Anatomical Relationships of Intracavernous Internal Carotid Artery to Intracavernous Neural Structures

ABSTRACT

The objective is to correlate the intracavernous internal carotid artery (ICA) with the position of the intracavernous neural structures. The cavernous sinuses of nine injected cadaveric heads were dissected bilaterally. As measured on computed tomographic angiograms from 100 adults, anatomical relationships and measurements of intracavernous ICA and neural structures were studied and correlated to the intracavernous ICA curvature. Intracavernous ICAs were classified as normal and redundant. The meningohypophyseal trunk (MHT) of normal ICAs appeared to be closely related to the abducens nerve compared with redundant ICAs (5.5 ± 2.1 mm versus 10.0 ± 2.5 mm, respectively; p = 0.001). The position of the inferolateral trunk (ILT) varied along the horizontal segment of the intracavernous ICA. On imaging studies the ICA curvature correlated with the kyphotic degree of the skull and similarity of the ICA curvature between sides. The safety margin for preventing iatrogenic intracavernous nerve injury during surgical exploration or transarterial embolization of vascular lesions around the MHT is high with redundant ICAs. In contrast, a transvenous endovascular approach via the inferior petrosal sinus may be too distant to reach the MHT when ICAs are redundant. Approaching lesions of the inferolateral trunk may be the same regardless of ICA type.

KEYWORDS

Abducens nerve - carotid-cavernous fistula - cavernous sinus anatomy - internal carotid artery - sympathetic nerve

