We report a rare case of schwannoma of the lateral wall of the cavernous sinus, an exceedingly rare lesion affecting this anatomical district, and discuss salient aspects of the surgical approach to the cavernous sinus, which are traditionally considered technically challenging due to the high risk of postoperative morbidity and mortality related to the presence of the cranial nerves and internal carotid artery

Caruso, Riccardo

Marrocco, Luigi

Pesce, Alessandro

Piccione, Emanuele

Wierzbicki, Venceslao

Case Reports in Surgery

English

PubMed

Riccardo Caruso

Alessandro Pesce

Venceslao Wierzbicki

Luigi Marrocco

Emanuele Piccione

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Surgical Approach to the Cavernous Sinus for a Trigeminal Schwannoma Resection: Technical Note and Case Report

Case ReportSurgical Approach to the Cavernous Sinus for a TrigeminalSchwannoma Resection: Technical Note and Case ReportRiccardo Caruso,1 Alessandro Pesce,2,3 Venceslao Wierzbicki,1Luigi Marrocco,1 and Emanuele Piccione11Neurosurgery Department, Celio Military Hospital, Rome, Italy2NESMOS Department, Sapienza University of Rome, Rome, Italy3Neurosurgery Department, Azienda Ospedaliera Sant’Andrea, Rome, ItalyCorrespondence should be addressed to Alessandro Pesce; ale pesce83@yahoo.itReceived 17 July 2016; Accepted 15 September 2016Academic Editor: Christophoros ForoulisCopyright © 2016 Riccardo Caruso et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.We report a rare case of schwannoma of the lateral wall of the cavernous sinus, an exceedingly rare lesion affecting this anatomicaldistrict, and discuss salient aspects of the surgical approach to the cavernous sinus, which are traditionally considered technicallychallenging due to the high risk of postoperative morbidity and mortality related to the presence of the cranial nerves and internalcarotid artery.1. IntroductionSchwannomas of the cavernous sinus are very rare andusually originate from the trigeminal nerve, though casesoriginating from the oculomotor nerves and from the carotidplexus have also been described in the literature [1–10]. In thisarticle, we report the case of a schwannoma of the lateral wallof the cavernous sinus that was surgically treated.2. Case PresentationIn July 2013, a 39-year-old man came to our attention: forthree months he had been complaining of diplopia whenlooking sideways to the right. In the last two weeks beforehis examination he had also been suffering from frequentepisodes of right-sided hemifacial paraesthesias. Upon neu-rological examination, it was revealed that there was a deficitof the 6th cranial nerve on the right side, which arose onlywhen the patient looked sideways, to the far right.The patient had undergone a cerebralMRI scan (Figure 1)that showed a 3 cm maximal diameter isointense lesion cen-tred in the region of the right cavernous sinus on T1-weightedimages. In T2-weighted images, the lesion was hyperintensecompared with the surrounding brain. The lesion presentedinhomogeneous enhancement after contrast injection.While in hospital, a CT angiography was performed inorder to document the relationship of the tumour with theICA and with the cavernous sinus. The mass appeared adja-cent to the wall of the carotid artery (Figure 2); the CT venousphase (Figure 3) showed that the cavernous sinus was