J Neurosurg 74:837-844, 1991

The Dolenc technique for cavernous sinus exploration

(cadaveric prosection)
Technical note

HARRY R. VAN LOVEREN, M.D., JEFFREY T. KELLER, Ptt.D., MAGDY EL-KALLINY, M.D.,
DANIEl. J. SCODARY,M.D., AND JOHN M. TEW, JR., M.D.
Department of Neurosurgery, Universityof Cincinnati College of Medicine, MayfieldNeurological
Institute, and Department of Neurosurgery, The Christ Hospital, Cincinnati, Ohio

~" This report describes a surgical approach to the cavernous sinus. Based on the work of Parkinson, Dolenc,
and other pioneering investigators, a comprehensive surgical approach for the treatment of lesions of the
cavernous sinus is distilled and presented in 12 simple steps. The approach to surgical exploration of this
region is divided into an extradural and intradural phase, each with six steps. The bony, neural, and/or vascular
structures of each step are discussed. These steps may be used in their entirety for total exploration of the
cavernous sinus, but also in part for lesions that involve only limited regions of the cavernous sinus. Either by
design or circumstance, every intracranial neurosurgeon will eventually be led to the cavernous sinus region,
and a clear understanding of cavernous sinus anatomy should be part of their armamentarium.

KEY WORDS 9 cavernous sinus 9 cranial nerve 9 skull base 9 surgical approach 9
anatomy

HE Intricate
" and compact neurovascular contents.J0
/ of the cavernous sinus led Dwight Parkmson
to describe it as the anatomical jewel box (Fig.
1). Because of this complexity, few have dared to ap-
proach this region surgically. The perception of an
ominous rate of surgical morbidity and mortality re-
sulted in situations in which even benign lesions ran a
malignant course. Classic anatomy texts have not pro-
vided the essential anatomical detail in a manner suit-
able for surgical exploration.
The first report of successful intracavernous surgery
was that of Browder.~ A carotid-cavernous fistula was
reported cured by packing muscle through an incision
in the roof of the cavernous sinus. However, it was not
until the work of Parkinson and R a m s a f 3 that the
"inoperability" of the cavernous sinus was seriously
challenged. They described an approach into the pos-
terior cavernous sinus through a triangle which now
bears Parkinson's name, bordered by the oculomotor
and trochlear nerves superiorly and the trigeminal and
abducens nerves inferiorly. The inherent risks of cir-
culatory arrest and the method used to achieve vascular
FJG. 1. Artist's enhancement of Dr. Oscar Batson's origi-
control in these procedures dissuaded others from nal cast of the cavernous sinus made at the University of
adopting this technique. More recently, drawing upon Cincinnati in the 1920's.

J. Neurosurg. / Voh~me 74/May, 1991 837

 H. R. van Loveren, et al.

FIG. 3. Superior view of the skull base depicting areas o1

bone to be removed at the extradural phase, la = posterior
two-thirds of the orbital floor; lb = roof of the optic canal;
2 = anterior clinoid process; 3 = lateral bony wall of the supe-
rior orbital fissure; 4 = bony rim of the foramen rotundum;
5 = bony rim of the foramen ovale; 6 = bone of Glasscock's
triangle overlying the horizontal portion of the petrous carotid
artery.

FIG. 2. Upper: Patient positioning for cavernous sinus
surgery. The patient is in a supine position, thorax elevaled
15~ neck extended, and head rotated 30 ~ from midline.
Lower: Drawing of the frontotemporal craniotomy with a
three-limb dural incision: Limb I is in line with the sylvian
fissure; Limb 2 is perpendicular to the optic nerve; and Limb
3 is parallel to the middle fossa dura. S.O.F. = superior orbital
fissure; II1 = the third cranial nerve.
existing knowledge as well as extensive personal re-
search, Dolenc 2 reported a method of cavernous sinus
exploration without the need for circulatory arrest.
Utilizing the work of Parkinson, ~~ Dolenc, 2'3 and
other pioneering investigators, we have developed a
comprehensive surgical approach for the treatment of
lesions of the cavernous sinus. This report attempts to
distill the seemingly complex Dolenc technique into a
series of 12 simple steps in order to promote the prac-
tical application of this information. These steps may
be used in whole for total exploration o f the cavernous
sinus, but also in part for lesions that involve only
limited regions of the cavernous sinus.
Operative Procedure
Surgical Positioning
The outcome o f any surgical procedure will be influ-
enced by appropriate patient positioning. Cavernous
sinus exploration is performed with the patient in a
supine position, neck extended, and head rotated 30 ~
from midline. Adjustments in head rotation will be
necessary during the procedure. A frontotemporal cra-
niotomy is employed which extends anteriorly along
the superior orbital rim to the midpoint of the orbit
and inferiorly to the zygoma (Fig. 2).

