The anterior clinoid process is the medial end of the lesser wing of the sphenoid, projecting posteriorly and medially over the optic canal. The internal carotid artery lies medial to the anterior clinoid process as it exits the cavernous sinus; the optic nerve lies medial and just inferior. The tentorial ring (the free edge of the tentorium cerebelli) attaches to the posterior clinoid process and may connect to the anterior via the petroclival ligament.
The anterior clinoid process is removed (anterior clinoidectomy) to expose paraclinoid ICA aneurysms that would otherwise be hidden beneath the bony shelf. The process is drilled extradurally to release the clinoid segment of the ICA, reducing the risk of premature aneurysm rupture during exposure. The optic nerve and ICA are the critical structures at risk during this manoeuvre. Hyperostotic anterior clinoid meningiomas invade and enlarge the process.
Extradural removal of the anterior clinoid process with a high-speed drill exposes the clinoid segment of the internal carotid artery for clipping of paraclinoid and ophthalmic segment aneurysms, with the optic nerve running just medial to the drill path requiring continuous identification and protection.
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