Endoscopic Endonasal Approach to the Lateral Wall of the Cavernous Sinus: A Cadaveric Feasibility Study

Objective: A transcranial extradural approach to the middle cranial fossa (MCF) requires separation of the dural layers of the lateral wall of the cavernous sinus. The authors tested the feasibility of an endonasal approach for this separation. Methods: A cadaveric feasibility study was conducted on the sides of 14 dry skulls and 10 fresh cadaveric heads. An endonasal, transsphenoidal, transpterygoid approach was taken to the MCF. The maxillary struts and medial greater wing of the sphenoid below the superior orbital fissure were drilled with transposition of the maxillary nerve. The lateral cavernous dural layers were split at the maxillary nerve with separation of the temporal lobe dura and exposure of the MCF bony base. The integrity of the cranial nerves and inner and outer dural layers of the lateral cavernous wall was checked. Different measurements of bony landmarks were obtained. Results: The integrity of the dural layers of the lateral cavernous wall and the cranial nerves were preserved in 10 heads. The mean area of the bony corridor was 4.68 ± 0.97 cm2, the V2-to-V3 distance was 15.21 ± 3.36 mm medially and 18.21 ± 3.45 mm laterally, and the vidian canal length was 13.01 ± 3.06 mm. Conclusions: Endonasal endoscopic separation of the lateral cavernous dural layers is feasible without crossing the motor cranial nerves, allowing better exposure of the MCF.

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Endoscopic supraorbital extradural approach to the cavernous sinus: a cadaver study

Journal of Neurosurgery ◽

10.3171/2010.10.jns101242 ◽

2011 ◽

Vol 114 (5) ◽

pp. 1331-1337 ◽

Cited By ~ 15

Author(s):

Fuminari Komatsu ◽

Mika Komatsu ◽

Tooru Inoue ◽

Manfred Tschabitscher

Keyword(s):

Cavernous Sinus ◽

Complex Structure ◽

Lateral Wall ◽

Middle Cranial Fossa ◽

Cadaver Study ◽

Minimal Invasiveness ◽

Small Complex ◽

Transcranial Approach ◽

Cranial Fossa ◽

Extradural Approach

Object The cavernous sinus is a small complex structure located at the central base of the skull. Recent extensive use of endoscopy has provided less invasive approaches to the cavernous sinus via endonasal routes, although transcranial routes play an important role in the approach to the cavernous sinus. The aims of this study were to evaluate the feasibility of the purely endoscopic transcranial approach to the cavernous sinus through the supraorbital keyhole and to better understand the distorted anatomy of the cavernous sinus via endoscopy. Methods Eight fresh cadavers were studied using 4-mm 0° and 30° endoscopes to develop a surgical approach and to identify surgical landmarks. Results The endoscopic supraorbital extradural approach was divided into 4 stages: entry into the extradural anterior cranial fossa, exposure of the middle cranial fossa and the periorbita, exposure of the superior cavernous sinus, and exposure of the lateral cavernous sinus. This approach provided superb views of the cavernous sinus structures, especially through the clinoidal (Dolenc) triangle. The lateral wall of the cavernous sinus, including the infratrochlear (Parkinson) triangle and anteromedial (Mullan) triangle, was also clearly demonstrated. Conclusions An endoscopic supraorbital extradural approach offers excellent exposure of the superior and lateral walls of the cavernous sinus with minimal invasiveness via the transcranial route. This approach could be an alternative to the conventional transcranial approach.

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Endoscopic Endonasal Approach to the Middle Cranial Fossa through the Cavernous Sinus Triangles: Anatomical Considerations

Neurologia medico-chirurgica ◽

10.2176/nmc.oa.2014-0092 ◽

2014 ◽

Vol 54 (12) ◽

pp. 1004-1008 ◽

Cited By ~ 6

Author(s):

Fuminari KOMATSU ◽

Shinri ODA ◽

Masami SHIMODA ◽

Masaaki IMAI ◽

Hideaki SHIGEMATSU ◽

...

Keyword(s):

Cavernous Sinus ◽

Middle Cranial Fossa ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Cranial Fossa

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Endoscopic Endonasal Approach to the Anteromedial Temporal Fossa and Mobilization of the Lateral Wall of the Cavernous Sinus Through the Inferior Orbital Fissure and V1-V2 Corridor: An Anatomic Study and Clinical Considerations

World Neurosurgery ◽

10.1016/j.wneu.2018.04.146 ◽

2018 ◽

Vol 116 ◽

pp. e169-e178 ◽

Cited By ~ 1

Author(s):

Shunya Hanakita ◽

Wei-Chieh Chang ◽

Kentaro Watanabe ◽

Daniel Ronconi ◽

Moujahed Labidi ◽

...

