Objective: Surgical removal of anterior clinoidal meningiomas (ACMs) remains a challenge because of its complicated relationship with surrounding meninges, major arteries and cranial nerves. This study aims to define the meningeal structures around the anterior clinoid process (ACP) and its surgical implications. Methods: Five dry skulls and 19 cadavers were used in the anatomical study. Cadavers were prepared as transverse, coronal, and sagittal plastinated sections, and the meningeal architecture around the ACP was studied with dissecting and confocal microscopies. The database of meningiomas in one single center was retrospectively reviewed, and the patients with ACMs were collected for clinical analysis. Results: The superior, lateral, medial surfaces, and the tip of ACP were covered by different layers and types of meninges. The ACMs were classified into four main types based on the sites of origin, possible extending pathways following meningeal dura. In the retrospective cohort of 131 ACMs, the percentage of types I, IIa, IIb, III, and IV were 42.0% (55/131), 19.8% (26/131), 9.2% (12/131), 16.8% (22/131), and 12.2% (16/131), respectively. We found that types IIa and I had higher chances for achieving Simpson grade 1-2 resection (92.3 and 85.4%, respectively), followed by type III (54.5%) and type IV (31.3%), while type IIb showed little chance of Simpson grade 1-2 resection. Univariate and multivariate analyses revealed ACM classification and tumor size (<3 cm) to be independent risk factors for achieving more extensive resection. Conclusion: The meningeal architecture around the ACP may guide and determine the origin and extension of ACMs. The classification based on the meningeal architecture helps to understand surgical anatomy as well as predicting surgical outcomes.
