Surgical Management of Cavernous Lesions

Surgical Methods and the History

Surgery of the cavernous sinus was first developed by pioneers Parkinson and Dolenc in the 1960–80s, mainly for cavernous sinus aneurysms. ^, It was gradually applied to cavernous sinus tumors, by parallel development of bypass of the carotid artery. In the 1990s cavernous sinus surgery was the hottest surgical subject in neurosurgery, with parallel development of microsurgical anatomy. ^, However the number of direct surgeries for primary cavernous sinus meningiomas gradually decreased after the millennium according to development of Gamma Knife radiosurgery, for ophthalmic complications could not be ignored for the patients. After the late 1990s, it has gradually been accepted that parasellar meningiomas are better treated in combination with surgical removal of the subdural part of the tumors and radiosurgery for the intra-cavernous part. Epidural surgery for trigeminal schwannomas has an advantage to preserve ophthalmic functions. Endoscopic transsphenoidal surgery is developing recently for pituitary adenomas and chordomas invading into the cavernous sinus.

Front-Temporal Epi- and Subdural Approach (Dolenc)

This approach was originally indicated for C3 aneurysms. Today the indication is extended for clinoid meningiomas invading the apex of the cavernous sinus. ^, The optional technique is the orbito-zygomatic approach to access the tumors with orbital or infra-temporal fossa extension. Bypass of the carotid artery has been added optionally in case of tumor invasion to the artery.

Fronto-Temporal Epidural (Interdural) Approach

This approach has been developed for trigeminal neurinomas extending in the middle fossa with or without orbital extension, and cavernous sinus hemangiomas. The basic method is constituted with anterior clinoidectomy, separation of periosteal membrane lateral to the superior orbital fissure, foramen rotundum, and ovale. Meningeal dura can be tacked to expose the tumor, and the temporal lobe is not necessary to expose.

Subtemporal Epidural (Interdural) Approach

This approach is indicated for middle fossa trigeminal neurinomas with or without invasion into infratemporal fossa and parasellar chordomas. ^, A benefit of the approach is that opening superior orbital fissure is not necessary. For neurinomas, periosteal dura is cut to enter the interdural tumor space, without exposure of the temporal lobe. Zygomatic osteotomy is optionally added for large tumors or tumors invading infratemporal fossa to reduce retraction damage to the temporal lobe.

Subtemporal Anterior Petrosal Approach (Kawase)

This approach was originally indicated for lower basilar trunk aneurysms and the indication has been extended to petroclival meningiomas invading the parasellar area. Accessibility both to middle and posterior fossae is a merit of this approach, and it has been indicated for dumbbell trigeminal neurimas and parasellar chordomas invading posterior fossa. Epidural resection of petrous apex, tentorial incision, and Meckel cave exposure with or without opening the posterior cavernous sinus are the fundamental surgical processes. Tumors extending into infratemporal fossa can be accessed by combination of zygomatic approach ( zygomatic petrosal approach ).

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