Extended Endoscopic Endonasal Clipping of Intracranial Aneurysms: An Anatomic Feasibility Study.

BACKGROUND: Intracranial aneurysms (IAs) located in the midline region represent formidable challenge owing to their deep location. The objective of this study was to assess feasibility and identify the limitations of endoscopic endonasal clipping of IAs. We further aimed to describe the locations and characteristics of aneurysms that may be amenable for endoscopic endonasal clipping; thus outlining the indications of these approaches. METHODS: Fifteen latex-injected cadaveric heads were used for endoscopic endonasal exposure of anterior and posterior cerebral circulations. An aneurysm simulator model with 2 different sizes was used at the common sites for IAs to emulate a real surgery. Key measured parameters included "exposure of vessels and their respective perforators," "ability to gain proximal/distal control," and "possibility of clip placement" according to the size, direction, and location of the aneurysm model. Maneuverability of instruments and the need for pituitary gland transposition were assessed and recorded as well. RESULTS: Exposure of the anterior communicating artery complex and the common sites of posterior circulation aneurysms were feasible. The size, location, and direction of the aneurysm model had an impact on obtaining proximal and/or distal control, and the ability of clip placement. CONCLUSIONS: Clipping of midline aneurysms of the posterior circulation is feasible via endoscopic endonasal approach. Small-sized ventrally and medially directed aneurysm models carried a better probability of getting proximal and/or distal control, as well as better overall ability to place a clip. The endonasal route seems to provide a limited condition for proper management of anterior circulation aneurysms.

Endonasal anatomy of the olfactory neural network: Surgical implications.

OBJECTIVES/HYPOTHESIS: Define the anatomic distribution of the olfactory filaments within specific mucosal regions of the nasal cavity. STUDY DESIGN: Cadaveric study. METHODS: Seventeen cadaveric specimens (34 sides) were dissected to study the anatomical distribution and density of olfactory fila within different regions of the nasal cavity. Olfactory fila were dissected retrogradely to their point of entry into the anterior cranial fossa through the cribriform plate. Anatomic relationships among various components of the olfactory system and their corresponding arterial supply were determined subjectively. RESULTS: The highest density of olfactory fila was found at the mucosa of the ethmoid roof and superior turbinates. Olfactory fila were found at regions not previously considered to be part of the olfactory system: lateral wall of the nose, ethmoidal bullae, and between the os sphenoidale and arc of the posterior choana. Furthermore, at the septum, 20% of the olfactory fila crossed contralaterally before exiting the nose. The anterior ethmoidal arteries were the primary blood supply to the olfactory epithelium. CONCLUSIONS: This study suggests that olfactory filaments extend beyond previously established boundaries. These findings may have clinical implications regarding oncologic resections and could serve as the foundation for the development of techniques that better preserve olfactory function. LEVEL OF EVIDENCE: NA Laryngoscope, 2473-2477, 2018.