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Cavernous sinus medial wall: dural or fibrous layer? Systematic review of the literature

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Abstract

The cavernous sinus (CS) has one of the most complex anatomical networks of the skull base and because of the diversity of its contents is involved in many pathological processes. Nevertheless, anatomical literature concerning the CS is still controversial, so a systematic literature review was performed to find out the microanatomy of the medial wall of the CS and its clinical importance on sellar pathologies. Experimental studies from English-language literature between 1996 and 2010 were identified in MEDLINE, LILACS, and Cochrane databases. After analysis, two tables were prepared exhibiting the major points of each article. Fourteen experimental studies were included in the tables. Four studies concluded that the medial wall of the CS is composed of a loose, fibrous structure, and the remaining ten presumed that the medial wall is formed by a dural layer that constitutes the lateral wall of the sella. The lack of definition standards and of methodological criteria led to variation in the results among different studies. Thus, this hindered results comparison, possibly explaining the different observations.

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Acknowledgment

The authors wish to thank Cassius Vinicius Reis, MD (Belo Horizonte, MG) for providing the figures.

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Authors and Affiliations

  1. Department of Neurosurgery, Hospital da Força Aérea do Galeão, Rio de Janeiro, RJ, Brazil

    Mariangela Barbi Gonçalves & José Alberto Landeiro

  2. Department of Neurology, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil

    Mariangela Barbi Gonçalves & Regina Maria Papais Alvarenga

  3. Department of Neurosurgery, Center of Neurology and Neurosurgery Associates, Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil

    Jean Gonçalves de Oliveira

  4. University of Central Arkansas, Conway, AR, USA

    Hillary Ann Williams

  5. Department of Neurosurgery, Universidade Federal Fluminense, Niterói, RJ, Brazil

    José Alberto Landeiro

  6. Rua Nina Rodrigues 72/602 Jardim Botânico, 22461-100, Rio de Janeiro, RJ, Brazil

    Mariangela Barbi Gonçalves

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  1. Mariangela Barbi Gonçalves
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  2. Jean Gonçalves de Oliveira
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Correspondence to Mariangela Barbi Gonçalves.

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Comments

Takeshi Mikami, Sapporo, Japan

The authors reported on variations in the morphology of the cavernous sinus medial wall, which has a complex anatomy and adjoins important neurovascular structures. The morphological details are interesting, and an anatomical review of the region would benefit neurosurgeons seeking to develop effective surgical strategies for dealing with pituitary lesions, procedures that reduce the risk of surgical complications when such lesions are excised. In particular, the recent introduction of endoscopic endonasal transsphenoidal techniques for surgery of the pituitary gland has spurred development of numerous modifications and approaches aimed at providing wider surgical views, including exposure of the cavernous sinus so that tumors located within the cavernous sinus can be excised. Therefore, detailed knowledge of cavernous sinus medial wall anatomy is increasingly important.

Our clinical experience led us to believe that the medial wall of the cavernous sinus was a loose fibrous tissue, so recognition of the dural layer by many anatomical researchers was surprising. As the authors pointed out, however, the definition of these structures may be unclear, and, regrettably, their paper does not reach useful conclusions on this subject. In any case, the medial wall of the cavernous sinus is a weak structure, and it is certain that careful manipulation of it is indispensable during clinical procedures.

Benoit JM Pirotte, Brussels, Belgium

M. Goncalves and coworkers provide here a very useful and detailed critical literature review on the controversial nature of the cavernous sinus medial wall. In this paper, the authors state accurately the anatomical and clinical relevance of that issue. Actually, there is a large variability of methods (anatomical/microscopical dissection, histological/MRI analysis) and description of the thickness and nature of the CS medial wall. The presented analysis appears convincing, and the number of 385 collected samples in the review is significant. The authors did a real effort to collect such data, and they should be encouraged in further investigating in that field. Indeed, there is an urgent need of a consensus on that matter. This paper emphasizes that original systematic anatomical and/or MRI studies are lacking and should be conducted.

Takeshi Kawase, Tokyo, Japan

Because of technological advancement such as endoscopy, the origin of the the cavernous sinus has been the focus of studies again. This paper presents an interesting summary of data from 14 current papers concerning the topic.

It might be a mutual understanding that the parasellar compartment is located in the interdural space between the periosteum of the sphenoid sinus and the meningeal dura of the lateral wall. In those papers, there was a consensus that the lower medial wall between the cavernous sinus and sphenoid sinus could be the periosteal origin. However, their opinions varied on the upper medial wall which separates the cavernous sinus and the pituitary body. One of their common finding of the upper medial wall was “a very thin and loose connective tissue.” However, their opinions on the histological origin were different.

A way to solve the histological question is by considering the three following hypotheses: If the pituitary body could be placed in the epidural space, the medial wall might be the periosteal dura. If it could be in the subdural space, the membrane might be the meningeal dura. However, both the periosteal and meningeal dura are commonly not so loose but more tight, showing different histological findings. It must be considered on the third hypothesis that the pituitary body could be in the interdural space, like the parasellar compartment. We have to recall our memory from current surgery of the cavernous sinus that the “deep layer (inner layer)” of the cavernous sinus was thin and loose, having an easy surgical cleavage plane from the meningeal dura of the lateral wall. By our histological and clinical study, the “deep layer” was found around the cranial nerves, protecting those from injury. I found the nature of the medial wall, with similarity to the “deep layer”, in the following points:

1. A loose, semitransparent, and thin nature.

2. Protection of the pituitary body.

3. Presence of easy surgical cleavage plane from the suprasellar dura (diaphragma sellae).

(Data from Fig. 2F [8])

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Gonçalves, M.B., de Oliveira, J.G., Williams, H.A. et al. Cavernous sinus medial wall: dural or fibrous layer? Systematic review of the literature. Neurosurg Rev 35, 147–154 (2012). https://doi.org/10.1007/s10143-011-0360-3

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