Tumors of the lateral wall of the cavernous sinus

1992 ◽  
Vol 77 (4) ◽  
pp. 508-514 ◽  
Author(s):  
Magdy El-Kalliny ◽  
Harry van Loveren ◽  
Jeffrey T. Keller ◽  
John M. Tew
Keyword(s):  
Cavernous Sinus ◽  
Cranial Nerve ◽  
Tumor Resection ◽  
Lateral Wall ◽  
Content Type ◽  
Nerve Preservation ◽  
Membranous Layer ◽  
Microsurgical Approach ◽  
Dural Wall ◽  
Fine Print

✓ The lateral dural wall of the cavernous sinus is composed of two layers, the outer dural layer (dura propria) and the inner membranous layer. Tumors arising from the contents of the lateral dural wall are located between these two layers and are classified as interdural. They are in essence extradural/extracavernous. The inner membranous layer separates these tumors from the venous channels of the cavernous sinus. Preoperative recognition of tumors in this location is critical for selecting an appropriate microsurgical approach. Characteristics displayed by magnetic resonance imaging show an oval-shaped, smooth-bordered mass with medial displacement but not encasement of the cavernous internal carotid artery. Tumors in this location can be resected safely without entering the cavernous sinus proper by using techniques that permit reflection of the dura propria of the lateral wall (methods of Hakuba or Dolenc). During the last 5 years, the authors have identified and treated five patients with interdural cavernous sinus tumors, which included two trigeminal neurinomas arising from the first division of the fifth cranial nerve, two epidermoid tumors, and one malignant melanoma presumed to be primary. The pathoanatomical features that make this group of tumors unique are discussed, as well as the clinical and radiological findings, and selection of the microsurgical approach. A more favorable prognosis for tumor resection and cranial nerve preservation is predicted for interdural tumors when compared with other cavernous sinus tumors.

Operative management of tumors involving the cavernous sinus

1986 ◽  
Vol 64 (6) ◽  
pp. 879-889 ◽  
Author(s):  
Laligam N. Sekhar ◽  
Aage R. Møller
Keyword(s):  
Cavernous Sinus ◽  
Cranial Nerve ◽  
Preoperative Evaluation ◽  
Operative Procedure ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Petrous Apex ◽  
Content Type ◽  
The Third ◽  
Fine Print

✓ In the past, neurosurgeons have been reluctant to operate on tumors involving the cavernous sinus because of the possibility of bleeding from the venous plexus or injury to the internal carotid artery (ICA) or the third, fourth, or sixth cranial nerves. The authors describe techniques for a more aggressive surgical approach to neoplasms in this area that are either benign or locally confined malignant lesions. During the last 2 years, seven tumors involving the cavernous sinus have been resected: six totally and one subtotally. The preoperative evaluation included axial and coronal computerized tomography, cerebral angiography, and a balloon-occlusion test of the ICA. Intraoperative monitoring of the third, fourth, sixth, and seventh cranial nerves was used to assist in locating the nerves and in avoiding injury to them. The first major step in the operative procedure was to obtain proximal control of the ICA at the petrous apex and distal control in the supraclinoid segment. The cavernous sinus was then opened by a lateral, superior, or inferior approach for tumor resection. Temporary clipping and suture of the ICA was necessary in one patient. None of the patients died or suffered a stroke postoperatively. Permanent trigeminal nerve injury occurred in three patients; in two, this was the result of tumor invasion. One patient suffered temporary paralysis of the third, fourth, and sixth cranial nerves, and in another the sixth cranial nerve was temporarily paralyzed. Preoperative cranial nerve deficits were improved postoperatively in three patients. Radiation therapy was administered postoperatively to four patients. These seven patients have been followed for 6 to 18 months to date and none has shown evidence of recurrence of the intracavernous tumor.