com-pressed and medialized by the tumour rather than invadedby it. On the basis of the images and of the clinical historyof the patient it was theorized that the tumour might havedeveloped in the virtual space existing between the dura andthe inner membrane of the lateral wall of the cavernous sinus(Figure 4).The patient underwent microneurosurgery using the pte-rional approach; we opened the dura, moved with a spatulathe medial part of the temporal pole, and exposed the lateralwall of the cavernous sinus, which was severely bulgingespecially in the lower part. The dura of the wall of thecavernous sinuswas incisedwhere it protruded themost, thusexposing a well-capsulized grey-yellowish tumour (Figure 5).With an ultrasonic aspirator the tumour was partially emp-tied, thus also draining two small intratumoural cysts full ofyellow fluid; then, the cleavage of the capsule was performed.Hindawi Publishing CorporationCase Reports in SurgeryVolume 2016, Article ID 6458189, 5 pageshttp://dx.doi.org/10.1155/2016/64581892 Case Reports in Surgery(a) (b)(d) (c)Figure 1: One can see clockwise the MR images of the tumour on T1-weighted, on T1 with contrast, and on T2-weighted images.The cleavage was quite easy both in the lateral and in theinferior parts where the capsule was adjacent to the dura, butit becamemore difficult in themiddle as there was a very thin,pulsing membrane that in some areas adhered to the tumour.Once the dissection was completed, the tumour, alreadypartially emptied, was removed en bloc. After the removal,there was a slight leakage of arterial blood from the innermembrane; however, haemostasis was easily achieved byapplying a gelatin matrix hemostatic sealant into the cavity.The postoperative course was normal and, in the first fewhours after surgery, the 6th CN deficit and the paresthesiasdisappeared. The histological examination showed that thetumour was a schwannoma. An MRI scan (Figure 6) per-formed 5 months after surgery showed complete removal ofthe tumour.Before writing this paper, the patient was consulted andgave informed written explicit consent to this report.3. DiscussionApart from its rarity, we want to stress two features thatmake our case interesting: a clinical feature and the surgicaltechnique used.We believe that the tumour we operated on was atrigeminal schwannoma (Figure 7), even though the firstsymptom was a deficit of the 6th CN.The scans, in fact, showthat the tumour was growing in the space between the duramater and the inner membrane of the cavernous sinus lateralwall where the branches of the trigeminal nerve run,while the6th CN runs inside the venous sinus [11–13]. In the literaturethere are other cases of neurinoma of the 5th CN with aclinical onset of palsy in the 6th CN [14].From the anatomical viewpoint, the lateral wall of thecavernous sinus, which is more properly named paraclinoidarea, is composed of a fold of the two layers of the duramater: the endosteal and meningeal layers. In this region, themeningeal layer represents the outer layer of the cavernoussinus, while the endosteal one is the inner layer and thusenvelops the intracavernous course of the 3rd, 4th, and 5thCN [15].The exact localization of the tumour in what is usually anominal area between the dura mater of the outer layer andthe inner membrane made us carry out the surgery of theschwannoma