Child's Nervous System

https://doi.org/10.1007/s00381-018-3875-x

REVIEW PAPER

A comprehensive review of the clivus: anatomy, embryology, variants,

pathology, and surgical approaches
Rabjot Rai 1 & Joe Iwanaga 2 & Ghaffar Shokouhi 3 & Marios Loukas 1 & Martin M. Mortazavi 4 & Rod J. Oskouian 5 &
R. Shane Tubbs 1,2

Received: 14 June 2018 / Accepted: 18 June 2018

# Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Introduction The clivus is a bony structure formed by the fusion of the basioccipital and basispheniod bone at the sphenooccipital
synchondrosis. This downward sloping structure from the dorsum sellae to the foramen magnum is derived from mesoderm and
ectoderm properties.
Methods This comprehensive review of the clivus will discuss its basic anatomy, embryology, pathological findings, and surgical
implications. The clivus is an endochondral bone, formed under two processes; first, a cartilaginous base is developed, and it is
secondly reabsorbed and replaced with bone. Knowledge of its embryological structure and growth of development will clarify
the pathogenesis of anatomical variants and pathological findings of the clivus.
Conclusions Understanding the anatomy including proximity to anatomical structures, adjacent neurovasculature properties, and
anatomical variants will aid neurosurgeons in their surgical management when treating pathological findings around the clivus.

Keywords Clivus . Skull base . Notochord . Anatomy . Embryology . Surgery

Introduction variants and pathologies associated with the clivus requires

The clivus (Latin: slope or hill) (Figs. 1 and 2) is an important
structure situated at the central base of the skull. The clivus
(also known as Blumenbach’s clivus after German physiolo-
gist and anthropologist Johann Friedrich 1752–1840) is a
bony structure formed when the basal portion of the occipital
bone, the basioccipital, combines with the body of the sphe-
noid bone, the basisphenoid, at the sphenooccipital
synchondrosis [10]. This bone slants upward and forward
from the anterior aspect of foramen magnum to the posterior
clinoid processes [3, 7, 10]. Understanding the anatomical
* Joe Iwanaga
joei@seattlesciencefoundation.org
1
Department of Anatomical Sciences, St. George’s University, St.
George’s, Grenada
2
Seattle Science Foundation, 550 17th Ave, James Tower, Suite 600,
Seattle, WA 98122, USA
3
Neurosciences Research Center, Tabriz University of Medical
Sciences, Tabriz, Iran
4
California Institute of Neuroscience, Thousand Oakes, CA, USA
5
Swedish Neuroscience Institute, Seattle, WA, USA
extensive knowledge regarding the basic anatomy and embry-
ology of the clivus.
Anatomy
The clivus is a central configuration of the skull base and
measures about 4 to 5.5 cm long and about 3 cm wide at its
midpoint. Its angulation is varied but is on average, 116°.
When addressing the anatomy of the clivus, it is vital to un-
derstand its location in terms of adjacent structures. The clivus
descends inferiorly from the dorsum sellae to the anterior bor-
der of the foramen magnum (Fig. 3) [13]. The anterior border
of the clivus, on the other hand, is not as distinct as it blends
with the sphenoid bone adjacent the sphenoidal sinus [10].
Lateral to the clivus is the petro-occipital fissure housing the
inferior petro-occipital vein connecting the cavernous sinus to
the internal jugular vein (Fig. 3) [10, 13]. The lateral borders
of the clivus are related to cranial nerves V through XII, the
internal jugular veins, and the inferior petrosal sinuses (Fig. 4)
[3]. The basal subarachnoid space anterior to the brain stem is
related to its posterior surface [13]. The medulla oblongata
and pons lie adjacent to the posterior surface of the clivus,
but are separated by the prepontine and perimedullary cisterns

