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The “candy wrapper” of the pituitary gland: a road map to the parasellar ligaments and the medial wall of the cavernous sinus

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Abstract

Purpose

The anatomy of the medial wall of the cavernous sinus (MWCS) and parasellar ligaments (PLs) has acquired increasing importance in endoscopic endonasal (EE) surgery of the cavernous sinus (CS), including resection of the MWCS in functioning pituitary adenomas (FPAs). Although anatomical studies have been published, it represents a debated topic due to their complex morphology. The aim is to offer a description of the PLs that originate from the MWCS and reach the lateral wall of the cavernous sinus (LWCS), proposing the “candy wrapper” model. The relationships between the neurovascular structures and histomorphological aspects were investigated.

Methods

Forty-two CSs from twenty-one human heads were studied. Eleven specimens were used for EE dissection; five underwent a microscopic dissection. Five specimens were used for histomorphological analysis.

Results

Two groups of PLs with a fan-shaped appearance were encountered. The anterior group included the periosteal ligament (55% sides) and the carotico-clinoid complex (100% sides), formed by the anterior horizontal and the carotico-clinoid ligaments. The posterior group was formed by the posterior horizontal (78% sides), and the inferior hypophyseal ligament (34% sides). The periosteal ligament originated inferiorly from the MWCS, reaching the periosteal dura. The anterior horizontal ligament was divided in a superior and inferior branch. The superior one continued as the carotid-oculomotor membrane, and the inferior branch reached the CN VI. The carotico-clinoid ligament between the middle and anterior clinoid was ossified in 3 sides. The posterior horizontal ligament was related to the posterior genu and ended at the LWCS. The inferior hypophyseal ligament followed the homonym artery. The ligaments related to the ICA form part of the adventitia.

Conclusion

The “candy wrapper” model adds further details to the previous descriptions of the PLs. Understanding this complex anatomy is essential for safe CS surgery, including MWCS resection for FPAs.

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Data Availability

All data supporting the findings of this study are available within the paper and its Supplementary Information.

Abbreviations

CN:

Cranial nerve

CS:

Cavernous sinus

EE:

Endoscopic endonasal

FPA:

Functional pituitary adenoma

ICA:

Internal carotid artery

ILT:

Infero latero trunk

LWCS:

Lateral wall of cavernous sinus

MWCS:

Medial wall of cavernous sinus

MHT:

Meningohypophyseal trunk

PL:

Parasellar ligament

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Acknowledgements

The authors wish to thank the generosity of those who donated their bodies to science for anatomical studies.

Funding

S.S. received a financial support by “Fondazione Beretta”, Brescia, Italy. Joseph I. and Barbara Ashkins Endowed Professorship in Neurosurgery, Mayo Clinic, Rochester, MN. Charles B. and Ann L. Johnson Endowed Professorship in Neurosurgery, Mayo Clinic, Rochester, MN.

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Authors and Affiliations

  1. Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy

    Simona Serioli & Marco Maria Fontanella

  2. Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA

    Simona Serioli, Pedro Plou, Luciano C. P. C. Leonel & Maria Peris-Celda

  3. Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA

    Simona Serioli, Pedro Plou, Luciano C. P. C. Leonel, Stephen Graepel, Michael J. Link, Carlos D. Pinheiro-Neto & Maria Peris-Celda

  4. Neurosurgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

    Pedro Plou

  5. Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy

    Barbara Buffoli & Rita Rezzani

  6. Vita-Salute San Raffaele University and Pathology Unit, IRCCS San Raffaele, Milan, Italy

    Pietro Luigi Poliani

  7. Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy

    Francesco Doglietto

  8. Catholic University School of Medicine, Rome, Italy

    Francesco Doglietto

  9. Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA

    Michael J. Link, Carlos D. Pinheiro-Neto & Maria Peris-Celda

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  1. Simona Serioli
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Contributions

Conception and design: Serioli, Plou, Peris-Celda. Acquisition of data: Serioli, Plou, Buffoli. Analysis and interpretation of data: Serioli, Plou, Peris-Celda. Drafting the article: Serioli. Critically revising the article: Plou, Peris-Celda. Reviewed submitted version of manuscript: All the authors. Approved the final version of the manuscript on behalf of all authors: Peris-Celda. Study supervision: Peris-Celda.

Corresponding author

Correspondence to Maria Peris-Celda.

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The study was approved by the Institutional Review and Biospecimens Committee, performed in accordance with the principles defined by the Declaration of Helsinki.

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Informed consent was obtained for the Fig. 7.

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Simona Serioli and Pedro Plou contributed equally.

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Serioli, S., Plou, P., Leonel, L.C.P.C. et al. The “candy wrapper” of the pituitary gland: a road map to the parasellar ligaments and the medial wall of the cavernous sinus. Acta Neurochir 165, 3431–3444 (2023). https://doi.org/10.1007/s00701-023-05736-x

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