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Anatomy and surgery of the cavernous sinus
196
Surg Neurol 1990;34:196-199
Book Reviews
Surgery of the Skull Base: An Interdisciplinary Approach. By M. Samii and W. Draf. 507 pages. $265.00. Berlin: Springer, 1989. Professors Samii (a neurosurgeon) and Draf (an otolaryngologist) have compiled a monograph based on their experience as collaborators in the surgical management of skull base lesions in Hannover, West Germany, since 1979. They describe techniques they have found successful in handling congenital lesions, trauma, and inflammatory conditions as well as tumors. The first 70 pages of this book are devoted to a description of skull base anatomy by Professor Johannes Lang of Wurzburg University. Although Professor Lang makes a number of pertinent surgical points, his attention to the measurement of various distances and angles at the skull base provides little practical information for the surgeon. Some of the anatomical sketches included are useful, but, in general, this chapter is underillustrated. The black and white photographs of cadaver specimens add little. The second chapter deals with lesions of the anterior cranial fossa. Traumatic lesions make up a good portion of this discussion, and most are considered from an outside-in approach, rather than management from inside the dura mater outward, as most neurosurgeons view these problems. Although Professor Samii is a skilled microsurgeon, the illustrations in this chapter suggest he prefers to treat anterior fossa neoplasms by classical neurosurgical techniques, including the extensive brain retraction necessary to produce sufficiently wide exposures to allow one to work without the operating microscope. Considerable time is spent discussing the surgical treatment of trauma of the orbit and midface and also orbital neoplasms. The first mention of a modern neurosurgical operation appears on page 210, where microsurgical excision of a tuberculum sella meningioma is briefly described. The chapter on middle cranial fossa lesions begins with an extensive discussion of the long history of surgical failures with carotid-cavernous sinus fistulae. Modern operations for this condition are mentioned briefly but are neither described nor discussed. Transsphenoidai and transcranial methods of handling pituitary tumors are described in detail, but techniques for treating craniopharyngiomas are mentioned only in figure legends and in a briefcase report. The surgical management of tumors of the cavernous sinus, a topic of considerable interest in the current neurosurgical literature, is not mentioned. Neurosurgeons will find the strength of this book to be the 150-page segment dealing with techniques for managing tumors of the middle fossa skull base, the cerebellopontine angle, the clivus, and those invading the petrous bone. Obviously, this is where Professor Samii's primary interest and unique experience lie. His discussion of surgical technique in these chapters is generally clear, concise, and useful. It is © 1990 by Elsevier Science Publishing Co., Inc.
somewhat annoying that he has chosen to support his remarks with individual case reports rather than summarizing the results of his methods in the tradition of Professor Yasargil. His recent journal contributions demonstrate considerable experience with certain of these tumors, and I was disappointed not to find his overall experience with skull base tumors given here in detail. Nevertheless, neurosurgeons dealing with these challenging lesions will find these chapters useful and enlightening. The final chapters provide a brief description of methods for managing tumors of the craniospinal junction, and a rather complete discussion of techniques of facial nerve decompression and reconstruction. This book suffers from a paucity of good-quality illustrations. It contains a number of helpful sketches, but virtually all of the surgical photographs were either underexposed when made or were sabotaged in the printing process. All are in black and white, and few have real value for the reader. The authors seem to be preoccupied with postoperative photographs confirming excellent cosmetic results and functioning cranial nerves. Although fully half of this book deals with material few experienced neurosurgeons will find of interest, it is probably a worthwhile investment for surgeons dealing with difficult basal tumors of the middle and posterior cranial fossae. LARRY A. ROGERS, M.D. Charlotte, North Carolina
Anatomy and Surgery of the Cavernous Sinus. By Vinko V. Dolenc. 344 pages. $160.00. New York: Springer, 1989. For 250 years anatomists have considered the cavernous sinus to be a true dural sinus containing segments of the internal carotid artery and cranial nerves I I I - V I . By the middle of this century, some began to question this concept, suggesting that perhaps the "sinus" was merely an extensive plexus of veins, rather than a true dural sinus containing internal trabeculations. The laboratory and clinical experiences of neurosurgical pioneer Dwight Parkinson supported this thinking, confirming that the cavernous "sinus" was more accurately a free space between leaves of dura mater containing a formidable plexus of veins as well as the carotid artery and cranial nerves. In the past decade several groups of neurosurgeons have confirmed that precise microsurgical techniques allow one to operate within the cavernous "sinus" while remaining outside these veins. They also found that these venous networks are sparse when associated with mass lesions and that even when present, these veins may be opened with impunity by surgeons armed 0090-3019/90/$3.50