The abducens nerve

1974 ◽  
Vol 41 (5) ◽  
pp. 561-566 ◽  
Author(s):  
Hilel Nathan ◽  
Georges Ouaknine ◽  
Isaac Z. Kosary
Keyword(s):  
Cavernous Sinus ◽  
Subarachnoid Space ◽  
Cranial Nerve ◽  
Rectus Muscle ◽  
Abducens Nerve ◽  
The Other ◽  
Sixth Cranial Nerve ◽  
Content Type ◽  
Lateral Rectus Muscle ◽  
Fine Print

✓ The authors describe the origins and course of the sixth cranial nerve in 62 cadaver or autopsy cases and describe three patterns. In Pattern 1 the nerve originates and runs all its way as a single trunk. In Pattern 2 it originates as a single trunk, but splits into two branches in the subarachnoid space, while in Pattern 3 it originates as two separate trunks. In both Patterns 2 and 3 the trunks perforate the dura mater independently and enter the cavernous sinus by passing one above and the other below the petrosphenoidal ligament. In the sinus the two trunks fuse into a single trunk which then continues to the lateral rectus muscle. The practical neurological importance of these variations is discussed.

Transsphenoidal approach to infrasellar tumors involving the cavernous sinus

1990 ◽  
Vol 73 (4) ◽  
pp. 513-517 ◽  
Author(s):  
Nobuo Hashimoto ◽  
Haruhiko Kikuchi
Keyword(s):  
Cavernous Sinus ◽  
Cranial Nerve ◽  
Cranial Nerves ◽  
Transsphenoidal Approach ◽  
Skull Base Tumors ◽  
Content Type ◽  
Operating Field ◽  
Cranial Nerve Palsies ◽  
Operative Complications ◽  
Fine Print

✓ The authors review their 2-year experience with a rhinoseptal transsphenoidal approach to skull-base tumors of various pathologies involving both the sphenoid and cavernous sinuses. Eight patients with cranial nerve palsies attributable to compression of the contents of the cavernous sinus and/or optic canal are included in this report. Among these patients, a total of 17 cranial nerves were affected. Postoperative normalization was achieved in eight nerves, significant improvement in seven nerves, and no improvement in two nerves. There were no operative complications of aggravation of cranial nerve palsies in this series. In spite of the limited operating field, the results demonstrate the effectiveness and safety of this approach. The authors recommend that this approach be considered before more aggressive surgery is undertaken.

Intracranial sympathetic pathways associated with the sixth cranial nerve

1974 ◽  
Vol 40 (2) ◽  
pp. 236-243 ◽  
Author(s):  
J. A. Johnston ◽  
Dwight Parkinson
Keyword(s):  
Cavernous Sinus ◽  
Cranial Nerve ◽  
Abducens Nerve ◽  
Sixth Cranial Nerve ◽  
Content Type ◽  
Photographic Documentation ◽  
Parasellar Region ◽  
Fine Print

✓ During a continuing study of the anatomy of the parasellar region, a macroscopically identifiable nerve has been observed to leave the foramen lacerum and join the abducens nerve within the cavernous sinus. A description and photographic documentation of this sympathetic branch to the fifth cranial nerve by way of the sixth cranial nerve are presented.

Outcome of aggressive removal of cavernous sinus meningiomas

1994 ◽  
Vol 81 (2) ◽  
pp. 245-251 ◽  
Author(s):  
Franco DeMonte ◽  
Harold K. Smith ◽  
Ossama Al-Mefty
Keyword(s):  
Cavernous Sinus ◽  
Cranial Nerve ◽  
The Other ◽  
Surgical Removal ◽  
Content Type ◽  
Formidable Challenge ◽  
Acute Hypothyroidism ◽  
Total Tumor Removal ◽  
Subtotal Removal ◽  
Fine Print

