The Medial Wall of the Cavernous Sinus: Microsurgical Anatomy

Neurosurgery ◽  
2004 ◽  
Vol 55 (1) ◽  
pp. 179-190 ◽  
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.

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

2019 ◽  
Vol 131 (1) ◽  
pp. 122-130 ◽  
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.

Development of Artificial Cranial Base Model With Soft Tissues for Practical Education

2010 ◽  
Vol 66 (suppl_2) ◽  
pp. onsE339-onsE341 ◽  
Author(s):  
Kentaro Mori ◽  
Takuji Yamamoto ◽  
Yasuaki Nakao ◽  
Takanori Esaki
Keyword(s):  
Cavernous Sinus ◽  
Dura Mater ◽  
Soft Tissues ◽  
Surgical Simulation ◽  
Cranial Nerves ◽  
Single Layer ◽  
Lateral Wall ◽  
Cranial Base ◽  
Superior Orbital Fissure ◽  
3 Dimensional

Abstract OBJECTIVE Improved educational tools for anatomic understanding and surgical simulation of the cranial base are needed because of the limited opportunities for cadaver dissection. A 3-dimensional cranial base model with retractable artificial dura mater is essential to simulate the epidural cranial base approach. METHODS We developed our 3-dimensional cranial base model with artificial dura mater, venous sinuses, cavernous sinus, internal carotid artery, and cranial nerves, and the extradural temporopolar approach was simulated using this new model. INSTRUMENTATION This model can be dissected with a surgical drill because of the artificial bone material. The periosteal dura was reconstructed in the medial wall of the cavernous sinus, periorbita, and periosteal bridge in the superior orbital fissure with yellow silicone. The meningeal dura was made with brown silicone. The single-layer dura mater could be dissected from the bone surface and retracted with a surgical spatula. RESULTS Extradural drilling of the superior orbital fissure and opening of the optic canal were similar to actual surgery. Extradural anterior clinoidectomy was performed via the extradural space by retracting the artificial dura mater. The artificial dura propria of the lateral wall in the cavernous sinus was successfully peeled from the artificial cranial nerves to complete the extradural temporopolar approach. CONCLUSION The improved 3-dimensional cranial base model provides a useful educational tool for the anatomic understanding and surgical simulation of extradural cranial base surgery.

scholarly journals Pterygopalatine Fossa: Microsurgical Anatomy and its Relevance for Skull Base Surgery

2020 ◽  
Author(s):  
Gustavo Rassier Isolan ◽  
Julio Mocellin Bernardi ◽  
João Paulo Mota Telles ◽  
Nícollas Nunes Rabelo ◽  
Eberval Gadelha Figueiredo
Keyword(s):  
Skull Base ◽  
The Body ◽  
Pterygopalatine Fossa ◽  
Surgical Approaches ◽  
Maxillary Artery ◽  
Microsurgical Anatomy ◽  
Extensive Resection ◽  
Maxillary Nerve ◽  
Adjacent Structures ◽  
Surgical Field

Abstract Introduction The purpose of this study was to define the anatomical relationships of the pterygopalatine fossa (PPF) and its operative implications in skull base surgical approaches. Methods Ten cadaveric heads were dissected at the Dianne and M Gazi Yasargil Educational Center MicrosurgicaLaboratory, in Little Rock, AK, USA. The PPF was exposed through an extended dissection with mandible and pterygoid plate removal. Results The PPF has the shape of an inverted cone. Its boundaries are the pterygomaxillary fissure; the maxilla, anteriorly; the medial plate of the pterygoid process, and greater wing of the sphenoid process, posteriorly; the palatine bone, medially; and the body of the sphenoid process, superiorly. Its contents are the maxillary division of the trigeminal nerve and its branches; the pterygopalatine ganglion; the pterygopalatine portion of the maxillary artery (MA) and its branches; and the venous network. Differential diagnosis of PPF masses includes perineural tumoral extension along the maxillary nerve, schwannomas, neurofibromas, angiofibromas, hemangiomas, and ectopic salivary gland tissue. Transmaxillary and transpalatal approaches require extensive resection of bony structures and are narrow in the deeper part of the approach, impairing the surgical vision and maneuverability. Endoscopic surgery solves this problem, bringing the light source to the center of the surgical field, allowing proper visualization of the surgical field, extreme close-ups, and different view angles. Conclusion We provide detailed information on the fossa's boundaries, intercommunications with adjacent structures, anatomy of the maxillary artery, and its variations. It is discussed in the context of clinical affections and surgical approaches of this specific region, including pterygomaxillary disjunction and skull base tumors.

