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Cavernous Sinus Approach
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Pituitary
gland
Clivus
Chiasm
Medial wall CS
Men hyp a.
C3
C4
Upper ring
C5
VIcn
Fig. 13.7 Opening of the cavernous
sinus. To avoid damage of ICA and
nerves in specimen, the opening
and removal of periosteal layer
should be performed in a medial
to lateral direction starting from
the pituitary gland. After the
dural removal, it is possible to
expose all the intracavernous sinus
segment of ICA, the VI CN, and
the meningohypophyseal artery.
C3, paraclival; C4, infrasellar; C5,
parasellar of ICA; Men hyp a.,
meningohypophyseal artery.
ILT
VICN
a
Fig. 13.8 Arteries of the cavernous sinus. Two major arterial branches derive from the ICA in the cavernous sinus: the inferolateral
trunk (ILT) and the meningohypophyseal trunk (MHT). The former is identifi able throughout gentle medial retraction of ICA (a).
The ILT divides where the sympathetic fi bers arising from the ICA join the VI cranial nerve. At that level, the ILT gives origin to
the proximal superior branch, which runs posteriorly along the inferior aspect of the trochlear nerve, and supplies the proximal
portions of the oculomotor, trochlear, and ophthalmic nerves. A second branch is represented by the artery to the superior orbital
fi ssure, which courses in the apex of the anteromedial triangle of the cavernous sinus between the fi rst two trigeminal nerves.
From this point, its branches and the main portion continue toward the superior orbital fi ssure entering it, providing along its
course small feeders to distal portion of the III, IV, VI, and V1 cranial nerves. ILT ends with two terminal branches, one to foramen
rotundum and one to foramen ovale, respectively, which provide the supply to distal portion of V2 and V3 (b). The MHT trunk
can be identifi ed following backward the inferior hypophyseal artery (IHA), located in the medial compartment of CS. This trunk
originates three branches: the IHA, the tentorial artery, also known as Bernasconi–Cassinari artery, and the dorsal meningeal
artery. Bernasconi–Cassinari artery supplies the proximal and middle portion of the third nerve and the fourth nerve along the
cavernous sinus lateral wall and tentorial edge.
ICA
PG
IHA
b
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Chiasm
Pituitary
gland
C5
C6
C4
Upper ring
IIICN
IVCN
VICN
Sup orb
fiss
Fig. 13.9 Exposure of lateral
compartment of cavernous sinus. The
involvement of lateral compartment
of CS can be due to tumors extending
in this compartment. To analyze this
region in dissection, it is necessary
to displace medially the ICA after
the removal of periosteal layer. It
is important to pay attention to
the VI CN that run free in the CS
close to the lateral wall of ICA. The
others CN (III, IV, V1, and V2) are
embedded between the periosteal
and dural layers of lateral wall of CS.
C3, paraclival; C4, infrasellar; C5,
parasellar; C6, intracranial segments
of internal carotid artery; Sup orb fi ss,
superior orbital fi ssure.
C3
C5
C4
C3
a b
Fig. 13.10 Nerves in the cavernous sinus. After pituitary resection, the course of the nerves of the CS is full exposed (a). The III CN
originates from the midbrain and runs in the interpeduncular cisterns. It crosses the basilar artery, passing between the posterior
communicating artery and the superior cerebellar artery (b). Then, it enters in the lateral wall of CS, where it courses directed toward
the superior orbital fi ssure. The VI CN is coming from the dorsal surface of brainstem at the junction between the mesencephalon and
the pons. It courses along the free margin of the tentorium and enters in the lateral wall of CS inferiorly to the III CN. The VI CN exiting
from the Dorello’s canal comes into the CS, where it courses free within the sinus. With a 30-degree scope, the V CN coming from the
pons and directed toward the Meckel’s cave is also visible. C3, paraclival; C4, infrasellar; C5, parasellar.
IIICN
IVCN
IVCN
V2CN
IICN
IVCN
VCN
VICN
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IIcn
Sup. orb.
