Endoscopic transorbital approach to the cavernous sinus lateral compartment (anatomical cadaver study)

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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Classification of Pituitary Adenomas Invading the Cavernous Sinus Assisted by Three-Dimensional Multimodal Imaging and Its Clinical Application

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1715597 ◽

2020 ◽

Author(s):

Yukun Zhang ◽

Shaohua Tu ◽

Lian Duan ◽

Weilun Fu ◽

Jianbo Wang ◽

...

Keyword(s):

Cavernous Sinus ◽

Pituitary Adenomas ◽

Multimodal Imaging ◽

Three Dimensional ◽

Lateral Wall ◽

Lateral Compartment ◽

Posterior Compartment ◽

Grade 3 ◽

Distinct Separation

Abstract Introduction To help diagnose and evaluate the prognosis of pituitary adenoma with cavernous sinus (CS) invasion and guide endonasal endoscopic surgery (EES) assisted by intraoperative navigation (ION) with three-dimensional multimodal imaging (3D-MMI). We propose a classification of CS invasion based on 3D-MMI. Methods We picked some appropriate cases and reconstructed the 3D-MMI and then classified them into 3 grades according to the stereo relationship among ICA, tumor and CS in 3D-MMI. Then, we applied different strategies according to their grade to remove pituitary adenomas that invaded the CS. Results All 38 patients were divided into 3 grades. Tumors compressing the ICA and CS without CS invasion were divided into grade 1. Tumors encasing the ICA and invading the superior-posterior compartment and/or anterior-inferior compartment but without distinct separation of the ICA and CS lateral wall were deemed as grade 2. Tumors encasing the ICA and filling the lateral compartment of the CS that dissociated the lateral wall from the ICA were deemed as grade 3. The 3D-MMI enabled adequate spatial visualization of the ICA, CS and tumors. All patients were operated on under the guidance of ION with 3D-MMI. Conclusions Classification based on 3D-MMI can better demonstrate the relationships among tumor, ICA and CS in a stereo and multi-angle view, which will have significance in guiding the surgical strategy.

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Endoscopic Transorbital Superior Eyelid Approach for the Management of Selected Spheno-orbital Meningiomas: Preliminary Experience

Operative Neurosurgery ◽

10.1093/ons/opx100 ◽

2017 ◽

Vol 14 (3) ◽

pp. 243-251 ◽

Cited By ~ 19

Author(s):

Iacopo Dallan ◽

Stefano Sellari-Franceschini ◽

Mario Turri-Zanoni ◽

Matteo de Notaris ◽

Giacomo Fiacchini ◽

...

Keyword(s):

Cavernous Sinus ◽

Tumor Volume ◽

Endoscopic Management ◽

Symptom Improvement ◽

Female Ratio ◽

Presenting Symptoms ◽

Endoscopic Transorbital ◽

Superior Eyelid Approach ◽

Orbital Meningioma ◽

Male To Female

Abstract BACKGROUND Feasibility and safety of spheno-orbital meningioma resection by means of endoscopic-assisted transorbital route. OBJECTIVE To evaluate the feasibility and outcomes of the transorbital endoscopic management of selected spheno-orbital meningiomas. As secondary aims, symptom improvement and tumor volume removed were evaluated. METHODS Retrospective chart evaluation of patients with spheno-orbital meningiomas treated by means of endoscopic transorbital superior eyelid approach in 3 referral centers over the last 4 yr. RESULTS Fourteen cases were included in this study. In 4 patients, the transorbital endoscopic approach was combined with an endonasal route. Mean age was 51 and male-to-female ratio was 1:6. In 8 patients (57.1%), an intraorbital involvement was observed, 3 of them (21.4%) showed significant intraconal disease. No patient presented significant cavernous sinus infiltration. Main presenting symptoms were proptosis, diplopia, and visual impairment in 14, 6, and 6 patients, respectively. Mean proptosis improvement was 2 mm (standard deviation 2.3). We observed no major postoperative complications. CONCLUSION Our preliminary clinical experience seems to demonstrate that selected spheno-orbital meningiomas can be safely managed by means of an endoscopic transorbital route through a superior eyelid approach. Patients with orbital or cavernous sinus infiltration are at highest risk of persistence.

