Pretemporal Transcavernous Approach to Cavernous Sinus Meningioma with Suprasellar Extension Synchronous with Sphenoid Wing Meningioma: Operative Technique: 2-Dimensional Operative Video.

Abstract

Cavernous sinus meningiomas with suprasellar extension are challenging because of their proximity to the optic nerves, pituitary stalk, cranial nerves, and the cavernous/supraclinoid internal carotid artery (ICA). This complex anatomy necessitates precise microsurgical corridors for safe resection. The patient consented for the procedure and the publication of their images. Queen's University ethics board approved this publication. A 67-year-old woman who experienced a tonic-clonic seizure with left-sided weakness was found to have a right sphenoid wing meningioma and a synchronous meningioma involving the cavernous sinus with suprasellar extension. Tumors were resected via a right-sided pretemporal transcavernous approach.¹ A third asymptomatic left frontobasal meningioma was managed conservatively with clinical observation. This approach allows for the resection of tumors originating from the cavernous sinus with extension into the suprasellar or posterior fossa locations. The presence of an interosseous bridge (IOB)² between the anterior and posterior clinoid processes posed a challenge to clinoidectomy and required meticulous drilling techniques. Essential steps: 1) Dissection and removal of the meningeal layer of the lateral wall of the cavernous sinus. 2) Anterior clinoidectomy and skeletonization of the third nerve in the cavernous sinus and gentle inferior mobilization for safe drilling of the IOB/posterior clinoid to enhance access to suprasellar region. 3) Cutting around the distal dural ring for safe superior mobilization of ICA during the resection of the suprasellar component. 4) Gentle dissection of the tumor from optic nerve, third nerve, and pituitary stalk and preservation of critical vessels (PCOM, anterior choroidal,³ superior hypophyseal arteries).