3D‑exoscopic extradural Hakuba‑Dolenc approach with manipulation of pneumatized anterior clinoid process for the prevention of cerebrospinal fluid leakage

Acta Neurochirurgica (2025) 167:165

This study describes a 3D-exoscopic extradural Hakuba-Dolenc approach with a hybrid technique for anterior clinoidectomy in cases with pneumatized anterior clinoid process, aiming to prevent cerebrospinal fluid leakage during skull base surgery. The technique was effective, with no postoperative CSF leakage observed.

• Describes a modified 3D-exoscopic extradural Hakuba-Dolenc approach to anterior clinoidectomy, focusing on preventing cerebrospinal fluid (CSF) leakage, especially in cases with pneumatized anterior clinoid process (ACP).

• The hybrid technique combines drilling and biting for safe removal of the ACP, minimizing mucosal injury and CSF leak risk.

• Preoperative thin-slice bone CT is essential to identify anatomical variations of ACP and avoid complications.

• Careful interdural dissection of the lateral cavernous wall is performed, with hemostasis for venous bleeding.

• Gelfoam is placed in the sphenoid sinus to isolate mucosa and prevent CSF leakage.

• The approach was effective, with no CSF leakage or neurological deficits postoperatively and at 3-month follow-up.

• Key risks include CSF rhinorrhea and potential optic nerve injury; patients should be informed preoperatively.

• Technique is indicated for paraclinoid aneurysm and certain skull base tumors.