✓ Despite recent advances in surgery of the cavernous sinus, meningiomas in that area offer a formidable challenge. The rationale for aggressive surgical removal of cavernous sinus meningiomas is based on the presumption that the extent of removal is inversely related to the rate of recurrence. Over the past 10 years, 41 patients with histologically benign meningiomas involving the cavernous sinus underwent aggressive surgery. Total removal, as confirmed by intraoperative inspection and postoperative radiological studies, was achieved in 31 patients (76%). Twelve patients have been followed for more than 5 years; 10 underwent total tumor removal and only one of these experienced recurrence (5 years after surgery). The other two patients underwent subtotal removal and had symptomatic and radiological evidence of regrowth 3 and 4 years after surgery. Pre-existing cranial nerve deficits improved in only 14% of the patients, remained unchanged in 80%, and worsened permanently in 6%. Seven patients experienced a total of 10 new cranial nerve deficits, four of which involved the nerves subserving ocular motor function. Extraocular muscle function did not worsen in the 25 patients with a seeing eye ipsilateral to the tumor, and no instance of visual worsening occurred. Two patients died 4 months after surgery, one from severe delayed vasospasm and hypothalamic infarction and the other because of a myocardial infarction. Another patient died from a pulmonary embolus on the 9th postoperative day. There were three instances of cerebral ischemia; one was transient, lasting less than 24 hours, while two were related to injury of the middle cerebral artery and resulted in residual hemiplegia. Other complications included three cases of nonfatal pulmonary emboli, two cerebrospinal fluid leaks, and one instance each of exposure keratitis, acute hypothyroidism, and cerebral edema.

Outcomes of decompressive surgery for cavernous sinus meningiomas: long-term follow-up in 50 patients

2020 ◽  
Vol 132 (2) ◽  
pp. 380-387 ◽  
Author(s):  
Yair M. Gozal ◽  
Gmaan Alzhrani ◽  
Hussam Abou-Al-Shaar ◽  
Mohammed A. Azab ◽  
Michael T. Walsh ◽  
...  
Keyword(s):  
Optic Nerve ◽  
Cavernous Sinus ◽  
Cranial Nerve ◽  
Tumor Resection ◽  
Lateral Wall ◽  
Senior Author ◽  
Tumor Control ◽  
Subtotal Resection ◽  
Adjuvant Radiation ◽  
Neurological Morbidity

OBJECTIVECavernous sinus meningiomas are complex tumors that offer a perpetual challenge to skull base surgeons. The senior author has employed a management strategy for these lesions aimed at maximizing tumor control while minimizing neurological morbidity. This approach emphasizes combining “safe” tumor resection and direct decompression of the roof and lateral wall of the cavernous sinus as well as the optic nerve. Here, the authors review their experience with the application of this technique for the management of cavernous sinus meningiomas over the past 15 years.METHODSA retrospective analysis was performed for patients with cavernous sinus meningiomas treated over a 15-year period (2002–2017) with this approach. Patient outcomes, including cranial nerve function, tumor control, and surgical complications were recorded.RESULTSThe authors identified 50 patients who underwent subtotal resection via frontotemporal craniotomy concurrently with decompression of the cavernous sinus and ipsilateral optic nerve. Of these, 25 (50%) underwent adjuvant radiation to the remaining tumor within the cavernous sinus. Patients most commonly presented with a cranial nerve (CN) palsy involving CN III–VI (70%), a visual deficit (62%), headaches (52%), or proptosis (44%). Thirty-five patients had cranial nerve deficits preoperatively. In 52% of these cases, the neuropathy improved postoperatively; it remained stable in 46%; and it worsened in only 2%. Similarly, 97% of preoperative visual deficits either improved or were stable postoperatively. Notably, 12 new cranial nerve deficits occurred postoperatively in 10 patients. Of these, half were transient and ultimately resolved. Finally, radiographic recurrence was noted in 5 patients (10%), with a median time to recurrence of 4.6 years.CONCLUSIONSThe treatment of cavernous sinus meningiomas using surgical decompression with or without adjuvant radiation is an effective oncological strategy, achieving excellent tumor control rates with low risk of neurological morbidity.

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.