Surgical Approach
The approach to surgical exploration of the cavern-
TABLE 1 ous sinus is divided into an extradural and intradural
Stepsfi)r explorationof the cavernous sinus phase (Table 1). Each phase comprises six individual
steps. All extradural steps involve removal of bone from
Extradural Stage Intradural Stage
the anterior and middle cranial fossae. These areas of
l a: orbitalroof; l b: optic canal 1: duralopening bone confine portions of the cavernous sinus, as well
2: anteriorclinoid process 2: carotidrings
3: superiororbital fissure 3: oculomotornerve as the orbit, superior orbital fissure, Meckel's cave, and
4: foramenrotundum 4: trochlearnerve petrous carotid artery. The removal o f these bony areas
5: foramenovale 5: trigeminalnerve is the key to unlocking the neurovascular structures for
6: Glasscock'striangle 6: abducensnerve intradural exploration (Fig. 3). The intradural steps

838 J. Neurosurg. / Volume 74 / May, 1991

Cavernous sinus exploration
FIG. 4. Extradural Steps 1 and 2. In Step I, starting from the inferior half of the "keyhole," the posterior
two-thirds of the orbital roof is removed, followedby unroofing of the optic canal. Step 2 involvesextradural
removal of the anterior clinoid process. S.O.K = superior orbital fissure; ICA = internal carotid artery.
essentially unlock the neurovascular structures from
dural confinement while allowing the surgeon to remain
extracavernous. Application of this approach facilitates
control of the arterial and venous circulation, obviating
the need for circulatory arrest.
Extradural Stage
Step la: Orbital Roof The dura is separated from
the floor of the anterior cranial fossa. The posterior
two-thirds of the orbital roof is removed with a high-
speed drill* and conventional rongeurs. The medial
portion of the orbital roof which slopes downward
towards the cribriform plate is preserved to avoid entry
into ethmoid and sphenoid air cells (Fig. 4).
Step Ib: Optic Canal. The bony roof of the optic
canal is removed with a diamond burr. This permits
mobilization of the optic nerve which is essential to
avoid optic nerve injury during subsequent dissection
of the anterior clinoid process (Fig. 4).
Step 2: Anterior Clinoid Process. With a diamond
burr, the anterior clinoid process is cored leaving a thin
shell of cortical bone which can be fractured in upon
itself. This will also expose the bony strut beneath the
optic nerve. Removal of the medial sphenoid wing and
* High-speed drill manufactured by Midas Rex Pneumatic
Tools Inc., Fort Worth, Texas.
J. Neurosurg. / Volume 74/May, 1991
bony strut disconnects the anterior clinoid process from
the skull base (Fig. 4).
The anterior clinoid process lies within the antero-
medial triangle bordered by the optic nerve medially
and oculomotor nerve laterally. The anterior loop of
the carotid artery lies within the floor of this triangle.
This is the clinoid segment of the internal carotid artery
(ICA) which is neither intracavernous nor intradural.
The majority of carotid-ophthalmic aneurysms which
appear to have an intracavernous component actually
arise from the clinoid segment of the ICA and violate
the distal dural ring.
Step 3: Superior Orbital Fissure. Removal of the
medial sphenoid wing will have revealed the dura ov-
erlying the superior orbital fissure. The lateral bony wall
of the superior orbital fissure is thinned, fractured, and
removed (Fig. 5).
Step 4: Foramen Rotundurn. A small island of
bone separates the inferior aspect of the superior orbital
fissure from the foramen rotundum. The anterolateral
rim of the foramen is removed with a diamond burr
permitting mobilization of the maxillary division of the
trigeminal nerve (Fig. 5).
Step 5: Foramen Ovale. Elevation of the middle
fossa dura is continued to the vertical inclination of the
petrous pyramid, revealing both the foramen ovale and
839

