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

Laboratory investigation

Restricted access


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.


Eight fresh cadavers were studied using 4-mm 0° and 30° endoscopes to develop a surgical approach and to identify surgical landmarks.


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.


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.

Abbreviations used in this paper: ACP = anterior clinoid process; ICA = internal carotid artery.

Article Information

Address correspondence to: Fuminari Komatsu, M.D., Ph.D., Department of Neurosurgery, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan. email: fkomatsu@fukuoka-u.ac.jp.

Please include this information when citing this paper: published online December 10, 2010; DOI: 10.3171/2010.10.JNS101242.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Outline of the endoscopic supraorbital extradural approach. Left: Surgical stages are divided on the endocranial surface of the dry skull as follows: 1, entry into the extradural anterior cranial fossa; 2, exposure of the middle cranial fossa and the periorbita; 3, exposure of the superior cavernous sinus; and 4, exposure of the lateral cavernous sinus. Right: Photograph showing the surgical trajectory from the supraorbital keyhole to the cavernous sinus. Note that the endoscope proceeds toward the cavernous sinus medial to the temporal lobe and beneath the frontal lobe. This trajectory eliminates the need for brain retraction.

  • View in gallery

    Endoscopic views at the stage of entering the extradural anterior skull base after a right supraorbital keyhole craniotomy. Left: The sphenoid ridge (SR), which is the boundary between the anterior and middle cranial fossa, is exposed. The base of the ACP (AC) and the orbital roof (OR) are identified medially. Right: Enlarged view of the base of the ACP. The optic nerve (ON) with the falciform ligament and the roof of the optic canal (OC) are visible medially. FD = frontal dura.

  • View in gallery

    Endoscopic views at the stage of exposure of the middle cranial fossa and periorbita (PO). A: After removal of the lateral portion of the anterior skull base (composed of the frontal bone and lesser and greater wings of the sphenoid bone), the rostral aspect of the temporal lobe dura (TD) is exposed. B: Furthermore, the periorbita and duplication of the dura (DD) extending from the dura of the anteromedial side of the temporal lobe to the periorbita are exposed. The ACP and part of the roof of the optic canal are preserved. C: The temporal lobe dura is elevated from the floor of the middle cranial fossa (MF). The second division of the trigeminal nerve (V2) with the foramen rotundum is shown. FN = frontal nerve.

  • View in gallery

    Anterior clinoidectomy. The arterial system (red) and venous system (blue) were injected with colored rubber. Left: The midportion of the ACP was hollowed out. The clinoid segment of the ICA and venous pool are visible through the thin ACP. Right: Following removal of the ACP, an enlarged view of the clinoidal triangle is shown. The endoscopic view displays the carotidoculomotor membrane (CM) caudally, frontal lobe dura cranially, optic nerve with the optic sheath medially, and anteromedial aspect of the tentorium (TE) laterally. The clinoid portion (CP) of the ICA in the dural carotid collar is demonstrated behind the optic nerve. The optic strut (OS) is located between the optic nerve and the clinoid segment of the ICA.

  • View in gallery

    Enlarged views of the cavernous sinus through the clinoidal triangle. A: The lateral wall of the cavernous sinus is pushed laterally to show the inner structure of the cavernous sinus. It displays the extensive lateral venous space. The ICA courses medially, and each segment of the ICA in the cavernous sinus is exhibited. The carotid collar (CC) is preserved, although the proximal dural ring was removed. The oculomotor nerve, the first division of the trigeminal nerve (V1), and the abducent nerve (VI) are exhibited laterally. B: The foramen lacerum (FL) was disclosed after the abducent nerve was displaced laterally. Structures around the petrous apex (PA) including the petrolingual ligament (PL), the Meckel cave (MC), and the superior petrosal sinus (SP) are exhibited on the same view. C: Posterior bend (PB) of the ICA and the posterior-superior venous space are shown. AB = anterior bend of the ICA; AV = anterior vertical segment of the ICA; DR = distal dural ring; HO = horizontal segment of the ICA; PV = posterior vertical segment of the ICA; PW = posterior wall of the cavernous sinus; II = optic nerve; III = oculomotor nerve.

  • View in gallery

    Branches of the ICA and the abducent nerve are shown. A: The artery of the inferior cavernous sinus (AI, inferolateral trunk) arises from the horizontal segment (HO) of the ICA. The artery of the inferior cavernous sinus crosses the abducent nerve, and then courses between the abducent nerve and the first division of the trigeminal nerve. B: The meningohypophysial artery (asterisk) arises from the posterior bend (PB) of the ICA. C: The abducent nerve courses between the petrosphenoidal ligament (PS) and the superior surface of the petrous apex (PA) in the venous confluence. D: The abducent nerve is visible in the venous confluence. Fibrous trabeculae are partially left in the basilar plexus (BP). IP = inferior petrosal sinus.