Book Reviews
only with standard microsurgical skills of maintaining hemostasis. With these facts established, only a more complete understanding of the relationships between the paraseUar cranial nerves and blood vessels blocks the way to routine surgical treatment of intracavernous lesions. Over the past decade Professor Dolenc's papers and personal presentations demonstrating his considerable surgical experience with intracavernous lesions have excited the curiosity and imagination of neurosurgeons everywhere. He more than anyone else has transformed intracavernous surgery from a daring idea into reality. Now he has put together an atlas devoted to the surgical anatomy of this complex region, which is of monumental proportions. He has distilled from his experience the important anatomical keys to the microsurgical management of paraseUar lesions and has presented them succinctly and in an orderly manner. In his foreward to this book, Professor Yasargil concludes that this "microsurgical anatomical study is a new step in the 100 year history of neurosurgery." Virtually each odd-numbered page contains a large photograph in full color of either a microsurgical exposure of an intracavernous lesion or a microsurgical cadaver dissection demonstrating pertinent anatomical details of this region. The opposite page includes an analogous drawing that is fully labeled. The author insisted that the book be printed locally in Ljubljana, his home in northern Yugoslavia, so that he could personally supervise the reproduction of the illustratious. His efforts were rewarded: the photographs and drawings are of exceptional quality, and each is presented beautifully. The text is clear and it reads smoothly, characteristics uncommon among works from centers where English is not the primary language. Dolenc emphasizes tailoring the surgical approach to agiven intracavernous lesion to its unique relationship with nearby blood vessels and cranial nerves, eschewing the one or two "favorite" approaches others have proposed previously. He has organized the surface anatomy of the cavernous sinus and neighboring regions into 10 different "windows" or triaugles formed by key structures. Cadaver illustrations in the first part of the book define each triangle, and subsequent surgical photographs demonstrate convincingly their practical applications. The author describes in detail his surgical approach to the cavernous sinus region, freely sprinkling the text with nuggets of surgical wisdom concerning problems one might encounter along the way and tricks to overcome them. Figure 67 on page 144 demonstrates the changing anatomical relationships of important parasellar landmarks as the patient's head is rotated and/or tilted from the basic position for pterional craniotomies into one of eight different key positions. This interesting figure illustrates subtleties of three-dimensional anatomy that are crucial to obtaining ideal exposure of various parasellar lesions. Professor Dolenc enjoys an impressive experience with intracavernous lesions of all types, including neoplasms, vascular malformations, and aneurysms, lesions that most neurosurgeons see only occasionally. But what he has learned from his surgical experience is of considerable value to any surgeon treating the more common paraseUar aneurysms, including the difficult carotid-ophthalmic lesions that notoriously abut onto the cavernous sinus or are partially contained within it. Furthermore, he describes in detail his method of exposiug the petrous
Surg Neurol 197 1990;34:196-199
segment of the internal carotid artery, a useful alternative to identifying this vessel extracranially for the purpose of obtaining proximal control prior to dissecting giant carotid aneurysms and carotid-ophthalmic aneurysms. Moreover, his technique of extradurally removing the roof of the orbit and the anterior clinoid process and, ultimately, the posterior clinoid process and part of the clivus from within the dura mater dramatically facilitates the exposure of aneurysms of the upper part of the basilar artery via the pterional approach. This book's usefulness extends beyond the neurosurgical virtuoso fortunate to have access to rare intracavernous tumors. It should be in the library of every neurosurgeon who treats intracranial aneurysms or middle fossa tumors whether or not they directly invade the sinus; furthermore, any surgeon who has entertained even a fleeting thought of attacking an intracavernous lesion or who has experienced a nightmare concerning the formidable surgical problems presented by the cavernous sinus will find it fascinating. In addition, anyone interested in middle cranial fossa anatomy, either from the perspective of surgeon or anatomist, or anyone interested in the history of neurosurgery should own this book. It will be used and discussed by generations of neurosurgeous. LARRY A. ROGERS, M.D. Charlotte, North Carolina
G r e a t M e n w i t h Sick B r a i n s By Bengt Ljunggren, M.D., $ 3 5 . 0 0 . P a r k R i d g e , Illinois: Association of Neurological
a n d O t h e r Essays. P h . D . 130 pages. American S u r g e o n s , 1990.
