex
Anterior clinoid process to the dorsum sellae. Its upper limit is constituted by the

Optical canal and the

and the optic strut posterior petroclinoid fold. The abducens nerve enters the
cavernous sinus by passing through Dorello’s canal beneath
the petrosphenoid or Gruber’s ligament (that runs from the
Orbital roof

petrous apex to the clivus) [20, 34, 38].

Anterior

orbit
The cavernous segment of the ICA is situated within the
cavernous sinus, where it gives rise to the meningohypophy-
relationship with the 6th

seal and inferolateral trunks, as well as McConnell’s cap-

lesser wing of sphenoid

pericarotid sympathetic
segment of the Sylvian
cistern, and the carotid

rolateral trunk in close

Ophthalmic segment of
It gives rise to the infe-

the carotid artery and

cranial nerve and the
bone, the sphenoidal

sular arteries [22, 34, 38]. The abducens nerve is located

the anterior clinoid
It continues with the

within its intracavernous course, lateral to the internal

carotid artery, beneath the origin of the inferolateral trunk
and medial to the ophthalmic nerve (V1). The carotid sym-
process
cistern

plexus

pathetic plexus accompanies the internal carotid artery in its

Lateral

course through the cavernous sinus.

The distal dural ring and

Orbital aspect of frontal

lobe and the olfactory
the ophthalmic artery

Anterior clinoidectomy
Orbital surface of the
frontal lobe and the
olfactory tract

We describe a step-by-step dissection of the extradural and

intradural anterior clinoidectomy techniques and the expo-
Superior

sure provided by both surgical procedures.

tract

For both surgical techniques, the cadaveric specimen was

placed simulating the surgical position: supine and neutral
Anterior clinoid process It covers the anterior half The ophthalmic segment

position without deflection and lateralization between 30

of the internal carotid
artery and the optic

and 45 degrees. The fixation was done with the aid of a

Table 2  Bone, neural and vascular relationships with the cavernous sinus

Tuberculum sellae

three-pronged Mayfield head clamp. Subsequently, a stand-

ard pterional approach was performed [3, 35, 42].
The carotid sulcus of the Hypophysis
nerve
Medial

Extradural clinoidectomy
and the ophthalmic seg-

Once the pterional approach has been performed [9], the

located below the ACP
of the cavernous sinus

ments of the ICA it is

between the clinoidal

orbital roof is removed by drilling on its intracranial surface,

roof, the transition

Ophthalmic artery

as well as the lesser wing of the sphenoid until the meningo-

sphenoid bone

orbital band is exposed (Fig. 3a). The meningo-orbital band

constitutes a landmark [1, 15, 26, 33] that indicates the most
Inferior

lateral portion of the SOF. The meningo-orbital artery and

fold is then coagulated and cut, starting a peeling between
the meningeal and the endosteal leaves of the temporal dura,
Internal carotid artery

to expose the anterior third of the lateral wall of the cavern-

ous sinus, IIICN, V1 and V2. At this point, it is possible to
visualize the lateral aspect of the ACP (Fig. 3b).
Optic nerve

The frontal dura in close relationship to the lateral orbital

wall is posteriorly retracted to expose the optic nerve and
roof of the optic canal. At this point, two of the three anchors

