Dural Venous System in the Cavernous Sinus: A Literature Review and Embryological, Functional, and Endovascular Clinical Considerations

Abstract

The cavernous sinus (CS) is one of the cranial dural venous sinuses. It differs from other dural sinuses due to its many afferent and efferent venous connections with adjacent structures. It is important to know well about its complex venous anatomy to conduct safe and effective endovascular interventions for the CS. Thus, we reviewed previous literatures concerning the morphological and functional venous anatomy and the embryology of the CS. The CS is a complex of venous channels from embryologically different origins. These venous channels have more or less retained their distinct original roles of venous drainage, even after alterations through the embryological developmental process, and can be categorized into three longitudinal venous axes based on their topological and functional features. Venous channels medial to the internal carotid artery “medial venous axis” carry venous drainage from the skull base, chondrocranium and the hypophysis, with no direct participation in cerebral drainage. Venous channels lateral to the cranial nerves “lateral venous axis” are exclusively for cerebral venous drainage. Venous channels between the internal carotid artery and cranial nerves “intermediate venous axis” contribute to all the venous drainage from adjacent structures, directly from the orbit and membranous skull, indirectly through medial and lateral venous axes from the chondrocranium, the hypophysis, and the brain. This concept of longitudinal venous axes in the CS may be useful during endovascular interventions for the CS considering our better understandings of its functions in venous drainage.

Revisit the Cavernous Sinus from Fetus to Adult—New and Old Data

“…These differentiation intensities of venous condensations were not evident in the fetuses, perhaps due to their small sizes. A recent review by Mitsuhashi et al (), divided the cavernous sinus into three clinically important axes: medial, intermediate and lateral. The medial venous axis carried venous drainage from the skull base, chondrocranium and hypophysis; the lateral axis was exclusively for cerebral venous drainage.…”

Assessment of Therapeutic Access Routes for Endovascular Therapy of Cavernous Sinus-dural Arteriovenous Fistula

“…The CS is a complex of venous channels with embryologically different origins, and these venous channels have retained their distinct original roles of venous drainage. 2) Mitsuhashi et al divided the intracavernous venous channels into three longitudinal venous axes based on their embryological development and functional characteristics: the "lateral venous axis," "medial venous axis," and "intermediate venous axis." 2) The axes are linked through the venous connections between them.…”

“…The medial and lateral venous axes of the CS drain posteriorly into the IPS. 2) This concept of intracavernous longitudinal venous axes may contribute to clinical practice, especially in catheter advancement into the CS. Considering our cases based on this concept, in Case 1, the affected CS with the shunted pouch was on the lateral venous axis to which the SMCV belongs.…”

“…Transvenous embolization (TVE) is generally accepted as the first choice for endovascular intervention to treat CS-dAVF. [1][2][3][4][5][6][7][8] Furthermore, with the development of DSA, detailed diagnosis of the shunted pouch has become possible; selective TVE has also become possible in recent years. 9) In TVE for CS-dAVF, the inferior petrosal sinus (IPS) is usually selected as the initial access route to the affected CS because of its accessibility.…”

“…Moreover, the CS structure is not simple, and some compartments may develop by partition formation. The CS is a complex of venous channels with embryologically different origins, 2) and it may also affect compartmentalization.…”