It has been over 2 years since Bengt Ljunggren asked me for advice about how to publish this material. I, therefore, had the opportunity to read it, but I did not realize the fortuitous result of my suggestion to him that he inquire as to whether the American Association of Neurological Surgeons would be interested in publishing this. Fortunately, that organization has appointed Dr. Robert Wilkins as chairman of the Publications Committee, and Dr. Wilkins, who has been responsible for so much historical and important neurosurgical and neurological literature in the past, has taken this upon himself. This is a most interesting book, well illustrated, and well written. There are many aspects of this historical collection that will be totally unknown by North American neurologists and neurosurgeons, and Bengt Ljunggren deserves immense credit for having researched this material so thoroughly. He comes from a background of men of great scientific merit, and he knew many people who had much knowledge of the materials about which he wrote. I found chapter 8, '°The Case of the Sleepy Sea Lord," which had been previously published in SurgicalNeurology, the most exciting of the descriptions and was particularly interested in it, since it revealed a great deal of material during my own lifetime, World War II. The book has so much to admire that I hesitate to mention one inaccuracy. This is on page 89, "Surprising Autopsy Findings," in which Dr. Ljunggren says, "Harry Zimmerman, who
Surg Neurol 1990;34:196-199
Book Reviews
Surgery of the Skull Base: An Interdisciplinary Approach. By M. Samii and W. Draf. 507 pages. $265.00. Berlin: Springer, 1989. Professors Samii (a neurosurgeon) and Draf (an otolaryngologist) have compiled a monograph based on their experience as collaborators in the surgical management of skull base lesions in Hannover, West Germany, since 1979. They describe techniques they have found successful in handling congenital lesions, trauma, and inflammatory conditions as well as tumors. The first 70 pages of this book are devoted to a description of skull base anatomy by Professor Johannes Lang of Wurzburg University. Although Professor Lang makes a number of pertinent surgical points, his attention to the measurement of various distances and angles at the skull base provides little practical information for the surgeon. Some of the anatomical sketches included are useful, but, in general, this chapter is underillustrated. The black and white photographs of cadaver specimens add little. The second chapter deals with lesions of the anterior cranial fossa. Traumatic lesions make up a good portion of this discussion, and most are considered from an outside-in approach, rather than management from inside the dura mater outward, as most neurosurgeons view these problems. Although Professor Samii is a skilled microsurgeon, the illustrations in this chapter suggest he prefers to treat anterior fossa neoplasms by classical neurosurgical techniques, including the extensive brain retraction necessary to produce sufficiently wide exposures to allow one to work without the operating microscope. Considerable time is spent discussing the surgical treatment of trauma of the orbit and midface and also orbital neoplasms. The first mention of a modern neurosurgical operation appears on page 210, where microsurgical excision of a tuberculum sella meningioma is briefly described. The chapter on middle cranial fossa lesions begins with an extensive discussion of the long history of surgical failures with carotid-cavernous sinus fistulae. Modern operations for this condition are mentioned briefly but are neither described nor discussed. Transsphenoidai and transcranial methods of handling pituitary tumors are described in detail, but techniques for treating craniopharyngiomas are mentioned only in figure legends and in a briefcase report. The surgical management of tumors of the cavernous sinus, a topic of considerable interest in the current neurosurgical literature, is not mentioned. Neurosurgeons will find the strength of this book to be the 150-page segment dealing with techniques for managing tumors of the middle fossa skull base, the cerebellopontine angle, the clivus, and those invading the petrous bone. Obviously, this is where Professor Samii's primary interest and unique experience lie. His discussion of surgical technique in these chapters is generally clear, concise, and useful. It is © 1990 by Elsevier Science Publishing Co., Inc.