Microsurgical Anatomy Of The Oculomotor Cistern

2006 ◽  
Vol 58 (suppl_4) ◽  
pp. ONS-220-ONS-228 ◽  
Author(s):  
Carolina Martins ◽  
Alexandre Yasuda ◽  
Alvaro Campero ◽  
Albert L. Rhoton
Keyword(s):  
Cavernous Sinus ◽  
Average Length ◽  
Lateral Wall ◽  
Posterior Wall ◽  
Oculomotor Nerve ◽  
Microsurgical Anatomy ◽  
Lower Margin ◽  
Anterior Clinoid Process ◽  
Interpeduncular Cistern ◽  
Adjacent Part

Abstract Objective: To define the characteristics of the arachnoidal sleeve and cistern that accompany the oculomotor nerve through the cavernous sinus roof. Methods: Forty cavernous sinuses were examined using 3 to 40x magnification. Information was obtained about the size of the oculomotor cistern and its relationship to the roof of the cavernous sinus and anterior clinoid process. Results: An arachnoidal sleeve and cistern, referred to as the oculomotor cistern, accompanied the oculomotor nerve into the roof of all the cavernous sinuses examined. The oculomotor cistern extends from the oculomotor porus, where the nerve enters the roof of the cavernous sinus, to the area below the tip or the adjacent part of the lower margin of the anterior clinoid process. From the porus, the nerve passes forward and downward to the depth of the cistern where it becomes incorporated into the fibrous lateral wall of the cavernous sinus. The width of the cistern was maximal at the oculomotor porus averaged 5.5 mm (range, 3.0–9.2 mm), and tapered slightly towards the midpoint and deep end of the cistern. The cistern's average length was 6.5 mm (range, 3.0–11.0 mm). The oculomotor nerve usually coursed closer to the anterior than the posterior wall of the cistern at the level of the oculomotor porus. Conclusion: The oculomotor cistern, an arachnoidal and dural cuff, accompanies the oculomotor nerve through the cavernous sinus roof to the area just below or anterior to the lower edge of the tip of the anterior clinoid process. The segment of the nerve inside the oculomotor cistern is interposed between its free portion in the interpeduncular cistern and the part of its course where it is incorporated into the fibrous lateral wall of the cavernous sinus. The cistern can be opened to aid in the exposure and mobilization of the nerve in dealing with pathology in the area.

Endoscopic endonasal transcavernous posterior clinoidectomy with interdural pituitary transposition

2014 ◽  
Vol 121 (1) ◽  
pp. 91-99 ◽  
Author(s):  
Juan C. Fernandez-Miranda ◽  
Paul A. Gardner ◽  
Milton M. Rastelli ◽  
Maria Peris-Celda ◽  
Maria Koutourousiou ◽  
...  
Keyword(s):  
Pituitary Gland ◽  
Cavernous Sinus ◽  
Venous Drainage ◽  
Surgical Anatomy ◽  
Medial Wall ◽  
Endoscopic Endonasal ◽  
Interpeduncular Cistern ◽  
Working Space ◽  
Petroclival Meningiomas ◽  
Extradural Approach

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.

Microanatomy of the hypophyseal fossa boundaries

1998 ◽  
Vol 88 (4) ◽  
pp. 743-752 ◽  
Author(s):  
Christophe Destrieux ◽  
Médard K. Kakou ◽  
Stéphane Velut ◽  
Thierry Lefrancq ◽  
Michel Jan
Keyword(s):  
Pituitary Gland ◽  
Cavernous Sinus ◽  
Treatment Plan ◽  
Lateral Wall ◽  
Histological Techniques ◽  
Content Type ◽  
Cavernous Sinus Invasion ◽  
Inferior Aspect ◽  
Diaphragma Sellae ◽  
Fine Print