not by entering the cavernous sinus through theParkinson triangle [16, 17] but by attacking it directly byopening the dura where it bulged out the most. This surgicalCase Reports in Surgery 3Figure 2: The CT angiography shows that the tumour is adjacent to the wall of the right internal carotid artery.Figure 3: The CT venous phase shows that the cavernous sinus is compressed and medialized by the tumour rather than invaded by it.10 11 1 29 8 7 6 53 412Figure 4: Anatomical diagram of the cavernous sinus: 1: hypophysis, 2: internal carotid artery, 3: 6th CN, 4: meningeal (outer) layer, 5:cavernous sinus, 6: sphenoid sinus, 7: endosteal (inner) layer, 8: V1, 9: V2, 10: 4th CN, 11: 3rd CN, and 12: the outer layer at the diaphragmasellae. The endosteal layer is marked in green, while the meningeal layer is marked in yellow.4 Case Reports in Surgery(a) (b)Figure 5: In (a), the arrow indicates the bulging of the lateral wall of the cavernous sinus caused by the tumour; in (b), the arrow points tothe appearance of the tumour after the incision of the dura.Figure 6: An MRI scan performed 5 months after surgery shows complete removal of the tumour.(a) (b) (c)Figure 7: (a) Hematoxylin and Eosin, 20x: the classical histopathology of a schwannoma, hypercellular matrix composed of spindle cells withelongated nuclei, (b) with strong positive S100 immunostaining, and (c) rare mitotic figures outlined with Ki-67 immunostaining.choice, together with the caution in dissecting the tumouralcapsule from the inner membrane, allowed us to removethe tumour while remaining outside of the venous sinusand therefore avoiding the copious bleeding that makesperforming surgery on this area particularly difficult. Thisway we also managed to preserve the various cranial nerveswithout having to expose them and isolate them one byone. The ICA trunk was not exposed but simply perceivedthrough the pulsation of the inner membrane. We chose anintradural approach, but we could have achieved the samesurgical results with an epidural approach [18–20].In conclusion, our choice of surgical technique wassuccessful and the removal of the tumour was fairly uncom-plicated.Case Reports in Surgery 5AbbreviationsICA: Internal carotid arteryMRI: Magnetic Resonance ImagingCN: Cranial nerve.Competing InterestsThe authors certify that they have no affiliations with orinvolvement in any organization or entity with any financialinterest (such as honoraria; educational grants; participationin speakers’ bureaus; membership, employment, consultan-cies, stock ownership, or other equity interests; and experttestimony or patent-licensing arrangements) or nonfinan-cial interest (such as personal or professional relationships,affiliations, knowledge, or beliefs) in the subject matter ormaterials discussed in this manuscript. The authors confirmtheir adherence to ethical standards and have no financialdisclosures that would be a potential conflict of interests withthis publication. The authors have no personal, financial, orinstitutional interest in any of the drugs, materials, or devicesdescribed in this article.References[1] A. Cerillo, M. Bianco, N. Narciso et al., “Trigeminal cysticneurinoma in the cavernous sinus. Case report,” Journal ofNeurosurgical Sciences, vol. 39, no. 3, pp. 165–170, 1995.