Fig. 1 Inferior view of fetal skull base noting the clivus and its sphenoid
(S) and occipital (O) parts. Note the intervening spheno-occipital
synchondrosis (SOS). For reference, also note the occipital condyles
(OC) and foramen magnum (FM)
(Fig. 2). The tectorial membrane and superior longitudinal
band of the cruciate ligament both attach to the posteroinferior
surface of the clivus (Fig. 5). The tectorial membrane is an
extension of the posterior longitudinal ligament, which ex-
tends from the posterior surface of the bodies of C1-C2 toward
the clivus [10].
The clivus takes on a concave shape when viewed
posterosuperiorly and is more prominent inferiorly at the lo-
cation of the jugular tubercles, which project on the lateral
inferior margins of the clivus [3, 10]. The fibrous raphe of
the pharynx (superior pharyngeal constrictor muscle), longus
capitus, rectus capitus anterior, and the anterior atlanto-
occipital membrane are found in connection to the inferior
surface, exocranial part, of the clivus [10]. The posterior sur-
face, endocranial part, of the clivus is smooth, composed of
Fig. 2 Left: midsagittal section
through a cadaveric specimen
noting the clivus (yellow line).
Note the relationships with it and
surrounding structures such as the
pons and medulla oblongata.
Right: hemisected skull noting the
clivus (black line) and its
relationship with the upper
cervical spine
Childs Nerv Syst
Fig. 3 Internal view of left hemisected skull noting the clivus and some
related anatomical structures such as the sigmoid sinus (SS), internal
auditory meatus (IAM), dorsum sellae (SD), and petro-occipital fissure
(POF)
cortical bone, and is covered with dura mater [7, 10]. On a
midsagittal section, the clivus is a wedged shaped bone, which
is thicker anteriorly and becomes thinner posteriorly [7]. Close
examination of the central portion of the clivus demonstrates
cancellous bone containing bone marrow, which may be var-
iably pneumatized [7, 10, 13].
Embryology
Understanding the embryology of the clivus may explain pa-
thologies that occur in the region secondary to developmental
remnants. The mesoderm and ectoderm are both involved in
the development of the skull base; mesoderm develops into
the posterior cranial fossa base, and neural crest cells are in-
volved in the growth of parts anterior to the notochord [4]. The
skull base is composed of vertebral parts; this includes the
notochord (chorda dorsalis), which ends at the junction below
the dorsum sellae [7]. The clivus is an endochondral bone; its
progression involves cartilaginous formation followed by re-
absorption preceding bone deposition [17].
Childs Nerv Syst
Fig. 4 Schematic drawings of the clivus and surrounding
neurvasculature. Left: note the optic chiasm (OC) and trigeminal ganglion
(V) and wedged between them, the oculomotor and trochlear nerves. At
the clivus, not the abducens nerve (VI) entering Dorello’s canal and in
blue, the basilar venous plexus. Right: note the exposed course of the
During development, the notochord follows an intricate
path where it exits the skull base to the outer surface of the
future clivus and where irregular processes are produced
(Fig. 6) [7]. At the basisphenoid, the notochord enters and
reaches the caudal extent of the hypophysis where the cranial
base begins its development [12]. A thick mass of mesen-
chyme surrounds the brain, appearing first in the occipital
side, and enclosing the notochord as it moves toward the hy-
pophysis to contour the clivus and dorsum sellae; this is
known as the membranous stage. Due to the abundance of
sulfated glycosaminoglycan at the rostral tip of the notochord,
it initiates the process of condensation and chondrification of
the occipital sclerotome-derived mesenchyme forming the
parachordal cartilage; this is known as the cartilaginous stage.
The initial chondrification centers commence at the
Fig. 5 Midsagittal view of the craniocervical junction noting the
ligamentous attachments onto the clivus and specifically, its
basioccipital part (B). From the apex of the odontoid process (OP) note
the apical ligament (AL). The anterior atlanto-occipital membrane
(AAOM) is seen as a continuation of the anterior longitudinal ligament
up to the clivus. Note the superior band (SB) of the cruciate ligament
extending superiorly to the basion and covered posteriorly by the
tecotoiral membrane (pink)
right abducens nerve (VI) on the clivus (the overlying clival dura is
removed on the right side of this image) compared to its extra and
intradural parts on the left side. The basilar venous plexus is seen as is
the trigeminal (V) and oculomotor (III) nerves
basioccipital and extend toward the cartilaginous centers of
the future basal extent of the sphenoid bone [13]. By the sixth
week of development, the basisphenoid includes two ossifica-
tion centers, and by the seventh week, the basioccipital portion
of the occipital bone is developed [4, 13]. At birth, the clivus is
composed of partially ossified basioccipital and basisphenoid
parts separated by the spheno-occipital synchondrosis [12].
The clivus remains a heterogeneous structure divided by
the spheno-occipital synchondrosis until adolescence [10].
This structure remains a staple as a growth zone, as it is a
primary region for the longitudinal growth of the skull base.
Complete ossification of the synchondrosis (Fig. 7) takes
place at the age of 13 to 18 years in males and 12 to 16 years
in females [15].
The anterior arch of the atlas is an embryological structure
relating to the hypochordal blastemas. It is a part of the skull
base, and during the development of the hypochordal blaste-
mas, the proatlas and other vertebral levels are subsequently
Fig. 6 Upper: embryological components contributing to the
craniocervical junction. Note the hypochordal bow of sclerotome 4 (S4)
forming the basiocciput of the clivus. Lower: note the pathway of the
notochord through the axis and up into and around the clivus
 Childs Nerv Syst