fiss
Periorbita
IIIcn
C5
C4
C3
ab
Fig. 13.11 Superior orbital fi ssure, foramen rotundum, and ovale. At the superior orbital fi ssure, the III, IV, VI, and V1 are entering in
the orbit from the CS (a). Indeed, III CN at this level divides in two divisions; the inferior is directed to the inferior rectus and inferior
oblique. Similarly, the superior division of the III CN, which provides the innervations of the medial and superior rectus, passes in the
superior orbital fi ssure in the Zinn’s annulus. At the superior orbital fi ssure, V1 divides in its three divisions (frontal, nasociliar, and
lacrimal). The frontal nerve passes through the superior orbital fi ssure courses on the levator palpebrae muscle, where it divides in the
supratrochlear and supraorbital nerve. The lacrimal nerve passes above the lateral rectus muscle to innervate the lacrimal gland. The
nasociliar nerve, which is the only branch of V1 passing through the Zinn’s annulus, divides in the nasal nerve, which gives origin to
the anterior and posterior ethmoidal nerves and the ciliar nerve. The trochlear nerve passes medially and above the levator palpebrae
directed toward the superior oblique muscle. The VI CN passes in the superior orbital fi ssure below the ophthalmic nerve to enter in
the lateral rectus muscle. From the gasserian ganglion, the other two branches of trigeminal nerve arise. V2 is directed toward the
foramen rotundum, to enter into the pterygopalatine fossa, while V3 enters in the foramen ovale to pass into the infratemporal fossa
(b). Internal carotid artery C2, intratemporal; C3, paraclival; C4, infrasellar; C5, parasellar Fiss; Sup. orb. fi ss, superior orbital fi ssure.
Meckel’s
cave
C2
VI cn
V2
V3
C3
Tem p
lobe
C4
Meckel’s
cave
C2
V1
V2
V3
Sup hypo a
Chiasm
Pituitary
stalk
Left
IIcn
C4
Fig. 13.12 Relationship with
supradiaphragmatic structures. By
opening the optic nerve sheet and
the upper ring of ICA, it is possible to
localize the ophthalmic artery (Ophth
A) that runs back to follow the optic
nerve into the optic canal to the orbit
cavity, the superior hypophyseal
artery (Sup hypo a), pituitary stalk,
and chiasm. C3, paraclival; C4,
infrasellar.
Ophth a
Upper ring
C3
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a b
OC
OCr
Pituitary
ICA
area
gland
cd
Fig. 13.13 (a–d) Transpterygoid approach landmark and navigation system. The neuronavigation system is a very useful device to
better recognize the ICA position during the bone removal and dura opening, mainly in not complete pneumatized sphenoid sinuses.
After the opening of anterior wall of sphenoid sinus and the removal of the all intersinusal septae, all landmarks are visible for the
cavernous sinus area: the optic canal (OC)—upper limit; pituitary gland—medial limit; orbit apex—antero-superior-lateral limit, foramen
rotundum—antero-inferior-lateral limit; the pterygoid canal, where the vidian nerve runs—medial limit. The pterygoid canal (vidian nerve)
is a very useful landmark to localize the genu between the paraclival and petrous segment of ICA. OCr, optic carotid recess.
The tumor removal can be performed with the
microsurgical two-hand technique. Dissection of
the tumor from the surrounding dural structures
and normal pituitary gland is made in a progressive
central debulking manner with suction or curettes. In
this phase, we prefer to keep the endoscope fixed on a
holder. The portion of the tumor invading the medial
compartment is resected, following its extension and
using the same opening in the medial wall of CS that the
tumor created to invade the compartment (Fig. 13.14).
In case of involvement of the posterosuperior
compartment of CS, the resection is extended to this
portion following the tumor growth through the
intracavernous carotid loop. At the end of the tumor
removal, venous bleeding is usually not significant and
Pterygoid canal
can easily be controlled with hemostatic absorbable
material. Afterward, the inspection of the surgical field
with 30- and 45-degree- angled endoscopes permits
the detection and removal of neoplastic residues
(Fig. 13.14). The dura can be opened also laterally to the
ICA, after its identification with technological devices,
to access lateral compartments of CS (Fig. 13.15). The
tumor removal technique in this region is not dissimilar
to the previous one. Also in this case, bleeding from CS
is usually not significant and can be controlled with
hemostatic absorbable material. The surgical defect
can be closed using absorbable material, whereas in the
case of a cerebrospinal fluid (CSF) leak we usually repair
using free graft with fat and/or mucoperiosteum taken
from the middle turbinate or nasoseptal flap.
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OCr
C5
ab
Fig. 13.14 Opening of the anterosuperior compartment of the CS. The dural incision begins in the sellar region and is progressively
extended, from medial to lateral (a). Maximal care is required during the sectioning of the dura in front of the carotid artery to
avoid injury to the ICA and to the meningohypophyseal artery (b). CS, cavernous sinus; C3, paraclival segment of ICA; C5, parasellar
segment of ICA; Men hyp a, meningohypophyseal artery; OCr, optic carotid recess.
