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Here we describe a cranio-orbital pretemporal approach with anterior clinoidectomy for the removal of a large clinoid meningioma with unwrapping of the encircled internal carotid artery and decompression of the optic nerve. The patient is a 66-year-old female who presented with left-sided homonymous hemianopsia with past medical history of primary open angle glaucoma and hypertension. On exam, the patient was fully alert and oriented with no focal motor deficits. On admission, examination by a neuro-ophthalmologist revealed left inferior nasal visual field deficit with no visual acuity deficits and no papilledema. Preoperative MRI reveals a dural-based tumor in the region of the left anterior clinoid process, consistent with the findings of a large clinoidal meningioma, wrapping around the left internal carotid artery, its bifurcation and A1. The tumor is seen abutting A-com, elevating the M1 segment of the middle cerebral artery and invading the left optic canal. Surgical resection was recommended to decompress the optic nerve in an effort to preserve and potentially improve vision. Histopathological diagnosis was also desired to guide treatment plans. Risks of the procedure include hemorrhage, visual loss, vascular injury, seizure, stroke, infection, CSF leak, and death. The potential benefits were visual preservation and potential improvement as well as tissue diagnosis. Alternative treatments include radiosurgery, but due to the mass effect of the lesion on surrounding vascular structures as well as the optic nerve, not thought to be a good treatment option. Given the progressive visual field deficits, observation with serial imaging was not chosen. Patient was placed in supine position with head fixed in the Mayfield head holder. A shoulder roll was placed, and the head was elevated and rotated approximately 20 degrees to the right to facilitate venous drainage and optimize the angle of the approach corridor. An illustrative depiction of the setup as well as the incision and craniotomy can be seen here. Necessary equipment included the surgical microscope and navigation system. A 5 mm coarse diamond drill was used to drill the orbital roof and a 2 mm diamond drill was used for the clinoid. A left cranio-orbital craniotomy and extradural dissection was performed to include an extradural anterior clinoidectomy as well as the unroofing of the optic canal with the coarse diamond drill. The Sylvian fissure was split and identification of the internal carotid artery and bifurcation, as well as A1, M1, and M2 was performed. as well as sharp incision of the falciform ligament for optic nerve decompression. Tumor was resected and a standard closure was performed. Left-sided curvilinear incision was made. The temporalis muscle was reflected inferiorly and out of the way to avoid obstruction of the roof and lateral wall of the orbit. Simple stitch retraction was used for efficient soft tissue retraction. A standard left cranio-orbital craniotomy was performed. The orbital roof and lateral wall of the orbit as well as the frontal and temporal lobe dura can be seen here. The orbital roof and lateral wall of the orbit were removed using the 5 mm coarse diamond self-irrigating drill. Gelfoam powder was used to maintain hemostasis throughout the extradural portion of the exposure. A needle nose rongeur was used to complete bony removal and decompression of the lateral wall of the orbit. The orbital segment of the optic nerve can be seen here as it is being decompressed. Here, the meningo-orbital artery stump is identified, which had been previously coagulated and sharply incised. A 1 mm Kerrison rongeur was used for careful removal of the base of the clinoid process connecting the intraorbital and intracranial portions of the optic canal. The tip of the anterior clinoid process was mobilized and removed after it had been previously thinned down with the diamond drill. The roof of the optic canal is thinned with the 2 mm diamond drill bit. Unroofing of the optic canal was completed with the 1 mm Kerrison rongeur, revealing the fully decompressed optic nerve in the canal as can be seen here. After dural opening, the dural-based tumor is revealed in the pretemporal region. Care was taken to not use retractors during the intradural portion of the procedure. The Sylvian fissure splitting is performed with sharp dissection, revealing the MCA bifurcation with visualization of M1, which was superiorly displaced by the tumor. Dissection was performed with use of the bipolar spreading technique along M1 with identification of the ICA bifurcation. The origin of A1 from the bifurcation can be visualized here. Careful dissection of the perforators was performed. The Stealth navigation probe was used to periodically assess and guide safe and meticulous dissection. The tumor was removed in piecemeal fashion. Debulking of the tumor in the temporal fossa was performed and sent for biopsy. The ultrasonic aspirator was used for debulking. The portion of the tumor along the sphenoid and anterior fossa was resected. The distal ICA, left A1 segment of ACA and left optic nerve are seen here. The dural attachment of the tumor is coagulated and peeled back with the bipolar. The tumor was then thinned down and debulked before dissection of the tumor off the carotid artery. The tumor was then slowly dissected off the carotid artery with care to avoid vessel injury. Here we can see the posterior communicating artery, the anterior choroidal artery, and the optic nerve coming into view, with the tumor lateral to the carotid artery. Further unwrapping of the tumor off the carotid artery is done. The oculomotor nerve can be seen below the carotid artery. Further tumor resection allows visualization of anatomical landmarks with more of the ICA and optic nerve now visualized. All anatomical structures were carefully preserved. Further continuous debulking was performed with the ultrasonic aspirator, using a rotten dissector to protect the ICA and elevate tumor off the artery. After the tumor was thinned out with the ultrasonic aspirator, further piecemeal resection of the tumor was performed using sharp dissection to remove tumor adjacent to the optic nerve. In the final stage of ICA unwrapping, tumor was coagulated and sharply excised for precise piecemeal removal along the artery. The dural attachment of the tumor was carefully coagulated. The falciform ligament was elevated with a hook and opened with sharp dissection using an 11 blade knife. This allowed complete decompression of the optic nerve. The distal dural ring is sharply incised with micro scissors with visualization of the now open optic canal. Remaining small pieces of tumor were meticulously removed and the dural attachment was coagulated, leaving the left ICA unwrapped and the left optic nerve fully decompressed. The last of the tumor was cleaned off the temporal fossa floor. Clinoidal meningiomas more commonly present in females and most commonly present with headache and visual deficits. The most preferable treatment is typically surgical resection due to the close proximity to the optic nerve, making radiosurgery less favorable. These meningiomas are typically grade 1. Complete tumor resection was confirmed on post-op imaging. The patient's vision was preserved with no new neuro deficits. Post-op neuro-ophthalmological report showed marginal improvement. Final surgical pathology was consistent with Grade 1 meningioma. Postoperative imaging on the bottom row reveals gross total resection of the tumor with intact vascular structures. Post-op CT demonstrates complete left anterior clinoidectomy. The patient is doing well post-op.