foramen spinosum. The middle meningeal artery tra-
versing the foramen spinosum is sacrificed. The anter-
olateral boundaries of the foramen ovale are expanded
enabling mobilization of the mandibular nerve (Fig. 6).
Step 6." Glasscock's Triangle. Glasscock's trian-
gle, 4,5 or the posterolateral triangle, is bordered laterally
by a line between the foramen spinosum and the arcuate
eminence and medially by the groove of the greater
superficial petrosal nerve; it has as its base the dorsal
aspect of the third division of the trigeminal nerve. The
greater superficial petrosal nerve is sacrificed to avoid
traction injury to the geniculate ganglion and facial
nerve. The bone of Glasscock's triangle is removed with
a diamond burr exposing the lateral loop of the ICA
within the petrous bone. Unroofing of the petrous bone
over the ICA should not proceed posteriorly beyond
the point where the ICA turns vertically if injury to the
cochlea is to be avoided. Exposure of the petrous ICA
permits proximal arterial control and offers a potential
site for bypass vascular grafting (Fig. 6).
Intradural Stage
Step 1: Dural Opening. The dural opening begins
along the line of the sylvian fissure. The incision is
extended medially, perpendicular to the optic nerve,
and laterally across the temporal lobe (Fig. 2 lower).
FIG. 5. Extradural Steps 3 and 4. Step 3 involves fracture and removal of the lateral bony wall of the
superior orbital fissure (S.O.F.). Step 4 comprises removal of the bony tim of the foramen rotundum. V2 =
the second division of the trigeminal nerve.
840
H. R. v a n L o v e r e n , et al.
Step 2: Carotid Rings. The ICA is fixed by two
dural rings: the proximal ring is the exit point of the
ICA from the cavernous sinus and the distal ring is the
point where the ICA becomes intradural. The clinoid
segment of the ICA lies between these two rings. These
tings are sectioned allowing mobilization of the clinoid
segment and entry into the anterior cavernous sinus
(Fig. 7).
Step 3." Oculomotor Nerve. The oculomotor nerve
is identified as it enters the edge of the tentorial dura
lateral to the posterior clinoid process. The dura over-
lying the third nerve is incised using an arachnoid knife.
This incision is carried rostrally to the point at which
the third nerve crosses the ICA (anterior loop) (Fig. 8).
This avoids injury to the trochlear nerve which crosses
over the oculomotor nerve in the superior orbital fis-
sure. The deep membranous layer of the lateral wall of
the cavernous sinus separates these nerves from the
venous channels of the cavernous sinus.
Step 4: Troehlear Nerve. The troehlear nerve is
identified as it enters the edge of the tentorial dura
posterolateral to the oeulomotor nerve. Dissection of
dura overlying the fourth nerve is continued anteriorly
into the superior orbital fissure (Fig. 8).
Step 5. Trigeminal Nerve. The ophthalmic division
of the trigeminal nerve is identified rostrally near the
J. Neurosurg. / Volume 74/May, 1991
 FIG. 6. Extradural Steps 5 and 6. In Step 5, after the middle meningeal artery (MMA) is sacrificed, the
bony rim of the foramen ovale is drilled and widened. In Step 6, the horizontal petrous carotid artery is
exposed by drilling the bone of Glasscock's triangle. Immediately lateral to the petrous carotid artery lies the
tensor tympani muscle and deep to this muscle is the eustachian tube. GPN = greater superficial petrosal
nerve; ICA = internal carotid artery; S.O.F. = superior orbital fissure; V2 and V3 = second and third divisions
of the trigeminal nerve.

FIG. 7. Intradural Steps 1 and 2. In Step 1, a three-limb dural incision is made as depicted in Fig. 2 lower.
Step 2 involves sectioning the carotid rings. The internal carotid artery (ICA) leaves the cavernous sinus at the
proximal carotid ring and becomes intradural at the distal dural ring. The clinoid segment of the ICA is
visualized between the proximal and distal dural rings. S.O.F. = superior orbital fissure; P.C. = posterior
clinoid process; roman numerals denote cranial nerves.

J. Neurosurg. / Volume 74/May, 1991 841

 H. R. van Loveren, et al.

FIG. 8. Intradural Steps 3 to 5. The lateral dural wall of the cavernous sinus and Meckel's cave is dissected
from the underlying cranial nerves. Cranial nerves III, IV, and VI merge as they enter the superior orbital
fissure. P.C. = posterior clinoid process; ICA = internal carotid artery; roman numerals denote cranial nerves.