C5
VI cn
Pituitary
gland
Medial wall
CS
Clivus
Pituitary
gland
OCr
C5
Pituitary
gland
Medial wall
CS
C3
Men hyp a
Pituitary
Gland
IIIcn
C5
C4
C3
ab
Fig. 13.15 Opening of the anteroinferior and lateral compartment of CS. After the removal of periosteal layer of medial wall of
the CS, it is possible to see all intracavernous segments of the ICA (a). After the localization of VI CN, it is possible to medialize the
parasellar segment of ICA and to expose the lateral compartment of CS (b). CS, cavernous sinus; C3, paraclival segment of ICA; C4,
infrasellar segment of ICA; C5, parasellar segment of ICA; Men hyp a, meningohypophyseal artery; OCr, optic carotid recess.
Men hyp a
13.3 Case Example
A 39-year-old man was referred for a giant pituitary
adenoma. He had had previous surgery (microscopic transsphenoidal approach) elsewhere. The resection was partial and the patient did not undergo any
Clivus
Vi cn
C4
further investigations or neuroradiologic examinations, until he was referred to a sleep-disorder center
due to sleep apnea syndrome. The patient presented the typical somatic feature of acromegaly, and
basal growth hormone (GH) biohumoral essays levels were 28.3 ng/mL and the insulin growth factor-1
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(IGF-1) was 947 mUI/mL. After the oral glucose suppression test, the GH value was 8.9 ng/mL. The patient also presented hyperprolactinemia (75 ng/mL),
hypogonadotropic hypogonadism (testosterone 1.5
ng/mL; LH: 2 mUI/mL; FSH: 3.9 mUI/mL), and central hypothyroidism (TSH: 0.31 mUI/mL; FT4: 5.4 ng/mL). The
MRI showed an endosellar pituitary adenoma (Hardy–
Wilson grade 2E), invading the right CS with a Knops
grade of 4 (Fig. 13.16a). The hypersecretion did not normalize and the tumor did not reduce its volume despite
treatment with sandostatin and cabergoline. Moreover,
a hyperintense signal in T1WI and T2WI in the lateral asymmetric portion, possible expression of local
ischemia or hemorrhage, became evident. The patient
was operated though an extended EEA. After drilling
the bone structures in the posterior wall of sphenoidal
sinus, the course of the right ICA was identified with
the neuronavigation system and Doppler. The dura was
medially opened allowing resection of the tumor in this
portion of CS. The tumor had a soft consistency and it
was suitable to be resected by curettes and suction. Afterward, the dura lateral to the right ICA was incised as
well and the portion in the anteroinferior and lateral
compartment of CS were removed in the same manner
(Fig. 13.16b). The histologic examination revealed a
mixture of GH and PRL adenoma with Ki67 marker of
3%. Postoperative course was unremarkable and the patient was discharged 4 days later. The postoperative MRI
after 3 months showed a subtotal tumor removal with a
small remnant in the anteroinferior compartment of CS
(Fig. 13.16c). The hypersecretion of GH was reduced to
3.5 ng/mL and the IGF-1 to 376 mUI/mL. Prolactin levels
were 15 ng/mL, and, after oral glucose tolerance test,
the GH valued did not suppress under 0.8 ng/mL, and
thus the treatment with cabergoline and sandostatin
was restarted, achieving control of the hypersecretion
after 6 months.
13.4 Complications
In our experience, the awaking of patient is obtained
immediately after surgery, with spontaneous breathing and resuming prompt feeding in the following hours.
The discomfort and pain are usually very limited, and
a single dose of nonsteroidal anti-inflammatory drug
administered 6 hours after surgery is normally sufficient
to control the postoperative headache. If no intraoperative
CSF leak is observed, the patient can stand up the following morning and can be discharged 3 days after surgery.
Conversely, if a CSF is observed, we suggest keeping the
patient at supine bed rest for 3 days, without any external
lumbar drainage, to avoid increasing the risk of pneumocephalus. The postoperative MRI is performed in the first
3 days after surgery for cases with lateral compartments
involvement. The following MRI is scheduled 3 months
later in all cases, along with the ophthalmologic evaluation and endocrinological assessments. Afterwards, the
patient is followed up every 6 to 12 months, with repeated
neuroradiologic and clinical assessments. In case of postoperative CSF leak, we prefer a very aggressive management
of the complication, with prompt endoscopic endonasal
reintervention. With this approach, we found a low risk of
injuring the CNs, and postoperative transient of permanent
ophthalmoplegia occurred very rarely in our series. This is
because the III, IV, and VI CNs are protected by the lateral
wall of CS. The more vulnerable nerve is the VI CN, as its
course is free from the CS. It is usually displaced inferiorly,
laterally, and posteriorly by the tumor mass, and often it
can be observed only once the tumor has been removed.
