Microsurgical Resection of Recurrent Cavernous Sinus Hemangioma by Superior and Lateral Approach: 2-Dimensional Operative Video

Abstract This video shows the technical nuances of microsurgical resection of recurrent cavernous sinus (CS) hemangioma by superior and lateral approach. A 77-yr-old woman presented with headache and difficulty in vision in right eye for 6 mo. She had previously undergone attempted resection of a right CS tumor in another hospital with partial removal, and the tumor had grown significantly. Neurological examination revealed proptosis, cranial nerve 3 palsy, and loss of vision in right eye (20/200). Left side visual acuity was 20/20. Brain magnetic resonance imaging (MRI) demonstrated a large CS mass with homogeneous enhancement, measuring 3.3 × 3.3 × 2.6 cm, extending into the suprasellar cistern with mass effect on the right optic nerve. It extended anteriorly to the region of the right orbital apex and abuted the basilar artery posteriorly. She underwent right frontotemporal craniotomy, posterolateral orbitotomy and anterior clinoidectomy as well as optic nerve decompression, and the CS tumor was removed by superior and lateral approach. An incision was made into the superior wall of the CS medial to the third nerve. On lateral aspect the tumor had extended outside the CS through the Parkinson's triangle. Posteriorly it extended through the clival dura. Anteriorly tumor encased the carotid artery and it was gradually dissected away. At the end of the operation, all of the cranial nerves were intact. Postoperative MRI showed near complete tumor resection with preservation of the internal carotid artery. At 6 mo follow-up her modified Rankin Scale was 1 and vision in left eye was normal. Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

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Endoscopic endonasal transcavernous approach for invasive corticotroph pituitary adenoma

Neurosurgical Focus: Video ◽

10.3171/2020.4.focusvid.19949 ◽

2020 ◽

Vol 2 (2) ◽

pp. V2

Author(s):

Ming-Ying Lan ◽

Wei-Hsin Wang

Keyword(s):

Cavernous Sinus ◽

Diagnostic Tests ◽

Tumor Resection ◽

Cranial Nerves ◽

Surgical Anatomy ◽

Total Resection ◽

Endoscopic Endonasal ◽

Cavernous Sinus Invasion ◽

The Right

This is a 37-year-old woman who presented with weight gain, a moon-shaped face, and muscle weakness for 4 months. Cushing’s disease was confirmed after a series of diagnostic tests. MRI demonstrated a pituitary macroadenoma with right cavernous sinus invasion and encasement of the right ICA. An endoscopic endonasal approach was performed, and gross-total resection could be achieved without injury of the cranial nerves. The Cushing’s syndrome improved gradually after the surgery. Histopathology revealed a corticotroph adenoma. In this surgical video, we demonstrate the strategies of tumor resection according to a surgical anatomy-based classification of the cavernous sinus from an endonasal perspective.The video can be found here: https://youtu.be/aNXFRdGfjpI.

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Transcavernous Approach for Gross Total Resection of a Dumbbell-Shaped Giant Trigeminal Schwannoma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1729995 ◽

2021 ◽

Author(s):

Sima Sayyahmelli ◽

Emel Avci ◽

Burak Ozaydin ◽

Mustafa K. Başkaya

Keyword(s):

Skull Base ◽

Cavernous Sinus ◽

Tumor Resection ◽

Mass Effect ◽

World Health ◽

Gross Total Resection ◽

Petrous Apex ◽

Total Resection ◽

Who Grade ◽

Trigeminal Schwannoma

AbstractTrigeminal schwannomas are rare nerve sheet tumors that represent the second most common intracranial site of occurrence after vestibular nerve origins. Microsurgical resection of giant dumbbell-shaped trigeminal schwannomas often requires complex skull base approaches. The extradural transcavernous approach is effective for the resection of these giant tumors involving the cavernous sinus.The patient is a 72-year-old man with headache, dizziness, imbalance, and cognitive decline. Neurological examination revealed left-sided sixth nerve palsy, a diminished corneal reflex, and wasting of temporalis muscle. Magnetic resonance imaging (MRI) showed a giant homogeneously enhancing dumbbell-shaped extra-axial mass centered within the left cavernous sinus, Meckel's cave, and the petrous apex, with extension to the cerebellopontine angle. There was a significant mass effect on the brain stem causing hydrocephalus. Computed tomography (CT) scan showed erosion of the petrous apex resulting in partial anterior autopetrosectomy (Figs. 1 and 2).The decision was made to proceed with tumor resection using a transcavernous approach. Gross total resection was achieved. The surgery and postoperative course were uneventful, and the patient woke up the same as in the preoperative period. MRI confirmed gross total resection of the tumor. The histopathology was a trigeminal schwannoma, World Health Organization (WHO) grade I. The patient continues to do well without any recurrence at 15-month follow-up.This video demonstrates important steps of the microsurgical skull base techniques for resection of these challenging tumors.The link to the video can be found at https://youtu.be/TMK5363836M

