Quantitative anatomical comparison of transnasal and transcranial approaches to the clivus

  • Edoardo Agosti
  • Giorgio Saraceno
  • Jimmy Qiu
  • Barbara Buffoli
  • Marco Ferrari
  • Elena Raffetti
  • Francesco Belotti
  • Marco Ravanelli
  • Davide Mattavelli
  • Alberto Schreiber
  • Lena Hirtler
  • Luigi F. Rodella
  • Roberto Maroldi
  • Piero Nicolai
  • Fred Gentili
  • Walter Kucharczyk
  • Marco M. Fontanella
  • Francesco DogliettoEmail author
Original Article - Neurosurgical Anatomy
Part of the following topical collections:
  1. Neurosurgical anatomy


Background and objective

The clivus was defined as “no man’s land” in the early 1990s, but since then, multiple approaches have been described to access it. This study is aimed at quantitatively comparing endoscopic transnasal and microsurgical transcranial approaches to the clivus in a preclinical setting, using a recently developed research method.


Multiple approaches were performed in 5 head and neck specimens that underwent high-resolution computed tomography (CT): endoscopic transnasal (transclival, with hypophysiopexy and with far-medial extension), microsurgical anterolateral (supraorbital, mini-pterional, pterional, pterional transzygomatic, fronto-temporal-orbito-zygomatic), lateral (subtemporal and subtemporal transzygomatic), and posterolateral (retrosigmoid, far-lateral, retrolabyrinthine, translabyrinthine, and transcochlear). An optic neuronavigation system and dedicated software were used to quantify the working volume of each approach and calculate the exposure of different clival regions. Mixed linear models with random intersections were used for statistical analyses.


Endoscopic transnasal approaches showed higher working volume and larger exposure compared with microsurgical transcranial approaches. Increased exposure of the upper clivus was achieved by the transnasal endoscopic transclival approach with intradural hypophysiopexy. Anterolateral microsurgical transcranial approaches provided a direct route to the anterior surface of the posterior clinoid process. The transnasal endoscopic approach with far-medial extension ensured a statistically larger exposure of jugular tubercles as compared with other approaches. Presigmoid approaches provided a relatively limited exposure of the ipsilateral clivus, which increased in proportion to their invasiveness.


This is the first anatomical study that quantitatively compares in a holistic way exposure and working volumes offered by the most used modern approaches to the clivus.


Clivus Comparative study Endoscopy Microsurgery Quantitative study Skull base surgery 



cerebrospinal fluid


computed tomography


Digital Imaging and Communications in Medicine


endoscopic transnasal transclival approach


endoscopic transnasal transclival approaches


ETCA with far-medial extension


ETCA with intradural hypophysiopexy approach


Far-lateral approach


Fronto-temporal-orbito-zygomatic approach

GTx-Eyes II – UHN

Guided Therapeutics software developed at University Health Network – Toronto, Canada


Innovation Development Exploration Assessment Long term


internal acoustic canals


mini-pterional approach


microsurgical transcranial approaches


pterional approach


pterional transzygomatic approach


supraorbital approach


presigmoid retrolabyrinthine infratentorial approach


retrosigmoid approach


subtemporal approach


subtemporal transzygomatic approach


presigmoid transcochlear infratentorial approach


presigmoid translabyrinthine infratentorial approach



We thank Prof. R. Rezzani, Ph.D., Head of the Section of Anatomy and Pathophysiology of Brescia, for study support, Prof. Giuseppe Lanzino, M.D., for study supervision, and Elisa Colombo, M.S., for her guidance.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Research involving human participants and/or animals and informed consent

This work was performed according to the ethical standards of our Institutional Review Board. All human cadaveric studies have been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The manuscript does not contain clinical studies or patient data.

Supplementary material

701_2019_4152_MOESM1_ESM.docx (2 mb)
ESM 1 (DOCX 2.03 MB)


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Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  • Edoardo Agosti
    • 1
  • Giorgio Saraceno
    • 1
  • Jimmy Qiu
    • 2
  • Barbara Buffoli
    • 3
  • Marco Ferrari
    • 4
  • Elena Raffetti
    • 5
  • Francesco Belotti
    • 1
  • Marco Ravanelli
    • 6
  • Davide Mattavelli
    • 4
  • Alberto Schreiber
    • 4
  • Lena Hirtler
    • 7
  • Luigi F. Rodella
    • 3
  • Roberto Maroldi
    • 6
  • Piero Nicolai
    • 4
  • Fred Gentili
    • 8
  • Walter Kucharczyk
    • 9
  • Marco M. Fontanella
    • 1
  • Francesco Doglietto
    • 1
    Email author
  1. 1.Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of BresciaBresciaItaly
  2. 2.TECHNA InstituteUniversity Health NetworkTorontoCanada
  3. 3.Section of Anatomy and Physiopathology, Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly
  4. 4.Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
  5. 5.Department of Public Health Sciences, Karolinska InstituteStockholmSweden
  6. 6.Radiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of BresciaBresciaItaly
  7. 7.Division of Anatomy, Center for Anatomy and Cell BiologyMedical University of ViennaViennaAustria
  8. 8.Department of Neurosurgery, Toronto Western HospitalUniversity of TorontoTorontoCanada
  9. 9.Department of Medical ImagingUniversity of TorontoTorontoCanada

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