Surgery performed by Dr. Carlos Eduardo da Silva
SurgSchool hosts the Full video of this surgerywhich can be viewed in its entirety on the online surgical training appThe intervention, entitled Giant chondrosarcoma of the cavernous sinus, was carried out by the Dr. Carlos Eduardo da Silva, neurosurgeon of the Federal University of Health Sciences of Porto Alegre (Brazil), with extensive experience in skull base and vascular surgery.
Introduction
El cavernous sinus chondrosarcoma It represents a rare and complex entity within parasellar tumor pathology. Its locally aggressive behavior, frequent bone infiltration, and close relationship with critical neurovascular structures necessitate a highly specialized surgical strategy.
In this case, Dr. Carlos Eduardo da Silva addresses a Giant chondrosarcoma of the cavernous sinus, with extradural extension lateral to the internal carotid artery, by means of a transcranial transcavernous approach through the middle fossa, with the aim of achieving macroscopically complete resection in a single surgical procedure.
The surgical indications These include progressive neurological deficits—in this patient, sixth cranial nerve palsy with diplopia and headache—and radiological evidence of cavernous compression and invasion. This approach is prioritized over endonasal alternatives when the lesion is predominantly extradural, lateral to the carotid artery, and has a significant hyperostotic bone component.
Preoperative planning
La contrast-enhanced magnetic resonance imaging It showed a heterogeneous lesion involving the lateral wall of the cavernous sinus and the right paracellar region, with bone infiltration of the petrous apex and superior clivus. Three-dimensional characterization of the tumor confirmed its location. extradural and lateral to the carotid artery, a key factor in selecting the approach.
From an anatomical point of view, planning requires a thorough knowledge of the triangles of the middle fossa and cavernous sinusas well as laboratory training in middle fossa peeling and parasellar region. Patient selection was optimal: young male, without comorbidities and with focal neurological deficit, candidate for aggressive resection with curative intent.
Description of the surgical approach
A extradural approach to the middle fossa with transcavernous accesswhich allows working with short instruments, fine movements and direct control of critical structures.
Among its and advantages Key advantages include the preservation of nasal anatomy and physiology, the possibility of wide tumor resection under direct vision, and simultaneous access to the cavernous sinus and petrous apex. limitationsIt requires a long learning curve and advanced anatomical knowledge.
Key surgical steps
The patient was positioned supine, with the head secured in a three-point fixation system and rotated approximately 45°, optimizing exposure of the petrous apex and superior clivus. An inverted question mark incision was made, followed by a pterional craniotomy.
A relevant technical gesture was the minimum front dural opening for CSF drainage from the optic-carotid cistern, achieving brain relaxation without the need for continuous lumbar drainage.
El extradural peeling of the middle fossa It began with coagulation and sectioning of the meningo-orbital band, exposing the lateral wall of the cavernous sinus and the extradural tumor.
During this phase, the Dr. Carlos Eduardo da Silva He made the milling of the anterior clinoid processfacilitating anatomical orientation and safe access. The opening of the lateral wall of the cavernous sinus was guided by neurophysiological monitoring, optimizing the preservation of the cranial nerves.
La tumor debulking It began through the infratrochlear triangle (Parkinson's triangle)progressively extending the peeling towards V3 and Meckel's cave. The internal carotid cavernousachieving complete resection of the surrounding tumor without leaving any residue attached to its wall.
A decisive point was the aggressive bone resection of the petrous apex and adjacent clivus, where the tumor showed hyperostotic infiltration. The final exposure allowed visualization of the dura mater of the posterior fossa, completing a wide and controlled resection.
Critical points and risks
The structures at greatest risk include the cavernous internal carotid arterycranial nerves III, IV, V, and VI, and the cavernous sinus itself are involved. Potential complications include oculomotor deficit, CSF fistula, and cavernous bleeding.
Prevention is based on meticulous extradural opening, systematic use of neurophysiological monitoring, and early identification of the carotid artery before deep resection maneuvers.
Surgical tips & pearls
Dr. Carlos Eduardo da Silva's experience underscores that the success of this approach depends more on the precise extradural peeling than in the intratumoral phase. Wide bone resection, even beyond the visible tumor volume, is key in chondrosarcomas with a hyperostotic component. Cerebral relaxation through focal cisternal drainage significantly reduces morbidity.
Common mistakes and pitfalls
A common mistake is underestimate bone infiltrationleaving microscopic remnants that can lead to recurrence. Another pitfall is opening the cavernous sinus without a clear anatomical landmark, increasing the risk of neurovascular injury.
Results and postoperative considerations
Postoperative CT and MRI confirmed complete resection The tumor was located in the paracellar region and posterior fossa. The patient experienced transient paresis of the third cranial nerve, with complete recovery, while the previous paralysis of the sixth cranial nerve remained.
It was indicated adjuvant radiotherapy using radiosurgery, in accordance with the standard management of chondrosarcoma. After three years of follow-upNo tumor recurrence was evident, and the patient returned to work after ophthalmological correction of diplopia.
For whom is this surgery especially useful?
This case is particularly valuable for advanced residents in neurosurgery, young assistants who begin skull base surgery and expert surgeons interested in perfecting extradurally oriented transcavernous approaches.