Fig. 7 Axial (left) and sagittal

(right) CT images of the skull ba-
se. Note the spheno-occipital
synchondrosis (arrows). The con-
tribution of the basiocciput part
(BO) of the clivus and its contri-
bution to the skull base, and in
particular, the anterior aspect of
the foramen magnum is seen at
left

absorbed (Figs. 6 and 8). However, failure of reabsorption can
lead to variation at the caudal end of the clivus [7].
Anatomical variants
As mentioned earlier, the clivus is developed from the fusion
of the basiocciput and basisphenoid across the spheno-
occipital synchondrosis. This portion of the central skull base
has variations to its structure based on its development. A
study conducted by DiChiro and Anderson (1965) observed
94 cadaver skulls in normal adults and found the majority
(77.66%) had a slight concavity of the clivus surface of mostly
1 to 2 mm with a few outliers of 3 mm. From the remainder of
the population, 19% had a flat clivus, and 0.03% had a convex

Fig. 8 Developmental
derivations of the craniocervical
junction noting the lower clivus
origin from the 4th occipital
sclerotome (dark blue)
Childs Nerv Syst
clivus. The study also noted occasionally findings of more
than 4-mm concavity in the posterior portion of the clivus in
patients with posterior fossa tumors and conditions causing
longstanding increased intracranial pressure. Other changes
noted in the clivus include grooves from the overlying basilar
artery with an incidence of 1% [13, 16].
Basilar impression is softening of surrounding bones such
as the clivus and is due to, for example, osteoporosis, rickets,
and von Recklinghausen disease [16]. Clival scalloping is
sometimes seen in the Chiari II malformation [22].
Platybasia is another variation where the clivus is positioned
more horizontally, causing the sphenoidal angle to widen.
This angle enlargement can be due to elevation of the dorsal
or frontal side of the angle [16].
A shortened clivus is a typical finding in all patients with
achondroplasia and Chiari II malformation. In patients with
idiopathic, or without achondroplasia, findings of a shortened
clivus can be attributed toward the premature merging or due
to reduced developmental growth of the spheno-occipital
synchondrosis [13].
Rare anatomical variants of the clivus include Sauser’s fis-
sure, also known as the basilar transverse fissure. Its develop-
ment may be present on one or both sides and can be formed
either completely or partially. The basilar fissure may distin-
guish the margin of the basioticum and basioccipital bones
contingent upon the development of the basilar portion of
the occipital bone [7, 23].
The basilar processes are variants seen in 4% of the popu-
lation; they consist of unilateral or bilateral small bony protu-
berance at the anterior boundary of the foramen magnum. It is
believed that their pathogenesis is derived from remnants of
the lateral hypochordal blastema of the proatlas. In rare occur-
rences, the larger basilar processes communicate with the an-
terior arch of the atlas resulting in instability of the
atlantooccipital joint [7]. If the hypochordal blastema of the
proatlas persisted in the medial aspect, it would give rise to a
third condyle at the anterior margin of the foramen magnum
[16]. A much scarcer variant is the arcus praebasioccipitalis
occurring in 0.03% of the population. It is an osseous mass in
the shape of a horseshoe positioned at the anterior margin of
the foramen magnum formed by the complete persistence of
the hypochordal blastemas. It may affect the functioning of the
craniovertebral joints.
The presences of bony canals through the clivus (Fig. 9) are
suggested to contain communicating vessels with the internal
and external venous plexus. When the basal segment of the
occipital canal contains a bony canal known as basilar canalis,
it may carry a previous basivertebral veins originating from
the vertebral material integrated into the skull base. It is pres-
ent among 8% of the population; however, the median basilar
canalis, which emerges from the midline of the basiocciput,
has a prevalence of 20% in newborns and is rarely seen in
adults, only 1%. The embryology of the basilar canals is
Fig. 9 Skeletal sample of the basiocciput noting clival canals. One canal
seen at left is filled with a pipe cleaner for clarity. Another canal on the
right is seen at the arrow
suggested to be (1) vascular origins or (2) remnants of the
notochord [8]. However, Sheikh et al. presented a case report
of a fossa navicularis, a subtype of the basilar canalis, and
found no indication of lymphoidal, glandular, or notochord
tissue upon histological analysis. In this case, the composition
of the fossa navicularis was loose connective tissue, collagen,
and elastic fibers, with vascular origins of veins, arteries, and
capillaries [21].
The apical ligament (Fig. 5) ascends from the apex of the
dens to anterior margin (basion) of the foramen magnum. If
ossified, it can present as a bony spur on the clivus [6, 7].
Another adaptation includes the ossification of the enclosed
material while the core remains ligamentous, resulting in a
tube-like development instead of spur [7].
Arterial supply and venous relationships
The arterial supply of the clivus (Fig. 10) is primarily derived
from two vessels. The first is a branch off the internal carotid
artery, the meningohypophyseal trunk, and the second main
vessel is a branch of the ascending pharyngeal artery, the pos-
terior meningeal artery [18]. There are many variations re-
garding the meningohypophyseal trunk in terms of its
branching and anastomoses [25]. The meningohypophyseal
trunk gives off the dorsal meningeal artery, which passes pos-
teriorly through the cavernous sinus, within Dorello’s canal
with the abducens nerve and the inferior petrosal sinus, to
supply the clival dura mater. Alongside the inferior petrosal
sinus runs the lateral clival artery, which anastomosis with the
posterior meningeal artery. The medial group of branches sup-
plies the apex of the clivus to the height of where the abducens
nerve emerges. A branch of the ascending pharyngeal artery,
the posterior meningeal artery, passes through the jugular fo-
ramen and enters the posterior cranial fossa supplying the
inferior dura mater of the clivus [18]. The blood supply of
the clivus is clinically significant due to the implications of
tumors. Dorsal to the clivus, the basilar artery and basilar