FIG. 9. Intradural Steps 5 and 6, involving complete exposure of the cavernous sinus and Meckel's cave.
The abducens nerve (VI) can be identified by retraction of the ophthalmic division of the trigeminal nerve
(VI). This is the only intracavernous cranial nerve. Roman numerals denote cranial nerves; ICA = internal
carotid artery.

842 J. Neurosurg. / Volume 74/May, 1991

Cavernous sinus exNoration

FIG. 10. Nine triangles of the cavernous sinus region. I = Anteromedial triangle: medial, optic nerve;
lateral, oculomotor nerve: base, dural edge. 2 = Paramedial triangle: medial, third nerve: lateral, trochlear
nerve; base, dural edge of tentorium. 3 = Parkinson's triangle: medial trochlear nerve: lateral, first division
of the trigeminal nerve (V~); base, dural edge of tentorium. 4 = Anterolateral triangle: medial, V~ trigeminal
nerve; lateral, second division of the trigeminal nerve (V2); base, line between V~ in the superior orbital fissure
and the foramen ovale. 5 = Lateral triangle: medial, Vz trigeminal nerve~ lateral, third division of the
trigeminal nerve (V3): base, line between the foramen rotundum and the foramen ovale. 6 = Posterolateral
(Glasscock's) triangle: lateral, line between the foramen spinosum and the arcuate eminence; medial, greater
superficial petrosal nerve: base, dorsal aspect of V3 trigeminal nerve. 7 = Posteromedial (Kawase's) triangle:
lateral, greater superficial petrosal nerve: medial, petrosal sinus: base, trigeminal nerve. 8 = Inferomedial
triangle: posterior view: medial, line between the posterior clinoid and the abducens nerve (VI) at Dorello's
canal; lateral, line between Dorello's canal and the trochlear nerve (IV) at the edge of the tentorium; base,
petrous apex. 9 = Inferolateral triangle; posterior view: medial, line between Dorello's canal and trochlear
nerve at the edge of the tentorium; lateral, line between Dorello's canal and the petrosal vein at the petrosal
sinus; base, petrous apex. Roman numerals denote cranial nerves.

superior orbital fissure and its dural covering is dissected
(Fig. 8). This dissection is carried posteriorly toward
Meckel's cave. At this stage the lateral wall of the
cavernous sinus is totally exposed, and the sinus may
be entered. Meckel's cave may be exposed by further
dissection of dura from the trigeminal ganglion and its
second and third divisions. The trigeminal ganglion is
separated from the ICA by the bony floor of Meckel's
cave which may be incompetent (Fig. 9).
Step 6. Abducens Nerve. The abducens nerve enters
the cavernous sinus via Dorello's canal. This nerve,
which may be duplicate or even triplicate, lies lateral to
the ICA. The abducens nerve is the only cranial nerve
truly within the cavernous sinus. The meningohypo-
physeal artery can be identified at the junction of the
abducens nerve and the ICA (Fig. 9).
Triangles of the Cavernous Sinus Region
Dolenc ~3 has expanded upon the original work of
Parkinson and Ramsay j3 by describing the cavernous
sinus region as a series of nine triangles. The compart-
mentalization of this complex anatomy aids in under-
standing the neurovascular relationships within the cav-
ernous sinus region (see Fig. 10 for a description of the
cavernous sinus triangles).
Internal Carotid Artery
The ICA changes direction through four loops in its
course from the petrous bone to the intradural space
(Fig. 11). The first loop (posterior loop or geniculum)
marks the transition of the petrous carotid artery from
a vertical to a horizontal position in the petrous bone.
The horizontal portion of the petrous carotid artery
runs anteromedial under the trigeminal ganglion, cross-
ing the foramen lacerum and forming the lateral loop.
The carotid artery then ascends into the posterior aspect
of the cavernous sinus where the medial loop is formed
lateral to the posterior clinoid process as the carotid