13
Surgical and Radiologic Anatomy

Fig. 3  a After performing a pretemporal variant of the pteri- ▸

onal approach (box), the meningo-orbital band is exposed. b The
meningo-orbital band and artery are coagulated and sectioned, from
this point the middle fossa peeling begins, until the anterior third of
the lateral aspect of the cavernous sinus is exposed. This surgical
gesture allowed us to expose the anterior clinoid process, its lateral
pillar lesser wing of the sphenoid and its medial pillar (roof of the
optic canal). c The posterior third of the roof and lateral wall of the
orbit are initially removed, and the roof of the optic canal drilled, thus
achieving early decompression of the optic nerve. In this point, we
complete the resection of the superomedial and lateral anchoring pil-
lars of the anterior clinoid process. d Direct view of the optic strut
(dissector) below to the optic nerve and superomedial to the oculo-
motor nerve. e After resecting the optic strut, the anterior clinoid pro-
cess is removed either as one piecemeal or by fragmentation. f The
clinoid segment of the internal carotid artery is observed between
the proximal dural ring (carotid-oculomotor membrane) and the dis-
tal dural ring. g Dural opening medial to the optic nerve and towards
the 3rd cranial nerve. The intradural segment of the optic nerve, cov-
ered by the falciform ligament, is exposed. The distal dural ring, the
carotid-oculomotor membrane and the carotid collar are seen sur-
rounding the clinoid segment of the internal carotid artery. Distal to
the distal dural ring, the ophthalmic segment of the carotid artery. h
The falciform ligament is sectioned, releasing the optic nerve. Then
the distal dural ring is sectioned in its lateral and posterior portion,
leaving a cuff attached to the carotid artery. i The optic nerve is gen-
tly retracted with a dissector exposing the origin of the ophthalmic
artery. Once recognized, the distal dural ring is sectioned below the
artery, in its anterior part. j The placement of a temporary clip is
simulated, occluding the internal carotid artery in its clinoid segment,
avoiding the ophthalmic artery. k and l The placement of a fenes-
trated clip simulates the treatment of medial or inferior variant para-
clinoid aneurysms.: Or. Roof orbital roof. Or. Lat. Wall orbital lateral
wall. M.O.B meningo-orbital band. ACP anterior clinoid process. III
N third nerve. V1 and V2 first and second divisions of the trigeminal
nerve. Op. N optic nerve. C.S.L.W cavernous sinus lateral wall. Op.
ST optic strut. Clin. Seg. ICA clinoid segment of the internal carotid
artery. Car Col: carotid collar. DDR distal dural ring. Falc. Lig fal-
ciform ligament. Op. Seg. ICA ophthalmic segment of the internal
The dura mater is opened in a T-shape configuration,
carotid artery. Oph. Ar ophthalmic artery from the medial aspect of the optic nerve to the oculomotor
nerve; and then following the sphenoidal impression related
to the stem of the sylvian fissure. The next step will consist
of the ACP (the roof of the optic canal and the lesser wing of the section of the falciform ligament to free the optic
of the sphenoid) are exposed (Fig. 4). nerve, facilitating its mobilization, and therefore, allowing
The following step consists on drilling the posterior third the visualization of the ophthalmic artery’s origin (Fig. 3h,
of the lateral wall of the orbit and roof, including the roof i). After identifying the ophthalmic artery’s emergence, the
of the optic canal (Fig. 3c), achieving not only the removal oculomotor membrane should be opened medial to the III
of the medial pillar of the ACP, but also a decompression CN and removed, to better identify the proximal and distal
of the optic nerve from the intradural compartment to the dural rings. Then, the distal dural ring is cut 360º around the
orbit (Fig. 5). Ultimately, the osseous remnant between the ICA usually below the origin of the ophthalmic artery, leav-
superior orbital fissure and the optic nerve, constituted by ing a cuff adhered to the internal carotid artery if necessary.
the optic strut, is removed by careful drilling with a 2-mm This will allow, after careful dissection, a greater mobiliza-
diameter diamond-coated dissecting tool head (Fig. 3d). tion of the internal carotid artery to achieve proximal con-
After completing these steps, the ACP can be mobilized, trol and exposure of the neck during paraclinoid aneurysms
and therefore, detached from its anchor sites, and can finally surgery [23].
be removed, either in one piece or in multiple fragments
(Fig. 3e). Intradural clinoidectomy
Once the clinoidectomy is achieved (Fig. 3f, g), the cli-
noid segment of the internal carotid artery is exposed, delim- After performing the pterional approach [3, 4, 42], being
ited by the proximal and distal dural rings and covered by the meningo-orbital band its medial boundary, the next step
the carotid collar and carotid-oculomotor membrane (Fig. 6). consists on opening the dura in C shape, centered over the

