Rima S Rindler1,2, Luciano C Leonel1,2, Stephen Graepel1, Edoardo Agosti1,2, Panagiotis Kerezoudis1,2, Carlos D Pinheiro-Neto1,2,3, Maria Peris-Celda4,5,6. 1. Department of Neurologic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA. 2. Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA. 3. Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN, USA. 4. Department of Neurologic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA. periscelda.maria@mayo.edu. 5. Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA. periscelda.maria@mayo.edu. 6. Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN, USA. periscelda.maria@mayo.edu.
Abstract
PURPOSE: Traditional endoscopic endonasal approaches to the cavernous sinus (CS) open the anterior CS wall just medial to the internal carotid artery (ICA), posing risk of vascular injury. This work describes a potentially safer midline sellar entry point for accessing the CS utilizing its connection with the inferior intercavernous sinus (IICS) when anatomically present. METHODS: The technique for the midline intercavernous dural access is described and depicted with cadaveric dissections and a clinical case. RESULTS: An endoscopic endonasal approach exposed the periosteal dural layer of anterior sella and CS. The IICS was opened sharply in midline through its periosteal layer. The feather knife was inserted and advanced laterally within the IICS toward the anterior CS wall, thereby gradually incising the periosteal layer of the IICS. The knife was turned superiorly then inferiorly in a vertical direction to open the anterior CS wall. This provided excellent access to the CS compartments, maintained the meningeal layer of the IICS and the medial CS wall, and avoided an initial dural incision immediately adjacent to the ICA. CONCLUSION: The midline intercavernous dural access to the CS assisted by a 90° dissector-blade is an effective modification to previously described techniques, with potentially lower risk to the ICA.
PURPOSE: Traditional endoscopic endonasal approaches to the cavernous sinus (CS) open the anterior CS wall just medial to the internal carotid artery (ICA), posing risk of vascular injury. This work describes a potentially safer midline sellar entry point for accessing the CS utilizing its connection with the inferior intercavernous sinus (IICS) when anatomically present. METHODS: The technique for the midline intercavernous dural access is described and depicted with cadaveric dissections and a clinical case. RESULTS: An endoscopic endonasal approach exposed the periosteal dural layer of anterior sella and CS. The IICS was opened sharply in midline through its periosteal layer. The feather knife was inserted and advanced laterally within the IICS toward the anterior CS wall, thereby gradually incising the periosteal layer of the IICS. The knife was turned superiorly then inferiorly in a vertical direction to open the anterior CS wall. This provided excellent access to the CS compartments, maintained the meningeal layer of the IICS and the medial CS wall, and avoided an initial dural incision immediately adjacent to the ICA. CONCLUSION: The midline intercavernous dural access to the CS assisted by a 90° dissector-blade is an effective modification to previously described techniques, with potentially lower risk to the ICA.
Authors: Juan C Fernandez-Miranda; Paul A Gardner; Milton M Rastelli; Maria Peris-Celda; Maria Koutourousiou; David Peace; Carl H Snyderman; Albert L Rhoton Journal: J Neurosurg Date: 2014-05-09 Impact factor: 5.115
Authors: Joao Paulo Almeida; Adriana Workewych; Hirokazu Takami; Carlos Velasquez; Selfy Oswari; Mohammed Asha; Antonio Bernardo; Fred Gentili Journal: World Neurosurg Date: 2020-10 Impact factor: 2.104