J. Neurosurg. / Volume 74~May, 1991 843


FIG. 11. Loops of the internal carotid artery (ICA). The
posterior loop marks the transition between the vertical and
horizontal petrous carotid artery, The lateral loop courses
deep to the trigeminal ganglion toward the foramen lacerum.
The medial loop is nearly vertical and marks the transition
between the vertical and horizontal cavernous carotid artery.
The anterior loop is nearly horizontal and brings the ICA
from the cavernous sinus through the clinoid segment into
the intradural compartment.
artery courses anteriorly. The anterior (fourth) loop in
the anterior cavernous sinus is nearly horizontal and
brings the ICA from the cavernous sinus through its
clinoid segment and into the intradural space (Fig. 11).
Comment
Intracavernous collateral vessels of the ICA have
been recognized since 1860, when Luschka described
the posteroinferior hypophyseal artery. 7 More recently,
Parkinson and Ramsey, ~-~3 Harris and Rhoton, 6 and
Lasjaunias, et al., 8 have described the major branches
of the intracavernous carotid artery: meningohypophy-
seal trunk, inferolateral trunk or inferior artery of the
cavernous sinus, and McConnel's capsular artery. The
reader is referred to the work of Lasjaunias 9 for a
comprehensive discussion of the anatomical and neu-
roradiological features of intracavernous carotid bran-
ches. This work is of particular value since consider-
ation of the vascular supply of the third through sixth
cranial nerves associated with the cavernous sinus as
well as collateral blood supply to this region are pre-
sented in exquisite detail.
The complex neurovascular, bony, and muscular
anatomy of the skull base have dissuaded neurosur-
geons from operating in this region for many decades.
Because of this, tumors of the skull base which are
histologically benign have been allowed to become a
844
H . R. v a n L o v e r e n , et al.
malignant problem for the patient. The primary tenet
of skull base surgery is that accessibility should not
determine the resectability of an otherwise benign tu-
mor. New corridors to tumors of the skull base are
being developed by a return to the traditional role of
neurosurgeon as neuroanatomist. In this particular case,
Parkinson ~~described the cavernous sinus as an "ana-
tomical jewel box," and understanding the anatomy as
presented in these 12 steps is the key that unlocks it.
Either by design or circumstance, every intracranial
neurosurgeon will eventually be led to the cavernous
sinus region and a clear understanding of cavernous
sinus anatomy should be part of their armamentarium.
Future anatomical investigation should be directed at
the vascular supply of cavernous cranial nerves which
are likely to be the most critical factor in preserving
neural function during surgery in this region.
References
1. Browder J: Treatment of carotid artery cavernous sinus
fistula. Report of a case. Arch Ophthalmol 18:95-102,
1937
2. Dolenc V: Direct microsurgical repair of intracavernous
vascular lesions. J Neurosurg 58:824-831, 1983
3. Dolcnc VV (ed): The Cavernous Sinus. New York:
Springer-Verlag, 1987
4. Glasscock ME III, Miller GW, Drake FD, et al: Surgery
of the skull base. Laryngoscope 88:905-923, 1978
5. Glasscock ME Ill, Smith PG, Bond AG, et al: Manage-
ment of aneurysms of the petrous portion of the internal
carotid artery by resection and primary anastomosis. La-
ryngoscope 93:1445-1453, 1983
6. Harris FS, Rhoton AL Jr: Anatomy of the cavernous
sinus. A microsurgical study. J Neurosurg 45:169-180,
1976
7. Lapresle J, Lasjaunias P: Cranial nerve ischemic arterial
syndromes. Brain 109:207-215, 1986
8. Lasjaunias P, Morel J, Mink J: The anatomy of the
inferolateral trunk (ILT) of the internal carotid artery.
Neuroradiology 13:215-220, 1977
9. Lasjaunias PL: Craniofacial and Upper Cervical Arteries:
Functional, Clinical and Angiographic Aspects. Balti-
more: Williams & Wilkins, 1981
10. Parkinson D: Carotid cavernous fistula. History and anat-
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York: Springer-Verlag, 1987, pp 3-29
11. Parkinson D: Collateral circulation of cavernous carotid
artery: anatomy. Can J Surg 7:251-268, 1964
12. Parkinson D: A surgical approach to the cavernous por-
tion of the carotid artery. Anatomical studies and case
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13. Parkinson D, Ramsay RM: Carotid cavernous fistula with
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191-195, 1963
Manuscript received April 17, 1990.
Accepted in final form September 21, 1990.
Address reprint requests to: Harry R. van Loveren, M.D.,
Department of Neurosurgery, University of Cincinnati
College of Medicine, 231 Bethesda Avenue, Cincinnati, Ohio
45267-0515.
J. Neurosurg. / Volume 74~May, 1991