Keyword(s):

Cavernous Sinus ◽

Lateral Wall ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Anatomic Study ◽

Endoscopic Endonasal ◽

Temporal Fossa ◽

Clinical Considerations ◽

Inferior Orbital Fissure

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EXTRADURAL TRANSCAVERNOUS APPROACH TO CAVERNOUS SINUS HEMANGIOMAS

Neurosurgery ◽

10.1227/01.neu.0000255333.95532.13 ◽

2007 ◽

Vol 60 (3) ◽

pp. 483-489 ◽

Cited By ~ 25

Author(s):

Ashish Suri ◽

Faiz U. Ahmad ◽

Ashok K. Mahapatra

Keyword(s):

Cavernous Sinus ◽

Surgical Complication ◽

Cranial Nerves ◽

Lateral Wall ◽

Middle Cranial Fossa ◽

Middle Meningeal Artery ◽

Anterior Clinoid Process ◽

Complete Excision ◽

Computed Tomographic ◽

Rapid Decompression

Abstract OBJECTIVE Cavernous sinus hemangiomas (CSHs) are uncommon lesions and comprise fewer than 1% of all parasellar masses. Because of their location, propensity for profuse bleeding during surgery, and relationship to complex neurovascular structures, they are notoriously difficult to excise. CLINICAL PRESENTATION The authors describe their experience with seven cases of CSHs. Headache and visual impairment were the most common presenting complaints, followed by facial hypesthesia and diplopia. Computed tomographic scans revealed iso- to hyperdense expansile lesions in the region of the cavernous sinus and middle cranial fossa. Magnetic resonance imaging scans revealed hypo- to isointense lesions on T1-weighted images and markedly hyperintense lesions on T2-weighted images, with marked homogeneous enhancement after contrast administration. INTERVENTION All CSHs were treated by a purely extradural transcavernous approach. This involved reduction of sphenoid ridge, exposure of the superior orbital fissure, drilling of the anterior clinoid process, coagulation and division of the middle meningeal artery, and peeling of the meningeal layer of the lateral wall of the cavernous sinus from the inner membranous layer. The cranial nerves in the lateral wall of the cavernous sinus were exposed (Cranial Nerves III and IV, as well as V1, V2, and V3). The tumor was accessed through its maximum bulge through either the lateral or anterolateral triangle. The tumor was removed via rapid decompression, coagulation of the feeder from the meningohypophyseal trunk, and dissection along the cranial nerves. All but one patient had complete tumor excision. Transient ophthalmoparesis (complete resolution in 6–8 wk) was the most common surgical complication. CONCLUSION To our knowledge, we describe one of the largest series of pure extradural transcavernous approaches to CSHs. CSHs are uncommon but challenging cranial base lesions. The extradural transcavernous approach allows complete excision with minimal mortality or long-term morbidity.

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Cavernous sinus compartments from the endoscopic endonasal approach: anatomical considerations and surgical relevance to adenoma surgery

Journal of Neurosurgery ◽

10.3171/2017.2.jns162214 ◽

2018 ◽

Vol 129 (2) ◽

pp. 430-441 ◽

Cited By ~ 13

Author(s):

Juan C. Fernandez-Miranda ◽

Nathan T. Zwagerman ◽

Kumar Abhinav ◽

Stefan Lieber ◽

Eric W. Wang ◽

...

Keyword(s):

