7 Cavernous Sinus and Meckel’s Cave

  • Georgios A. Zenonos
  • Stefan Lieber
  • Juan C. Fernandez-Miranda


The cavernous sinus and Meckel’s cave have traditionally been considered some of the most difficult areas to access surgically. With the advent of endoscopic and minimally invasive approaches, medial-to-lateral and anterior-to-posterior surgical corridors are added to the surgeon’s armamentarium. Although extensive literature exists discussing the relevant surgical anatomy and surgical approaches from a lateral/open perspective, the experience with endonasal approaches is still growing. In this chapter, we analyze our criteria when selecting the endonasal approach for pathology involving the cavernous sinus and Meckel’s cave, examine the intricate surgical anatomy of these areas focusing on the endonasal perspective, and provide relevant surgical pearls based on our experience. Furthermore, we discuss our operative setup and instrumentation, as well as postoperative care and complications.


Cavernous sinus Meckel’s cave Endoscopic anatomy Surgical technique Cavernous sinus compartments Patient selection Complications 



Cranial nerve


Cavernous sinus


Endoscopic endonasal approach


Internal carotid artery


  1. 1.
    Paluzzi A, Fernandez-Miranda JC, Tonya Stefko S, Challinor S, Snyderman CH, Gardner PA. Endoscopic endonasal approach for pituitary adenomas: a series of 555 patients. Pituitary. 2014;17(4):307–19.CrossRefGoogle Scholar
  2. 2.
    Koutourousiou M, Gardner PA, Fernandez-Miranda JC, Paluzzi A, Wang EW, Snyderman CH. Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations. J Neurosurg. 2013;118(3):621–31.CrossRefGoogle Scholar
  3. 3.
    Shin SS, Tormenti MJ, Paluzzi A, Rothfus WE, Chang YF, Zainah H, et al. Endoscopic endonasal approach for growth hormone secreting pituitary adenomas: outcomes in 53 patients using 2010 consensus criteria for remission. Pituitary. 2013;16(4):435–44.CrossRefGoogle Scholar
  4. 4.
    Taussky P, Kalra R, Coppens J, Mohebali J, Jensen R, Couldwell WT. Endocrinological outcome after pituitary transposition (hypophysopexy) and adjuvant radiotherapy for tumors involving the cavernous sinus. J Neurosurg. 2011;115(1):55–62.CrossRefGoogle Scholar
  5. 5.
    Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Gardner P, Osawa S, et al. The front door to meckel’s cave: an anteromedial corridor via expanded endoscopic endonasal approach- technical considerations and clinical series. Neurosurgery. 2009;64(3 Suppl):ons71–82; discussion ons-3.PubMedGoogle Scholar
  6. 6.
    Harris FS, Rhoton AL. Anatomy of the cavernous sinus. A microsurgical study. J Neurosurg. 1976;45(2):169–80.CrossRefGoogle Scholar
  7. 7.
    Hakuba A, Tanaka K, Suzuki T, Nishimura S. A combined orbitozygomatic infratemporal epidural and subdural approach for lesions involving the entire cavernous sinus. J Neurosurg. 1989;71(5 Pt 1):699–704.CrossRefGoogle Scholar
  8. 8.
    Inoue T, Rhoton AL Jr, Theele D, Barry ME. Surgical approaches to the cavernous sinus: a microsurgical study. Neurosurgery. 1990;26(6):903–32.CrossRefGoogle Scholar
  9. 9.
    Dolenc VV. A combined epi- and subdural direct approach to carotid-ophthalmic artery aneurysms. J Neurosurg. 1985;62(5):667–72.CrossRefGoogle Scholar
  10. 10.
    Parkinson D. A surgical approach to the cavernous portion of the carotid artery. Anatomical studies and case report. J Neurosurg. 1965;23(5):474–83.CrossRefGoogle Scholar
  11. 11.
    Perneczky A, Knosp E, Matula C. Cavernous sinus surgery. Approach through the lateral wall. Acta Neurochir. 1988;92(1–4):76–82.CrossRefGoogle Scholar
  12. 12.
    Fernandez-Miranda JC, Gardner PA, Rastelli MM Jr, Peris-Celda M, Koutourousiou M, Peace D, Snyderman CH, Rhoton AL Jr. Endoscopic endonasal transcavernous posterior clinoidectomy with interdural pituitary transposition. J Neurosurg. 2015;122(2):479. Scholar
  13. 13.