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Lateral Transmaxillosphenoidal Approach to the Lateral Compartment of the Cavernous Sinus: Technical Case Report

Skull Base ◽

10.1055/s-2007-991115 ◽

2007 ◽

Vol 17 (6) ◽

pp. 413-416 ◽

Cited By ~ 1

Author(s):

Mario Fraioli ◽

F. Contratti ◽

C. Fraioli ◽

R. Floris

Keyword(s):

Case Report ◽

Cavernous Sinus ◽

Lateral Compartment

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Optimal indications and limitations of endoscopic transorbital superior eyelid surgery for spheno-orbital meningiomas

Journal of Neurosurgery ◽

10.3171/2020.3.jns20297 ◽

2020 ◽

pp. 1-8 ◽

Cited By ~ 1

Author(s):

Doo-Sik Kong ◽

Yong Hwy Kim ◽

Chang-Ki Hong

Keyword(s):

Minimally Invasive Surgery ◽

Minimally Invasive ◽

Cavernous Sinus ◽

Invasive Surgery ◽

Infratemporal Fossa ◽

Wound Complications ◽

Total Resection ◽

Plaque Type ◽

Endoscopic Transorbital ◽

Orbital Rim

OBJECTIVESpheno-orbital meningiomas (SOMs) are complicated tumors that involve multiple structures at initial presentation, such as the orbit, temporalis muscle, sphenoidal bone, cavernous sinus, and temporal or infratemporal fossa. The infiltrative growth and complexity of this type of meningioma make total resection impossible. In this study, the authors evaluated the surgical outcome of the endoscopic transorbital approach (eTOA) for SOM. In addition, they identified optimal indications for the use of eTOA and analyzed the feasibility of this approach as a minimally invasive surgery for SOMs of varying types and locations at presentation.METHODSBetween September 2016 and December 2019, the authors performed eTOA in 41 patients with SOM with or without orbital involvement at 3 independent tertiary institutions. The authors evaluated the surgical outcomes of eTOA for SOM and investigated several factors that affect the outcome, such as tumor volume, tumor location, and the presence of lateral orbitotomy. Gross-total resection (GTR) was defined as complete resection of the tumor or intended subtotal resection except the cavernous sinus. This study was undertaken as a multicenter project (006) of the Korean Society of Endoscopic Neurosurgery (KOSEN-006).RESULTSThere were 41 patients (5 men and 36 women) with a median age of 52.0 years (range 24–73 years). Twenty-one patients had tumors that involved the orbital structure, while 14 patients had tumors that presented at the sphenoidal bone along with other structures, such as the cavernous sinus, temporal fossa, and infratemporal fossa. Fifteen patients had the globulous type of tumor and 26 patients had the en plaque type. Overall, GTR was achieved in 21 of 41 patients (51.2%), and complications included CSF leaks in 2 patients and wound complications in 2 patients. Multiple logistic regression analysis showed that the en plaque type of tumor, absence of lateral orbital rim osteotomy, involvement of the temporal floor or infratemporal fossa, and involvement of the orbit and medial one-third of the greater sphenoidal wing were closely associated with lower GTR rates (p < 0.05). Multivariate analysis revealed that the en plaque type of tumor and the absence of lateral orbital rim osteotomy were significant predictors for lower GTR rate.CONCLUSIONSThe en plaque type of SOM remains a challenge despite advances in technique such as minimally invasive surgery. Overall, clinical outcome of eTOA for SOM was comparable to the transcranial surgery. To achieve GTR, eTOA is recommended, with additional lateral orbital rim osteotomy for globulous-type tumors, without involving the floor of the temporal and infratemporal fossa.

