Patency of the Cavernous Sinus after Medial Wall Resection: A Tertiary Center Experience

Introduction: The cavernous sinus (CS) represents a challenging and complex anatomical region. The medial wall of the CS is a critical structure to resect to avoid recurrence in invading pituitary adenomas and other nonadenomatous CS invading lesions. Venous bleeding during opening and resection of the CS necessitates intra-sinus use of hemostatic agents, ceasing flow of blood through the structure during resection. However, the literature is scarce on the fate of CS patency after such prolonged hemostasis. This knowledge gap warrants attention, as it holds the potential to enhance our comprehension of the surgical outcomes and recovery trajectories of patients undergoing this type of procedure.

Methods: In this retrospective study looking at surgeries between 2021 and 2023, patients undergoing endoscopic endonasal approach (EEA) to resect CS invading tumors and requiring CS medial wall (CSMW) resection were included. SPSS was used to identify time required for CS to patency, percentage of CS patency, and factors associated to CS patency.

Results: 66 patients met inclusion criteria, with mean age at surgery found to be 49 years, and two thirds of the surgical population being female. Caucasians represented 59.1% of the study population, Hispanic 22.7%, Asians 12.1%, and the other ethnicities 6%. Overall, CS patency was achieved in 85% within the first 12 months and 92% by 18 months. Interestingly, bilateral resection of CSMW significantly increased rate of CS nonpatency between 3-12 months post-op by a factor of 5.25 (CI: 1.6–16.8, p = 0.04). Meningiomas also increased the rate of CS nonpatency during that timeframe by a factor of 10.25 (CI: 1.05-99.9, p = 0.045) when compared to pituitary adenomas and craniopharyngiomas. Previous endoscopic surgery to the central skull base and radiation to the head and neck did not increase CS nonpatency. Importantly, patency versus nonpatency was not associated with any significant difference in postoperative adverse events or effects.

Conclusion: The majority of patients undergoing CSMW resection have return of patency of the CS within the first year. Increased rates of nonpatency include bilateral CSMW resection and CSMW resection for the removal of meningiomas. Whether or not patency returns is not associated with any adverse event or effect. This is one more data point confirming safety of CSMW resection. Neurosurgery and rhinology skull base teams should train to safely perform resection of the CSMW when tumors invade this structure to increase chances of obtaining complete gross tumor resection.

Publication History

Article published online:
05 February 2024