cavernous sinus boundaries

The basilar sinus is the largest venous connection between the paired cavernous … Cavernous sinus Anatomy Boundaries Anterior - extends into medial end of superior orbital fissure. The average dimensions of the cavernous sinus are 2 cm long by 1 cm wide. 8Dr.GPK, OMFS Spetzler RF, Fukushima T, Martin N, et al: Petrous carotid-to-intradural carotid saphenous vein graft for intracavernous giant aneurysm, tumor, and occlusive cerebrovascular disease. Case report. The double-layered dura of the clivus extends anteriorly to form part of the posterior wall. The intracavernous horizontal segment of the ICA runs forward toward the anterior portion of the cavernous sinus where it curves upward (anterior loop) before exiting through the roof of the cavernous sinus (Fig. Sekhar LN, Burgess J, Akin O: Anatomical study of the cavernous sinus emphasizing operative approaches and related vascular and neural reconstruction. The intradural superior approach removes the anterior clinoid process and enters the cavernous sinus through the superior wall, either medially or laterally. The landmarks for this area in the middle fossa are the posterior border of the mandibular division of the trigeminal nerve anteriorly, the arcuate eminence posteriorly, the greater superficial petrosal nerve laterally, and the petrous ridge with the superior petrosal sinus medially. Romano A(1), Zuccarello M, van Loveren HR, Keller JT. The oculomotor and trochlear nerves and the first and second divisions of the trigeminal nerve course within the lateral wall of the sinus. It contains the clinoid segment of the ICA and is exposed by removing the anterior clinoid process either extradurally or intradurally. The foramen ovale lies more anteriorly than the foramen spinosum, which assumes a more lateral position. It is bounded on all sides by dura mater, which is continuous from the base of the middle and posterior cranial fossae and the diverging aspects of the tentorium.26,35,49 The floor and medial wall of the cavernous sinus are formed by a periosteal layer of dura. Schnitzlein HN, Murtagh FR, Arrington JA, et al: The sinus of the dorsum sellae. The ophthalmic division of the fifth cranial nerve runs within the deep layer of the lateral wall of the cavernous sinus in its lower portion and courses obliquely upward to exit the sinus through the superior orbital fissure. The anatomical triangles that define routes of access into the cavernous sinus as well as various surgical approaches commonly used in the management of lesions of the cavernous sinus are reviewed. Detailed knowledge of the anatomy of the cavernous sinus is essential for safe surgical approaches to the region. However, the presence of this space depends on the tortuosity and shape of the intracavernous ICA and can overlap with the anterior-inferior space. Most commonly the form is of septic cavernous sinus thrombosis. Day AL: Aneurysms of the ophthalmic segment. Within the carotid canal the ICA is surrounded by connective tissue and a periosteal lining. 3). This artery arises from the inferior and lateral side of the midportion of the intracavernous horizontal segment approximately 5 to 8 mm distal to the origin of the meningohypophyseal trunk. A small recess situated medial to the clinoidal segment of the ICA is called the carotid cave.25. The main drainage of the cavernous sinuses is through the superior petrosal sinus to the junction of the transverse and sigmoid sinuses and through the inferior petrosal sinus to the jugular bulb and internal jugular vein. Although the anatomy of the cavernous sinus is complex, detailed knowledge of this area is essential for safe surgical approaches to the region. 8 and 9). 4 and 9). The paraclinoidal ICA is a continuation of the anterior genu of the cavernous ICA and is within the clinoidal triangle in the roof of the CS; proximal (Prox.) The posterior boundaries of the cavernous sinus and sella were removed. Isamat F, Ferrer E, Twose J: Direct intracavernous obliteration of high-flow carotid-cavernous fistulas. After passing through the lateral ring, the artery runs under the trigeminal nerve—in most cases without a bony cover.17 The intracavernous vertical segment is the initial ascending portion of the ICA immediately distal to the foramen lacerum. In contrast, the oculomotor and trochlear nerves as well as the ophthalmic and maxillary branches of the trigeminal nerve pass between the superficial and deep layers of the lateral cavernous sinus wall.8, 17,18, 34, 35, 37, 44, 50 Umansky and Nathan50 demonstrated that these two layers of the cavernous sinus wall can be readily separated. With special reference to the nerves related to it. Rhoton AL, Jr., Inoue T: Microsurgical approach to the cavernous sinus. Parkinson D: A surgical approach to the cavernous portion of the carotid artery. The mandibular division does not enter the cavernous sinus and exits the cranium through the foramen ovale after passing over the lateral loop of the ICA. In this region, the third cranial nerve is separated from the anterior clinoid process by a thin layer of dura and can easily be injured during drilling and removal of the anterior