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Combined and simultaneous endoscopic endonasal and transorbital surgery for a Meckel’s cave schwannoma: technical nuances of a mini-invasive, multiportal approach

Journal of Neurosurgery ◽

10.3171/2020.4.jns20707 ◽

2020 ◽

pp. 1-10

Author(s):

Alberto Di Somma ◽

Cristobal Langdon ◽

Matteo de Notaris ◽

Luis Reyes ◽

Santiago Ortiz-Perez ◽

...

Keyword(s):

Minimally Invasive ◽

Skull Base ◽

Cavernous Sinus ◽

Lateral Wall ◽

Neurological Deficits ◽

Meckel’S Cave ◽

Endoscopic Endonasal ◽

Endoscopic Transorbital ◽

Meckel's Cave ◽

Surgical Teams

OBJECTIVEOver the years, Meckel’s cave pathologies have been judged off-limits because of high rates of morbidity. Even though several studies have defined various surgical routes with tolerable morbidity and mortality rates, controversies related to the optimal avenue to treat different categories of Meckel’s cave and cavernous sinus neoplasms persist.With unceasing energy to cultivate minimally invasive neurosurgical approaches, the endoscopic endonasal route has been tested, and the approach effectively performed, to provide a valid surgical window to these areas. In this dynamic and challenging scenario, another ventral endoscopic minimally invasive route—that is, the superior eyelid endoscopic transorbital approach—has been very recently proposed, and used in selected cases, to access the cavernous sinus and Meckel’s cave regions.METHODSThe authors report the technical nuances of a combined and simultaneous endoscopic endonasal and transorbital surgical treatment of a patient with a Meckel’s cave schwannoma. The operation involved collaboration among neurosurgery, otorhinolaryngology, and ophthalmology (oculoplastic surgery). The patient recovered well, had no neurological deficits, and was discharged to home 3 days after surgery.RESULTSThe multiportal combined route was proposed for the following reasons. The endonasal approach, considered to be more familiar to our skull base team, could allow control of possible damage of the internal carotid artery. From the endonasal perspective, the most inferior and medial portion of the tumor could be properly managed. Finally, the transorbital route, by means of opening the lateral wall of the cavernous sinus via the meningoorbital band, could allow control of the superolateral part of the tumor and, most importantly, could permit removal of the portion entering the posterior cranial fossa via the trigeminal pore. Simultaneous surgery with two surgical teams working together was planned in order to reduce operative time, hospital stay, and patient stress and discomfort, and to ensure “one-shot” complete tumor removal, with minimal or no complications.CONCLUSIONSThis study represents the translation into the real surgical setting of recent anatomical contributions related to the novel endoscopic transorbital approach and its simultaneous integration with the endoscopic endonasal pathway. Accordingly, it may pave the way for future applications related to minimally invasive, multiportal endoscopic surgery for skull base tumors.

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Endoscopic transorbital route to the cavernous sinus through the meningo-orbital band: a descriptive anatomical study

Journal of Neurosurgery ◽

10.3171/2016.8.jns16465 ◽

2017 ◽

Vol 127 (3) ◽

pp. 622-629 ◽

Cited By ~ 16

Author(s):

Iacopo Dallan ◽

Alberto Di Somma ◽

Alberto Prats-Galino ◽

Domenico Solari ◽

Isam Alobid ◽

...

