Taming the Cavernous Sinus: Technique of Hemostasis Using Fibrin Glue

Abstract Objective: Improved understanding of the microsurgical anatomy of the cranial base region has made surgery in and through the cavernous sinus safer. However, continuous venous oozing that occurs during cavernous sinus surgery can cause significant blood loss and poor visualization. We describe a technique that will help minimize cavernous sinus bleeding and improve the safety of the surgical steps. Methods: The lateral wall of the cavernous sinus is exposed. Cavernous sinus access windows between the V1 and V2 branches of the trigeminal nerve and posterior to the clinoidal internal carotid artery are used to inject fibrin glue into the different cavernous sinus compartments. Postoperative follow-up cerebral angiography in basilar apex aneurysms clipped using the transcavernous approach were evaluated for cavernous sinus patency during the venous phase. Results: Fibrin glue injection between V1 and V2 obliterated the lateral cavernous sinus compartment. Fibrin glue injection posterior to the clinoidal segment of the internal carotid artery obliterated the medial compartment of the cavernous sinus. These steps were used in 217 surgical procedures (95 benign and 9 malignant neoplastic lesions; 113 aneurysms). There were no significant clinical side effects. Follow-up angiographic controls of basilar aneurysms operated on via the transcavernous approach consistently showed the reestablishment of flow within the cavernous sinus as early as 2 to 3 months postoperatively. Conclusion: Presently, the use of hemostatic agents and the better understanding of the microsurgical anatomy of the cranial base and cavernous sinus enable us to tame the cavernous sinus and operate in and around it with a high degree of safety.

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Merits of intralesional fibrin glue injection in surgery for the cavernous sinus cavernous hemangiomas

Journal of Neurosurgery ◽

10.3171/jns.2002.97.3.0718 ◽

2002 ◽

Vol 97 (3) ◽

pp. 718-721 ◽

Cited By ~ 21

Author(s):

Il-Man Kim ◽

Man-Bin Yim ◽

Chang-Young Lee ◽

Eun-Ik Son ◽

Dong-Won Kim ◽

...

Keyword(s):

Surgical Treatment ◽

Fibrin Glue ◽

Cavernous Sinus ◽

Content Type ◽

Cavernous Hemangiomas ◽

Novel Method ◽

Glue Injection ◽

Tumor Bleeding ◽

Fine Print ◽

Intratumoral Injections

✓ In planning surgical treatment for extraaxial cavernous hemangiomas, care should be taken to control severe tumor bleeding. The authors present a case of a large cavernous hemangioma of the cavernous sinus, which was completely removed with the aid of multiple intratumoral injections of fibrin glue. This novel method is very effective for preventing excessive blood loss during surgery for this type of lesion.

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The Use of Fibrin Glue to Stop Venous Bleeding in the Epidural Space, Vertebral Venous Plexus, and Anterior Cavernous Sinus

Journal of Craniofacial Surgery ◽

10.1097/scs.0b013e31816ba9f4 ◽

2008 ◽

Vol 19 (2) ◽

pp. 546-547

Author(s):

Patrick Cole ◽

Larry Hollier

Keyword(s):

Fibrin Glue ◽

Cavernous Sinus ◽

Epidural Space ◽

Venous Plexus ◽

Venous Bleeding

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The Use of Fibrin Glue to Stop Venous Bleeding in the Epidural Space , Vertebral Venous Plexus, and Anterior Cavernous Sinus: Technical Note

Operative Neurosurgery ◽

10.1227/01.neu.0000289711.95426.50 ◽

2007 ◽

Vol 61 (suppl_3) ◽

pp. ONS-E51-ONS-E51 ◽

Cited By ~ 12

Author(s):

Laligam N. Sekhar ◽

Sabareesh K. Natarajan ◽

Tom Manning ◽

Dolin Bhagawati

Keyword(s):

Fibrin Glue ◽

Cavernous Sinus ◽

Epidural Space ◽

Senior Author ◽

Technical Note ◽

Venous Plexus ◽

Baxter Healthcare ◽

Superior Petrosal Sinus ◽

Venous Bleeding ◽

Glue Injection

Abstract Objective: Various techniques have been used to stop venous bleeding from the epidural space, vertebral venous plexus, and cavernous sinus. Here, we describe our experience with the use of fibrin glue to stop venous bleeding in these areas. Methods: During the last 8 years, the senior author (LNS) has used injection of Tisseel fibrin glue (Baxter Healthcare Corp., Deerfield, IL) into the epidural space (n = 200 patients), anterior cavernous sinus (n = 46 patients), vertebral venous plexus (n = 20 patients), and superior petrosal sinus (n = 20 patients) to assist in hemostasis. The technical nuances are illustrated in three videos. Results: Injection of fibrin glue in the epidural space, anterior cavernous sinus, and vertebral venous plexus yielded good results in assisting with hemostasis. Two patients experienced complications caused by occlusion of veins draining the brainstem after fibrin glue was injected into the superior petrosal sinus. Conclusion: Fibrin glue injection is an excellent option for hemostasis in the epidural space, anterior cavernous sinus, and vertebral venous plexus. However, based on our experience, fibrin glue injection into the superior petrosal sinus is not recommended.