clinoid process.18 The thin dural layer, however, extends further around the ICA to form the proximal ring, as mentioned earlier. The necessity of a definite topographical description of the region, in Dolenc VV (ed): Umansky F, Nathan H: The lateral wall of the cavernous sinus. The Gasserian ganglion (GG) and its branches are visible after the superficial layer of the lateral wall of the cavernous sinus and the dura of Meckel’s cave have been removed. These authors noted that the inner layer includes the sheaths that surround the cranial nerves after they penetrate the sinus wall. The preoperative diagnosis of cavernous sinus invasion is thus of great interest, but the possibility of normal lateral … The double-layered dura of the floor of the middle fossa extends medially at the superior border of the second division of the fifth cranial nerve to become the lateral wall of the cavernous sinus. The majority of fibers travel a few millimeters with the sixth cranial nerve before joining the ophthalmic division of the trigeminal nerve immediately before it enters the superior orbital fissure. Approach through the lateral wall. The lesser superficial petrosal nerve is lateral to the greater superficial petrosal nerve. Rhoton AL, Jr., Hardy DG, Chambers SM: Microsurgical anatomy and dissection of the sphenoid bone, cavernous sinus and sellar region. The cavernous sinus comprises multiple trabeculated venous channels that contain portions of the ocular motor cranial nerves (cranial nerves three, four, and six), the first and second divisions of the trigeminal nerve, the internal carotid artery, and the ocular sympathetic nerves. Push Boundaries. It originates from the medial loop and is always medial to the sixth cranial nerve where it crosses the vertical segment of the ICA. The meningohypophyseal trunk (truncus caroticocavernosus posterior) is the largest and the most proximal branch of the intracavernous ICA (Fig. Bilateral cavernous sinus involvement, on the other hand, has a more frequent occurrence in up to one-third of the cases. The cavernous sinus is located on either side of the pituitary fossa and body of the sphenoid bone between the endosteal and meningeal layers of the dura. Anteriorly, the cavernous sinus tapers and twists to terminate at the superior orbital fissure. The junction of this segment with the intrapetrous horizontal segment forms the posterior loop, which is completely surrounded by petrous bone. The margins of this compartment are limited by the medial aspect and lesser and greater wing of the sphenoid bone, the anterior and posterior clinoids, and the tip of the petrous pyramid. Each sinus has dural walls that surround a venous space through which a segment of the carotid artery with its branches, the abducens nerve and the sympathetic plexus, course. Cadaveric photograph (A) and illustration (B) showing the inferolateral view of the cavernous sinus region. (2018) Cavernous Sinus Anatomical Boundaries and Contents. Consequently, this area was considered a “no man’s land” for direct surgical intervention. It traverses the vertical segment of the intracavernous ICA medially to laterally and runs parallel to the horizontal segment underneath the ophthalmic division of the trigeminal nerve to reach the superior orbital fissure (Fig. Interest in direct surgical approaches to lesions of the cavernous sinus has grown as neuroradiological imaging and microsurgical technique have improved. This corridor is also well suited for exposing the complete course of the sixth cranial nerve from its entry through Dorello’s canal to its exit through the superior orbital fissure. The cavernous sinus (CS) pair is located near the center of the head on each side of the sella and body of the sphenoid bone. Renn WH, Rhoton AL, Jr. Microsurgical anatomy of the sellar region. Posteromedially, the compartment is continuous with the lateral edge of the clivus, and inferolaterally it extends into a funnel-shaped space around the internal carotid artery (ICA) through the foramen lacerum. Study The cavernous sinus - boundaries (dave's notes) flashcards from Janet Rhodes's class online, or in Brainscape's iPhone or Android app. The third cranial nerve, after entering the roof of the cavernous sinus lateral to the posterior clinoid process, runs in the deep layer of the lateral wall and lies immediately under the lower margin of the anterior clinoid process before it exits the sinus to enter the superior orbital fissure (Fig. Cavernous sinus syndrome describes symptoms comprising ophthalmoplegia, chemosis, proptosis, Horner syndrome, and/or trigeminal sensory loss evoked by vascular, inflammatory, traumatic, congenital, or neoplastic processes affecting the cavernous sinus near the midline of the frontotemporal part at the base of the skull.There are numerous diseases evoking cavernous sinus … The carotid siphon of the internal carotid artery, and cranial nerves III, IV, V (branches V1 and V2) and VI all pass through this blood filled space. 