The medial wall of the cavernous sinus. Part 1: Surgical anatomy, ligaments, and surgical technique for its mobilization and/or resection

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OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

ABBREVIATIONS CS = cavernous sinus; ICA = internal carotid artery.

Article Information

Correspondence Juan C. Fernandez-Miranda: Department of Neurological Surgery, Stanford University, Stanford, CA. drjfm@stanford.edu.

INCLUDE WHEN CITING Published online September 7, 2018; DOI: 10.3171/2018.3.JNS18596.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Medial wall of the CS. A: Superior view of a half-dissected sellar and parasellar region showing the relative position and relationship between the walls and roof of the CS. Yellow dashed lines mark the oculomotor triangle or posterior roof of the CS. B: Endoscopic anteroinferior view of a half-dissected sellar floor exhibiting the double-layered nature of the sellar floor, the transition of the outer dura (periosteal) layer from the sellar floor to the anterior wall of the CS, and the coursing of the inner dural layer toward the diaphragm and forming the medial wall of the CS. The parasellar ligaments can be seen attached to the medial wall. C: Endoscopic view of the sellar fossa after removal of the sellar floor, showing the pituitary gland wrapped inside the thin and transparent pituitary capsule and its loose connections, or pituitary ligaments, to the medial wall of the CS. D: Endoscopic view of the sellar fossa with mobilization of the pituitary gland to show the medial or sellar surface of the medial wall of the CS. A slight indentation of the wall by the ICA can be seen. The impression of the middle clinoid (removed), together with the proximal ring, serves as a good landmark for the caroticoclinoid ligament (present in Figs. 2 and 3) and the transition between cavernous and paraclinoid segments of the ICA. Ant. wall = anterior wall; Car. tr. = carotid triangle; Cav. ICA = cavernous ICA; Inn. dura = inner dura; Lat. wall = lateral wall; Med. wall = medial wall; Mid. clin. = middle clinoid; Ocul. tr. = Oculomotor triangle; Out. dura = outer dura; Paraclin. ICA = paraclinoid ICA; Paras. lig. = parasellar ligaments; Pit. = pituitary gland; Pit. cap. = pituitary capsule; Pit. lig. = pituitary ligament; Post. wall = posterior wall; Prox. ring = proximal ring. Copyright Juan C. Fernandez-Miranda. Published with permission. Figure is available in color online only.

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    Microscopic view of the caroticoclinoid ligament. Upper: Superior view of a half-dissected sellar and parasellar region showing a caroticoclinoid ligament that originates from the medial wall of the CS and attaches to the anterior clinoid process and continues with the proximal ring. The ligament has a large fenestration, which allows venous communication between the CS below and the clinoid space above. The dissection also shows the tight relationship between the caroticoclinoid ligament and the interclinoid ligament as they usually blend laterally before they both attach to the inferior surface of the anterior clinoid process. Lower: Schematic illustration that simplifies the anatomy of the upper panel and shows the 2 components of the caroticoclinoid ligament from the middle clinoid and medial wall of the CS and the relationship to the ICL. Ant. clin. = anterior clinoid; CCL = caroticoclinoid ligament; Clin. Sp. = clinoid space; ICL = interclinoid ligament; Med. wall = medial wall; Mid. clin. = middle clinoid; Pit. = pituitary gland; Post. clin. = posterior clinoid; Prox. ring = proximal ring. Copyright Juan C. Fernandez-Miranda. Published with permission. Figure is available in color online only.

