Endoscopic Endonasal Cavernous Sinus Surgery: An Anatomic Study

Neurosurgery ◽  
2001 ◽  
Vol 48 (4) ◽  
pp. 827-837 ◽  
Author(s):  
Alessandra Alfieri ◽  
Hae-Dong Jho
Keyword(s):  
Carotid Artery ◽  
Cavernous Sinus ◽  
Posterior Wall ◽  
Surgical Anatomy ◽  
Sinus Surgery ◽  
Endoscopic Endonasal ◽  
Sphenoidal Sinus ◽  
Optic Strut ◽  
Anatomic Basis ◽  
Planum Sphenoidale

Abstract OBJECTIVE The endoscopic surgical anatomy of the cavernous sinus was studied to establish an anatomic basis for endoscopic endonasal cavernous sinus surgery. METHODS Five adult cadaveric heads were studied with 0-, 30-, and 70-degree 4-mm rod-lens endoscopes. The posterior wall of the sphenoidal sinus was approached via a paraseptal, middle turbinectomy, or middle meatal approach. RESULTS The posterior bony wall of the sphenoidal sinus is subdivided into five vertical compartments: midline, bilateral paramedian, and bilateral lateral. The midline vertical compartment consists of the planum sphenoidale, tuberculum sellae, sella, and clival indentation. The paramedian vertical compartment is composed of the medial third of the optic canal and the carotid artery protuberance. The lateral vertical compartment contains four bony protuberances (optic, cavernous sinus apex, maxillary, and mandibular) and three depressions (carotico-optic, ophthalmomaxillary [V1–V2], and maxillomandibular [V2–V3]). The three depressions form anatomic triangles at the lateral vertical compartment: the optic strut triangle, which is bordered by the optic nerve, carotid artery, and oculomotor nerve (IIIrd cranial nerve); the V1–V2 triangle; and the V2–V3 triangle. The internal carotid artery at the posterior wall of the sphenoidal sinus can be subdivided into two main segments: the parasellar and the paraclival. The vidian canal is a landmark that leads to the foramen lacerum, the mandibular nerve, and the pterygopalatine fossa. CONCLUSION Endoscopic anatomy of the cavernous sinus has been studied via an endonasal route in cadaveric specimens to provide an anatomic basis for endoscopic endonasal cavernous sinus surgery.

scholarly journals Rare Clinical Onset of Nontraumatic Intracavernous Aneurysm of the Internal Carotid Artery: A Diagnostic and Therapeutic Challenge

2020 ◽  
Author(s):  
Enzo Emanuelli ◽  
Maria Baldovin ◽  
Claudia Zanotti ◽  
Sara Munari ◽  
Luca Denaro ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cavernous Sinus ◽  
Internal Carotid ◽  
Arterial Injury ◽  
Sphenoidal Sinus ◽  
Therapeutic Challenge ◽  
Cavernous Sinus Syndrome ◽  
Sellar Lesions ◽  
Risk Of Rupture

AbstractWhile the so-called pseudoaneurysms can result from arterial injury during trans-sphenoidal surgery or after a trauma, spontaneous aneurysms of cavernous–internal carotid artery (CICA) are rare. Symptoms vary and the differential diagnosis with other, more frequent, sellar lesions is difficult. We describe three cases of misdiagnosed CICA spontaneous aneurysm. In two cases the onset was with neuro-ophthalmological manifestations, classifiable as “cavernous sinus syndrome.” The emergency computed tomography scan did not show CICA aneurysm and the diagnosis was made by surgical exploration. The third patient came to our attention with a sudden severe unilateral epistaxis; endonasal surgery revealed also in this case a CICA aneurysm, eroding the wall and protruding into the sphenoidal sinus. When the onset was with a cavernous sinus syndrome, misdiagnosis exposed two patients to potential serious risk of bleeding, while the patient with epistaxis was treated with embolization, using coils and two balloons. Intracavernous nontraumatic aneurysms are both a diagnostic and therapeutic challenge, because of their heterogeneous onset and risk of rupture, potentially lethal. Intracavernous aneurysms can be managed with radiological follow-up, if asymptomatic or clinically stable, or can be surgically treated with endovascular or microsurgical techniques.

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

2019 ◽  
Vol 130 (4) ◽  
pp. 1304-1314 ◽  
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.

scholarly journals Endoscopic Endonasal Cavernous Sinus Surgery: An Anatomic Study

Neurosurgery ◽  
2001 ◽  
Vol 49 (5) ◽  
pp. 1271-1272 ◽  
Author(s):  
Ibrahim M. Ziyal ◽  
Tunçalp Özgen
Keyword(s):  
Cavernous Sinus ◽  
Sinus Surgery ◽  
Anatomic Study ◽  
Endoscopic Endonasal

Paratrigeminal, Paraclival, Precavernous, or All of the Above? A Circumferential Anatomical Study of the C3-C4 Transitional Segment of the Internal Carotid Artery

2017 ◽  
Vol 14 (4) ◽  
pp. 432-440 ◽  
Author(s):  
Eleonora Marcati ◽  
Norberto Andaluz ◽  
Sebastien C Froelich ◽  
Lee A Zimmer ◽  
James L Leach ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cavernous Sinus ◽  
Internal Carotid ◽  
Anatomical Study ◽  
Posterior Longitudinal Ligament ◽  
Petrous Apex ◽  
Meckel’S Cave ◽  
Endoscopic Endonasal ◽  
Meckel's Cave