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Zygomatic Approach to Cavernous Sinus Chordoma: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab126 ◽

2021 ◽

Author(s):

Antonio Aversa ◽

Ossama Al-Mefty

Keyword(s):

Carotid Artery ◽

Cavernous Sinus ◽

Infratemporal Fossa ◽

Cranial Nerves ◽

Radical Resection ◽

High Rate ◽

Petrous Apex ◽

High Dose ◽

Middle Fossa ◽

Cavernous Carotid Artery

Abstract Chordoma is not a benign disease. It grows invasively, has a high rate of local recurrence, metastasizes, and seeds in the surgical field.1 Thus, chordoma should be treated aggressively with radical resection that includes the soft tissue mass and the involved surrounding bone that contains islands of chordoma.2–5 High-dose radiation, commonly by proton beam therapy, is administered after gross total resection for long-term control. About half of chordoma cases occupy the cavernous sinus space and resecting this extension is crucial to obtain radical resection. Fortunately, the cavernous sinus proper extension is the easier part to remove and pre-existing cranial nerves deficit has good chance of recovery. As chordomas originate and are always present extradurally (prior to invading the dura), an extradural access to chordomas is the natural way for radical resection without brain manipulation. The zygomatic approach is key to the middle fossa, cavernous sinus, petrous apex, and infratemporal fossa; it minimizes the depth of field and is highly advantageous in chordoma located mainly lateral to the cavernous carotid artery.6–12 This article demonstrates the advantages of this approach, including the mobilization of the zygomatic arch alleviating temporal lobe retraction, the peeling of the middle fossa dura for exposure of the cavernous sinus, the safe dissection of the trigeminal and oculomotor nerves, and total control of the petrous and cavernous carotid artery. Tumor extensions to the sphenoid sinus, sella, petrous apex, and clivus can be removed. The patient is a 30-yr-old who consented for surgery.

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Far Lateral Approach for Resection of Transverse Ligament Cyst

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1701689 ◽

2020 ◽

Author(s):

Lattimore Madison Michael ◽

Vincent Nguyen ◽

Jaafar Basma ◽

William Mangham ◽

Nickalus Khan ◽

...

Keyword(s):

Spinal Cord ◽

Mass Effect ◽

Lateral Approach ◽

Microsurgical Anatomy ◽

Transverse Ligament ◽

Far Lateral Approach ◽

Adequate Understanding ◽

Far Lateral ◽

Microsurgical Resection ◽

Dentate Ligament

Abstract Objectives This study was aimed to describe a far lateral approach for microsurgical resection of a transverse ligament cyst, with emphasis on the microsurgical anatomy and technique. Design A far lateral craniotomy is performed in the lateral decubitus position. After opening the dura laterally, dural sutures are placed for retraction. A stitch placed through the dentate ligament is advantageous to rotate the spinal cord to allow access to the ventral cyst. The cyst is marsupirlized and mass effect on the spinal cord is relieved. Photographs of the region are borrowed from Dr Rhoton's laboratory to illustrate the microsurgical anatomy. Participants The first author performed the surgery and edited the video. Chart review and literature review were performed by the other authors. Outcome Measures Outcome was assessed with postoperative neurological function. Results The patient was discharged home after an uneventful hospital course. At short-term follow-up, the patient had a significant improvement in postoperative strength. Conclusion The far lateral approach provides an adequate corridor to the ventrolateral brainstem in combination with utilization of the dentate ligament to reach ventral cysts compressing the spinal cord. An adequate understanding of the relevant microsurgical anatomy is a key to safe surgery in this region.The link to the video can be found at: https://youtu.be/5MGVPO2Q2pI.