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    Endoscopic view of the caroticoclinoid ligament. A: Image obtained after the anterior wall and periosteal sellar floor have been removed and the ICA has been mobilized laterally to provide an anteroinferior view of the caroticoclinoid ligament. The ligament shows continuity with the dura of the medial wall. The posterior clinoid and interclinoid ligament can be clearly seen. The inferior hypophyseal artery originating from the posterior genu of the ICA is seen crossing the CS just anterior to the posterior clinoid and reaching the pituitary gland at the interlobar fissure. B: Schematic drawing illustrating the anatomy showed in panel A. C: Anterior endoscopic view of the upper sellar and paraclinoid region. The clinoid space was opened from lateral to medial, and the dissection was continued medially to separate the 2 layers of the diaphragma sellae—the inner layer and the outer layer, which are in continuity with the medial wall and roof of the CS, respectively. This view shows the construction of the caroticoclinoid ligament from bundles of fibers from the proximal ring via the middle clinoid and from the medial wall of the CS. A fenestration and venous connection between the clinoid space and CS can be seen. D: Endoscopic view of the lateral wall of the CS obtained by mobilizing the anterior genu of the ICA medially. This view shows the attachment of the caroticoclinoid ligament and interclinoid ligament to the inferior surface of the anterior clinoid process and their continuity with the proximal ring and oculomotor membrane. Med. wall = medial wall; Mid. clin. = middle clinoid; Pit. = pituitary gland; Post. clin. = posterior clinoid; Ant. clin. = anterior clinoid; CCL = caroticoclinoid ligament; CN III = third cranial nerve; Diaph. = diaphragma sellae; Diaph. inn. = diaphragm inner layer; Diaph. out. = diaphragm outer layer; ICL = interclinoid ligament; Inf. lat. trunk = inferolateral trunk; Inf. hyp. art. = inferior hypophyseal artery; Prox. ring = proximal ring. Copyright Juan C. Fernandez-Miranda. Published with permission. Figure is available in color online only.

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    Parasellar ligaments. A: Endoscopic view of the CS showing the direction and attachment of the superior parasellar ligament to the horizontal cavernous ICA. B: Superolateral view of the CS, revealing the attachment of the superior parasellar ligament on the upper wall of the horizontal cavernous ICA. Interestingly, in this specimen, there is ossification of both the interclinoid and caroticoclinoid ligaments. C: Endoscopic view showing a slim inferior parasellar ligament bridging the medial wall to the anterior wall of the CS. D: Intraoperative photograph of the rare common anchoring pattern, in which the inferior parasellar ligament and caroticoclinoid ligament (partly hidden) blend and form an X-shaped common ligament. E: Schematic illustration that simplifies the anatomy of the caroticoclinoid ligament, interclinoid ligament, and inferior parasellar ligaments. F: Subsequent dissection of the specimen in panel C shows the posterior parasellar ligament, which is quite thick in this case. The inferior hypophyseal artery can be seen coursing very close to the posterior parasellar ligament. The interclinoid and caroticoclinoid ligaments can also be identified. Ant. wall = anterior wall; CCL = caroticoclinoid ligament; Dist. ring = distal ring; Inf. lat. trunk = inferolateral trunk; Inf. hypo. art. = inferior hypophyseal artery; IPL = inferior parasellar ligament; Pit. = pituitary gland; Post. clin. = posterior clinoid; Prox. ring = proximal ring; PPL = posterior parasellar ligament; SPL = superior parasellar ligament. Copyright Juan C. Fernandez-Miranda. Published with permission. Figure is available in color online only.

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    Step-by-step medial wall resection. A: The exposure should include the sella, clinoid ICA, and anterior wall of the CS and can extend inferiorly to reveal the opening of inferior petrosal sinus into the CS. B: After removal of tumor, the medial surface of the medial wall of the CS should be inspected for tumor invasion. C: The transcavernous approach directly opens the anterior wall to expose and transect the ligaments and release the medial wall for resection. The numbered dashed lines show the location and order of the sequential cuts needed for complete resection of the medial wall. D: After the first cut through the inferior parasellar ligament, the medial wall can then be mobilized medially away from the ICA. Then, the second cut is performed through the sellar floor just lateral to posterior lobe and toward the dorsum sellae and posterior clinoid. E: The third cut separates the medial wall from the inner diaphragm (sellar roof) medially. F: After transecting the caroticoclinoid ligament, the medial wall is completely resected, and the interclinoid ligament and posterior clinoid are exposed. Ant. wall = anterior wall; Cav. ICA = cavernous ICA; CCL = caroticoclinoid ligament; Clin. ICA = clinoid ICA; Diaph = diaphragm sellae; ICL = interclinoid ligament; Inf hypo. art. = inferior hypophyseal artery; Inf. petr. sinus, inferior petrosal sinus; IPL = inferior parasellar ligament; Med. wall = medial wall; Pit. = pituitary gland; Post. clin. = posterior clinoid; Post. lobe = posterior lobe of pituitary gland. Copyright Juan C. Fernandez-Miranda. Published with permission. Figure is available in color online only.