Fig. 10 Blood supply to the
clivus derived from the
meninohypophyseal trunk, which
is shown here providing clival
and meningeal (dorsal meningeal)
branches
venous plexus are found and can create faint grooves on the
bone [3]. Since the original development of the basilar venous
plexus (Fig. 4) is related to the vertebral column, it is consid-
ered a constituent of Batson’s plexus [7].
Pathology
Non-neoplastic tumors
Fibrous dysplasia Fibrous dysplasia is a benign skeletal anom-
aly that may affect one or multiple bones, with a greater ten-
dency to affect long bones, ribs, and craniofacial bones [2].
The mature bone becomes replaced with a weaker substitute
of woven bone and fibrous tissue. More commonly, the disor-
der affects a single bone in 70% of cases and multiple bones in
30% [1]. McCune-Albright syndrome involves multiple bone
subtype of fibrous dysplasia, café-au-lait spots, and endocrine
disorders, in which the clivus and sphenoid bone may be in-
volved [14]. Imaging with a ground glass appearance is pa-
thognomonic for fibrous dysplasia.
Neurenteric cyst If CT images display an integral cortex with
lytic lesions, it should raise concerns of a possible neurenteric
cyst [7]. A location at the clivus is unusual but not surprising
given that the embryological nature involves dysgenesis of the
notochord during early development [11].
Ecchordosis physaliphora Ecchordosis physaliphora is a con-
genital hamartomatous lesion derived from notochord rem-
nants and is seen in approximately 2% of the population. It
is located in the retroclival region and projects toward the
intradural prepontine cistern. The tissue appears hypotense
on T1-weighted MRI and hypertense on T2-weighted MRI
with a lack of contrast enhancement compared to other tumors
such as chordomas. The clinical repercussion of this tumor-
like mass is bleeding or CSF leakage [7].
Childs Nerv Syst
Neoplastic tumors
Meningioma The dorsal dural surface of the clivus increases its
propensity of being affected by meningiomas. Due to the lack of
arachnoid granulations at the central aspect of the clivus, menin-
giomas arise more commonly at the petroclival line. As a result,
meningiomas are often located medial to the trigeminal nerve [7,
20]. When excising the tumor, neurosurgeons must be attentive
toward the vasculature surrounding the mass.
Chordomas Chordomas are similar to ecchordosis physaliphora
in that they are both relics of notochordal tissue. The direction of
travel of the notochord from the odontoid process moving ante-
riorly toward the basiocciput can lead to susceptibility of noto-
chord remnants within the area and lead to the development of
chordomas [24]. However, compared to ecchordosis
physaliphora, chordomas are malignant tumors arising within
the bone in a slow growing manner with a potential to metasta-
size via lymphatics or hematogenously [7]. Chordomas are un-
common and account for less than 1% of all intracranial tumors
[24]. They have a greater prevalence in males by the third and
fourth decades of life and commonly occur is the sacrum, clivus,
and cervical vertebrae. Approximately one-third occur at the
clivus originating within the bone as a well circumcised, midline
extradural soft-tissue mass and often affecting the abducens
nerve at initial presentation [5]. On imaging, clival chondromas
appear as soft tissue masses with lytic bone destruction. Due to
high fluid content of the chordomas, on T1-weighted MRI, they
appear hyperintense, while on T2-weighted MRI, they appear
hypotense (as opposed to ecchordosis physaliphora) with mod-
erate degree of contrast enhancement [7]. Treating chordomas are
difficult as they often recur and occupy a difficult location in
terms of neighboring neurovascular structures. Clival chordomas
sit in close proximity to the brain stem, thus compressive growth
and inadequately managed tumors often lead to high morbidity
and mortality [26].
Childs Nerv Syst
Surgical approaches
The location of masses on the clivus presents a challenge to
surgeons who must maintain vital structures adjacent to it
including the pituitary gland, internal carotid artery, cavernous
sinus, basilar artery, and brain stem. With slow growing tu-
mors such as chordomas, the extension of the tumor to sur-
rounding structures is already compromised during initiation
of symptoms and creates another barrier for surgeons to
achieve clear margins.
When accessing a clival mass, craniotomies usually
require excessive brain retraction, which can lead to com-
plications including cerebral infarction, hematoma, and
regional brain atrophy. Additionally, these approaches do
not give access to extradural portions of the tumor. The
microscopic transsphenoidal approach allows for better
visualization of the sella turcica and upper to middle
clivus [18]. The lower clivus and craniocervical junction
(CCV) are not adequately viewed, as they would be with