13

Fig. 3  (continued)
Fig. 4  Extradural exposure of the anterior clinoid process (ACP) after
peeling the middle fossa dura and retracting the frontal lobe. Note
for transparency the relationship between the PCA and the superior
orbital fissure, the carotid artery, and optic nerve
13
Surgical and Radiologic Anatomy
Fig. 5  After drilling the roof of the optic canal and the lesser wing
of the sphenoid, the optic strut is exposed (bone structure evidenced
between the optic nerve and the superior orbital fissure)
Fig. 6  By removing the optic strut and the anterior clinoid process,
the clinoid segment of the internal carotid artery is exposed
frontotemporal fold. We carry on by opening the proximal
sylvian cistern, along with the pericarotid cisterns. This
maneuver provides cerebrospinal fluid drainage and con-
sequently parenchymal relaxation. The carotid cistern is
exposed and visualized, together with its contents, the oph-
thalmic segment of the ICA, the optic nerve passing through
the optic canal, and the falciform ligament above it. The
ACP, covered by dura, is located immediately lateral and
partially concealing these structures (Fig. 7a, b).
Using a No. 11 scalpel blade, a transverse section is
made in the dura mater covering the ACP, from the medial
border of the optic canal to the superomedial limit of the
Surgical and Radiologic Anatomy

Fig. 8  Cut sites on the dura covering the anterior clinoid process.

The first cut should be as indicated by the black dotted line from the
medial limit of the optic canal to the free edge of the lesser wing of
the sphenoid. The second cut should be made as indicated by the
green dotted line, from the clinoid apex to the first cut

mobilized and removed, either in one piece or in multiple

fragments.
In case of the presence of osseous anchors due to calcifi-
cation of the dural fold, they should be removed under direct
vision, prior to the anterior clinoid process resection.
After completing the intradural clinoidectomy, the clinoid
segment of the internal carotid artery is exposed (Fig. 11),
between the proximal and distal dural rings (Figs. 7f and 12).
Fig. 7  a Right-side pterional approach. b After opening of the Syl- Once the falciform ligament is cut, the optic nerve can be
vian fissure, contents of carotid and optical cisterns are observed. gently mobilized from lateral to medial, to visualize the ori-
c The striped line delimits the dural incision that must be done gin of the ophthalmic artery. The clinoid segment is exposed
to expose the anterior clinoid process. d Anterior clinoid process
exposed after removing the overlying dura. e The roof of the optic
canal is drilled; the optic strut is observed in depths. f The anterior
clinoid process was removed, the clinoid segment of the internal
carotid artery is observed, as well as the distal dural ring. O.N optic
nerve. ACP anterior clinoid process. CA internal carotid artery. Oph.
A ophthalmic artery. Op. ST optic strut. DDR distal dural ring. CA
Clin Seg clinoid segment of the internal carotid artery

superior orbital fissure. A second cut is made from the cli-

noid apex towards the one previously performed, resulting
in a T-shaped dural incision (Figs. 7c, d and 8).
After cutting, dissecting and removing the dura mater
away from the anterior clinoid process, its superior surface
is exposed (Fig. 9). Following this maneuver, the roof of the
optic canal is drilled with a 2-mm diamond-coated dissect-
ing tool, as well as the medial portion of the lesser wing of
the sphenoid bone (Fig. 7e).
At last, the osseous remnant between the optic canal and
superior orbital fissure, constituted by the optic strut, must
Fig. 9  The drilling should begin at the medial limit of the optic canal
be removed by careful and intermittent drilling (Fig. 10). (in green color), towards the free edge of the lesser wing of the sphe-
Finally, once freed from its three anchors, the ACP is noid (blue color)

