Cavernous anatomy

1. Anatomy and Surgical approaches to
Cavernous sinus region
Presentor: Dr Shyam Sunder Reddy

2. Schema of discussion
Anatomy
Surgical Approaches
Historical perspective
Research and Advances

3. Surgical Anatomy of CavernousSinus

4. Surgical anatomy of cavernous sinus is best explained under
following
headings –
1)Bony relationships
2) Dural relationships
3) Venous relationships
4) Neural relationships
5) Arterial relationships

5. BONY
RELATIONSHIPS
MEDIAL –
-Middle clinoid
process
-Pituitary fossa
-Body of
sphenoid
-Carotid sulcus
(groove for
intracavernous
ICA at the lower
margin of the
sphenoid body)
ANTERIOR – Optic strut/ Anterior
clinoid process/ Lesser wing of
sphenoid
LATERAL –
-Greater
wing of
sphenoid
-Foramen
-rotundum
-ovale
-spinosum
POSTERIOR – Posterior clinoid
process/ Dorsum sella/ Petrous
apex/ Trigeminal impression

6. Dural
relationship
s

7. Floor & Medial wall – formed by single
periosteal layer of dura, supero- medially
it continues with dura of sella turcica.
Roof, Lateral & Posterior wall- are
double layered, formed by periosteal
layer of dura + dura proper of middle &
posterior fossa respectively.
-roof medially continues with Diaphragma
sella.

8. Venous
Anatomy
ORBIT
DUR
A
TRANSVERSE
SINUS
JUGULAR BULB
CIRCUL
AR
SINUS
AFFERENT DRAINAGE
– (IN)
1) Sphenoparietal
sinus
2)Sup.Ophthalmic
vein 3)Inf. Ophthalmic
vein 4)Superficial
Sylvian vein
(middle cerebral
vein) 5)Middle
meningeal vein
6)Central retinal vein
EFFERENT DRAINAGE –
(OUT)
1) Sup. & Inf. Petrosal
sinus
2)plexus of vein on ICA
drains into Pterygoid
plexus 3)Emissary veins of
Sphenoid foramen,
foramen ovale,

9. VENOUS SPACES WITHIN THE CAVERNOUS SINUS:
wal
l
LATERAL COMP.
-between the carotid and lateral
sinus Thin space
filled/ displaced by 5th N. tumor, ICA
aneurysm.
-Surgical appro. – posterolater./
subtemporal
MEDIAL COMP.
Between the
pituitary and
the carotid
-Invaded by
pituitary
tumor.
-Surgical
appro.
1)superiorly-
roof, medial to
3rd N.
2)inferiorly-
sphenoid sinus /
sella turcica
ANTEROINFERIOR COMP.
-Smallest, behind sup.
Orbital fissure.
invaded by orbital tumor.
surgical appro. –
Anterolaterally,
POSTEROSUPERIOR COMP. –
(largest
space)between the ICA and post.
half
of roof of
sinus
Filled by
sphenopetroclival
meningioma/ clival
chordoma.
Surgical appro.–
extradural,
subtemp./Kawa
se

10. Arterial Relationship
1)POST. VERTICAL
SEGMENT – fixed
by lateral fibrous ring.
– Doesn't give-off
branch.
2)POST. BEND –
Meningohypopheseal trunk -
give rise to 3 branches, i)
Tentorial A. of Bernasconi & Cassinari– courses
posterolaterally,
supply tent./ tentorial meningioma; IIIrd IV th nerves
ii) Inf. Hypopheseal A.– courses anteromedially, supply
post. Pituitary, anastomose to opp. side. iii)Dorsal
meningeal A.– courses posteroinferomedially,supply dura
along upper clivus, VI nerve
3)HORIZONTAL
SEG.
– 2 arteries,-i)Inf.
Cavernous sinus
A.- ii)McConnell
capsular A.-
arises medial
aspect,supply
capsule of pituitary
4)ANT.
BEND
5) ANT. VERTICAL SEG.-
divides into MCA,ACA

