The Medial Wall of the Cavernous Sinus: Surgical Anatomy, Ligaments, and Surgical Application

Object The object of this paper was to describe the surgical anatomy and technical nuances of the endonasal transcavernous posterior clinoidectomy approach with interdural pituitary transposition and to report the clinical outcome of this technical modification. Methods The surgical anatomy of the proposed approach was studied in 10 colored silicon-injected anatomical specimens. The medical records of 12 patients that underwent removal of the posterior clinoid(s) with this technique were reviewed. Results The natural anatomical corridor provided by the cavernous sinus is used to get access to the posterior clinoid by mobilizing the pituitary gland in an interdural fashion. The medial wall of the cavernous sinus is preserved intact and attached to the gland during its medial and superior mobilization. This provides protection to the gland, allowing for preservation of its venous drainage pathways. The inferior hypophyseal artery is transected to facilitate the manipulation of the medial wall of the cavernous sinus and pituitary gland. This approach was successfully performed in all patients, including 6 with chordomas, 5 with petroclival meningiomas, and 1 with an epidermoid tumor. No patient in this series had neurovascular injury related to the posterior clinoidectomy. There were no instances of permanent hypopituitarism or diabetes insipidus. Conclusions The authors introduce a surgical variant of the endoscopic endonasal posterior clinoidectomy approach that does not require intradural pituitary transposition and is more effective than the purely extradural approach. The endoscopic endonasal transcavernous approach facilitates the removal of prominent posterior clinoids increasing the working space at the lateral recess of the interpeduncular cistern, while preserving the pituitary function.

Download Full-text

The medial wall of the cavernous sinus. Part 1: Surgical anatomy, ligaments, and surgical technique for its mobilization and/or resection

Journal of Neurosurgery ◽

10.3171/2018.3.jns18596 ◽

2019 ◽

Vol 131 (1) ◽

pp. 122-130 ◽

Cited By ~ 6

Author(s):

Huy Q. Truong ◽

Stefan Lieber ◽

Edinson Najera ◽

Joao T. Alves-Belo ◽

Paul A. Gardner ◽

...

Keyword(s):

Cavernous Sinus ◽

Single Layer ◽

Lateral Wall ◽

Anterior Wall ◽

Surgical Anatomy ◽

Medial Wall ◽

Vertical Segment ◽

Anterior Clinoid Process ◽

Endoscopic Endonasal

OBJECTIVEThe medial wall of the cavernous sinus (CS) is often invaded by pituitary adenomas. Surgical mobilization and/or removal of the medial wall remains a challenge.METHODSEndoscopic endonasal dissection was performed in 20 human cadaver heads. The configuration of the medial wall, its relationship to the internal carotid artery (ICA), and the ligamentous connections in between them were investigated in 40 CSs.RESULTSThe medial wall of the CS was confirmed to be an intact single layer of dura that is distinct from the capsule of the pituitary gland and the periosteal layer that forms the anterior wall of the CS. In 32.5% of hemispheres, the medial wall was indented by and/or well adhered to the cavernous ICA. The authors identified multiple ligamentous fibers that anchored the medial wall to other walls of the CS and/or to specific ICA segments. These parasellar ligaments were classified into 4 groups: 1) caroticoclinoid ligament, spanning from the medial wall and the middle clinoid toward the clinoid ICA segment and anterior clinoid process; 2) superior parasellar ligament, connecting the medial wall to the horizontal cavernous ICA and/or lateral wall of the CS; 3) inferior parasellar ligament, bridging the medial wall to the anterior wall of the CS or anterior surface of the short vertical segment of the cavernous ICA; and 4) posterior parasellar ligament, which anchors the medial wall to the short vertical segment of the cavernous ICA and/or the posterior carotid sulcus. The caroticoclinoid ligament and inferior parasellar ligament were present in most CSs (97.7% and 95%, respectively), while the superior and posterior parasellar ligaments were identified in approximately half of the CSs (57.5% and 45%, respectively). The caroticoclinoid ligament was the strongest and largest ligament, and it was typically assembled as a group of ligaments with a fan-like arrangement. The inferior parasellar ligament was the first to be encountered after opening the anterior wall of the CS during an interdural transcavernous approach.CONCLUSIONSThe authors introduce a classification of the parasellar ligaments and their role in anchoring the medial wall of the CS. These ligaments should be identified and transected to safely mobilize the medial wall away from the cavernous ICA during a transcavernous approach and for safe and complete resection of adenomas that selectively invade the medial wall.