REFERENCES

• 1 Harris F S, Rhoton A L. Anatomy of the cavernous sinus. A microsurgical study.  J Neurosurg. 1976;  45(2) 169-180
• 2 Inoue T, Rhoton Jr A L, Theele D, Barry M E. Surgical approaches to the cavernous sinus: a microsurgical study.  Neurosurgery. 1990;  26(6) 903-932
• 3 Kawase T, van Loveren H, Keller J T, Tew J M. Meningeal architecture of the cavernous sinus: clinical and surgical implications.  Neurosurgery. 1996;  39(3) 527-534 discussion 534-536
• 4 Miyazaki Y, Yamamoto I, Shinozuka S, Sato O. Microsurgical anatomy of the cavernous sinus.  Neurol Med Chir (Tokyo). 1994;  34(3) 150-163
• 5 Parkinson D. Surgical anatomy of the lateral sellar compartment (cavernous sinus).  Clin Neurosurg. 1990;  36 219-239
• 6 Swanson M W. Neuroanatomy of the cavernous sinus and clinical correlations.  Optom Vis Sci. 1990;  67(12) 891-897
• 7 Taptas J N. The so-called cavernous sinus: a review of the controversy and its implications for neurosurgeons.  Neurosurgery. 1982;  11(5) 712-717
• 8 Umansky F, Nathan H. The lateral wall of the cavernous sinus. With special reference to the nerves related to it.  J Neurosurg. 1982;  56(2) 228-234
• 9 Umansky F, Valarezo A, Elidan J. The superior wall of the cavernous sinus: a microanatomical study.  J Neurosurg. 1994;  81(6) 914-920
• 10 Dolenc V. Direct microsurgical repair of intracavernous vascular lesions.  J Neurosurg. 1983;  58(6) 824-831
• 11 van Loveren H R, Keller J T, el-Kalliny M, Scodary D J, Tew Jr J M. The Dolenc technique for cavernous sinus exploration (cadaveric prosection). Technical note.  J Neurosurg. 1991;  74(5) 837-844
• 12 Koenigsberg R A, Vakil N, Hong T A et al.. Evaluation of platybasia with MR imaging.  AJNR Am J Neuroradiol. 2005;  26(1) 89-92
• 13 Bouthillier A, van Loveren H R, Keller J T. Segments of the internal carotid artery: a new classification.  Neurosurgery. 1996;  38(3) 425-432 discussion 432-433
• 14 Fischer E. Die Lageabweichungen der vorderen hirnarterie im gefassbild.  Zentralbl Neurochir. 1938;  3 300-313
• 15 Gibo H, Lenkey C, Rhoton Jr A L. Microsurgical anatomy of the supraclinoid portion of the internal carotid artery.  J Neurosurg. 1981;  55(4) 560-574
• 16 Ziyal I M, Ozgen T, Sekhar L N, Ozcan O E, Cekirge S. Proposed classification of segments of the internal carotid artery: anatomical study with angiographical interpretation.  Neurol Med Chir (Tokyo). 2005;  45(4) 184-190 discussion 190-191
• 17 Debrun G, Lacour P, Vinuela F, Fox A, Drake C G, Caron J P. Treatment of 54 traumatic carotid-cavernous fistulas.  J Neurosurg. 1981;  55(5) 678-692
• 18 Krisht A, Barnett D W, Barrow D L, Bonner G. The blood supply of the intracavernous cranial nerves: an anatomic study.  Neurosurgery. 1994;  34(2) 275-279, discussion 279
• 19 Tran-Dinh H. Cavernous branches of the internal carotid artery: anatomy and nomenclature.  Neurosurgery. 1987;  20(2) 205-210
• 20 Parkinson D. Collateral circulation of cavernous carotid artery: anatomy.  Can J Surg. 1964;  7 251-268
• 21 Lasjaunias P, Moret J, Doyon D, Vignaud J. C5 collaterals of the internal carotid siphon: embryology, angiographic anatomical correlations, pathological radio-anatomy (author's transl).  Neuroradiology. 1978;  16 304-305
• 22 Lasjaunias P, Moret J, Mink J. The anatomy of the inferolateral trunk (ILT) of the internal carotid artery.  Neuroradiology. 1977;  13(4) 215-220
• 23 Bergquist E, Willén R. Cavernous nodules in the dural sinuses. An anatomical, angiographic, and morphological investigation.  J Neurosurg. 1974;  40(3) 330-335
• 24 Parkinson D. Lateral sellar compartment: history and anatomy.  J Craniofac Surg. 1995;  6(1) 55-68
• 25 Johnston J A, Parkinson D. Intracranial sympathetic pathways associated with the sixth cranial nerve.  J Neurosurg. 1974;  40(2) 236-243
• 26 Parkinson D. Bernard, Mitchell, Horner syndrome and others?.  Surg Neurol. 1979;  11(3) 221-223
• 27 van Overbeeke J J, Jansen J J, Tulleken C A. The cavernous sinus syndrome. An anatomical and clinical study.  Clin Neurol Neurosurg. 1988;  90(4) 311-319
• 28 van Overbeeke J J, Dujovny M, Troost D. Anatomy of the sympathetic pathways in the cavernous sinus.  Neurol Res. 1995;  17(1) 2-8
• 29 Gutman I, Levartovski S, Goldhammer Y, Tadmor R, Findler G. Sixth nerve palsy and unilateral Horner's syndrome.  Ophthalmology. 1986;  93(7) 913-916
• 30 Silva M N, Saeki N, Hirai S, Yamaura A. Unusual cranial nerve palsy caused by cavernous sinus aneurysms. Clinical and anatomical considerations reviewed.  Surg Neurol. 1999;  52(2) 143-148 discussion 148-149
• 31 Tsuda H, Ishikawa H, Asayama K, Saito T, Endo S, Mizutani T. Abducens nerve palsy and Horner syndrome due to metastatic tumor in the cavernous sinus.  Intern Med. 2005;  44(6) 644-646
• 32 Barrow D L, Spector R H, Braun I F, Landman J A, Tindall S C, Tindall G T. Classification and treatment of spontaneous carotid-cavernous sinus fistulas.  J Neurosurg. 1985;  62(2) 248-256
• 33 Lewis A I, Tomsick T A, Tew Jr J M. Management of 100 consecutive direct carotid-cavernous fistulas: results of treatment with detachable balloons.  Neurosurgery. 1995;  36(2) 239-244 discussion 244-245
• 34 Théaudin M, Saint-Maurice J P, Chapot R et al.. Diagnosis and treatment of dural carotid-cavernous fistulas: a consecutive series of 27 patients.  J Neurol Neurosurg Psychiatry. 2007;  78(2) 174-179
• 35 Robinson D H, Song J K, Eskridge J M. Embolization of meningohypophyseal and inferolateral branches of the cavernous internal carotid artery.  AJNR Am J Neuroradiol. 1999;  20(6) 1061-1067
• 36 Kobayashi N, Miyachi S, Negoro M et al.. Endovascular treatment strategy for direct carotid-cavernous fistulas resulting from rupture of intracavernous carotid aneurysms.  AJNR Am J Neuroradiol. 2003;  24(9) 1789-1796
• 37 Wanke I, Doerfler A, Stolke D, Forsting M. Carotid cavernous fistula due to a ruptured intracavernous aneurysm of the internal carotid artery: treatment with selective endovascular occlusion of the aneurysm.  J Neurol Neurosurg Psychiatry. 2001;  71(6) 784-787
• 38 Ozveren M F, Uchida K, Aiso S, Kawase T. Meningovenous structures of the petroclival region: clinical importance for surgery and intravascular surgery.  Neurosurgery. 2002;  50(4) 829-836 discussion 836-837
• 39 Day J D, Fukushima T. Direct microsurgery of dural arteriovenous malformation type carotid-cavernous sinus fistulas: indications, technique, and results.  Neurosurgery. 1997;  41(5) 1119-1124 discussion 1124-1126
• 40 Guerrero C A, Raja A I, Naranjo N, Krisht A F. Obliteration of carotid-cavernous fistulas using direct surgical and coil-assisted embolization: technical case report.  Neurosurgery. 2006;  58(2) E382 discussion E382
• 41 Mullan S. Fistulas and vascular malformations of the dura and dural sinuses. In: Apuzzo MLJ Brain Surgery: Complication Avoidance and Management. 2nd ed. New York; Churchill Livingstone 1993: 1117-1141
• 42 Tu Y K, Liu H M, Hu S C. Direct surgery of carotid cavernous fistulae and dural arteriovenous malformations of the cavernous sinus.  Neurosurgery. 1997;  41(4) 798-805 discussion 805-806
• 43 Fukushima T, Day J. Intracavernous carotid artery aneurysms. Brain Surger: Complication Avoidance and Management. New York; Churchill 1993: 925-944
• 44 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
• 45 Javadpour M, Wallace M. Surgical management of cranial dural arteriovenous fistulas. Schmidek and Sweet's Operative Neurosurgical Techniques: Indications, Methods, and Results. Philadelphia; WB Saunders 2006: 1287-1305
• 46 Parkinson D. A surgical approach to the cavernous portion of the carotid artery. Anatomical studies and case report.  J Neurosurg. 1965;  23(5) 474-483
• 47 Dolenc V V. Surgery of vascular lesions of the cavernous sinus.  Clin Neurosurg. 1990;  36 240-255