somewhat annoying that he has chosen to support his remarks with individual case reports rather than summarizing the results of his methods in the tradition of Professor Yasargil. His recent journal contributions demonstrate considerable experience with certain of these tumors, and I was disappointed not to find his overall experience with skull base tumors given here in detail. Nevertheless, neurosurgeons dealing with these challenging lesions will find these chapters useful and enlightening. The final chapters provide a brief description of methods for managing tumors of the craniospinal junction, and a rather complete discussion of techniques of facial nerve decompression and reconstruction. This book suffers from a paucity of good-quality illustrations. It contains a number of helpful sketches, but virtually all of the surgical photographs were either underexposed when made or were sabotaged in the printing process. All are in black and white, and few have real value for the reader. The authors seem to be preoccupied with postoperative photographs confirming excellent cosmetic results and functioning cranial nerves. Although fully half of this book deals with material few experienced neurosurgeons will find of interest, it is probably a worthwhile investment for surgeons dealing with difficult basal tumors of the middle and posterior cranial fossae. LARRY A. ROGERS, M.D. Charlotte, North Carolina
Anatomy and Surgery of the Cavernous Sinus. By Vinko V. Dolenc. 344 pages. $160.00. New York: Springer, 1989. For 250 years anatomists have considered the cavernous sinus to be a true dural sinus containing segments of the internal carotid artery and cranial nerves I I I - V I . By the middle of this century, some began to question this concept, suggesting that perhaps the "sinus" was merely an extensive plexus of veins, rather than a true dural sinus containing internal trabeculations. The laboratory and clinical experiences of neurosurgical pioneer Dwight Parkinson supported this thinking, confirming that the cavernous "sinus" was more accurately a free space between leaves of dura mater containing a formidable plexus of veins as well as the carotid artery and cranial nerves. In the past decade several groups of neurosurgeons have confirmed that precise microsurgical techniques allow one to operate within the cavernous "sinus" while remaining outside these veins. They also found that these venous networks are sparse when associated with mass lesions and that even when present, these veins may be opened with impunity by surgeons armed 0090-3019/90/$3.50
Book Reviews
only with standard microsurgical skills of maintaining hemostasis. With these facts established, only a more complete understanding of the relationships between the paraseUar cranial nerves and blood vessels blocks the way to routine surgical treatment of intracavernous lesions. Over the past decade Professor Dolenc's papers and personal presentations demonstrating his considerable surgical experience with intracavernous lesions have excited the curiosity and imagination of neurosurgeons everywhere. He more than anyone else has transformed intracavernous surgery from a daring idea into reality. Now he has put together an atlas devoted to the surgical anatomy of this complex region, which is of monumental proportions. He has distilled from his experience the important anatomical keys to the microsurgical management of paraseUar lesions and has presented them succinctly and in an orderly manner. In his foreward to this book, Professor Yasargil concludes that this "microsurgical anatomical study is a new step in the 100 year history of neurosurgery." Virtually each odd-numbered page contains a large photograph in full color of either a microsurgical exposure of an intracavernous lesion or a microsurgical cadaver dissection demonstrating pertinent anatomical details of this region. The opposite page includes an analogous drawing that is fully labeled. The author insisted that the book be printed locally in Ljubljana, his home in northern Yugoslavia, so that he could personally supervise the reproduction of the illustratious. His efforts were rewarded: the photographs and drawings are of exceptional quality, and each is presented beautifully. The text is clear and it reads smoothly, characteristics uncommon among works from centers where English is not the primary language. Dolenc emphasizes tailoring the surgical approach to agiven intracavernous lesion to its unique relationship with nearby blood vessels and cranial nerves, eschewing the one or two "favorite" approaches others have