Cavernous Sinus ◽

Cranial Nerves ◽

Spatial Relationship ◽

Abducens Nerve ◽

Human Head ◽

Residual Tumor ◽

Surgical Anatomy ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal

OBJECTIVETumors with cavernous sinus (CS) invasion represent a neurosurgical challenge. Increasing application of the endoscopic endonasal approach (EEA) requires a thorough understanding of the CS anatomy from an endonasal perspective. In this study, the authors aimed to develop a surgical anatomy–based classification of the CS and establish its utility for preoperative surgical planning and intraoperative guidance in adenoma surgery.METHODSTwenty-five colored silicon–injected human head specimens were used for endonasal and transcranial dissections of the CS. Pre- and postoperative MRI studies of 98 patients with pituitary adenoma with intraoperatively confirmed CS invasion were analyzed.RESULTSFour CS compartments are described based on their spatial relationship with the cavernous ICA: superior, posterior, inferior, and lateral. Each compartment has distinct boundaries and dural and neurovascular relationships: the superior compartment relates to the interclinoidal ligament and oculomotor nerve, the posterior compartment bears the gulfar segment of the abducens nerve and inferior hypophyseal artery, the inferior compartment contains the sympathetic nerve and distal cavernous abducens nerve, and the lateral compartment includes all cavernous cranial nerves and the inferolateral arterial trunk. Twenty-nine patients had a single compartment invaded, and 69 had multiple compartments involved. The most commonly invaded compartment was the superior (79 patients), followed by the posterior (n = 64), inferior (n = 45), and lateral (n = 23) compartments. Residual tumor rates by compartment were 79% in lateral, 17% in posterior, 14% in superior, and 11% in inferior.CONCLUSIONSThe anatomy-based classification presented here complements current imaging-based classifications and may help to identify involved compartments both preoperatively and intraoperatively.

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Surgical Approaches to the Cavernous Sinus: A Microsurgical Study

Neurosurgery ◽

10.1227/00006123-199006000-00001 ◽

1990 ◽

Vol 26 (6) ◽

pp. 903-932 ◽

Cited By ~ 226

Author(s):

Tooru Inoue ◽

Albert L. Rhoton ◽

Dan Theele ◽

Margaret E. Barry

Keyword(s):

Carotid Artery ◽

Cavernous Sinus ◽

Infratemporal Fossa ◽

Lateral Wall ◽

Middle Cranial Fossa ◽

Surgical Approaches ◽

Anterior Clinoid Process ◽

Anatomic Variants ◽

Cranial Fossa ◽

Extradural Approach

Abstract The surgical approaches to the cavernous sinus were examined in 50 adult cadaveric cavernous sinuses using magnification of ×3 to ×40. The following approaches were examined: 1) the superior intradural approach directed through a frontotemporal craniotomy and the roof of the cavernous sinus: 2) the superior intradural approach combined with an extradural approach for removing the anterior clinoid process and unroofing the optic canal and orbit; 3) the superomedial approach directed through a supraorbital craniotomy and subfrontal exposure to the wall of the sinus adjacent to the pituitary gland; 4) the lateral intradural approach directed below the temporal lobe to the lateral wall of the sinus; 5) the lateral extradural approach for exposure of the internal carotid artery in the floor of the middle cranial fossa proximal to the sinus; 6) the combined lateral and inferolateral approach, in which the infratemporal fossa was opened and the full course of the petrous carotid artery and the lateral wall of the sinus were exposed and; 7) the inferomedial approach, in which the medial wall of the sinus was exposed by the transnasal-transsphenoidal route. It was clear that a single approach was not capable of providing access to all parts of the sinus. The intracavernous structures best exposed by each route are reviewed. The osseous relationships in the region were examined in dry skulls. Anatomic variants important in exposing the cavernous sinus are reviewed.

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Excision of Greater Superficial Petrosal Nerve Schwannoma Via a Pure Endoscopic Endonasal Approach

Ear Nose & Throat Journal ◽

10.1177/01455613211026397 ◽

2021 ◽

pp. 014556132110263

Author(s):

Zhenlin Wang ◽

Siyuan Zhang ◽

Yan Qi ◽

Lianjie Cao ◽

Pu Li ◽

...

Keyword(s):

Hearing Loss ◽

Clinical Features ◽

Middle Cranial Fossa ◽

Nerve Sheath Tumor ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Greater Superficial Petrosal Nerve ◽

Clinical Records

Greater superficial petrosal nerve (GSPN) schwannomas are an exceedingly rare nerve sheath tumor. The current literature search was conducted using Medline and Embase database by key search terms. Only 31 cases have been reported in the literature so far. Facial palsy, hearing loss, and xerophthalmia accounted for 48.4% (15), 41.9% (13), and 29% (9) of all cases, respectively. The middle cranial fossa approach was used in all previous reports. A retrospective review of 2 GSPN schwannomas patients treated by endoscopic endonasal approach (EEA) in our center was collected. Clinical records, including clinical features, pre- and postoperative images, surgery, and follow-up information, were reviewed. In all cases, clinical features including facial numbness and headache were found, with tinnitus in case 1, hearing loss, xerophthalmia in case 2. Imaging studies showed a solid mass that originated in the anterior of the petrous bone. Two patients were treated by EEA. Furthermore, no recurrence was found during the follow-up period (15-29 months) in both of the 2 cases after the operation. Complete resection of GSPN schwannomas can be achieved via the pure EEA. Endoscopic endonasal approach for radical removal of tumors is safe and feasible.

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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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