Object. The authors studied the heads of 17 adult cadavers and one fetus to clarify the anatomy of the sellar region, particularly the lateral boundaries of the hypophyseal fossa. Methods. Vascular injections and microdissection or histological techniques were used in this study. The roof of the cavernous sinuses and diaphragma sellae were part of a single horizontal dural layer that joined the two anterior petroclinoid folds. Laterally, the direction of this layer changed; it became the lateral wall of the cavernous sinus and joined the dura mater of the middle cerebral fossa. On the midline, this layer ballooned toward the sella through the diaphragmatic foramina, created a dural bag containing the hypophysis, and attached to the inferior aspect of the diaphragma sellae. As a consequence, no straight sagittal dural wall existed between the pituitary gland and cavernous sinus; the lateral border of the hypophyseal fossa was part of this anteroposterior and superoinferior convex bag. The authors stress the importance of the venous elements of the region and discuss the structure of the cavernous and coronary sinuses. Conclusions. Invasion of the cavernous sinus makes surgery more risky and difficult and may necessitate modification of the surgical treatment plan. The preoperative diagnosis of cavernous sinus invasion is thus of great interest, but the possibility of normal lateral expansions of the pituitary gland must be kept in mind. A lateral expansion of this gland into the cavernous sinus was encountered in 29% of the specimens, and an adenoma that developed in such an expansion could easily mimic cavernous sinus invasion.

scholarly journals Microsurgical and Endoscopic Anatomy of the Cavernous Sinus

2020 ◽  
Vol 39 (02) ◽  
pp. 083-094
Author(s):  
Gustavo Rassier Isolan ◽  
Francisco Luiz Souza Braga ◽  
Alvaro Campero ◽  
José Alberto Landeiro ◽  
Ricardo Marques Lopes de Araújo ◽  
...  
Keyword(s):  
Surgical Technique ◽  
Cavernous Sinus ◽  
Carotid Arteries ◽  
Lateral Wall ◽  
Endoscopic Approach ◽  
Microsurgical Anatomy ◽  
Endoscopic Findings ◽  
Endoscopic Anatomy ◽  
Pathological Conditions ◽  
Formalin Fixed

Abstract Objective To describe the endoscopic and microsurgical anatomy of the cavernous sinus (CS) with focus on the surgical landmarks in microsurgical anatomy. Materials and methods Ten formalin-fixed central skull base specimens (20 CSs) with silicone-injected carotid arteries were examined through an extended endoscopic transsphenoidal approach. Fifteen formalin-fixed heads were dissected to simulate the surgical position in CS approaches. Results Endoscopic access enables identification of the anterior and posterior surgical corridors. Structures within the CS and on its lateral wall could be visualized and studied, but none of the triangular areas relevant to the transcranial microsurgical anatomy were fully visible through the endoscopic approach. Conclusion The endoscopic approach to the CS is an important surgical technique for the treatment of pathological conditions that affect this region. Correlating endoscopic findings with the conventional (transcranial) microsurgical anatomy is a useful way of applying the established knowledge into a more recent operative technique. Endoscope can provide access to the CS and to the structures it harbors.

Medial Wall of the Cavernous Sinus

2002 ◽  
Vol 15 (2) ◽  
pp. 197-203 ◽  
Author(s):  
J. Buric ◽  
A. Alexandre ◽  
L. Corò ◽  
A. Azuelos
Keyword(s):  
Pituitary Gland ◽  
Cavernous Sinus ◽  
Surgical Planning ◽  
Medial Wall ◽  
Lateral Part ◽  
Fresh Cadaver ◽  
Entry Points ◽  
Posterior Clinoid Process ◽  
Cranial Fossa ◽  
Membranous Part

The medial wall (MW) of the cavernous sinus (CS) was studied to define its structure, position and relations with the other CS structures. The study was performed on twenty-five fresh cadaver specimens featuring the sellar and both parasellar regions and parts of the anterior, middle and posterior cranial fossa. Fifteen specimens were injected with auto-polymerizing two component colored substance while ten were left non injected. The uppermost membranous part of the MW of the CS was found dividing the pituitary gland from the CS on each side. This membrane represented the most lateral part of the dural capsule surrounding the pituitary gland and invariably showed its completeness. The position and shape of the MW of the CS was found to be determined by ligaments anchoring it to the nearby bone and dural formations: anteriorly it was anchored to the middle clinoid process (MCP), posteriorly to the dorsum sellae and posterior clinoid process (PCP), superiorly to the diaphragm sellae and the posterior interclinoid ligament and inferiorly to the lateral surface of the sphenoid body. The position of the MW of the CS and the shape of its points of anchorage were found to be the most important factors determining the presence, configuration and size of the entry points of the intercavernous venous communications through the sella. The knowledge of the MW of the CS could have implications both on neuroradiological interpretation and on surgical planning and treatment of lesions involving these regions.