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The So-Called Cavernous Sinus: A Review of the Controversy and Its Implications for Neurosurgeons

Neurosurgery ◽

10.1227/00006123-198211000-00019 ◽

1982 ◽

Vol 11 (5) ◽

pp. 712-717 ◽

Cited By ~ 118

Author(s):

John N. Taptas

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Cavernous Sinus ◽

Internal Carotid ◽

Cranial Nerves ◽

Sella Turcica ◽

Middle Cranial Fossa ◽

Cranial Fossa ◽

Base Of The Skull ◽

Extradural Space

Abstract The so-called cavernous sinus is a venous pathway, an irregular network of veins that is part of the extradural venous network of the base of the skull, not a trabeculated venous channel. This venous pathway, the internal carotid artery, and the oculomotor cranial nerves cross the medial portion of the middle cranial fossa in an extradural space formed on each side of the sella turcica by the diverging aspects of a dural fold. In this space the venous pathway has only neighborhood relations with the internal carotid artery and the cranial nerves. The space itself must be distinguished from the vascular and nervous elements that it contains. The revision of the anatomy of this region has not only theoretical interest but also important clinical implications.

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Endoscopic endonasal management of non-functioning pituitary adenomas with cavernous sinus invasion: a 10- year experience

Rhinology Journal ◽

10.4193/rhino14.309 ◽

2015 ◽

Vol 53 (4) ◽

pp. 308-316

Author(s):

F. Ferreli ◽

M. Turri-Zanoni ◽

F.R. Canevari ◽

P. Battaglia ◽

M. Bignami ◽

...

Keyword(s):

Cavernous Sinus ◽

Tumor Resection ◽

Mass Effect ◽

Extent Of Resection ◽

Tumor Control ◽

Endoscopic Endonasal ◽

Cavernous Sinus Invasion ◽

Visual Outcomes ◽

Contrast Enhanced ◽

Wait And See

Background: The management of Non-Functioning Pituitary Adenoma (NFPA) invading the cavernous sinus (CS) is currently a balancing act between the surgical decompression of neural structures, radiotherapy and a wait-and-see policy. Methods: We undertook a retrospective review of 56 cases of NFPA with CS invasion treated through an endoscopic endonasal approach (EEA) between 2000 and 2010. The Knosp classification was adopted to describe CS involvement using information from preoperative MRI and intraoperative findings. Extent of resection and surgical outcomes were evaluated on the basis of postoperative contrast-enhanced MRI. Endocrinological improvement and visual outcomes were assessed according to the most recent consensus criteria. Results: EEA was performed using direct para-septal, trans-ethmoidal-sphenoidal or trans-ethmoidal-pterygoidal-sphenoidal approach. Visual outcomes improved in 30 (81%) patients. Normalization or at least improvement of previous hypopituitarism was obtained in 55% of cases. A gross total resection was achieved in 30.3% of cases. The recurrence-free survival was 87.5%, with a mean follow-up of 61 months (range, 36-166 months). No major intraoperative or postoperative complications occurred. Discussion: EEA is a minimally-invasive, safe and effective procedure for the management of NFPA invading the CS. The extent of CS involvement was the main factor limiting the degree of tumor resection. The EEA was able to resolve the mass effect, preserving or restoring visual function, and obtaining adequate long-term tumor control.

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Eversion carotid endarterectomy with nerve-sparing component in a case of high location of common carotid artery bifurcation

Patologiya krovoobrashcheniya i kardiokhirurgiya ◽

10.21688/1681-3472-2021-3-94-99 ◽

2021 ◽

Vol 25 (3) ◽

pp. 94

Author(s):