2). At its exit from the bone, the artery is fixed by a thick fibrous band of dura known as the lateral ring (Fig. Figure 9. The cavernous sinus - boundaries (dave's notes), Anatomy: Head (based on dave's notes only so far). The triangle identifies the bone that must be removed to expose the horizontal intrapetrosal segment of the ICA for proximal control or for a bypass graft.47. Objective: This study was conducted to clarify the boundaries, relationships, and components of the medial wall of the cavernous sinus (CS). Some studies interpret the structure as a trabeculated intradural venous channel.2,17 Other studies have interpreted the cavernous sinus as a plexiform network of veins.34,35,48,49 Microanatomical dissections of fetal cavernous sinuses by Knosp et al.23 showed that this area was composed of a network of veins separated and surrounded by loose connective tissue. 8). Bone removal in this region enables access to the petroclival area, the anterolateral brain stem, and the vertebrobasilar junction through a corridor between the trigeminal nerve and facial-vestibulocochlear nerve complex. Mullan S: Treatment of carotid-cavernous fistulas by cavernous sinus occlusion. The dura mater of the pituitary gland separates the gland from the medial compartment of the cavernous sinus. 1). Despite advances in neuroimaging, neuroanesthesia, and microsurgical techniques, complications (cranial nerve injuries, cerebrovascular complications, and cerebrospinal fluid leakage) associated with direct operative procedures in the cavernous sinus region still remain high.3 New forms of therapy, such as stereotactic radiosurgery, endovascular techniques, and medical therapy in certain tumors (e.g., bromocriptine for treatment of prolactinomas) provide alternatives for the management of these lesions. The most common are neurogenic tumors and cavernoma. 4). The maxillary division is situated at the most posteroinferior aspect of the lateral wall and leaves the cranium through the foramen rotundum, following a more horizontal course than the first division. The medial and lateral boundaries of this space are defined by the lateral aspect of the third cranial nerve and by the medial aspect of the fourth cranial nerve, respectively (Fig. In certain occlusions of the cervical carotid artery, the antegrade progression of the thrombus may be prevented and the patency of the intrapetrous segment of the ICA may be maintained by retrograde anastomotic flow through the branches in this region.36. Symptoms of cavernous sinus lesions include any limitation of ocular movement, facial pain or numbness, partial or … This ring must be divided sharply during surgery to expose the clinoidal segment. This area of the lateral wall is quite thin and transparent and is therefore easily recognized as the triangular space defined by Parkinson.34. Sadasivan B, Ma SH, Dujovny M, et al: The anterior cavernous sinus space. The entire intracavernous segment of the ICA from the lateral ring to the proximal ring can be explored through this route. The meningohypophyseal trunk gives rise to three branches.8, 17, 22, 34 First, the tentorial artery or artery of Bernasconi-Cassinari, is the most constant branch of the trunk and supplies the tentorium. 5, Table 1). This space is limited medially by the lateral aspect of the fourth cranial nerve, laterally by the medial aspect of the ophthalmic division of the trigeminal nerve, and posteriorly by the dural edge between the entry points of these two nerves (Figs. The Gasserian ganglion is located outside the cavernous sinus in Meckel’s cave, which is a concavity at the apex of the petrous bone formed by the extension of the meninges from the posterior fossa along the fifth cranial nerve (Figs. Optimal exposure of all regions of the cavernous sinus is impossible through a single approach while maintaining proximal and distal control of the intracavernous ICA. Cavernous Sinus Meningiomas Keywords: cavernous sinus, meningiomas, microsurgical resection Antonio Bernardo, Philip E Stieg Abstract Meningiomas involving the cavernous sinus (CS) are some of the most challenging lesions of the skull base due to the dense surrounding neurovasculature, including the internal carotid artery (ICA) and plexus, cranial nerves (CNs) II … An orbitozygomatic-frontotemporal craniotomy increases extradural and intradural exposure and helps minimize brain retraction.16, 29. The ICA runs diagonally through the base of the skull extradurally, measuring approximately 6 cm along its intrapetrous and intracavernous course.8 From the point of its entry at the skull base to its exit into the subarachnoid space, the ICA courses laterally to medially in the coronal plane, posteriorly to anteriorly in the sagittal plane, and inferiorly to superiorly in the axial plane. Taptas JN: Must we still call cavernous sinus the parasellar vascular and nervous crossroads? Invasion of the cavernous sinus makes surgery more risky and difficult and may necessitate modification of the surgical treatment plan. Since our doors opened as a regional specialty center in 1962, we have grown into one of the premier destinations in the world for neurology and neurosurgery. However, the cavernous sinus ” • venous sinuses of dura and different working angles through the sphenoid.. 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