11. INFERIOR
HYPOPHYSEAL
ARTERY(FROM
POSTERIOR BEND
OF THE CAROTID)

12. Neural Relationships
IIIrd N.- Runs ant.- lat. &
inferiorly.
-enters CS through ROOF,
medial to
ant. Petroclinoid lig. Runs in
lateral
wall of CS, inferolateral to
ACP
During drilling of ACP 3rd
N. is vulnerable to injury.
IVth N.- enters ROOF postero-
lateral to IIIrd N. &inferomedial to
free edge of tent Runs in
lateral wall of CS ateroinferiorly
enters in SOF
SUPERIO
R
ORBIT
AL
FISSURE
3rd WITHIN
OCCULOMOT
OR CISTERN
4TH
6TH
(MEDIA
L TO
V1)
V1
IN THE
MECKEL’
S
CAVE
TENTORI
AL
EDGE

13. Vth N.- enters through Meckel’s
cave. V1 passes through lateral
wall of CS Runs anteriorly &
upwards, enters SOF
V2 passes for a short distance in lateral
wall of CS enters in f. rotundum
VIth N.- enters to CS through
Dorello’s canal runs anteriorly,
inferolateral to ICA in the substance
of CS lies medial to V1 enters
in SOF
Sympathetic fiber bundles, with
carotid a. emerges from the foramen
lacerum.
Some of the fibers join the VIth nerve
before ultimately being distributed to
the V1 division
to pupillodilator
& ciliary ganglion
sends symp. fibers
long ciliary nerves
HORNER’S SYN

14. 4th
SPHENOPETRO
SAL / GRUBER’S
LIGAMENT
6th
TRIGEMIN
AL GANGLION
REMOVED
PETROLING
UAL LIGAMENT
(ICA
passes
underneath)
GSP
N
V1
VIDIA
N
NERVE

15. EXPOSURE AFTER ANTERIOR
PETROSECTOMY
INTRAOP
VIEW
ANTERIOR
POSTERIO
R
SUPERIOR
CLIVUS
INFERIO
R
PETROS
AL
SINUS
V2
6TH IN THE
DORELLO’S
CANAL
4TH
3RD
AICA
PCOM
SCA
7th, 8th

16. Surgical approaches to cavernous
sinus
Fronto temporal Extradural & Intradural Approaches
Anterolateral Temporopolar transcavernous approaches
Lateral Approach to posterior cavernous sinus(Rhomboid
Approach)

17. Positionin
g

19. FRONTOTEMPORAL EXTRADURAL & INTRADURAL
APPROACH
Initially developed by DOLENC ––as anteromedial
transcavernous approach, for intracavernous aneurysm
UNDERWENT SEVERAL MODIFICATIONS
INDICATION ––Lesions confined to cavernous
sinus/ with supratentorial extension
ADVANTAGE --Can be combined with Middle fossa
transpetrosal approach for excision of for posterior
extension of tumor.

20. sylvian fissure
dissection ICA exposure
Intra petrous and intra cavernous
segments

21. ANTEROLATERAL TEMPOROPOLAR
TRANSCAVERNOUS APPROACH

23. Lateral Approach to posterior cavernous
sinus (Anterior Petrosectomy)

24. Lateral Approach to posterior cavernous sinus(Rhomboid
Approach)
--Bone to be drilled out in middle
fossa is geometrically RHOMBOID
SHAPE
Intersection of GSPN to V3
Intersection of line
projecting along the axis
of GSPN to AE
AE intersection with petrous
ridge
Porous trigeminus
GSPN can be sectioned, to
avoid VIIth N. retraction.

25. TECHNICAL CONSIDERATION OF
INTRACAVERNOUS TUMOR
RESECTIONINTRACAVERNOUS RESECTION-
Well encapsulated & nonadherent tumors can be
removed by 1)exposure of tumor capsule from
surrounding tissue
2) debulking of tumor
3) sharp dissection of tumor capsule from surrounding
tissue
Invasive & adherent tumors can be removed by
1) interruption of tumor blood supply from periphery of

26. THANK
YOU