Abstract BACKGROUND Although the term paraclival carotid pervades recent skull base literature, no clear consensus exists regarding boundaries or anatomical segments. OBJECTIVE To reconcile various internal carotid artery (ICA) nomenclatures for transcranial and endoscopic-endonasal perspectives, we reexamined the transition between lacerum (C3) and cavernous (C4) segments using a C1-C7 segments schema. In this cadaveric study, we obtained a 360°-circumferential view integrating histological, microsurgical, endoscopic, and neuroradiological analyses of this C3-C4 region and identified a distinct transitional segment. METHODS In 13 adult, silicone-injected, formalin-fixed cadaveric heads (26 sides), transcranial-extradural-subtemporal and endoscopic-endonasal CT­guided dissections were performed. A quadrilateral area was noted medial to Meckel's cave between cranial nerve VI, anterolateral and posterolateral borders of the lateral-paratrigeminal aspect of the precavernous ICA, and posterior longitudinal ligament. Endoscopically, a medial-paraclival aspect was defined. Anatomical correlations were made with histological and neuroradiological slides. RESULTS We identified a distinct precavernous C3-C4 transitional segment. In 18 (69%) specimens, venous channels were absent at the quadrilateral area, on the paratrigeminal border of the precavernous ICA. A trigeminal membrane, seen consistently on the superior border of V2, defined the lateral aspect of the cavernous sinus floor. The medial aspect of the precavernous ICA corresponded with the paraclival ICA. CONCLUSION Our study revealing the juncture of 2 complementary borders of the ICA, endoscopic endonasal (paraclival) and transcranial (paratrigeminal), reconciles various nomenclature. A precavernous segment may clarify controversies about the paraclival ICA and support the concept of a “safe door” for lesions involving Meckel's cave, cavernous sinus, and petrous apex.

scholarly journals Endoscopic and Microsurgical Approaches to the Cavernous Sinus – Anatomical Review

2017 ◽  
Vol 36 (03) ◽  
pp. 160-166
Author(s):  
Flavio Romero ◽  
Daphyne Ramires ◽  
Luigi Cristiano ◽  
Marcos Silva ◽  
Rodolfo Vieira
Keyword(s):  
Literature Review ◽  
Cavernous Sinus ◽  
Surgical Anatomy ◽  
Sinus Surgery ◽  
High Morbidity ◽  
Anatomical Structures

AbstractCavernous sinus surgery has always represented a surgical challenge due to the great importance of the surrounding anatomical structures and to the high morbidity associated to it. Although the anatomy of this region has been extensively described, controversy remains related to the best treatment and approaches for different kinds of lesions. In this article, a literature review was performed on the surgical anatomy and approaches to the cavernous sinus.

Taming the Cavernous Sinus: Technique of Hemostasis Using Fibrin Glue

2007 ◽  
Vol 61 (suppl_3) ◽  
pp. ONS-E52-ONS-E52 ◽  
Author(s):  
Niklaus Krayenbühl ◽  
Ahmad Hafez ◽  
Juha A. Hernesniemi ◽  
Ali F. Krisht
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Fibrin Glue ◽  
Cavernous Sinus ◽  
Internal Carotid ◽  
Cranial Base ◽  
Sinus Surgery ◽  
Microsurgical Anatomy ◽  
Glue Injection

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.

scholarly journals Endoscopic endonasal transcavernous approach for invasive corticotroph pituitary adenoma

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.

scholarly journals Endoscopic Endonasal Supraoptic and Infraoptic Approaches for Complex “Parasuprasellar” Lesions: Surgical Anatomy, Technique Nuances, and Case Series

2021 ◽  
Author(s):  
You Yuan Bao ◽  
You Qing Yang ◽  
Lin Zhou ◽  
Shen Hao Xie ◽  
Xiao Wu ◽  
...  
Keyword(s):  
Surgical Simulation ◽  
Tumor Resection ◽  
Case Series ◽  
Surgical Anatomy ◽  
Anterior Clinoid Process ◽  
Endoscopic Endonasal ◽  
Multiple Aneurysms ◽  
Suprasellar Region ◽  
Midline Approach ◽  
Planum Sphenoidale

Abstract Surgical management of lesions involving the lateral area of the suprasellar region, including the lateral aspect of the planum sphenoidale and a tight junction region of the optic canal (OC), the anterior clinoid process (ACP), and the internal carotid artery (ICA) and its dural rings, is extremely challenging. Here, the authors introduce two novels endoscopic endonasal supraoptic (EESO) and endoscopic endonasal infraoptic (EEIO) approaches to access these regions, namely, “parasuprasellar” area. Surgical simulation of the EESO and EEIO approaches to the parasuprasellar area was conducted in 5 silicon-injected specimens. The same techniques were applied in 12 patients involving the parasuprasellar area.The EESO and EEIO approaches can be used independently or in combination, but are more often employed as a complement to the endoscopic endonasal midline approach and transcavernous approach. In clinical application, the EESO and EEIO approaches were successfully performed in 12 patients harboring tumors and multiple aneurysms involving the parasuprasellar area. Gross total and subtotal tumor resection were achieved in 9 patients and 1 patient, respectively. For two patients with multiple aneurysms, the lesions were clipped selectively according to location and size. Visual acuity improved in 7 patients, remained stable in 4, and deteriorated in only 1. No postoperative intracranial infection or ICA injury occurred in this series. The EESO and EEIO approaches can be combined with the current endoscopic endonasal midline approach and transcavernous approach to remove extensive pathologies involving the intrasellar, suprasellar, sphenoid, and cavernous sinuses and even bifurcation of the ICA.

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