a transoral approach. This approach is limited, preventing
access to the upper clivus, pharyngeal space, and jugular
foramen. However, a maxillary osteotomy allows for ac-
cess to the upper, middle, and lower clival regions and the
CCV. However, the maxillary osteotomy approach re-
quires a facial incision, which may cause dysfunction
and deformities to adjacent regions. Lastly, the endoscop-
ic approach to the clivus provides a complete 360-degree
view of the clivus and its adjacent structures allowing for
complete resection of the tumor. This approach is not
without its limitations as it is more likely to cause intra-
cranial infection. The endoscopic technique provides an
off-center line of sight of the clivus, although this can
be conquered by the surgeon’s knowledge of clival anat-
omy and practical skills using the endoscope [9].
Conclusion
The clivus is adjacent to important anatomical structures,
which makes surgical approaches to this region complicat-
ed. The embryology of the clivus highlights the intricate
course of the notochord, and how remnants of the noto-
chord may lead to the development of pathological find-
ings. Understanding the anatomy and adjacent
neurovasculature structures and anatomical variants will
aid skull base surgeons in their management when treating
pathological findings around the clivus.
Compliance with ethical standards
Conflict of interest On behalf of all authors, the corresponding author
states that there is no conflict of interest.
References
1. Atalar M, Ozum U (2010) Monostotic fibrous dysplasia of the
clivus: imaging findings. Turk Neurosurg 20:77–81
2. DiCaprio MR, Enneking WF (2005) Fibrous dysplasia: pathophys-
iology, evaluation, and treatment. J Bone Joint Surg 87(8):1848–
1864
3. DiChiro GD, Anderson WB (1965) The clivus. Clin Radiol 16(3):
211–223. https://doi.org/10.1016/S0009-9260(65)80046-0
4. DiIeva A, Bruner E, Haider T, Rodella LF, Lee JM, Cusimano MD,
Tschabitscher M (2014) Skull base embryology: a multidisciplinary
review. Childs Nerv Syst 30(6):991–1000. https://doi.org/10.1007/
s00381-014-2411-x
5. Fernandez-Miranda JC, Gardner PA, Snyderman CH, Devaney KO
(2013) Clival chordomas: a pathological, surgical, and
radiotherapeutic review. Head Neck 36(6):892–906. https://doi.
org/10.1002/hed.23415
6. Fisahn C, Schmidt C, Rostad S, Li R, Rustagi T, Alonso F, Shoja
MM, Iwanaga J, Chapman JR, Oskouian RJ, Tubbs RS (2017)
Adult ligament of the dens lacks notochordal tissue: application to
better understanding the origins of skull base chordomas. World
Neurosurg 101:42–46
7. Hoffmann E, Prescher A (2011) The clivus: anatomy, normal var-
iants and imaging pathology. Clin Neuroradiol 22:123–129. https://
doi.org/10.1007/s00062-011-0083-4
8. Jacquemin C, Bosley TM, Al Saleh M, Mullaney P (2000) Canalis
basilaris medianus: MRI. Neuroradiology 42:121–123
9. Jiang WH, Zhao SP, Xie ZH, Zhang H, Zhang J, Xiao JY (2009)
Endoscopic resection of chordomas in different clival regions. Acta
Otolaryngol 129:71–83. https://doi.org/10.1080/
00016480801995404
10. Jinkins JR (2000) Atlas of neuroradiologic embryology, anatomy,
and variants. Lippincott Willams & Wilkins, Philadelphia, pp 63–
65 100, 116
11. Kapoor V, Johnson DR, Fukui MB, Rothfus WE, Jho HD (2002)
Neuroradiologic-pathologic correlation in a neurenteric cyst of the
clivus. Am J Neuroradiol 23(3):476–479
12. Kawase T, Shiobara R, Ohira R, Toya S (1996) Developmental
patterns and characteristic symptoms of petroclival meningiomas.
Neurol Med Chir 36:1–6
13. Koksel T, Crockard A (1990) BClivus^ through the eyes of the
transoral surgeon. Turk Neurosurg 1:146–150
14. Lustig LR, Holliday MJ, McCarthy EF, Nager GT (2001) Fibrous
dysplasia involving the skull base and temporal bone. Arch
Otolaryngol Head Neck Surg 127:1139–1247
15. Melsen B (1972) Time and mode of closure of the spehno-occipital
synchondrosis determined on human autopsy material. Acta Anat
83:112–118
16. Prescher A (1997) The craniocervical junction in man, the osseous
variations, their significant and differential diagnosis. Ann Anat
179:1–19. https://doi.org/10.1016/S0940-9602(97)80126-4
17. Sajisevi M, Hoang JK, Eapen R, Jang DW (2015) Nasopharyngeal
masses arising from embryologic remnants of the clivus: a case
series. J Neurol Surg Rep 72(2):e253–e257. https://doi.org/10.
1055/s-0035-1564603
18. Samii M, Knosp E (1992) Transoral Approach. In: Approaches to
the clivus: approaches to no man’s land. Springer-Verlag,
Heidelberg. https://doi.org/10.1007/978-3-642-76614-5_2
19. Schick B, Prescher A, Hofmann E, Steigerwald C, Draf W (2003)
Two occult skull base malformations causing recurrent meningitis
in a child: a case report. Eur Arch Otorhinolaryngol 206:518–521
20. Sekhar LN, Jannetta PJ, Burkhart LE, Janosky JE (1990)
Meningiomas involving the clivus: a six-year experience with 41
patients. Neurosurgery 27:764–781

