The Cavernous Sinus: A Multidisciplinary Approach to Vascular and Tumorous Lesions

The management of vascular and tumorous lesions of the parasellar region still remains one of the most demanding tasks in neurosurgery. It is only a short time ago that the major concepts of the anatomy of the so-called cavernous sinus were described in detail. Surgical interventions in this region are very complex, they are time-consuming and require an extensive back- ground of experience in surgery of the cranial base. Pioneer anatomical studies of the parasellar region done by Taptas, and the daring direct operative approach introduced by Parkinson pro- moted the development of modern neuroradiological intervention proce- dures, which were initiated by Serbinenko and further refined by Debrun, Vifiuela and others. The technique of the detachable balloon catheter stimulated surgeons to proceed with the direct operative approach to lesions of the parasellar region. Today, it is hard to imagine a successful man- agement of vascular pathologies of this region without a complementary use of the two techniques.

Table of Contents:
Historical review and pioneer work.- Carotid cavernous fistula. History and anatomy.- Must we still call cavernous sinus the parasellar vascular and nervous crossroads? The necessity of a definite topographical description of the region.- Anatomy.- Gross anatomy of the cavernous region.- The cavernous sinus. An anatomical study of its lateral wall.- The blood supply of the cranial nerves in the lateral wall of the cavernous sinus.- Microsurgical anatomy of collateral branches of the intracavernous internal carotid artery.- Anatomical remarks on the fetal cavernous sinus and on the veins of the middle cranial fossa.- Histoarchitecture of the cavernous sinus.- Diagnostic procedures.- Facial reflex examination for assessment of subclinical trigeminal nerve involvement in the cavernous sinus.- Dynamic CT scanning of the cavernous sinus.- Radiological grading of tumor extension of the cavernous sinus.- MR imaging: normal and invaded cav-ernous sinus studied with and without Gd-DTPA.- The utility of intravenous DSA for cavernous sinus venography.- Occlusion techniques.- Embolization techniques in the treatment of vascular lesions involving the cavernous sinus.- Endovascular therapy of vascular lesions of the cavernous sinus. Experience with 129 cases.- The detachable balloon technique in the treatment of direct carotid-cavernous fistulas.- Criteria for the differentiation of high-, moderate-, and low-flow carotid-cavernous sinus fistulas and their treatment with balloon catheters.- Closure of carotid-cavernous fistulas by intracavernous surgical insertion of biological materials.- Surgery of vascular lesions.- Carotid cavernous aneurysms and fistulae.- Traumatic carotid aneurysms of the cavernous sinus.- Strategies in intracavernous saccular aneurysms.- Para- and infraclinoidal aneurysms. Anatomy, surgical technique and report on 22 cases.- Direct approaches to vascular lesions in the cavernous sinus via the medial triangle.- Treatment of internal carotid infraclinoid aneurysms.- Direct operation on intracavernous giant aneurysm.- Treatment of intracavernous aneurysms of the ICA and CCFs by direct approach.- The antero-external approach to the internal carotid artery at the base of the skull and intrapetrously.- Tumor surgery.- The direct microsurgical approach to intracavernous tumors.- Usefulness of the orbitofrontomalar approach associated with bone reconstruction for frontotemporosphenoid meningiomas.- An orbitozygomaticomalar bone flap approach: a technical note.- Skull base approaches for meningiomas invading the cavernous sinus.- Trigeminal neurinomas. A special type of cavernous sinus tumors.- Treatment of tumors invading the cavernous sinus.- Pathological aspects in a series of 53 cavernous sinus tumors.- The transnasal approach to the cavernous sinus.- Transsphenoidal surgery of pituitary adenomas developed towards the cavernous sinus.