Keyword(s):

Cavernous Sinus ◽

Sagittal Plane ◽

Anatomical Study ◽

Lateral Wall ◽

Petrous Bone ◽

Surgical Approaches ◽

Anterior Portion ◽

Advantages And Disadvantages ◽

Endoscopic Transorbital ◽

Starting Point

OBJECTIVEExposure of the cavernous sinus is technically challenging. The most common surgical approaches use well-known variations of the standard frontotemporal craniotomy. In this paper the authors describe a novel ventral route that enters the lateral wall of the cavernous sinus through an interdural corridor that includes the removal of the greater sphenoid wing via a purely endoscopic transorbital pathway.METHODSFive human cadaveric heads (10 sides) were dissected at the Laboratory of Surgical NeuroAnatomy of the University of Barcelona. To expose the lateral wall of the cavernous sinus, a superior eyelid endoscopic transorbital approach was performed and the anterior portion of the greater sphenoid wing was removed. The meningo-orbital band was exposed as the key starting point for revealing the cavernous sinus and its contents in a minimally invasive interdural fashion.RESULTSThis endoscopic transorbital approach, with partial removal of the greater sphenoid wing followed by a “natural” ventral interdural dissection of the meningo-orbital band, allowed exposure of the entire lateral wall of the cavernous sinus up to the plexiform portion of the trigeminal root and the petrous bone posteriorly and the foramen spinosum, with the middle meningeal artery, laterally.CONCLUSIONSThe purely endoscopic transorbital approach through the meningo-orbital band provides a direct view of the cavernous sinus through a simple and rapid means of access. Indeed, this interdural pathway lies in the same sagittal plane as the lateral wall of the cavernous sinus. Advantages include a favorable angle of attack, minimal brain retraction, and the possibility for dissection through the interdural space without entering the neurovascular compartment of the cavernous sinus. Surgical series are needed to demonstrate any clinical advantages and disadvantages of this novel route.

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MICROSCOPIC AND ENDOSCOPIC EXTRACRANIAL APPROACHES TO THE CAVERNOUS SINUS: ANATOMIC STUDY

Operative Neurosurgery ◽

10.1227/01.neu.0000338943.08985.73 ◽

2009 ◽

Vol 64 (suppl_5) ◽

pp. ons413-ons422 ◽

Cited By ~ 7

Author(s):

Francesco Doglietto ◽

Liverana Lauretti ◽

Giorgio Frank ◽

Ernesto Pasquini ◽

Eduardo Fernandez ◽

...

Keyword(s):

Cavernous Sinus ◽

Lateral Compartment ◽

Endoscopic Approach ◽

Arterial System ◽

Transsphenoidal Approach ◽

Microscopic Approach ◽

Pterygoid Process ◽

Endoscopic Techniques ◽

Medial Pterygoid ◽

Good Exposure

Abstract OBJECTIVE In the past 2 decades, various extracranial approaches to the cavernous sinus (CS), using either microscopic or endoscopic techniques, have been described. The aim of this study was to describe the distinctive anatomic features of these approaches and compare their efficacy in exposing the sella and parasellar areas. METHODS Ten adult cadaver heads with red latex injected in the arterial system were used. Five different approaches were performed: 1) endonasal microscopic transsphenoidal approach; 2) sublabial microscopic transsphenoidal approach, including its variation described by Fraioli et al. (12); 3) transmaxillary microscopic approach; 4) paraseptal endoscopic transsphenoidal approach; and 5) transethmoid-pterygoid-sphenoidal endoscopic approach. The CS exposition was evaluated for each approach and a grading system, which considers surgical maneuverability as well as visualization, was used. RESULTS The medial CS compartment is well exposed with all endoscopic and microscopic transsphenoidal approaches, but it is insufficiently exposed with the transmaxillary approach. The variation to the sublabial microscopic approach suggested by Fraioli et al. allows its widest microsurgical exposure. The lateral compartment is well visualized with the transmaxillary microscopic and the endoscopic approaches. The major anatomic structures that can limit exposure of the CS lateral compartment are the posterior ethmoid and medial pterygoid process. CONCLUSION The sublabial transsphenoidal microscopic approach, with its variations, allows the most versatile extracranial microscopic exposure of the sella and CS. The paraseptal, binostril endoscopic approach allows a very good exposure of the CS; the transethmoid-pterygoid-sphenoidal endoscopic approach achieves the best maneuverability in the lateral compartment of the CS.

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