Rychen Jonathan, Xu Yuanzhi, Agostini Ludovico, Constanzo Felipe, Arifianto Muhammad Reza, Bex Alix, Xiao Limin, Vigo Vera, Cohen-Gadol Aaron A, Fernandez-Miranda Juan C
1Department of Neurosurgery, Stanford University, Stanford, California.
2The Neurosurgical Atlas, Carmel, Indiana.
J Neurosurg. 2025 Jun 27:1-12. doi: 10.3171/2025.3.JNS242768.
The carotidoclinoidal ligament (CCL) spans from the medial wall of the cavernous sinus (MWCS) to the internal carotid artery (ICA) and anterior clinoid process. In endoscopic endonasal transcavernous surgery, safe transection of the CCL requires not only knowledge of its typical anatomy, but also an understanding of its possible variations. The aim of this study was to analyze the anatomical variations of the CCL and the patterns of CCL invasion by pituitary adenomas (PAs).
This investigation comprised an anatomical and a clinical study. Endonasal dissections of 20 specimens (40 sides) were performed to investigate CCL variations. A retrospective analysis of 145 patients with PA invading the CS (160 CS sides) was conducted to report the incidence and patterns of CCL invasion.
The CCL was present in all investigated sides (n = 40). In the coronal plane, 1 CCL branch was found in 20 sides (50.0%) and ≥ 2 CCL branches were found in 20 sides (50.0%). The main CCL branch was defined as the medial continuation of the proximal dural ring, marking the transition from the cavernous to the paraclinoidal ICA segment. When additional accessory CCL branches were present, they attached to the paraclinoidal ICA (n = 17, 53.1%), the horizontal cavernous ICA segment (n = 10, 31.3%), and/or the anterior genu of the cavernous ICA (n = 5, 15.6%). The CCL most commonly attached to the upper (n = 29, 72.5%) and middle third (n = 26, 65.0%) of the MWCS. In the axial plane, the CCL was found to be a fenestrated membrane in 29 sides (72.5%) and an intact membrane in 11 sides (27.5%). All CCLs attached to at least the anterior third of the MWCS. Additionally, some CCLs attached to the middle third (n = 23, 57.5%) and/or the posterior third (n = 17, 42.5%). The CCL was connected to the inferior parasellar ligament in 14 sides (35.0%). Among all PAs invading the CS, the CCL was invaded in 36 cases (22.5%). Two patterns of CCL invasion were identified: 1) tumor adherent to and infiltrating the CCL fibers (n = 30, 83.3%), and 2) CCL thickened due to tumor growth within and along the fibers (n = 6, 16.7%).
This study represents a comprehensive analysis of the anatomical variations and patterns of invasion of the CCL, which is particularly relevant for the safe and effective resection of PA invading the CS.
颈动脉床突韧带（CCL）从海绵窦内侧壁（MWCS）延伸至颈内动脉（ICA）和前床突。在内镜鼻内经海绵窦手术中，安全切断CCL不仅需要了解其典型解剖结构，还需了解其可能的变异情况。本研究旨在分析CCL的解剖变异及垂体腺瘤（PA）侵犯CCL的模式。
本研究包括解剖学研究和临床研究。对20个标本（40侧）进行鼻内解剖以研究CCL变异。对145例侵犯海绵窦的PA患者（160侧海绵窦）进行回顾性分析，以报告CCL侵犯的发生率和模式。
所有研究侧（n = 40）均存在CCL。在冠状面上，20侧（50.0%）发现1支CCL分支，20侧（50.0%）发现≥2支CCL分支。主要CCL分支被定义为近端硬脑膜环的内侧延续，标志着从海绵窦段颈内动脉向床突旁段颈内动脉的过渡。当存在额外的副CCL分支时，它们附着于床突旁段颈内动脉（n = 17，53.1%）、海绵窦段颈内动脉水平段（n = 10，31.3%）和/或海绵窦段颈内动脉前膝部（n = 5，15.6%）。CCL最常附着于MWCS的上三分之一（n = 29，72.5%）和中三分之一（n = 26，65.0%）。在轴位面上，29侧（72.5%）的CCL为有孔膜，11侧（27.5%）为完整膜。所有CCL至少附着于MWCS的前三分之一。此外，一些CCL附着于中三分之一（n = 23，57.5%）和/或后三分之一（n = 17，42.5%）。14侧（35.0%）的CCL与鞍旁下韧带相连。在所有侵犯海绵窦的PA中，36例（22.5%）侵犯了CCL。确定了两种CCL侵犯模式：1）肿瘤附着并浸润CCL纤维（n = 30，83.3%），2）CCL因肿瘤在纤维内及沿纤维生长而增厚（n = 6，16.7%）。
本研究对CCL的解剖变异和侵犯模式进行了全面分析，这对于安全有效地切除侵犯海绵窦的PA尤为重要。