  • View in gallery

    The lateral wall of the cavernous sinus is shown after the dura was divided between the inner layer and outer layer (OL) of the cavernous sinus. A: The oculomotor nerve, trochlear nerve, and the first and second divisions of the trigeminal nerve are visible through the semitransparent inner layer of the cavernous sinus. B: The infratrochlear triangle is exposed with the slight temporal retraction. The lateral view of inferior-posterior part of the cavernous sinus is shown through this triangle. C: The anteromedial triangle is also exposed with the slight temporal retraction. GG = gasserian ganglion.


  • 1

    Abdel-Aziz KMFroelich SCDagnew EJean WBreneman JCZuccarello M: Large sphenoid wing meningiomas involving the cavernous sinus: conservative surgical strategies for better functional outcomes. Neurosurgery 54:137513842004

  • 2

    al-Mefty OAyoubi SSmith RR: Direct surgery of the cavernous sinus: patient selection. Acta Neurochir Suppl (Wien) 53:1171211991

  • 3

    Alfieri AJho HD: Endoscopic endonasal approaches to the cavernous sinus: surgical approaches. Neurosurgery 49:3543622001

  • 4

    Alfieri AJho HD: Endoscopic endonasal cavernous sinus surgery: an anatomic study. Neurosurgery 48:8278372001

  • 5

    Arbolay OLGonzález JGGonzález RHGálvez YH: Extended endoscopic endonasal approach to the skull base. Minim Invasive Neurosurg 52:1141182009

  • 6

    Cappabianca PCavallo LMEsposito FDe Divitiis OMessina ADe Divitiis E: Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery. Adv Tech Stand Neurosurg 33:1511992008

  • 7

    Cavallo LMCappabianca PGalzio RIaconetta Gde Divitiis ETschabitscher M: Endoscopic transnasal approach to the cavernous sinus versus transcranial route: anatomic study. Neurosurgery 56:2 SupplONS379ONS3892005

  • 8

    Ceylan SKoc KAnik I: Endoscopic endonasal transsphenoidal approach for pituitary adenomas invading the cavernous sinus. Clinical article. J Neurosurg 112:991072010. (Erratum in J Neurosurg 112:210 2010)

  • 9

    Ceylan SKoc KAnik I: Extended endoscopic approaches for midline skull-base lesions. Neurosurg Rev 32:3093192009

  • 10

    d'Avella ETschabitscher MSantoro ADelfini R: Blood supply to the intracavernous cranial nerves: comparison of the endoscopic and microsurgical perspectives. Neurosurgery 62:5 Suppl 2ONS305ONS3112008

  • 11

    de Andrade Júnior FCde Andrade FCde Araujo Filho CMCarcagnolo Filho J: Dysfunction of the temporalis muscle after pterional craniotomy for intracranial aneurysms. Comparative, prospective and randomized study of one flap versus two flaps dieresis. Arq Neuropsiquiatr 56:2002051998

  • 12

    Doglietto FLauretti LFrank GPasquini EFernandez ETschabitscher M: Microscopic and endoscopic extracranial approaches to the cavernous sinus: anatomic study. Neurosurgery 64:5 Suppl 2ONS413ONS4222009

  • 13

    Dolenc V: Direct microsurgical repair of intracavernous vascular lesions. J Neurosurg 58:8248311983

  • 14

    Dolenc VV: A combined epi- and subdural direct approach to carotid-ophthalmic artery aneurysms. J Neurosurg 62:6676721985

  • 15

    Dolenc VV: Extradural approach to intracavernous ICA aneurysms. Acta Neurochir Suppl (Wien) 72:991061999

  • 16

    Dolenc VV: Transcranial epidural approach to pituitary tumors extending beyond the sella. Neurosurgery 41:5425521997

  • 17

    el-Kalliny Mvan Loveren HKeller JTTew JM Jr: Tumors of the lateral wall of the cavernous sinus. J Neurosurg 77:5085141992

  • 18

    Frank GPasquini E: Endoscopic endonasal approaches to the cavernous sinus: surgical approaches. Neurosurgery 50:6752002

  • 19

    Frank GPasquini E: Endoscopic endonasal cavernous sinus surgery, with special reference to pituitary adenomas. Front Horm Res 34:64822006

  • 20

    Hakuba ATanaka KSuzuki TNishimura S: A combined orbitozygomatic infratemporal epidural and subdural approach for lesions involving the entire cavernous sinus. J Neurosurg 71:6997041989

  • 21

    Harris FSRhoton AL: Anatomy of the cavernous sinus. A microsurgical study. J Neurosurg 45:1691801976

  • 22

    Inoue TRhoton AL JrTheele DBarry ME: Surgical approaches to the cavernous sinus: a microsurgical study. Neurosurgery 26:9039321990