Download Full-text

Imaging and Demographic Characteristics Associated with Invasion of the Medial Wall of the Cavernous Sinus in Patients with Invasive Pituitary Adenomas

10.1055/s-0039-1679600 ◽

2019 ◽

Author(s):

Ezequiel Goldschmidt ◽

Salomon Cohen-Cohen ◽

Federico Angriman ◽

Carl Snyderman ◽

Eric Wang ◽

...

Keyword(s):

Cavernous Sinus ◽

Pituitary Adenomas ◽

Demographic Characteristics ◽

Medial Wall

Download Full-text

The Medial Wall of the Cavernous Sinus: Microsurgical Anatomy

Neurosurgery ◽

10.1227/01.neu.0000126953.59406.77 ◽

2004 ◽

Vol 55 (1) ◽

pp. 179-190 ◽

Cited By ~ 75

Author(s):

Alexandre Yasuda ◽

Alvaro Campero ◽

Carolina Martins ◽

Albert L. Rhoton ◽

Guilherme C. Ribas

Keyword(s):

Pituitary Gland ◽

Cavernous Sinus ◽

Thin Sheet ◽

Single Layer ◽

Lateral Wall ◽

The Body ◽

Medial Wall ◽

Microsurgical Anatomy ◽

Pituitary Fossa ◽

Adjacent Structures

Abstract OBJECTIVE: This study was conducted to clarify the boundaries, relationships, and components of the medial wall of the cavernous sinus (CS). METHODS: Forty CSs, examined under ×3 to ×40 magnification, were dissected from lateral to medial in a stepwise fashion to expose the medial wall. Four CSs were dissected starting from the midline to lateral. RESULTS: The medial wall of the CS has two parts: sellar and sphenoidal. The sellar part is a thin sheet that separates the pituitary fossa from the venous spaces in the CS. This part, although thin, provided a barrier without perforations or defects in all cadaveric specimens studied. The sphenoidal part is formed by the dura lining the carotid sulcus on the body of the sphenoid bone. In all of the cadaveric specimens, the medial wall seemed to be formed by a single layer of dura that could not be separated easily into two layers as could the lateral wall. The intracavernous carotid was determined to be in direct contact with the pituitary gland, being separated from it by only the thin sellar part of the medial wall in 52.5% of cases. In 39 of 40 CSs, the venous plexus and spaces in the CS extended into the narrow space between the intracavernous carotid and the dura lining the carotid sulcus, which forms the sphenoidal part of the medial wall. The lateral surface of the pituitary gland was divided axially into superior, middle and inferior thirds. The intracavernous carotid coursed lateral to some part of all the superior, middle, and inferior thirds in 27.5% of the CSs, along the inferior and middle thirds in 32.5%, along only the inferior third in 35%, and below the level of the gland and sellar floor in 5%. In 18 of the 40 CSs, the pituitary gland displaced the sellar part of the medial wall laterally and rested against the intracavernous carotid, and in 6 there was a tongue-like lateral protrusion of the gland that extended around a portion of the wall of the intracavernous carotid. No defects were observed in the sellar part of the medial wall, even in the presence of these protrusions. CONCLUSION: The CS has an identifiable medial wall that separates the CS from the sella and capsule of the pituitary gland. The medial wall has two segments, sellar and sphenoidal, and is formed by just one layer of dura that cannot be separated into two layers as can the lateral wall of the CS. In this study, the relationships between the medial wall and adjacent structures demonstrated a marked variability.

Download Full-text

Endoscopic endonasal transoculomotor triangle approach for adenomas invading the parapeduncular space: surgical anatomy, technical nuances, and case series

Journal of Neurosurgery ◽

10.3171/2017.10.jns17779 ◽

2019 ◽

Vol 130 (4) ◽

pp. 1304-1314 ◽

Cited By ~ 7

Author(s):

Cristian Ferrareze Nunes ◽

Stefan Lieber ◽

Huy Q. Truong ◽

Georgios Zenonos ◽

Eric W. Wang ◽

...