Is There an Identifiable Intact Medial Wall of the Cavernous Sinus? Macro- and Microscopic Anatomical Study Using Sheet Plastination

2013 ◽  
Vol 73 (suppl_1) ◽  
pp. ons106-ons110 ◽  
Author(s):  
Yuling Diao ◽  
Liang Liang ◽  
Chunjiang Yu ◽  
Ming Zhang
Keyword(s):  
Pituitary Gland ◽  
Cavernous Sinus ◽  
Anatomical Study ◽  
Pituitary Surgery ◽  
Middle Cranial Fossa ◽  
Medial Wall ◽  
Fibrous Network ◽  
Cranial Fossa ◽  
Dural Wall ◽  
Age Range

Abstract BACKGROUND: The medial wall of the cavernous sinus is believed to play a significant role in determining the direction of growth of pituitary adenomas and in planning pituitary surgery. However, it remains unclear whether there is a dural wall between the pituitary gland and the cavernous sinus. OBJECTIVE: To identify and trace the membranelike structures medial to the cavernous sinus and around the pituitary gland and their relationships with surrounding structures. METHODS: Sixteen cadavers (7 females and 9 males; age range, 54-89 years; mean age, 77 years) were used in this study and prepared as 16 sets of transverse (5 sets), coronal (2 sets), and sagittal (9 sets) plastinated sections that were examined at both macro- and microscopic levels. RESULTS: The pituitary gland was fully enclosed in a fibrous capsule, but the components between the anterosuperior aspect of the gland capsule and the cavernous sinus. Posteroinferiorly, however, this dural layer disappeared as it fused with the capsule. A weblike loose fibrous network connected the capsule, carotid artery, venous plexus, and the dura of the middle cranial fossa. CONCLUSION: The medial wall of the cavernous sinus consists of both the meningeal dura and weblike loose fibrous network, which are located at the anterosuperior and posteroinferior aspects, respectively.

scholarly journals Magnetic resonance imaging of cavernous sinus invasion by pituitary adenoma diagnostic criteria and surgical findings

2004 ◽  
Vol 62 (2b) ◽  
pp. 437-443 ◽  
Author(s):  
Joaquim O. Vieira Jr. ◽  
Arthur Cukiert ◽  
Bernardo Liberman
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Gland ◽  
Cavernous Sinus ◽  
Predictive Value ◽  
Lateral Wall ◽  
Preoperative Imaging ◽  
Cavernous Sinus Invasion ◽  
Normal Pituitary Gland ◽  
Sensitivity Specificity ◽  
Dural Wall

This study used MRI to define preoperative imaging criteria for cavernous sinus invasion (CSI) by pituitary adenoma (PA). MR images of 103 patients with PA submitted to surgery (48 with CSI) were retrospectively reviewed. The following MR signs were studied and compared to intraoperative findings (the latter were considered the gold standard for CSI detection): presence of normal pituitary gland between the adenoma and CS, status of the CS venous compartments, CS size, CS lateral wall bulging, displacement of the intracavernous internal carotid artery (ICA) by adenoma, grade of parasellar extension (Knosp-Steiner classification) and percentage of intracavernous ICA encased by the tumor. Statistical analysis was performed using qui-square testing and sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were obtained for each MR finding. The following signs have been found to represent accurate criteria for non-invasion of the CS: 1- normal pituitary gland interposed between the adenoma and the CS (PPV, 100%); 2- intact medial venous compartment (PPV, 100%); 3- percentage of encasement of the intracavernous ICA lower than 25% (NPV, 100%) and 4- medial intercarotid line not crossed by the tumor (NPV, 100%). Criteria for CSI were: 1- percentage of encasement of the intracavernous ICA higher than 45%; 2- occlusion of three or more CS venous compartments and 3- occlusion of the CS lateral venous compartment. The CS was very likely to be invaded if the inferior venous compartment was not detected (PPV. 92,8%), if the lateral intercarotid line was crossed (PPV. 96,1%) or if a bulging lateral dural wall of the CS was seen (PPV, 92,3%). The preoperative diagnosis of CSI by PA is extremely important since endocrinological remission is rarely obtained after microsurgery alone in patients with invasive tumors. The above mentioned MR imaging criteria may be useful in advising most of the patients preoperatively on the potential need for complimentary therapy after surgery.

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