Anatomical study of the orbitozygomatic transsellar-transcavernous-transclinoidal approach to the basilar artery bifurcation

Object. An anatomical study in which measurements were obtained was undertaken to demonstrate that the orbito-zygomatic transcavernous-transclinoidal approach provides excellent exposure of the trunk of the basilar artery (BA) and its bifurcation. Methods. Bilateral stepwise dissections were performed on 10 fixed cadaver heads with the aid of X 3 to X 40 magnifications. A frontotemporal craniotomy was made, followed by an orbito-zygomatic osteotomy. After the dura mater had been opened, the sylvian fissure was widely separated. The anteromedial triangle of the cavernous sinus was opened to mobilize the internal carotid artery medially. The sella turcica and the dorsum sellae were exposed. The posterior clinoid process and the dorsum sellae were drilled to expose a length of BA that included its bifurcation. Measurements were obtained following the frontotemporal craniotomy, orbito-zygomatic osteotomy, and drilling of the posterior clinoid process to quantify the exposures provided by these procedures. Excellent exposure of the trunk of the BA and its bifurcation was achieved. The structures in the interpeduncular cistern and the prepontine cistern were also exposed. There was an average gain of a 13.4-mm-long segment of the BA, which in some surgeries can be invaluable. The angle of exposure that was achieved with the BA bifurcation located at the apex increased markedly. Moreover, this method widened the oculomotor nerve-carotid artery corridor for easier access to the BA bifurcation region. Conclusions. This approach combines the advantages granted by most conventional approaches to aneurysms of the BA bifurcation. The approach is suitable for aneurysms situated at a high, normal, or low position on the BA bifurcation. It exposes a sufficient length of the BA trunk to place a temporary clip.