OBJETIVES
The purpose of this study is to consider the surgical strategies noticing surgical interlayer’s corridors through membranes respecting these important anatomical structures.
MATERIALS AND METHODS
- ØThe walls of the cavernous sinus was studied in 15 cadaver heads (30 specimens) fixed in formalin. The heads were placed in a Sugita head holder and turned 450 from the side of dissection.
- ØEight cases report of cavernous sinus tumors using lateral and upper interdural corridor
ANATOMICAL OBSERVATIONS
LATERAL WALL
Superolateral view of the right cavernous sinus after removal of the anterior clinoid process.
Separation of the superficial layer of the lateral wall LW(sl) from its deep layer LW(dl).
Lateral view of the right cavernous sinus after removal superficial and deep layers of the lateral wall of the cavernous sinus. The cranial nerves of the lateral wall is surrounded by a dural sheath DSIII, DSIV, DSV1, DSV2.
ANTERIOR WALL
Superolateral view of the left cavernous sinus and superior orbital fissure after removal of the anterior clinoid process and superficial and deep layers of the superior and lateral wall of the cavernous sinus. Note the virtual anterior wall of the cavernous sinus corresponding to the convergence of the nerve at the superior orbita fissure.
SUPERIOR WALL
Superior view of the right cavernous sinus.
The superior wall of the sinus (broken line) is divided into two triangles by a dotted line overlying the interclinoid ligament: the oculomotor trigone (OT) posterolaterally and the carotid trigone (CT) anteromedially.
The superficial layer of the superior wall of the sinus has been incised and separated from the deep layer. Carotid trigone: one solid dot and one open dot; in the area of the oculomotor trigone: two solid dots and two open dots,; and in the area of the clinoid space:three solid dots and three open dots, respectively.
MEDIAL WALL
Lateral view of the left cavernous sinus after removal of the lateral wall and internal carotid artery. Note the membrane of the sellar area of the medial wall of the sinus MW(sa) and endosteal dural of the carotid canal corresponds sphenoid area of the medial wall MW(sa). This separation is clearly identified ( stars)
POSTERIOR WALL
Posterior view of the left cavernous sinus.
The dural posterior wall has triangular shape: superior: posterior petroclinoid ligament. (long arrow) , medial: the top half of an imaginary line dottep across from the posterior clinoid process to foramen dural of the abducens nerve. (arrow head), inferior : an imaginary line across from the dural foramen of the trigeminal nerve to the lower limit medial point. (short arrow),
Posterior view of the left cavernous sinus.
The posterior petroclinoid ligament (arrow head),and superficial layers of the superior, lateral and posterior walls has been removed.
Clearly seen the deep layer in the área in the posterior wall (PW(dl).
Posterior view of the left cavernous sinus.
The deep layer of the posterior wall of the cavernous sinus, venous blood of the cavernous and basilar sinus has been removed. Note the triangular shape similar of the dural limitation.
CASE REPORT
CHARACTERISTICS OF REPORTED PATIENTS
| Numbers of cases: | 8 cases |
| Age: | 45 – 64 years old |
| Sex: | 4 Female – 4 Male |
| Clinical picture: | Upper Orbital Fissure S.(1) , cavernous sinus S. (6),neuralgia Trigeminal (1), Exophthalmos (3). |
| Type of Tumor: | Meningioma (4), trigeminal Schwuannoma (1),
Pituitary Macroadenoma (1),Granuloma (1), |
| Surgical approach: | Dolenc technique: Epi-subdural approach (5),
Skull-Orbito-zygomatic (3) |
| Location: | Interdural (2), Intradural – Intracavernous (5),
Invasive (1) |
| Tumor resection: | Total macroscopic (5), Subtotal 3 |
| KPS pre-surgical: | 60 (4) – 70 (1) – 80 (3) |
| KPS post -surgical: | 70 (2) – 80 (3) – 90 (2) – 100 (1) |
| Complications: | Intracerebral hematoma after surgery (1) – hydrocephalus (1)
|
INTRACAVERNOUS MYELOMA
Cranio-orbitocigomatic extra-intradural approach for tumors of the cavernous sinus
SF: skin flap, O: Orbit, FD: frontal dura, TD: temporal dura, short arrow: mandibular branch of the V nerve, long arrow: maxillary branch of the V nerve, arrow head: ophthalmic branch of the V nerve, star: Gasser’s ganglion, Diamond: optic nerve, III: oculomotor nerve, dots sequence: clinoid area, point: tumor and surgicel
PREOPERATIVE CORONAL AND AXIAL
T1 – WEIGHTED MRI
POST-OPERATIVE CORONAL AND AXIAL
T1 – WEIGHTED MRI
CONCLUSIONS
The dural of the lateral, superior and posterior wall of the cavernous sinus is formed of two layers: a smooth superficial layer and a thin less defined deep layer.
The superficial layer of the superior wall is continuous medially with the diaphragm sellae and the deep layer with the upper part of the medial wall of the cavernous sinus which coincides with the pituitary capsule. The bottom part of the medial wall corresponds to the endosteal dura of the carotid canal.
The anterior wall of the cavernous sinus is in contact with the superior orbital fissure and clinoid space at the top.
The purpose of this studio is to consider the surgical strategies noticing surgical corridors through membranes respecting these important anatomical structures.