    Labib MA, Prevedello DM, Carrau R, Kerr EE, Naudy C, Abou Al-Shaar H, et al. A road map to the internal carotid artery in expanded endoscopic endonasal approaches to the ventral cranial base. Neurosurgery. 2014;10(Suppl 3):448–71; discussion 71.CrossRefGoogle Scholar
  14. 14.
    Fernandez-Miranda JC, Tormenti M, Latorre F, Gardner P, Snyderman C. Endoscopic endonasal middle clinoidectomy: anatomic, radiological, and technical note. Neurosurgery. 2012;71(2 Suppl Operative):ons233–9; di scussion ons9.PubMedGoogle Scholar
  15. 15.
    Labib MA, Prevedello DM, Fernandez-Miranda JC, Sivakanthan S, Benet A, Morera V, et al. The medial opticocarotid recess: an anatomic study of an endoscopic “key landmark” for the ventral cranial base. Neurosurgery. 2013;72(1 Suppl Operative):66–76; discussion.PubMedGoogle Scholar
  16. 16.
    Martins C, Yasuda A, Campero A, Rhoton AL Jr. Microsurgical anatomy of the oculomotor cistern. Neurosurgery. 2006;58(4 Suppl 2):ONS-220-7; discussion ONS-7-8.Google Scholar
  17. 17.
    Fernandez-Miranda JC, Gardner PA, Rastelli MM Jr, Peris-Celda M, Koutourousiou M, Peace D, et al. Endoscopic endonasal transcavernous posterior clinoidectomy with interdural pituitary transposition. J Neurosurg. 2014;121(1):91–9.CrossRefGoogle Scholar
  18. 18.
    Barges-Coll J, Fernandez-Miranda JC, Prevedello DM, Gardner P, Morera V, Madhok R, et al. Avoiding injury to the abducens nerve during expanded endonasal endoscopic surgery: anatomic and clinical case studies. Neurosurgery. 2010;67(1):144–54; discussion 54.CrossRefGoogle Scholar
  19. 19.
    Rhoton ALJ. The supratentorial cranial space: microsurgical anatomy and surgical approaches. Neurosurgery. 2002;51(4):S1–iii.CrossRefGoogle Scholar
  20. 20.
    Micko AS, Wohrer A, Wolfsberger S, Knosp E. Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification. J Neurosurg. 2015;122(4):803–11.CrossRefGoogle Scholar
  21. 21.
    Van Rompaey J, Suruliraj A, Carrau R, Panizza B, Solares CA. Meckel’s cave access: anatomic study comparing the endoscopic transantral and endonasal approaches. Eur Arch Otorhinolaryngol. 2014;271(4):787–94.CrossRefGoogle Scholar
  22. 22.
    Pinheiro-Neto CD, Fernandez-Miranda JC, Rivera-Serrano CM, Paluzzi A, Snyderman CH, Gardner PA, et al. Endoscopic anatomy of the palatovaginal canal (palatosphenoidal canal): a landmark for dissection of the vidian nerve during endonasal transpterygoid approaches. Laryngoscope. 2012;122(1):6–12.CrossRefGoogle Scholar
  23. 23.
    Snyderman CH, Kassam AB. Endoscopic techniques for pathology of the anterior cranial fossa and ventral skull base. J Am Coll Surg. 2006;202(3):563.CrossRefGoogle Scholar
  24. 24.
    Vaz-Guimaraes F, Rastelli MM Jr, Fernandez-Miranda JC, Wang EW, Gardner PA, Snyderman CH. Impact of dynamic endoscopy and bimanual-binarial dissection in endoscopic Endonasal surgery training: a laboratory investigation. J Neurol Surg B Skull Base. 2015;76(5):365–71.CrossRefGoogle Scholar
  25. 25.
    Zwagerman NT, Shin S, Wang EW, Fernandez-Miranda JC, Snyderman CH, Gardner PA. A prospective, randomized control trial for lumbar drain placement after endoscopic endonasal skull base surgery. J Neurol Surg B Skull Base. 2016;77(S 02):LFP-13-03.Google Scholar
  26. 26.
    Koutourousiou M, George Z, Fernandez-Miranda J, Eric W, Carl S, Paul G. Surgical management of primary cavernous sinus tumors. J Neurol Surg B Skull Base. 2013;74(S 01):A230. Scholar
  27. 27.
    Raza SM, Donaldson AM, Mehta A, Tsiouris AJ, Anand VK, Schwartz TH. Surgical management of trigeminal schwannomas: defining the role for endoscopic endonasal approaches. Neurosurg Focus. 2014;37(4):E17.CrossRefGoogle Scholar
  28. 28.
    Shin SS, Gardner PA, Stefko ST, Madhok R, Fernandez-Miranda JC, Snyderman CH. Endoscopic endonasal approach for nonvestibular schwannomas. Neurosurgery. 2011;69(5):1046–57; discussion 57.PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Georgios A. Zenonos
    • 1
  • Stefan Lieber
    • 1
  • Juan C. Fernandez-Miranda
    • 1
  1. 1.Department of NeurosurgeryUniversity of Pittsburgh Medical CenterPittsburghUSA

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