I. V. Makarov ◽

A. S. Borisenkov ◽

I. A. Migunov

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Common Carotid Artery ◽

Preoperative Evaluation ◽

Cranial Nerves ◽

Hospital Medicine ◽

Nerve Sparing ◽

Left Internal Carotid Artery ◽

Brachiocephalic Trunk ◽

The Right

We performed carotid endarterectomy on a patient with 75% stenosis of the left internal carotid artery (ICA), 70% stenosis of the left common carotid artery (CCA), 60% stenosis of the right ICA and 55% stenosis of the right CCA after a transient ischaemic attack on the premises of the surgical unit of Russian Railways Hospital–Medicine (Samara), which is the clinical site for the care of surgical diseases at Samara State Medical University. During the preoperative evaluation and physical examination, we determined that the chance of high CCA bifurcation was high because the patient had a brachymorphic physique and his neck was short and broad. In fact, during the surgical exploration of the carotid triangle area, the CCA bifurcation was identified 7 ± 0.5 cm higher than the shield-like cartilage rim; thus the CCA bifurcation area crossed the stems of the glossopharyngeal (IX), vagus (X) and hypoglossal (XII) nerves, which precluded classic carotid endarterectomy. We then decided to perform carotid endarterectomy, using the eversion method and transposing the ICA above the rami of the cranial nerves. Through this method, we minimised traction and nerve stem trauma during the process of reconstructing brachiocephalic trunk arteries, prevented morbidities involving the cranial nerves during postsurgical period, accelerated the patient’s recovery and improved the patient’s quality of life. With further patient monitoring during the early and late postoperative periods, no abnormalities of peripheral innervation occurred.Received 26 March 2021. Revised 6 May 2021. Accepted 11 May 2021.Funding: The study did not have sponsorship.Conflict of interest: The authors declare no conflicts of interests.Contribution of the authors: The authors contributed equally to this article.

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Anterior approaches in juvenile nasopharyngeal angiofibromas with intracranial extension

Otolaryngology ◽

10.1016/s0194-5998(00)70256-7 ◽

2000 ◽

Vol 122 (2) ◽

pp. 277-283 ◽

Cited By ~ 33

Author(s):

Giovanni Danesi ◽

Benedict Panizza ◽

Antonio Mazzoni ◽

Vincenzo Calabrese

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Cavernous Sinus ◽

Internal Carotid ◽

Surgical Excision ◽

Residual Tumor ◽

Lateral Approach ◽

Treatment Modalities ◽

Intracranial Extension ◽

Midface Degloving

Although surgery is regarded as the mainstay of treatment for juvenile nasopharyngeal angiofibromas (JNAs), ancillary treatment modalities such as radiotherapy and on rare occasions chemotherapy are still recommended by many for intracranial extension with apparent radiologic involvement of the cavernous sinus and internal carotid artery. Further, most authors undertaking surgical excision of this subgroup of patients would recommend a lateral or combined frontal and lateral approach for its removal. In a series of 49 cases of JNA, 14 were found during surgery to have intracranial extradural extension; the anterior approach was used for their removal. Although in these cases, on radiography the cavernous sinus often looked to be invaded and the internal carotid artery was displaced superolaterally, there was no difficulty in establishing a plane of dissection. Total removal was achieved in 11 of the 14 cases with a single-stage procedure. Of the 3 cases with residual tumor, only 1 occurred intracranially. Removal was achieved by a subtemporal approach in this case. For the extracranial residual tumors 1 required a midface degloving and the other, with a 1-cm residual tumor in the nasopharynx, has been treated conservatively for 6 years with no evidence of growth. No deaths or significant complications have occurred, and radiotherapy has not been required. We conclude that JNAs are tumors with a predilection for spread but that rarely invade dura, acting instead to displace it. We believe that surgery is the method of choice for treating these lesions and that an anterior surgical approach with microsurgical techniques should be used in the first instance. In the last 2 cases we preferred a midface degloving technique to avoid facial scarring and because this approach allows a widening of the surgical field if needed by the performance of bilateral maxillary free bone flaps. On the rare occasion that a lateral approach, with its attendant permanent conductive hearing loss, is found to be necessary for total tumor removal, this can be done as a staged procedure. This may be necessary when the tumor has spread lateral to the horizontal internal carotid artery.

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Surgical Resection of a Cavernous Malformation of the Anterior Perforated Substance: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy354 ◽

2018 ◽

Vol 17 (2) ◽

pp. E64-E64

Author(s):

Alejandro Enriquez-Marulanda ◽

Abdulrahman Y Alturki ◽

Luis C Ascanio ◽

Ajith J Thomas ◽

Christopher S Ogilvy

Keyword(s):