  • 23

    Jho HDCarrau RLKo YDaly MA: Endoscopic pituitary surgery: an early experience. Surg Neurol 47:2132231997

  • 24

    Jho HDHa HG: Endoscopic endonasal skull base surgery: Part 2—The cavernous sinus. Minim Invasive Neurosurg 47:9152004

  • 25

    Kawase Tvan Loveren HKeller JTTew JM: Meningeal architecture of the cavernous sinus: clinical and surgical implications. Neurosurgery 39:5275361996

  • 26

    Krisht ABarnett DWBarrow DLBonner G: The blood supply of the intracavernous cranial nerves: an anatomic study. Neurosurgery 34:2752791994

  • 27

    Lanzino GSekhar LNHirsch WLSen CNPomonis SSnyderman CH: Chordomas and chondrosarcomas involving the cavernous sinus: review of surgical treatment and outcome in 31 patients. Surg Neurol 40:3593711993

  • 28

    Liu HSDi X: Endoscopic endonasal surgery for biopsy of cavernous sinus lesions. Minim Invasive Neurosurg 52:69732009

  • 29

    Nitzan DWAzaz BConstantini S: Severe limitation in mouth opening following transtemporal neurosurgical procedures: diagnosis, treatment, and prevention. J Neurosurg 76:6236251992

  • 30

    O'Sullivan MGvan Loveren HRTew JM Jr: The surgical resectability of meningiomas of the cavernous sinus. Neurosurgery 40:2382471997

  • 31

    Parkinson D: A surgical approach to the cavernous portion of the carotid artery. Anatomical studies and case report. J Neurosurg 23:4744831965

  • 32

    Patel MRShah RNSnyderman CHCarrau RLGermanwala AVKassam AB: Pericranial flap for endoscopic anterior skull-base reconstruction: clinical outcomes and radioanatomic analysis of preoperative planning. Neurosurgery 66:5065122010

  • 33

    Pepper JPWadhwa AKTsai FShibuya TWong BJ: Cavernous carotid injury during functional endoscopic sinus surgery: case presentations and guidelines for optimal management. Am J Rhinol 21:1051092007

  • 34

    Reisch RPerneczky A: Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery 57:4 SupplONS242ONS2552005

  • 35

    Reisch RStadie AKockro RGawish ISchwandt EHopf N: The minimally invasive supraorbital subfrontal key-hole approach for surgical treatment of temporomesial lesions of the dominant hemisphere. Minim Invasive Neurosurg 52:1631692009

  • 36

    Renn WHRhoton AL Jr: Microsurgical anatomy of the sellar region. J Neurosurg 43:2882981975

  • 37

    Roth JSingh ANyquist GFraser JFBernardo AAnand VK: Three-dimensional and 2-dimensional endoscopic exposure of midline cranial base targets using expanded endonasal and transcranial approaches. Neurosurgery 65:111611302009

  • 38

    Sekhar LNBurgess JAkin O: Anatomical study of the cavernous sinus emphasizing operative approaches and related vascular and neural reconstruction. Neurosurgery 21:8068161987

  • 39

    Sekhar LNMøller AR: Operative management of tumors involving the cavernous sinus. J Neurosurg 64:8798891986

  • 40

    Tanoue SKiyosue HOkahara MSagara YHori YKashiwagi J: Para-cavernous sinus venous structures: anatomic variations and pathologic conditions evaluated on fat-suppressed 3D fast gradient-echo MR images. AJNR Am J Neuroradiol 27:108310892006

  • 41

    Umansky FValarezo AElidan J: The superior wall of the cavernous sinus: a microanatomical study. J Neurosurg 81:9149201994

  • 42

    van Loveren HRKeller JTel-Kalliny MScodary DJTew JM Jr: The Dolenc technique for cavernous sinus exploration (cadaveric prosection). Technical note. J Neurosurg 74:8378441991

  • 43

    Yasuda ACampero AMartins CRhoton AL Jrde Oliveira ERibas GC: Microsurgical anatomy and approaches to the cavernous sinus. Neurosurgery 56:1 SupplONS4ONS272005

  • 44

    Youssef ASAgazzi Svan Loveren HR: Transcranial surgery for pituitary adenomas. Neurosurgery 57:1 SupplONS168ONS1752005

  • 45

    Zhao BWei YKLi GLLi YNYao YKang J: Extended transsphenoidal approach for pituitary adenomas invading the anterior cranial base, cavernous sinus, and clivus: a single-center experience with 126 consecutive cases. Clinical article. J Neurosurg 112:1081172010


Cited By



All Time Past Year Past 30 Days
Abstract Views 91 91 8
Full Text Views 120 120 0
PDF Downloads 129 129 1
EPUB Downloads 0 0 0


Google Scholar