The lateral wall of the cavernous sinus

1982 ◽  
Vol 56 (2) ◽  
pp. 228-234 ◽  
Author(s):  
Felix Umansky ◽  
Hilel Nathan
Keyword(s):  
Cavernous Sinus ◽  
Deep Layer ◽  
Lateral Wall ◽  
Superficial Layer ◽  
Content Type ◽  
Deep Layers ◽  
Fine Print

✓ In a study of the cavernous sinus in 70 specimens, the lateral wall of the sinus was found to be formed by two layers: a superficial, dural layer and a deep layer. The latter was formed by the sheaths of nerves III, IV, and V1,2 plus a reticular membrane extending between the sheaths. This membrane was often incomplete, particularly beween the sheaths of nerves III and IV above, and V1 below. These findings do not conform with the descriptions of a single dural layer of the lateral wall, with nerves III, IV, and V1,2 embedded in it, nor to other descriptions showing the cavity of the sinus divided into two compartments by a septum close to the lateral wall, with nerves III, IV, and V1 located within the septum. In the present study, the superficial and the deep layers of the lateral wall were found to be loosely attached to each other and easy to separate. In no case was a superficial compartment of the sinus found to be present between the two layers, and the nerves were never found to be running embedded in the superficial layer.

The superior wall of the cavernous sinus: a microanatomical study

1994 ◽  
Vol 81 (6) ◽  
pp. 914-920 ◽  
Author(s):  
Felix Umansky ◽  
Alberto Valarezo ◽  
Josef Elidan
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cavernous Sinus ◽  
Internal Carotid ◽  
Deep Layer ◽  
Lateral Wall ◽  
Anterior Clinoid Process ◽  
Content Type ◽  
Carotid Canal ◽  
Fine Print

✓ The superior wall of the cavernous sinus was studied in 30 specimens obtained from 15 cadaver heads fixed in formalin. Trapezoidal in shape, the superior wall of cavernous sinus is limited laterally by the anterior petroclinoid ligament, medially by the dura of the diaphragma sellae, anteriorly by the endosteal dura of the carotid canal, and posteriorly by the posterior petroclinoid ligament. An interclinoid ligament bisects the wall, dividing it into two triangles: the carotid trigone anteromedially and the oculomotor trigone posterolaterally. Similar to the lateral wall of the cavernous sinus, the superior wall is formed by two layers: a smooth superficial dural layer and a thin, less defined deep layer. In the area of the carotid trigone, both layers separate to wrap the anterior clinoid process. The removal of this process will reveal a “clinoid space” medial to which the internal carotid artery can be identified. This clinoid segment of the artery, still extracavernous, is surrounded by two fibrous rings: a distal ring formed by fibers of the superficial dural layer and a proximal ring related to the deep dural layer. Below the proximal ring, the internal carotid artery becomes intracavernous; above the distal ring, the artery is continuous with its supraclinoid segment. The complex dural anatomy of the superior wall, its fibrous rings, and the clinoid space in relation to a superior surgical approach to the cavernous sinus are discussed.

Reconstruction of the third through sixth cranial nerves during cavernous sinus surgery

1992 ◽  
Vol 76 (6) ◽  
pp. 935-943 ◽  
Author(s):  
Laligam N. Sekhar ◽  
Giuseppe Lanzino ◽  
Chandra N. Sen ◽  
Spiros Pomonis
Keyword(s):  
Cavernous Sinus ◽  
Cranial Nerve ◽  
Recovery Of Function ◽  
Cranial Nerves ◽  
Sinus Surgery ◽  
Content Type ◽  
The Third ◽  
Successful Recovery ◽  
Cranial Nerve Function ◽  
Fine Print

✓ Sixteen reconstruction procedures of the third through sixth cranial nerves were carried out in 14 patients during operations on 149 tumors involving the cavernous sinus. A direct end-to-end anastomosis was performed in five nerves, whereas in 11 cases the nerve stumps were bridged by means of an interposing nerve graft. The sixth cranial nerve was most frequently reconstructed (nine cases). In four cases, the fifth nerve or root was repaired. The third nerve was reconstructed in two patients, and the fourth nerve was repaired in only one case. Recovery of function, either partial or complete, was observed in 13 nerves: the third in two instances, the fourth in one, the fifth in three, and the sixth in seven. No return of function occurred in three nerves. In patients with a successful recovery of cranial nerve function, either binocular function or the cosmetic result was improved. These results suggest that repair of the third through sixth cranial nerves injured during surgery should be pursued in suitable patients.

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