Arteries Paving the Way for Centrifugal Excision of Anterior Clinoidal Meningioma

The anterior clinoidal meningiomas often engulf/encase or compress the internal carotid artery (ICA) and its branches, the optic nerve (ON), and structures passing through the superior orbital fissure (SOF). The transsylvian route of excising a tumor poses difficulty in exposing and safeguarding encased vessels. In addition, it may jeopardize the bulging brain and stretched veins, especially in large tumors. The objective is to present an operative video to demonstrate the technique of “centrifugal opening” and removal of anterior clinoidal meningiomas. The ICA, ON, and SOF are exposed after extradural anterior clinoidectomy. The dural base is devascularized and incised radially. Cuts start proximally from these neurovascular structures. The tumor is then debulked and removed by tracing these structures from proximal to distal. The arachnoid and veins are preserved. Early identification of the ICA, ON, and SOF provides better control and allows preservation of these structures despite their engulfment, encasement, or compression. The perforators and arteries are skeletonized in a stepwise manner to achieve maximal safe resection. Even with brain edema, the arachnoid and adjacent veins can be preserved. The technique was used by the authors in >15 cases with good outcome. Thus the discussed technique imparts better control of neurovascular structures with minimal handling of adjacent brain and veins, thereby allowing a more aggressive resection.