Anatomy and Surgery of the Cavernous Sinus
The decision of Harvey Cushing to leave general surgery and concentrate on the infant field of central nervous system surgery was in retrospect a landmark in the history of neurosurgery. His concentrated work, and also that of his colleague Walter Dandy, originated with the desires of both pioneers to understand surgical anatomy and neurophysiology. The fundamental knowledge and surgical techni ques that they provided became the standard of excellence for several generations of neurosurgeons; so much so that the general belief was that the surgical techniques could not be improved upon. Twenty-five to thirty years ago microtechniques began to appear in a few surgical research centers, they were then gradually applied to clinical neurosurgery and have contributed to a new level of understanding in surgical anatomy and neurophysiology. We are now fortunate to have a new standard of morbidity and mortality in the surgical treatment of intrathecal aneurysms, angiomas, and tumors. It has been said that microneurosurgery was reaching its limits, especially when treating lesions in and around the cavernous sinus and skull base; those lesions notorious for involvement of the dural and extradural compartments, with a tendency to infiltrate adjacent nerves and blood vessels. The dangers of uncontrollable hemorrhage from the basal sinuses and post-operative CSF rhinorrhea appeared unsurmountable. The lateral aspects of the petro-clival region have been of interest to a few pioneering ENT surgeons and neurosurgeons but the cavernous sinus in most respects has remained the final unconquered summit.
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11 Anatomy of the cavernous sinus
Inferolateral trigeminal triangle
13 Relation of the internal carotid artery to the surgical triangles and bony sinuses
14 Relation of the cavernous sinus to the sella
15 Venous system of the cavernous sinuses
2 General approach to the cavernous sinus
31 Combined epi and subdural approach to carotid ophthalmic aneurysms
Middle cranial fossa subregion
Posterolateral Glasscocks triangle
Posteromedial Kawases triangle
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anteriorly anterolateral triangle anteromedial triangle anteroposterior views approach artery wall basilar artery basilar tip aneurysm bony cavernous sinus CT scan dissection distal dural ring dorsal drilling dura propria epidural ethmoid sinus exposed fibrous foramen lacerum foramen rotundum foramen spinosum greater petrosal nerve horizontal segment ICA ML ICA(AL IIlrd nerve incision inferomedial intracavernous aneurysms intracavernous ICA aneurysm intradural IVth lateral aspect lateral loop lateral ring lateral views lateral wall Left carotid angiograms lesion lllrd nerve medial aspect medial loop meningioma middle cranial fossa middle meningeal artery muscle oculomotor trigone ophthalmic artery optic canal orbit paramedial triangle parasellar Parkinson's triangle patient PCoA petroclinoid ligament petrous bone pituitary body posterior loop Postoperative angiograms showing Preoperative angiograms showing proximal ring resection retraction seen sella shown sinuses skull base sphenoid wing surgery surgical Surgicel sutures temporary clip tentorial tissue tumor vein venous blood venous injection visualized Vlth nerve