The transnasal approach to the cavernous sinus

Loyo, M; Sanchez-Marle, J. F.; Valle, Ramiro del; Mares, M.

doi:10.1007/978-3-7091-6982-7_35

Cited by 7 publications

(3 citation statements)

References 10 publications

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“…Anterior approaches to the skull base have offered various degrees of exposure to primarily midline lesions of the hypophysis, clivus, or posterior circulating vascular lesions, and include the transbasal, extended transfrontal, transseptal transsphenoidal, facial translocation, transmaxillary, transmaxillary transnasal, midfacial degloving, transoral, mandible splitting transoral, transcervical transclival, and anterior cervical. 4,5,7,9,10,12,26–32 For large or local extensions of the various lesions to the parasellar region, petrous bone, or cavernous sinus, the limited lateral access and difficulty in attaining proximal control of the ICA confines the usefulness of these approaches. 8,13,18 …”

Section: Discussionmentioning

confidence: 99%

Extradural Extranasal Combined Transmaxillary Transsphenoidal Approach to the Cavernous Sinus: A Minimally Invasive Microsurgical Model

2000

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The authors have previously described an extradural transmaxillary approach to the anterior com· partment of the cavernous sinus. In an effort to expand the surgical access to that area without n cessitating a craniotomy or wide transfacial dissec· tion, they present a modification of the transmaxillary approach to the sellar region and cavernous sinus. Methods: The approach was developed on 12 fresh and 12 embalmed cadaveric specimen, and 2 dry skulls. The initial sublabial incision is followed by a maxillotomy to expose the course of the infraorbital nerve (terminal branch of maxillary branch of the trigeminal n erve) on the roof of the maxillary sinus. The route of the infraorbital n erve is traced to the pterygopalatine fossa a s a guide to the foramen rotund um. Superomedial drilling of the foramen rotund um is then p erformed to r eveal the contents of the superior orbital fissure. After the n erves are safely identi· fled in the superior orbital fi ssure, m edial enlargem ent of the window into the cavernous sinus is made possible by drilling the lateral and posterior wall and septum of the sphenoid sinus. R esults: The combined transmaxillary transsphenoidal approach offers an excellent exposure of the sellar and infrasellar r egion. The approach offer s clear visualization of the ipsilat· eral loop of the carotid artery, the pituitaryfossa, and the cranial n erves of the ipsilateral cavernous sinus. Mean operative reach is 38 mm from the posterior wall of the maxillary sinus to the ipsilateral carotid loop and 56 mm to the contralateral loop. The width of the operative window is 26 mm at the base within the cavernous sinus. Conclusion: The model offer s a minimally invasive approach that avoids the n eed for era· niotomy or violating the nasal cavity. It may be safely From the Departments of Neurological S urgery (1.s.,

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Section: Discussionmentioning

confidence: 99%

Extradural Extranasal Combined Transmaxillary Transsphenoidal Approach to the Cavernous Sinus: A Minimally Invasive Microsurgical Model

2000

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“…Fox 22 has described the trans cervical approach to basilar artery aneurysms. In 1987, Archer and colleagues 3 advocated the use of a Le Fort I maxillotomy as an approach to distal vertebral and midbasilar artery aneurysms, whereas Loyo et al 49 used a maxillotomy to approach the cavernous sinus. All of these studies confirmed the appeal and the long-standing development of the anterior approaches.…”

