The medial wall of the cavernous sinus (CS) is often invaded by pituitary adenomas. Surgical mobilization and/or removal of the medial wall remains a challenge.
Endoscopic endonasal dissection was performed in 20 human cadaver heads. The configuration of the medial wall, its relationship to the internal carotid artery (ICA), and the ligamentous connections in between them were investigated in 40 CSs.
The medial wall of the CS was confirmed to be an intact single layer of dura that is distinct from the capsule of the pituitary gland and the periosteal layer that forms the anterior wall of the CS. In 32.5% of hemispheres, the medial wall was indented by and/or well adhered to the cavernous ICA. The authors identified multiple ligamentous fibers that anchored the medial wall to other walls of the CS and/or to specific ICA segments. These parasellar ligaments were classified into 4 groups: 1) caroticoclinoid ligament, spanning from the medial wall and the middle clinoid toward the clinoid ICA segment and anterior clinoid process; 2) superior parasellar ligament, connecting the medial wall to the horizontal cavernous ICA and/or lateral wall of the CS; 3) inferior parasellar ligament, bridging the medial wall to the anterior wall of the CS or anterior surface of the short vertical segment of the cavernous ICA; and 4) posterior parasellar ligament, which anchors the medial wall to the short vertical segment of the cavernous ICA and/or the posterior carotid sulcus. The caroticoclinoid ligament and inferior parasellar ligament were present in most CSs (97.7% and 95%, respectively), while the superior and posterior parasellar ligaments were identified in approximately half of the CSs (57.5% and 45%, respectively). The caroticoclinoid ligament was the strongest and largest ligament, and it was typically assembled as a group of ligaments with a fan-like arrangement. The inferior parasellar ligament was the first to be encountered after opening the anterior wall of the CS during an interdural transcavernous approach.
The authors introduce a classification of the parasellar ligaments and their role in anchoring the medial wall of the CS. These ligaments should be identified and transected to safely mobilize the medial wall away from the cavernous ICA during a transcavernous approach and for safe and complete resection of adenomas that selectively invade the medial wall.
Barges-CollJFernandez-MirandaJCPrevedelloDMGardnerPMoreraVMadhokR: Avoiding injury to the abducens nerve during expanded endonasal endoscopic surgery: anatomic and clinical case studies. Neurosurgery67:144–1542010
CeylanSAnikIKocKKokturkSCeylanSCineN: Microsurgical anatomy of membranous layers of the pituitary gland and the expression of extracellular matrix collagenous proteins. Acta Neurochir (Wien)153:2435–24432011
CeylanS, AnikI, KocK, KokturkS, CeylanS, CineN, : Microsurgical anatomy of membranous layers of the pituitary gland and the expression of extracellular matrix collagenous proteins. 153:2435–2443, 20112196922510.1007/s00701-011-1182-3)| false
Cohen-CohenSGardnerPAAlves-BeloJTTruongHQSnydermanCHWangEW: The medial wall of the cavernous sinus. Part 2: Selective medial wall resection in 50 pituitary adenoma patients. J Neurosurg [epub ahead of print September72018. DOI: 10.3171/2018.5.JNS18595]
Cohen-CohenS, GardnerPA, Alves-BeloJT, TruongHQ, SnydermanCH, WangEW, : The medial wall of the cavernous sinus. Part 2: Selective medial wall resection in 50 pituitary adenoma patients. 7, 2018. DOI: 10.3171/2018.5.JNS18595])| false
DiaoYLiangLYuCZhangM: Is there an identifiable intact medial wall of the cavernous sinus? Macro- and microscopic anatomical study using sheet plastination. Neurosurgery73 (1 Suppl Operative):ons106–ons1102013
DiaoY, LiangL, YuC, ZhangM: Is there an identifiable intact medial wall of the cavernous sinus? Macro- and microscopic anatomical study using sheet plastination. 73 (1 Suppl Operative):ons106–ons110, 201310.1227/NEU.0b013e3182889f2b)| false
DietemannJL, KehrliP, MaillotC, DinizR, ReisMJr, NeugroschlC, : Is there a dural wall between the cavernous sinus and the pituitary fossa? Anatomical and MRI findings. 40:627–630, 199810.1007/s002340050653)| false
SongtaoQ, YuntaoL, JunP, ChuanpingH, XiaofengS: Membranous layers of the pituitary gland: histological anatomic study and related clinical issues. 64 (3 Suppl):ons1–ons10, 200910.1227/01.NEU.0000327688.76833.F7)| false
Tobenas-DujardinACDuparcFLaquerriereAMullerJMFregerP: Embryology of the walls of the lateral sellar compartment: apropos of a continuous series of 39 embryos and fetuses representing the first six months of intra-uterine life. Surg Radiol Anat25:252–2582003
Tobenas-DujardinAC, DuparcF, LaquerriereA, MullerJM, FregerP: Embryology of the walls of the lateral sellar compartment: apropos of a continuous series of 39 embryos and fetuses representing the first six months of intra-uterine life. 25:252–258, 200310.1007/s00276-003-0117-y)| false