21. Sheikh S, Iwanaga J, Rostad S, Rustagi T, Oskouian RJ, Tubbs RS
(2017) The first histological analysis of the tissues lining the fossa
navicularis: insights to its etiology. Cureus 9(5):e1299. https://doi.
org/10.7759/cureus.1299
22. Shoja MM, Johal J, Oakes WJ, Tubbs RS (2018) Embryology and
pathophysiology of the Chiari I and II malformations: a compre-
hensive review. Clin Anat 31(2):202–215
23. Shoja MM, Ramdhan R, Jensen CJ, Chern JJ, Oakes WJ, Tubbs RS
(2018) Embryology of the craniocervical junction and posterior
fossa, part I: development of the upper vertebrae and skull. Clin
Anat 31(4):466–487
24. Tushar R, Nagula SV, Tardieu GG, Saker E, Shoja MM, Loukas M,
Oskouian RJ, Tubbs RS (2017) Update on the notochord including
Childs Nerv Syst
its embryology, molecular development, and pathology: a primer
for the clinician. Cureus 9(4):e1134. https://doi.org/10.7759/cureus.
1137
25. Vutskits L, Reisch R, Patonay L, Fries G (1996) The Brete mirabile^
of the clivus and the dorsum sellae. A microanatomical study.
Minim Invasive Neurosurg 39(4):138–140. https://doi.org/10.
1055/s-2008-1052234
26. Zorlu F, Gurkaynak M, Yildez F, Oge K, Lale Atahan I (2000)
Conventional external radiotherapy in the management of clivus
chordomas with overt residual disease. Neurol Sci 21:203–207.
https://doi.org/10.1007/s10072007007