The more fearing complication of this surgery is the ICA
injury. It is mandatory to recognize its course and its loop
with neuronavigation and intraoperative Doppler during
all the stages of the surgery to avoid any damages. In case
of bleeding, compression by means of patties is required
to stop the blood outflow and to identify the lesion on
Fig. 13.16 At the preoperative MRI, the giant PTA involving the right CS is shown. The spontaneous hyperintensity is sign of
apoplectic degeneration of a portion of the tumor (a). In the intraoperative image with 0-degree endoscope, the two dural opening,
lateral and medial to the ICA, are shown (b). A pattie inside the CS shows tumor resection also behind the ICA. At the MRI after 3
months, a very small portion of the tumor around the ICA in the anteroinferior compartment is present (c).
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the arterial wall, in this case, whenever possible many
authors suggest to cover the defect with a piece of muscle. Some authors proposed to coagulate or repair the leak
suturing the arterial wall; these strategies can be effective for small injuries, but in case of massive blood outflow we advise to perform an angiography as soon as the
bleeding has been controlled to localize the hemorrhagic
source and coiling the vessel. The main risk of this procedure is represented by brain infarction if no contralateral
blood compensation is provided to the side of the carotid
occlusion. In this circumstance, some authors propose to
perform an arterial bypass to guarantee a sufficient blood
flow in the middle cerebral and anterior cerebral artery
territories. However, we believe that the best approach for
this dramatic complication is its prevention. This should
be achieved in a multimodal way: the anatomic knowledge of the region is crucial to predict the course of the
ICA; the technological support is mandatory to confirm
the surgeon anatomic recognition and verify the position
of these vessels; and finally, a proper case selection and
surgical technique, avoiding sharp instruments, or tumor
resection in blind areas, working bimanually and avoiding any tractions. Finally, the surgeon’s experience is relevant to reduce the surgical morbidity.
13.5 Tips and Tricks
We believe that EEA to the CS should be part of the armamentarium of a skull base and pituitary neurosurgeon, representing a valid tool in a great variety of cases. It provides
the opportunity to achieve a satisfactory tumor removal,
and it has demonstrated to be a replicable and standardized technique that can be learnt, transmitted, and adopted with satisfaction by more generations of surgeons.
Proper patient selection and the use of technological
devices such as neuronavigation, intraoperative Doppler,
and neurophysiological monitoring, coupled with a
detailed anatomic knowledge of the region, represent the
more relevant elements to avoid complications.
References
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Chapter 14
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14.1 Indications 144
Endonasal
Endoscopic–Assisted
Intraorbital Approach
14.2 Surgical Steps 144
14.3 Case Example 149
14.4 Complications 149
14.5 Tips and Tricks 151
14.6 Dedicated Instrumentations 153
Endonasal Endoscopic–Assisted Intraorbital Approach
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14 Endonasal Endoscopic–Assisted Intraorbital
Approach
Iacopo Dallan, Giacomo Fiacchini, Matteo de Notaris
Introduction
The surgical management of orbital lesions is technically
demanding regardless of the approach used. Traditional
external approaches have been used in the past to address
medially located lesions, usually by means of extensive
surgical work. Endoscopic transnasal approaches have
been recently introduced for the management of such
located lesions. The direct approach, short trajectory, and
an enhanced visualization allowed by the endoscope represent the critical aspect of such techniques.
14.1 Indications
Endoscopic endonasal technique allows one to approach
adequately the medial and inferomedial wall of the orbit
(Figs. 14.1 and 14.2).
• Orbital and optic canal decompression.
• Medial and inferomedial wall fractures repair.
• Lesions of the medial extraconal spaces, mainly infero-
medially located.
• Extraconal medially located orbital apex lesions.
• Selected lesions of the medial intraconal space, mainly
inferomedially located (for radical removal or diagnostic purpose).
• In combination with superior and inferior eyelid ap-
proach, it can be used to manage more complex lesions
(multiportal surgery).
14.2 Surgical Steps
Probably, the coronal views of the preoperative computed
tomography (CT) and/or magnetic resonance imaging (MRI)
scans are the most important perspective to look for when
dealing with intraorbital lesions. An anterior-to-posterior
visualization allows identifying anatomic details, reducing
AEC
OC
SOF
OS
IOF
Fig. 14.1 Possible area of the transnasal orbitotomy. AEC,
anterior ethmoidal canal; IOF, inferior orbital fi ssure; OC, optic
canal; OS, optic strut; SOF, superior orbital fi ssure. Black arrow
indicates the infraorbital groove.
NS
a
Fig. 14.2 Endoscopic view (a) and cadaver section (b) of the left nasal cavity. C, choana; IT, inferior turbinate; MM, middle meatus;
MT, middle turbinate; NF, nasal fl oor; NS, nasal septum; OC, optic canal; SS: sphenoid sinus, ST: superior turbinate; tIT, tail of the
inferior turbinate.
144
MT
C
tIT
NF
MM
OC
SS
IT
b
ST
MT
IT
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