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Effect of Fibrin Glue Injection Into the Cavernous Sinus for Hemostasis During Transcavernous Surgery on the Cerebral Venous Draining System

Operative Neurosurgery ◽

10.1227/neu.0000000000001324 ◽

2017 ◽

Vol 13 (2) ◽

pp. 224-231 ◽

Cited By ~ 4

Author(s):

Terushige Toyooka ◽

Naoki Otani ◽

Kojiro Wada ◽

Arata Tomiyama ◽

Hideaki Ueno ◽

...

Keyword(s):

Fibrin Glue ◽

Cavernous Sinus ◽

Venous Drainage ◽

Oxidized Cellulose ◽

Brain Swelling ◽

Drainage Pattern ◽

Injection Volume ◽

3 Dimensional ◽

Glue Injection ◽

Computed Tomography Venography

Abstract BACKGROUND: The extradural temporopolar transcavernous approach can be used to treat central skull base pathologies, but control of bleeding from the opened cavernous sinus is essential. Oxidized cellulose cotton packing and fibrin glue injection can be used, but the effect on the postoperative venous draining pattern remains unclear. OBJECTIVE: To investigate changes in the venous drainage pattern immediately after transcavernous surgery with and without fibrin glue injection into the bleeding cavernous sinus. METHODS: A total of 82 patients treated via the transcavernous approach were retrospectively divided into 2 groups based on the hemostasis methods. Both pre- and postoperative angiography and/or 3-dimensional computed tomography venography were available for 24 patients in the cotton packing group and 12 patients in the fibrin glue group. RESULTS: Postoperative change in the venous draining pattern was observed in 5 of the 24 patients in the cotton packing group and in 3 of the 12 patients in the fibrin glue group. One of the 82 patients showed postoperative brain swelling due to obstruction of the sphenoparietal sinus. The volume of injected fibrin glue ranged from 0.5 to 2.5 mL (mean, 1.1 ± 0.5 mL), but none of the patients had brain swelling. CONCLUSION: Direct fibrin glue injection into the opened cavernous sinus is relatively safe, but a change in the venous draining pattern occurs in 25% of patients. The study indicates the potential danger of the change in the venous draining pattern and recommends limiting the injection volume of fibrin glue in transcavernous surgery to avoid complications related to venous congestion.

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Case Report: Internal Carotid Artery Thrombosis: A Rare Complication After Fibrin Glue Injection for Cavernous Sinus Hemostasis

Frontiers in Surgery ◽

10.3389/fsurg.2021.730408 ◽

2021 ◽

Vol 8 ◽

Author(s):

Hugo Andrade-Barazarte ◽

Zhongcan Chen ◽

Chenyi Feng ◽

Visish M. Srinivasan ◽

Charuta G. Furey ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Skull Base ◽

Fibrin Glue ◽

Cavernous Sinus ◽

Internal Carotid ◽

Rare Complication ◽

Patient Consent ◽

Venous Bleeding ◽

Glue Injection

Background: Fibrin glue injection within the cavernous sinus (CS) is a demonstrably safe and simple technique to control venous bleeding with a low complication rate. However, this technique does have inherent risks. We illustrate 2 cases of internal carotid artery (ICA) thrombosis after fibrin glue injection in the CS for hemostasis.Methods: After encountering this complication recently, we conducted a retrospective review of the surgical database of 2 senior neurosurgeons who specialize in cerebrovascular and skull base surgery to identify patients with any complications associated with the use of fibrin glue injection for hemostasis. Approval was given by respective institutional review boards, and patient consent was obtained.Results: Of more than 10,000 microsurgery procedures performed by 2 senior neurosurgeons with a combined experience of 40 years, including procedures for aneurysms and skull base tumors, 2 cases were identified involving ICA thrombosis after fibrin glue injection in the CS for hemostasis. Both cases involved severe ischemic complications as a result of the ICA thrombosis. In this article, we present their clinical presentation, characteristics, management, and outcomes.Conclusion: Direct injection of fibrin glue into the CS for hemostasis can effectively control venous bleeding and facilitate complex dissections. However, it can be associated with ICA thrombosis, with subsequent serious ischemia and poor prognosis. Although this complication appears to be rare, increased awareness of this problem should temper the routine use of fibrin glue in anterior clinoidectomy and transcavernous approaches.

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