proposed previously. He has organized the surface anatomy of the cavernous sinus and neighboring regions into 10 different "windows" or triaugles formed by key structures. Cadaver illustrations in the first part of the book define each triangle, and subsequent surgical photographs demonstrate convincingly their practical applications. The author describes in detail his surgical approach to the cavernous sinus region, freely sprinkling the text with nuggets of surgical wisdom concerning problems one might encounter along the way and tricks to overcome them. Figure 67 on page 144 demonstrates the changing anatomical relationships of important parasellar landmarks as the patient's head is rotated and/or tilted from the basic position for pterional craniotomies into one of eight different key positions. This interesting figure illustrates subtleties of three-dimensional anatomy that are crucial to obtaining ideal exposure of various parasellar lesions. Professor Dolenc enjoys an impressive experience with intracavernous lesions of all types, including neoplasms, vascular malformations, and aneurysms, lesions that most neurosurgeons see only occasionally. But what he has learned from his surgical experience is of considerable value to any surgeon treating the more common paraseUar aneurysms, including the difficult carotid-ophthalmic lesions that notoriously abut onto the cavernous sinus or are partially contained within it. Furthermore, he describes in detail his method of exposiug the petrous
Surg Neurol 197 1990;34:196-199
segment of the internal carotid artery, a useful alternative to identifying this vessel extracranially for the purpose of obtaining proximal control prior to dissecting giant carotid aneurysms and carotid-ophthalmic aneurysms. Moreover, his technique of extradurally removing the roof of the orbit and the anterior clinoid process and, ultimately, the posterior clinoid process and part of the clivus from within the dura mater dramatically facilitates the exposure of aneurysms of the upper part of the basilar artery via the pterional approach. This book's usefulness extends beyond the neurosurgical virtuoso fortunate to have access to rare intracavernous tumors. It should be in the library of every neurosurgeon who treats intracranial aneurysms or middle fossa tumors whether or not they directly invade the sinus; furthermore, any surgeon who has entertained even a fleeting thought of attacking an intracavernous lesion or who has experienced a nightmare concerning the formidable surgical problems presented by the cavernous sinus will find it fascinating. In addition, anyone interested in middle cranial fossa anatomy, either from the perspective of surgeon or anatomist, or anyone interested in the history of neurosurgery should own this book. It will be used and discussed by generations of neurosurgeous. LARRY A. ROGERS, M.D. Charlotte, North Carolina
G r e a t M e n w i t h Sick B r a i n s By Bengt Ljunggren, M.D., $ 3 5 . 0 0 . P a r k R i d g e , Illinois: Association of Neurological
a n d O t h e r Essays. P h . D . 130 pages. American S u r g e o n s , 1990.
It has been over 2 years since Bengt Ljunggren asked me for advice about how to publish this material. I, therefore, had the opportunity to read it, but I did not realize the fortuitous result of my suggestion to him that he inquire as to whether the American Association of Neurological Surgeons would be interested in publishing this. Fortunately, that organization has appointed Dr. Robert Wilkins as chairman of the Publications Committee, and Dr. Wilkins, who has been responsible for so much historical and important neurosurgical and neurological literature in the past, has taken this upon himself. This is a most interesting book, well illustrated, and well written. There are many aspects of this historical collection that will be totally unknown by North American neurologists and neurosurgeons, and Bengt Ljunggren deserves immense credit for having researched this material so thoroughly. He comes from a background of men of great scientific merit, and he knew many people who had much knowledge of the materials about which he wrote. I found chapter 8, '°The Case of the Sleepy Sea Lord," which had been previously published in SurgicalNeurology, the most exciting of the descriptions and was particularly interested in it, since it revealed a great deal of material during my own lifetime, World War II. The book has so much to admire that I hesitate to mention one inaccuracy. This is on page 89, "Surprising Autopsy Findings," in which Dr. Ljunggren says, "Harry Zimmerman, who