[2] M. B. Eisenberg, O. Al-Mefty, F. DeMonte, and G. T. Burson,“Benign nonmeningeal tumors of the cavernous sinus,” Neuro-surgery, vol. 44, no. 5, pp. 949–954, 1999.[3] T. Inoue, M. Fukui, T. Matsushima, K. Hasuo, and M. Mat-sunaga, “Neurinoma in the cavernous sinus: report of twocases,” Neurosurgery, vol. 27, no. 6, pp. 986–990, 1990.[4] M. Lanotte,M. T. Giordana, C. Forni, andC. A. Pagni, “Schwan-noma of the cavernous sinus. Case report and review of theliterature,” Journal of Neurosurgical Sciences, vol. 36, no. 4, pp.233–238, 1992.[5] M. Necmettin Pamir, T. Kilic, M. Memet Özek, K. Özduman,and U. Türe, “Non-meningeal tumours of the cavernous sinus:a surgical analysis,” Journal of Clinical Neuroscience, vol. 13, no.6, pp. 626–635, 2006.[6] L. Mascarenhas, Z. Magalhaes, M. Honavar et al., “Schwan-noma of the abducens nerve in the cavernous sinus,” ActaNeurochirurgica, vol. 146, no. 4, pp. 389–392, 2004.[7] T. D. Nadkarni, K. S. Dindorkar, K. Desai, and A. Goel, “Cav-ernous sinus thrombosis and air embolism following surgery foracoustic neurinoma: a case report,”Neurology India, vol. 50, no.2, pp. 201–203, 2002.[8] T. Nakagawa, K. Uchida, M. F. Ozveren, and T. Kawase,“Abducens schwannoma inside the cavernous sinus proper: casereport,” Surgical Neurology, vol. 61, no. 6, pp. 559–563, 2004.[9] T. Oyoshi, K. Hirahara, M. Nino et al., “Trigeminal neurinomain the cavernous sinus revealed by intratumoral hemorrhage:a case report,” Neurological Surgery, vol. 22, no. 2, pp. 175–178,1994.[10] U. Türe, A. Şeker, Ö. Kurtkaya et al., “Internal carotid plexusschwannoma of the cavernous sinus: case report,”Neurosurgery,vol. 52, no. 2, pp. 435–439, 2003.[11] E. R. Laws, “New anatomical description of the cavernous sinussurface and its significance in microsurgery—Comment,” SkullBase Surgery, vol. 7, article 191, 1997.[12] A. Prescher, D. Brors, and K. von Ammon, “New anatomicaldescription of the cavernous sinus surface and its significancein microsurgery,” Skull Base Surgery, vol. 7, no. 4, pp. 183–191,1997.[13] M. El-Kalliny, H. van Loveren, J. T. Keller, and J. M. Tew Jr.,“Tumors of the lateral wall of the cavernous sinus,” Journal ofNeurosurgery, vol. 77, no. 4, pp. 508–514, 1992.[14] J. Yamashita, R. Asato, H. Handa, S. Nakao, and M. Ogata,“Abducens nerve palsy as initial symptomof trigeminal schwan-noma,” Journal of Neurology, Neurosurgery and Psychiatry, vol.40, no. 12, pp. 1190–1197, 1977.[15] A. L. Rhoton, “The cavernous sinus, the cavernous venousplexus, and the carotid collar,” Neurosurgery, vol. 51, supple-ment, no. 4, pp. 375–410, 2002.[16] D. Parkinson, “Cavernous sinus exploration,” Journal of Neuro-surgery, vol. 76, pp. 341–342, 1992.[17] D. Parkinson, “Lateral sellar compartment O.T. (Cavernoussinus): history, anatomy, terminology,” Anatomical Record, vol.251, no. 4, pp. 486–490, 1998.[18] G. Mariniello, P. Cappabianca, S. Buonamassa, and E. De Div-itiis, “Surgical treatment of intracavernous trigeminal schwan-nomas via a fronto-temporal epidural approach,” Clinical Neu-rology and Neurosurgery, vol. 106, no. 2, pp. 104–109, 2004.[19] G. Zada, J. D. Day, and S. L. Giannotta, “The extraduraltemporopolar approach: a review of indications and operativetechnique,” Neurosurgical Focus, vol. 25, no. 6, p. E3, 2008.[20] V. V. Dolenc, “Frontotemporal epidural approach to trigeminalneurinomas,” Acta Neurochirurgica, vol. 130, no. 1–4, pp. 55–65,1994.