13

Fig. 10  Exposure of the optic strut between the optic nerve and the
superior orbital fissure
Fig. 11  Final view of the clinoid segment of the ICA after completing
the clinoidectomy
after dissecting the carotid-oculomotor membrane and the
distal dural ring, as described previously [21, 23, 25, 38].
Discussion
Tumor or vascular pathology of the paraclinoid region is
challenging procedures not only for young neurosurgeons
but also for senior ones, due to the complex anatomy of
the region [1, 7, 8, 13, 14, 21, 26, 27]. It is of paramount
13
Surgical and Radiologic Anatomy
Fig. 12  a Exposure obtained after performing an intradural clinoid-
ectomy. Both optic nerves, optic chiasm and the right ophthalmic
segment of the internal carotid artery are observed. Partially cover-
ing the optic nerve, there is a remnant of the falciform ligament and
below the optic nerve the distal dural ring and the transition of the
extradural internal carotid artery to the intradural segment. b Mag-
nified vision of the previous image in which is observed the clinoid
segment of the internal carotid artery enveloped by the carotid col-
lar, from the proximal dural ring (carotid-oculomotor membrane) to
the distal dural ring. Note for transparency the passage of blue dye
in the clinoid venous plexus from the cavernous sinus. c The falci-
form ligament and the distal dural ring were resected leaving a cuff
attached to the arterial wall, this maneuver allows the mobilization of
the optic nerve and the visualization of the ophthalmic artery, it also
offers a greater range of movement for manipulation of the internal
carotid artery. d The optic nerve is gently retracted superiorly with
a dissector, allowing the ophthalmic artery to be observed. e A tem-
porary clip was placed in the clinoid segment of the internal carotid
artery preserving the ophthalmic artery, simulating proximal vascu-
lar control in paraclinoid aneurysms surgery. f A fenestrated clip was
placed simulating the treatment of a medial variant paraclinoid aneu-
rysm. Falc. Lig falciform ligament. Op. N optic nerve. DDR distal
dural ring. Op. Seg. ICA ophthalmic segment of the internal carotid
artery. Car Coll carotid collar. Clin Seg ICA clinoid segment of the
internal carotid artery. ACA: anterior communicating artery. Oph Ar
ophthalmic artery. ACI internal carotid artery
Surgical and Radiologic Anatomy
importance to master this anatomy to understand and exe-
cute the different microsurgical procedures described.
There are multiple classifications of the ICA’s anatomy
[2, 7, 8, 17, 22, 34], and it is a remaining discussion whether
the clinoid segment of the ICA (limited by the proximal and
distal dural rings) is or is not included inside the cavernous
sinus.
Some authors believe that the true roof of the cavernous
sinus is the proximal dural ring and the carotid-oculomotor
membrane, thus considering the ICA’s clinoid segment as
extracavernous [2, 7, 8, 25, 41].
The other authors propose that the proximal dural ring is
incomplete, or its carotid union wrapped around the carotid
collar is lax, allowing the passage of blood between the cav-
ernous sinus and the venous lagoons that surround the ICA’s
clinoid segment, therefore, considering the clinoid segment
as intracavernous [10, 11, 22, 34, 37, 38, 42, 43].
When exposing the clinoid segment of the ICA, copious
venous bleeding of these venous lagoons may occur. Based
on this, and from a surgical point of view, we consider the
clinoid segment as intracavernous. The neurosurgeon must
be prepared to deal with vigorous bleeding coming from the
cavernous sinus [21].
Both clinoidectomy techniques are widely accepted and
the authors have reported different advantages and disadvan-
tages, since the first procedure described by Dolenc [10, 11].
The selection between one or the other will depend both, on
the surgeon’s preference as well as on the type of pathol-
ogy to be treated, on their relationships to the surrounding
structures and the anatomical variants (mainly those related
to the anterior clinoid process).
Intradural clinoidectomy
The main advantage of the intradural technique is the direct
visualization of the neurovascular structures adjacent to the
ACP when drilling, as well as, in cases of carotid ophthalmic
aneurysms, the protection of the aneurysm dome when it is
attached and/or erodes the ACP [36, 39].
At the same time, opening the Sylvian fissure will allow
direct visualization of the ACP or its anatomic variants
(osseous bridge between the anterior and posterior clinoid
processes, or the presence of a carotidclinoidal foramen
between the anterior and middle clinoid processes) [13, 24,
32, 42].
On the other side, the intradural clinoidectomy also has
its drawbacks. The most feared one is the risk of injuring
neurovascular structures during the drilling, which require
the surgeon’s experience and skills to avoid it. Concomi-
tantly, the visualization of the superior surface of the ACP
hinders or impedes the view of the optic strut when trying
to remove it [23, 24, 26, 36, 39].
Extradural clinoidectomy
The main advantage offered by this technique is to be per-
formed completely in the extradural space, so the dura cov-
ers and protects adjacent eloquent structures [23, 39]. When
opening the posterior third of the roof and lateral wall of the
orbit in the early stages of the clinoidectomy, we achieve an
early decompression of the optic pathway, greater mobility
of the optic nerve and exposure of the anterior margin of the
distal dural ring below the optic nerve.
Among the disadvantages, it is noted that the same dura
that would protect the underlying structures also prevents the
direct visualization of these neurovascular structures adja-
cent to the ACP. Specially while dealing with paraclinoid
aneurysms, an incidental rupture of the aneurysmal dome
may complicate the surgery at an early stage or even pass
unnoticed during the procedure [7, 8, 39]. In addition, by
requiring peeling of the anterior third of the lateral wall of
the cavernous sinus, venous bleeding from the cavernous
sinus and/or damage to the nerves that run through the lat-
eral wall of the sinus can potentially occur.
When performing the anterior clinoidectomy, visual dis-
turbances may occur with both techniques described [7, 8,
23, 24, 26, 36, 39]. Caution should be taken when exposing
the superior orbital fissure, considering that the oculomotor,
trochlear, abducens and the first division of the trigeminal
nerve are in proximity, as well as when working on the optic
canal and the optic strut. The proximity to the optic nerve,
specially while working with a high speed drill, may produce
both mechanical and thermal injuries to it. To avoid the lat-
ter, constant irrigation with saline solution and intermittent
drilling with frequent pauses, avoiding overheating the drill
or bone and consequently the optic nerve are recommended
[23, 24, 26, 39].
ACP anatomical variants
Certain ACP variants may hinder the extradural clinoidec-
tomy [32]. Longer anterior clinoid processes will require,
in case of performing an extradural clinoidectomy, greater
dural dissection and posterior extension during the peeling
of the middle fossa. In these cases, intradural clinoidectomy
with sylvian fissure dissection may be convenient, which
will allow direct vision of the clinoidal apex.
The presence of an osseous bridge between the anterior
and posterior clinoid processes or the existence of a carotid-
clinoidal foramen (an osseous bridge connecting the anterior
and the middle clinoid processes) makes the extradural cli-
noidectomy more risky, due to the possibility of injuring the
ICA, the oculomotor or the optic nerves. In these cases, it
may be preferable to perform the intradural approach, which
will allow, through direct vision of these osseous bridges,
the section of them prior to the clinoidectomy [24, 39].
13

