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

Laboratory investigation

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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.

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.

Headings

Figures

  • 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.

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