11 Endoscopic Endonasal Transclival Approach to the Posterior Fossa

Jose Luis Porras, Jr., Debraj Mukherjee, Carl H. Snyderman, Eric W. Wang, and Paul A. Gardner

Abstract

The endoscopic endonasal transclival approach (EETCA) facilitates direct access to lesions of the posterior fossa with no cerebral retraction and minimal neurovascular manipulation. Through the clivus, one may access a range of structures including the basilar apex, floor of the third ventricle, ventral pons, ventral medulla, and the vertebral arteries. Although this approach is used most commonly for extradural midline or paramedian lesions including chordoma and chondrosarcoma, it may also be employed for intradural lesions such as meningioma. With careful preoperative planning that includes high-resolution imaging, lesion resection may be achieved either with or without an adjunctive approach, depending upon its extent beyond the confines of the internal carotid artery (ICA) and lower cranial nerve boundaries. Resultant skull base defects are typically large, and can feature high-flow cerebrospinal fluid (CSF) leaks, and therefore require careful skull base reconstruction emphasizing use of a vascular flap and multilayer reconstruction as well as adjuvant CSF diversion.

Key words

endoscopic endonasal approach - transclival - posterior fossa - chordoma - chondrosarcoma - meningioma

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