The ACP can also be pneumatized, and thus communi-
cates with the sphenoidal sinus or the posterior ethmoidal
sinuses [24, 39]. Consequently, the anterior clinoidectomy
may expose or lacerate the mucosa lining these air cells,
which may result in pneumocephalus, cerebrospinal fluid
leakage and postoperative meningitis. The exposed sinus
must be obliterated either with bone wax, fat and/or muscle,
to avoid these complications [5, 23].
To perform the correct pre-surgical evaluation, it is essen-
tial to carry a computed tomography to assess these variants.
Conclusion
Due to the neurovascular, dural and osseous relationships,
the anatomy of the paraclinoid region remains a challenge.
Therefore, it becomes essential to have a thorough knowl-
edge of the topography of the region while planning to per-
form an anterior clinoidectomy.
We have performed a systematic review of the anatomy
of the paraclinoid region. We made a step-by-step descrip-
tion of anterior clinoidectomy technique, in its intra- and
extradural variants, in cadaveric preparations for a better
understanding.
The selection of an extradural or intradural technique
should be done by considering the surgeon’s anatomical
knowledge, surgical experience and skills, as well as the
individual pathology and anatomical conformation.
Author contributions  GFC: manuscript writing, BJL: manuscript edit-
ing, MC: manuscript writing, TGAA: review and editing, FSE: review
and editing, PF: resources: data curation, OCM: visualization, RPA:
project development, QQV: resources and project development.
Funding  The authors declare that we have no funding.
Compliance with ethical standards  18. Gonzalez-Darder JM (2007) Intradural anterior clinoidectomy.
Conflict of interest The authors declare that we have no competing
financial interests or personal relationships that could have appeared to
influence the work reported in this paper.
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