Keyword(s):

Cavernous Sinus ◽

Case Series ◽

Surgical Anatomy ◽

Oculomotor Nerve ◽

Oculomotor Nerve Palsy ◽

Tumor Extension ◽

Endoscopic Endonasal ◽

Transcranial Approach ◽

Surgical Corridor ◽

Dural Opening

OBJECTIVEPituitary adenomas may extend into the parapeduncular space by invading through the roof of the cavernous sinus. Currently, a transcranial approach is the preferred choice, with or without the combination of an endonasal approach. In this paper the authors present a novel surgical approach that takes advantage of the natural corridor provided by the tumor to further open the oculomotor triangle and resect tumor extension into the parapeduncular space.METHODSSix injected specimens were used to demonstrate in detail the surgical anatomy related to the approach. Four cases in which the proposed approach was used were retrospectively reviewed.RESULTSFrom a technical perspective, the first step involves accessing the superior compartment of the cavernous sinus. The interclinoid ligament should be identified and the dura forming the oculomotor triangle exposed. The oculomotor dural opening may be then extended posteriorly toward the posterior petroclinoidal ligament and inferolaterally toward the anterior petroclinoidal ligament. The oculomotor nerve should then be identified; in this series it was displaced superomedially in all 4 cases. The posterior communicating artery should also be identified to avoid its injury. In all 4 cases, the tumor invading the parapeduncular space was completely removed. There were no vascular injuries and only 1 patient had a partial oculomotor nerve palsy that completely resolved in 2 weeks.CONCLUSIONSThe endoscopic endonasal transoculomotor approach is an original alternative for removal of tumor extension into the parapeduncular space in a single procedure. The surgical corridor is increased by opening the dura of the oculomotor triangle and by working below and lateral to the cisternal segment of the oculomotor nerve.

Download Full-text

The Surgical Anatomy of the Cavernous Sinus

Extra-Intracranial Vascular Anastomoses Microsurgery at the Edge of the Tentorium - Advances in Neurosurgery ◽

10.1007/978-3-642-70603-5_35 ◽

1985 ◽

pp. 206-211

Author(s):

R. Ramina ◽

M. Samii ◽

H. Baumann ◽

P. C. Warnke

Keyword(s):

Cavernous Sinus ◽

Surgical Anatomy

Download Full-text

Cavernous sinus invasion by pituitary macroadenomas: neuroradiological, clinical and surgical correlation

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x1998000100017 ◽

1998 ◽

Vol 56 (1) ◽

pp. 107-110 ◽

Cited By ~ 10

Author(s):

ARTHUR CUKIERT ◽

MARIO ANDRIOLI ◽

JAYME GOLDMAN ◽

MARCIA NERY ◽

LUIS SALGADO ◽

...

Keyword(s):

Carotid Artery ◽

Cavernous Sinus ◽

Gold Standard ◽

Pituitary Tumors ◽

Medial Wall ◽

Cavernous Sinus Invasion ◽

Mri Features ◽

Pituitary Macroadenomas

The classical imaging gold-standard for this diagnosis is the presence of tumor lateral to the carotid artery. Seventeen patients with pituitary macroadenomas with intraoperative confirmation of cavernous sinus invasion were studied with MRI. Only 8 patients had tumor lateral to the carotid artery; 13 had tumor within the carotid syphon and all lacked the ring enhancement of the medial wall of the cavernous sinus. In 10 patients, widening of the posterior double leaflets of the cavernous sinus could be. All patients were operated by the transesphenoidal route. Only one patient was cured by surgery alone. Only 3 patients disclosing the above mentioned MRI features were identified in a series of 250 patients and did not have cavernous sinus invasion. The present criteria proved to be useful in the pre-operative diagnosis of cavenous sinus invasion and patients' counselling. Pre-operative diagnosis of cavernous sinus invasion of pituitary tumors has a great impact in the management of such patients.

Download Full-text