Perspectives on the approaches to lesions in and around the cavernous sinus

Abstract

Surgery for lesions that arise in the cavernous sinus and its vicinity is a formidable challenge. Dolenc was the first to describe a stepwise surgical approach to the cavernous sinus in a comprehensive fashion. Since the understanding of the cavernous sinus surgical anatomy has increased among neurosurgeons and enabled the development of modern skull base techniques. The knowledge of the relationships of the internal carotid artery with the anterior clinoid process in the anterior part of the sinus was crucial for the surgery of paraclinoid aneurysms. The same is true for basilar tip aneurysm surgery in regards to the relationships of the internal carotid, oculomotor nerve, and posterior clinoid process in the posterior part of the sinus. In general terms and for practical purposes, we review the two most commonly used surgical approaches to the cavernous sinus: (1) the superior approach (which can be subdivided into an anterior and a posterior route) and (2) the lateral extradural route. The surgical approach to paraclinoid aneurysms and the pretemporal orbitozygomatic transcavernous approach to basilar tip aneurysms are also reviewed.