Surgical approach to the cavernous sinus for a trigeminal schwannoma resection: technical note and case report

We report a rare case of schwannoma of the lateral wall of the cavernous sinus, an exceedingly rare lesion affecting this anatomical district, and discuss salient aspects of the surgical approach to the cavernous sinus, which are traditionally considered technically challenging due to the high risk of postoperative morbidity and mortality related to the presence of the cranial nerves and internal carotid artery.</jats:p

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Case ReportSurgical Approach to the Cavernous Sinus for a TrigeminalSchwannoma Resection: Technical Note and Case ReportRiccardo Caruso,1 Alessandro Pesce,2,3 VenceslaoWierzbicki,1Luigi Marrocco,1 and Emanuele Piccione11Neurosurgery Department, Celio Military Hospital, Rome, Italy2NESMOS Department, Sapienza University of Rome, Rome, Italy3Neurosurgery Department, Azienda Ospedaliera Sant’Andrea, Rome, ItalyCorrespondence should be addressed to Alessandro Pesce; ale pesce83@yahoo.itReceived 17 July 2016; Accepted 15 September 2016Academic Editor: Christophoros ForoulisCopyright © 2016 Riccardo Caruso et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.We report a rare case of schwannoma of the lateral wall of the cavernous sinus, an exceedingly rare lesion affecting this anatomicaldistrict, and discuss salient aspects of the surgical approach to the cavernous sinus, which are traditionally considered technicallychallenging due to the high risk of postoperative morbidity and mortality related to the presence of the cranial nerves and internalcarotid artery.1. IntroductionSchwannomas of the cavernous sinus are very rare andusually originate from the trigeminal nerve, though casesoriginating from the oculomotor nerves and from the carotidplexus have also been described in the literature [1–10]. In thisarticle, we report the case of a schwannoma of the lateral wallof the cavernous sinus that was surgically treated.2. Case PresentationIn July 2013, a 39-year-old man came to our attention: forthree months he had been complaining of diplopia whenlooking sideways to the right. In the last two weeks beforehis examination he had also been suffering from frequentepisodes of right-sided hemifacial paraesthesias. Upon neu-rological examination, it was revealed that there was a deficitof the 6th cranial nerve on the right side, which arose onlywhen the patient looked sideways, to the far right.The patient had undergone a cerebralMRI scan (Figure 1)that showed a 3 cm maximal diameter isointense lesion cen-tred in the region of the right cavernous sinus on T1-weightedimages. In T2-weighted images, the lesion was hyperintensecompared with the surrounding brain. The lesion presentedinhomogeneous enhancement after contrast injection.While in hospital, a CT angiography was performed inorder to document the relationship of the tumour with theICA and with the cavernous sinus. The mass appeared adja-cent to the wall of the carotid artery (Figure 2); the CT venousphase (Figure 3) showed that the cavernous sinus was com-pressed and medialized by the tumour rather than invadedby it. On the basis of the images and of the clinical historyof the patient it was theorized that the tumour might havedeveloped in the virtual space existing between the dura andthe inner membrane of the lateral wall of the cavernous sinus(Figure 4).The patient underwent microneurosurgery using the pte-rional approach; we opened the dura, moved with a spatulathe medial part of the temporal pole, and exposed the lateralwall of the cavernous sinus, which was severely bulgingespecially in the lower part. The dura of the wall of thecavernous sinuswas incisedwhere it protruded themost, thusexposing a well-capsulized grey-yellowish tumour (Figure 5).With an ultrasonic aspirator the tumour was partially emp-tied, thus also draining two small intratumoural cysts full ofyellow fluid; then, the cleavage of the capsule was performed.Hindawi Publishing CorporationCase Reports in SurgeryVolume 2016, Article ID 6458189, 5 pageshttp://dx.doi.org/10.1155/2016/64581892 Case Reports in Surgery(a) (b)(d) (c)Figure 1: One can see clockwise the MR images of the tumour on T1-weighted, on T1 with contrast, and on T2-weighted images.The cleavage was quite easy both in the lateral and in theinferior parts where the capsule was adjacent to the dura, butit becamemore difficult in themiddle as there was