References

1

Barges-Coll JFernandez-Miranda JCPrevedello DMGardner PMorera VMadhok R: Avoiding injury to the abducens nerve during expanded endonasal endoscopic surgery: anatomic and clinical case studies. Neurosurgery 67:1441542010

2

Bergland RMRay BSTorack RM: Anatomical variations in the pituitary gland and adjacent structures in 225 human autopsy cases. J Neurosurg 28:93991968

3

Buric JAlexandre ACorò LAzuelos A: Medial wall of the cavernous sinus. Riv Neuroradiol 15:1972032002

4

Ceylan SAnik IKoc KKokturk SCeylan SCine N: Microsurgical anatomy of membranous layers of the pituitary gland and the expression of extracellular matrix collagenous proteins. Acta Neurochir (Wien) 153:243524432011

5

Chi JGLee MH: Anatomical observations of the development of the pituitary capsule. J Neurosurg 52:6676701980

6

Ciric I: On the origin and nature of the pituitary gland capsule. J Neurosurg 46:5966001977

7

Cohen-Cohen SGardner PAAlves-Belo JTTruong HQSnyderman CHWang EW: The medial wall of the cavernous sinus. Part 2: Selective medial wall resection in 50 pituitary adenoma patients. J Neurosurg [epub ahead of print September 72018. DOI: 10.3171/2018.5.JNS18595]

8

Destrieux CKakou MKVelut SLefrancq TJan M: Microanatomy of the hypophyseal fossa boundaries. J Neurosurg 88:7437521998

9

Diao YLiang LYu CZhang M: Is there an identifiable intact medial wall of the cavernous sinus? Macro- and microscopic anatomical study using sheet plastination. Neurosurgery 73 (1 Suppl Operative):ons106ons1102013

10

Dietemann JLKehrli PMaillot CDiniz RReis M JrNeugroschl C: Is there a dural wall between the cavernous sinus and the pituitary fossa? Anatomical and MRI findings. Neuroradiology 40:6276301998

11

Fernandez-Miranda JCGardner PARastelli MM JrPeris-Celda MKoutourousiou MPeace D: Endoscopic endonasal transcavernous posterior clinoidectomy with interdural pituitary transposition. J Neurosurg 121:91992014

12

Fernandez-Miranda JCTormenti MLatorre FGardner PSnyderman C: Endoscopic endonasal middle clinoidectomy: anatomic, radiological, and technical note. Neurosurgery 71 (2 Suppl Operative):ons233ons2392012

13

Gonçalves MBde Oliveira JGWilliams HAAlvarenga RMPLandeiro JA: Cavernous sinus medial wall: dural or fibrous layer? Systematic review of the literature. Neurosurg Rev 35:1471542012

14

Kassam ABPrevedello DMThomas AGardner PMintz ASnyderman C: Endoscopic endonasal pituitary transposition for a transdorsum sellae approach to the interpeduncular cistern. Neurosurgery 62 (3 Suppl 1):57742008

15

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

16

Kehrli PAli MReis M JrMaillot CDietemann JLDujovny M: Anatomy and embryology of the lateral sellar compartment (cavernous sinus) medial wall. Neurol Res 20:5855921998Pubmed

17

Knappe UJFink TFisseler-Eckhoff ASchoenmayr R: Expression of extracellular matrix-proteins in perisellar connective tissue and dura mater. Acta Neurochir (Wien) 152:3453532010

18

Kural CSimsek GGGuresci SArslan EKilic CTehli O: Histological structure of the medial and lateral walls of cavernous sinus in human fetuses. Childs Nerv Syst 31:6997032015

19

Lang J: Hypophyseal ligaments. Acta Neurochir (Wien) 130:1441461994Pubmed

20

Peker SKurtkaya-Yapicier OKiliç TPamir MN: Microsurgical anatomy of the lateral walls of the pituitary fossa. Acta Neurochir (Wien) 147:6416492005

21

Rhoton ALJ Jr: The cavernous sinus, the cavernous venous plexus, and the carotid collar. Neurosurgery 51 (4 Suppl):S375S4102002

22

Songtao QYuntao LJun PChuanping HXiaofeng S: Membranous layers of the pituitary gland: histological anatomic study and related clinical issues. Neurosurgery 64 (3 Suppl):ons1ons102009

23

Tobenas-Dujardin ACDuparc FLaquerriere AMuller JMFreger P: 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 Anat 25:2522582003

24

Yasuda ACampero AMartins CRhoton AL JrRibas GC: The medial wall of the cavernous sinus: microsurgical anatomy. Neurosurgery 55:1791902004

25

Yilmazlar SKocaeli HAydiner FKorfali E: Medial portion of the cavernous sinus: quantitative analysis of the medial wall. Clin Anat 18:4164222005

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