• Michael Kim, Alexander I Evins, Hitoshi Fukuda, Namhee Kim, Philip E Stieg, and Antonio Bernardo.
• Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA; Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, NewYork, New York, USA.
• World Neurosurg. 2020 Jul 1; 139: 558-566.

BackgroundAnatomical variations of the course of the internal carotid artery (ICA) may complicate surgical clipping of posterior communicating artery (PCoA) aneurysms by narrowing the retrocarotid window. We evaluated the efficacy of the periclinoid surgical maneuvers for expanding the retrocarotid window and analyzed computed tomography angiography (CTA) data from patients with PCoA aneurysms to define parameters for low-coursing ICAs.MethodsUsing cadaveric specimens, standard pterional craniotomies were fashioned and extradural or intradural periclinoid surgical maneuvers-cutting of the meningo-orbital band, anterior clinoidectomy, and cutting of the distal dural ring (DDR)-were performed, and their relative advantages for expanding the retrocarotid window were assessed. Additionally, preoperative CTA data from 24 patients with PCoA aneurysms used to calculate the angles of the ICA relative to the skull base.ResultsPericlinoid maneuvers, especially the anterior clinoidectomy, provided additional exposure of the retrocarotid space. Cutting of the DDR allowed for partial mobilization of the ICA and widened the retrocarotid surgical window, enhancing maneuverability. The anterior clinoidectomy with cutting of the DDR allowed for enhanced exposure of the medial, middle, and posterolateral aspects of the retrocarotid space. Cutting the anterior petroclinoid fold and mobilizing cranial nerve III provided wide exposure of the lateral aspect of retrocarotid space.ConclusionWhen clipping PCoA aneurysms in the presence of normal-coursing ICAs (approximately ≥30° ICA angle), a standard pterional craniotomy with anterior clinoidectomy and cutting of the DDR allows for substantial expansion of the retrocarotid window.Copyright © 2020 Elsevier Inc. All rights reserved.

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