a very thin,pulsing membrane that in some areas adhered to the tumour.Once the dissection was completed, the tumour, alreadypartially emptied, was removed en bloc. After the removal,there was a slight leakage of arterial blood from the innermembrane; however, haemostasis was easily achieved byapplying a gelatin matrix hemostatic sealant into the cavity.The postoperative course was normal and, in the first fewhours after surgery, the 6th CN deficit and the paresthesiasdisappeared. The histological examination showed that thetumour was a schwannoma. An MRI scan (Figure 6) per-formed 5 months after surgery showed complete removal ofthe tumour.Before writing this paper, the patient was consulted andgave informed written explicit consent to this report.3. DiscussionApart from its rarity, we want to stress two features thatmake our case interesting: a clinical feature and the surgicaltechnique used.We believe that the tumour we operated on was atrigeminal schwannoma (Figure 7), even though the firstsymptom was a deficit of the 6th CN.The scans, in fact, showthat the tumour was growing in the space between the duramater and the inner membrane of the cavernous sinus lateralwall where the branches of the trigeminal nerve run,while the6th CN runs inside the venous sinus [11–13]. In the literaturethere are other cases of neurinoma of the 5th CN with aclinical onset of palsy in the 6th CN [14].From the anatomical viewpoint, the lateral wall of thecavernous sinus, which is more properly named paraclinoidarea, is composed of a fold of the two layers of the duramater: the endosteal and meningeal layers. In this region, themeningeal layer represents the outer layer of the cavernoussinus, while the endosteal one is the inner layer and thusenvelops the intracavernous course of the 3rd, 4th, and 5thCN [15].The exact localization of the tumour in what is usually anominal area between the dura mater of the outer layer andthe inner membrane made us carry out the surgery of theschwannoma not by entering the cavernous sinus through theParkinson triangle [16, 17] but by attacking it directly byopening the dura where it bulged out the most. This surgicalCase Reports in Surgery 3Figure 2: The CT angiography shows that the tumour is adjacent to the wall of the right internal carotid artery.Figure 3: The CT venous phase shows that the cavernous sinus is compressed and medialized by the tumour rather than invaded by it.10 11 1 29 8 7 6 53 412Figure 4: Anatomical diagram of the cavernous sinus: 1: hypophysis, 2: internal carotid artery, 3: 6th CN, 4: meningeal (outer) layer, 5:cavernous sinus, 6: sphenoid sinus, 7: endosteal (inner) layer, 8: V1, 9: V2, 10: 4th CN, 11: 3rd CN, and 12: the outer layer at the diaphragmasellae. The endosteal layer is marked in green, while the meningeal layer is marked in yellow.4 Case Reports in Surgery(a) (b)Figure 5: In (a), the arrow indicates the bulging of the lateral wall of the cavernous sinus caused by the tumour; in (b), the arrow points tothe appearance of the tumour after the incision of the dura.Figure 6: An MRI scan performed 5 months after surgery shows complete removal of the tumour.(a) (b) (c)Figure 7: (a) Hematoxylin and Eosin, 20x: the classical histopathology of a schwannoma, hypercellular matrix composed of spindle cells withelongated nuclei, (b) with strong positive S100 immunostaining, and (c) rare mitotic figures outlined with Ki-67 immunostaining.choice, together with the caution in dissecting the tumouralcapsule from the inner membrane, allowed us to removethe tumour while remaining outside of the venous sinusand therefore avoiding the copious bleeding that makesperforming surgery on this area particularly difficult. Thisway we also managed to preserve the various cranial nerveswithout having to expose them and isolate them one byone. The ICA trunk was not exposed but simply perceivedthrough the pulsation of the inner membrane. We chose anintradural approach, but we could have achieved the samesurgical results with an epidural approach [18–20].In conclusion, our choice of surgical technique wassuccessful and the removal of the tumour was fairly uncom-plicated.Case Reports in Surgery 5AbbreviationsICA: Internal carotid arteryMRI: Magnetic Resonance ImagingCN: Cranial nerve.Competing InterestsThe authors certify that they have no affiliations with orinvolvement in any organization or entity with any financialinterest (such as honoraria; educational grants; participationin speakers’ bureaus; membership, employment, consultan-cies, stock ownership, or other equity interests; and experttestimony or patent-licensing arrangements) or nonfinan-cial interest (such as personal or professional relationships,affiliations, knowledge, or beliefs) in the subject matter ormaterials discussed in this manuscript. The authors confirmtheir adherence to ethical standards and have no financialdisclosures that would be a potential conflict of interests withthis publication. The authors have no personal, financial, orinstitutional interest in any of the drugs, materials, or devicesdescribed in this article.References[1] A. Cerillo, M. Bianco, N. Narciso et al., “Trigeminal cysticneurinoma in the cavernous sinus. Case report,” Journal ofNeurosurgical Sciences, vol. 39, no. 3, pp. 165–170, 1995.[2] M. B. Eisenberg, O. Al-Mefty, F. DeMonte, and G. T. Burson,“Benign nonmeningeal tumors of the cavernous sinus,” Neuro-surgery, vol. 44, no. 5, pp. 949–954, 1999.[3] T. Inoue, M. Fukui, T. Matsushima, K. Hasuo, and M. Mat-sunaga, “Neurinoma in the cavernous sinus: report of twocases,” Neurosurgery, vol. 27, no. 6, pp. 986–990, 1990.[4] M. Lanotte,M. T. Giordana, C. Forni, andC. A. Pagni, “Schwan-noma of the cavernous sinus. Case report and review of theliterature,” Journal of Neurosurgical Sciences, vol. 36, no. 4, pp.233–238, 1992.[5] M. Necmettin Pamir, T. Kilic, M. Memet O¨zek, K. O¨zduman,and U. Tu¨re, “Non-meningeal tumours of the cavernous sinus:a surgical analysis,” Journal of Clinical Neuroscience, vol. 13, no.6, pp. 626–635, 2006.[6] L. Mascarenhas, Z. Magalhaes, M. Honavar et al., “Schwan-noma of the abducens nerve in the cavernous sinus,” ActaNeurochirurgica, vol. 146, no. 4, pp. 389–392, 2004.[7] T. D. Nadkarni, K. S. Dindorkar, K. Desai, and A. Goel, “Cav-ernous sinus thrombosis and air embolism following surgery foracoustic neurinoma: a case report,”Neurology India, vol. 50, no.2, pp. 201–203, 2002.[8] T. Nakagawa, K. Uchida, M. F. Ozveren, and T. Kawase,“Abducens schwannoma inside the cavernous sinus proper: casereport,” Surgical Neurology, vol. 61, no. 6, pp. 559–563, 2004.[9] T. Oyoshi, K. Hirahara, M. Nino et al., “Trigeminal neurinomain the cavernous sinus revealed by intratumoral hemorrhage:a case report,” Neurological Surgery, vol. 22, no. 2, pp. 175–178,1994.[10] U. Tu¨re, A. S¸eker, O¨. Kurtkaya et al., “Internal carotid plexusschwannoma of the cavernous sinus: case report,”Neurosurgery,vol. 52, no. 2, pp. 435–439, 2003.[11] E. R. Laws, “New anatomical description of the cavernous sinussurface and its significance in microsurgery—Comment,” SkullBase Surgery, vol. 7, article 191, 1997.[12] A. Prescher, D. Brors, and K. von Ammon, “New anatomicaldescription of the cavernous sinus surface and its significancein microsurgery,” Skull Base Surgery, vol. 7, no. 4, pp. 183–191,1997.[13] M. El-Kalliny, H. van Loveren, J. T. Keller, and J. M. Tew Jr.,“Tumors of the lateral wall of the cavernous sinus,” Journal ofNeurosurgery, vol. 77, no. 4, pp. 508–514, 1992.[14] J. Yamashita, R. Asato, H. Handa, S. Nakao, and M. Ogata,“Abducens nerve palsy as initial symptomof trigeminal schwan-noma,” Journal of Neurology, Neurosurgery and Psychiatry, vol.40, no. 12, pp. 1190–1197, 1977.[15] A. L. Rhoton, “The cavernous sinus, the cavernous venousplexus, and the carotid collar,” Neurosurgery, vol. 51, supple-ment, no. 4, pp. 375–410, 2002.[16] D. Parkinson, “Cavernous sinus exploration,” Journal of Neuro-surgery, vol. 76, pp. 341–342, 1992.[17] D. Parkinson, “Lateral sellar compartment O.T. (Cavernoussinus): history, anatomy, terminology,” Anatomical Record, vol.251, no. 4, pp. 486–490, 1998.[18] G. Mariniello, P. Cappabianca, S. Buonamassa, and E. De Div-itiis, “Surgical treatment of intracavernous trigeminal schwan-nomas via a fronto-temporal epidural approach,” Clinical Neu-rology and Neurosurgery, vol. 106, no. 2, pp. 104–109, 2004.[19] G. Zada, J. D. Day, and S. L. Giannotta, “The extraduraltemporopolar approach: a review of indications and operativetechnique,” Neurosurgical Focus, vol. 25, no. 6, p. E3, 2008.[20] V. V. Dolenc, “Frontotemporal epidural approach to trigeminalneurinomas,” Acta Neurochirurgica, vol. 130, no. 1–4, pp. 55–65,1994.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

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Surgical approach to the cavernous sinus for a trigeminal schwannoma resection: technical note and case report

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