Section: All Old Roads Lead To the Clivusmentioning

confidence: 99%

Anterior clivectomy: surgical technique and clinical applications

Al‐Mefty

Kadri²,

Hasan³

et al. 2008

JNS

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Object Midline clival lesions, whether involving the clivus or simply situated anterior to the brainstem, present a technical challenge for adequate exposure and safe resection. The authors describe, as a minimally invasive technique, an anterior clivectomy performed via an expanded transsphenoidal approach coupled with the use of a neuronavigation on mobile head and endoscopic-assisted technique. Wide and direct exposure, with the ability to resect extra- and intradural tumors, was achieved without mortality and with a low rate of complications. Methods Cadaveric dissections were performed to outline the landmarks and measure the window that is created by resecting the clivus anteriorly. The technique was used in 43 patients to resect tumors located at or invading the clivus. The initial exposure of the clivus was obtained via the sublabial transsphenoidal approach. The wall of the anterior maxilla, often on 1 side, was removed to allow a wide side-to-side opening of the nasal speculum. Using neuronavigation, the authors made clivectomy windows by drilling the clivus between anatomical landmarks. Bilateral intraoperative neurophysiological monitoring was used (somatosensory evoked potentials, brainstem auditory evoked responses, and cranial nerves VI–XII). Results Of the 43 patients, 26 were female and 17 were male, and they ranged in age from 3.5 to 76 years (mean 41.5 years). Thirty-eight patients harbored a chordoma and 5 a giant invasive pituitary adenoma. Gross-total resection of the tumor was achieved in 34 cases (79%). Nine patients (21%) had residual tumor unreachable through the anterior clivectomy, and this required a second-stage resection. Four patients developed new transient extraocular movement deficits. One patient developed a permanent cranial nerve VI palsy. Twenty-seven patients with chordoma underwent postoperative proton-beam radiotherapy. Tumor recurred in 19% of these cases. In 3 patients a cerebrospinal fluid leak developed during hospitalization and was treated successfully. Two other patients presented with a delayed cerebrospinal fluid leak after radiotherapy. Only 1 patient, who had previously undergone Gamma Knife surgery, experienced postoperative hemiparesis. Conclusions A complete anterior clivectomy via a simple extension of the transsphenoidal approach allows the surgeon access to different lesions involving the clivus or situated anterior to the brainstem. The exposure is similar to that provided by more extensive transfacial approaches. Instrument manipulation is easy. Neuronavigation, endoscopy, and intraoperative monitoring are easily incorporated and enhance the capability and safety of this approach.

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“…Loyo et al, 1987 CCF, Barrow type unknown Sublabial transmaxillary transsphenoidal Sealing substance (fibrin & factor VIII) Not mentioned Barker et al, 1994 CCF, Barrow Type A External transethmoidal transsphenoidal Gianturco coil DSA revealed a Type B CCF on the right side. A:…”

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confidence: 99%

Endoscope-assisted transsphenoidal puncture of the cavernous sinus for embolization of carotid-cavernous fistula in a neurosurgical hybrid operating suite

Tang¹,

Liao²,

Chen

et al. 2017

Journal of Neurosurgery

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Endovascular embolization is the treatment of choice for carotid-cavernous fistulas (CCFs), but failure to catheterize the cavernous sinus may occur as a result of vessel tortuosity, hypoplasia, or stenosis. In addition to conventional transvenous or transarterial routes, alternative approaches should be considered. The authors present a case in which a straightforward route to the CCF was accessed via transsphenoidal puncture of the cavernous sinus in a neurosurgical hybrid operating suite. This 82-year-old man presented with severe chemosis and proptosis of the right eye. Digital subtraction angiography revealed a Type B CCF with a feeding artery arising from the meningohypophyseal trunk of the right cavernous segment of the internal carotid artery. The CCF drained through a thrombosed right superior ophthalmic vein that ended deep in the orbit; there were no patent sinuses or venous plexuses connecting to the CCF. An endoscope-assisted transsphenoidal puncture created direct access to the nidus for embolization. Embolic agents were deployed through the puncture needle to achieve complete obliteration. Endoscope-assisted transsphenoidal puncture of the cavernous sinus is a feasible alternative to treat difficult-to-access CCFs in a neurosurgical hybrid operating suite.

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The transnasal approach to the cavernous sinus

Cited by 7 publications

References 10 publications

Extradural Extranasal Combined Transmaxillary Transsphenoidal Approach to the Cavernous Sinus: A Minimally Invasive Microsurgical Model

Extradural Extranasal Combined Transmaxillary Transsphenoidal Approach to the Cavernous Sinus: A Minimally Invasive Microsurgical Model

Anterior clivectomy: surgical technique and clinical applications

Endoscope-assisted transsphenoidal puncture of the cavernous sinus for embolization of carotid-cavernous fistula in a neurosurgical hybrid operating suite

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