Optic Tract ◽

Brain Magnetic Resonance Imaging ◽

Mass Effect ◽

Brain Structures ◽

Acute Onset ◽

Elective Resection ◽

Cavernous Malformations ◽

Patient Consent ◽

Magnetic Resonance Imaging Mri ◽

The Right

Abstract Cavernous malformations (CMs) are intracranial vascular anomalies of the brain blood vessels which are usually asymptomatic but sometimes may cause headache, seizures, or focal neurologic symptoms.1 The latter may be attributed to either hemorrhage of the lesion or due to associated mass effect.2 Here, we describe the case of a 27-yr-old woman who had an acute onset of headache and occasional left sided peripheral visual disturbances. A brain computed tomography scan revealed intraparenchymal hemorrhage near the right hypothalamus and a brain magnetic resonance imaging (MRI) was consistent with an anterior perforated substance CM. Medical management was pursued but severe headache persisted for several weeks to the point of interfering with normal daily function. Given the evidence of past hemorrhage and the persistence of symptoms, a microsurgical resection was indicated. She was scheduled for an elective resection through a right frontotemporal craniotomy. The lesion was found in the right anterior perforated substance, just above the optic tract and was resected without complications. The patient was neurologically stable at discharge. At 4-mo follow-up, the patient had a significantly decreased intensity of headache and an adequate resection cavity on MRI. Otherwise, she was neurologically intact. Cavernous malformations of deep brain structures, such as the anterior perforated substance can be surgically treated but carry a challenging procedure with a risk of visual deficits. In the following video illustration, we narrate this operative case and highlight the nuances of this approach. Patient consent was obtained for the submission of the video to this journal.

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Abstract 1122‐000129: Management of Traumatic Carotid‐Cavernous Fistulas in the Acute Setting of Penetrating Brain Injury

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000129 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Sonam Thind ◽

Andrea Loggini ◽

Faten El Ammar ◽

Jonatan Hornik ◽

Scotttt Mendelson ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Carotid Artery ◽

Cavernous Sinus ◽

Gunshot Wounds ◽

Flow Diverter ◽

High Flow ◽

Antithrombotic Agents ◽

Traumatic Subarachnoid Hemorrhage ◽

The Right ◽

Carotid Cavernous Fistulas

Introduction : Traumatic carotid‐cavernous fistulas (tCCFs) represent abnormal vascular shunt between the carotid artery, in its cavernous segment, and the cavernous sinus, after direct or indirect trauma. Literature on tCCF associated with gunshot wounds (GSW) is scarce and is unique due to potential risk of exsanguination or bleeding into the brain proper. Furthermore, the management of tCCF in the GSW population is particularly relevant as gunshot patients represent a unique challenge be it due to the presence of concomitant cranio‐cervical vascular injury, other organ involvement, or contraindications for anticoagulation and /or antithrombotic use. Methods : Case presentation Case A Patient is a 23 y/o female with GSW to the right side of the head with multiple skull base fractures and right temporal lobe penetrating injury with retained bullet fragment, traumatic subarachnoid hemorrhage in the basal cisterns, diffuse cerebral edema, and a 5mm right to left midline shift. Patient also has a high‐flow right tCCF with significant arterialization of cortical veins. Patient underwent venous coiling of the cavernous sinus with flow diverter stents in the arterial wall of the cavernous segment of the carotid artery. The patient remained in the hospital fifty‐one days and suffered multiple neurological complications, including cerebral vasospasm, development of a pseudoaneurysm in the right anterior choroidal artery that was embolized, and hydrocephalus, requiring ventriculo‐peritoneal shunting (VPS). Patient had a GOSE 2 at the discharge to a long‐term acute care facility. Results : Case B Patient is a 30 y/o male with GSW to the left side of the head with left hemispheric subdural hematoma, left temporal lobe injury, and diffuse traumatic subarachnoid hemorrhage. The injury also resulted in a temporal bone fracture, lateral to the carotid canal, and extensive left facial fractures. Patient also has a high‐flow left tCCF that was also treated successfully with cavernous sinus coiling with flow diverter stenting of the carotid artery at the site of the fistula after initiating antithrombotic agents. Post the tCCF repair the patient developed a CSF leak that necessitated an extensive surgical repair that would not have been possible while on antithrombotic agents. At this point, the patient underwent balloon test occlusion (BTO) and sacrifice of the carotid artery at the site of the fistula. Patient was discharged to acute rehab facility with a GOSE of 5. Conclusions : Traumatic CCF may occur in patient with gunshot wounds to the head, representing an extreme of penetrating mechanisms associated with this type of injury. Current penetrating brain injury guidelines are outdated and provide no consensus on management of this condition. Embolization of the fistula, flow diversion via stenting of the fistula site and finally vessel sacrifice are viable options depending on the size of the fistula, flow grade, collateral flow, phase on injury, and concomitant injury that may dictate permissibility of antithrombotic therapy.

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