Cavernous sinus
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Citation:
Gaillard F, Hacking C, Yap J, et al. Cavernous sinus. Reference article, Radiopaedia.org (Accessed on 13 Dec 2024) https://doi.org/10.53347/rID-5258
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5258
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At the time the article was created Frank Gaillard had no recorded disclosures.
View Frank Gaillard's current disclosures
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Disclosures:
At the time the article was last revised Craig Hacking had the following disclosures:
- Philips Australia, Paid speaker at Philips Spectral CT events (ongoing)
These were assessed during peer review and were determined to not be relevant to the changes that were made.
View Craig Hacking's current disclosures
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Synonyms:
- Cavernous sinuses
The cavernous sinuses are paired dural venous sinuses.
Gross anatomy
The cavernous sinus is located on either side of the pituitary fossa and body of the sphenoid bone. It is most easily thought of as existing between the endosteal and meningeal layers of the dura although some additional complexity is present 5. It spans from the apex of the orbit to the apex of the petrous temporal bone. Unlike other dural venous sinuses, it is divided by numerous fibrous septa into a series of small caves, which is where its name is derived from. The normal lateral wall should be either straight or concave.
Boundaries
- roof: fold of dura mater attached to the anterior and middle clinoid processes
- anterior wall: medial end of the superior orbital fissure
- posterior wall: petrous apex
- medial wall: endosteum overlying the body of the sphenoid bone
- lateral wall: dura mater from the ridge of the roof to the floor of the middle cranial fossa
- floor: endosteum overlying the base of the greater wing of the sphenoid bone
Relations
- superiorly: middle cerebral artery, optic chiasm
- anteriorly: apex of the orbit
- posteriorly: cerebral peduncle
- medially: pituitary fossa, pituitary gland
- laterally: temporal lobe (medial surface), Meckel's cave (posteroinferiorly)
- inferiorly: sphenoid sinus
Dural anatomy
The lateral wall of the cavernous sinus is primarily formed by the continuation of the meningeal layer of the dura, flowing medially up from the floor of the middle cranial fossa, over the cavernous sinus, to the clinoid processes before forming the diaphragma sella. From here, the meningeal layer passes downwards to surround the pituitary gland, thus forming the medial wall of the cavernous sinus. In contrast, the floor of the cavernous sinus is formed by the endosteal layer of the meninges (actually just periosteum) that covers the sphenoid bone and passes medially across the midline below the pituitary gland, separated from the aforementioned meningeal layer by the intercavernous sinus 5.
The nerves in the lateral wall of the cavernous sinus are surrounded by thin connective tissue and thus, the lateral wall of the cavernous sinus has two layers; a thick meningeal layer and a much thinner translucent layer surrounding the cranial nerves 5,6. This thin layer is variably described as being meningeal in origin 6, or continuous with the endosteal layer 5.
Vascular connections
It receives venous blood from:
- inferior and superior ophthalmic veins
- intercavernous sinus
- sphenoparietal sinus
- superficial middle cerebral vein
- occasionally
- central retinal vein
- a frontal tributary of the middle meningeal vein
Drainage of the cavernous sinus is via:
- superior petrosal sinus to the transverse sinus
- inferior petrosal sinus directly to the jugular bulb
- venous plexus on the internal carotid artery (ICA) to the clival (basilar) venous plexuses
- emissary veins passing through the
- foramen Vesalii
- foramen ovale: communicates between the cavernous sinus and pterygoid venous plexus
- foramen lacerum
Depending on relative pressures the superior ophthalmic veins either drain to or from the cavernous sinus.
Additionally, the cavernous sinuses connect to each other via the intercavernous sinuses.
Contents
These can be remembered with the mnemonic O TOM CAT.
Nerves
The cavernous sinus transmits multiple cranial nerves to the superior orbital fissure and foramen rotundum. These are:
- in the lateral wall from superior to inferior
- oculomotor nerve (CN III)
- trochlear nerve (CN IV)
-
trigeminal nerve (CN V)
- ophthalmic division
- maxillary division: within the very inferolateral aspect of the cavernous sinus wall or even outside the sinus rather than truly within it 4
- traversing the sinus
- abducens nerve (CN VI): inferolateral to the internal carotid artery
Artery
The internal carotid artery enters the posterior inferior aspect of the sinus and bends upon itself as the carotid siphon (cavernous segment - C4). Two branches arise from this segment: meningohypophyseal trunk and inferolateral trunk.
The artery is surrounded by a plexus of sympathetic nerves from the superior cervical ganglion.
Fat
Fatty deposits may be present within the cavernous sinus, especially in obese patients or in those who are taking corticosteroids 3.
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Related pathology
Quiz questions
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References
- 1. Standring S, Gray H. Gray's anatomy, the anatomical basis of clinical practice. Churchill Livingstone. (2008) ISBN:0443066841. Read it at Google Books - Find it at Amazon
- 2. Safdieh JE. Netter's Concise Neuroanatomy. Saunders. (2007) ISBN:1933247223. Read it at Google Books - Find it at Amazon
- 3. Razek AA, Castillo M. Imaging lesions of the cavernous sinus. AJNR Am J Neuroradiol. 2009;30 (3): 444-52. doi:10.3174/ajnr.A1398 - Pubmed citation
- 4. Tubbs RS, Hill M, May WR, Middlebrooks E, Kominek SZ, Marchase N, Shoja MM, Loukas M, Oakes WJ. Does the maxillary division of the trigeminal nerve traverse the cavernous sinus? An anatomical study and review of the literature. (2008) Surgical and radiologic anatomy : SRA. 30 (1): 37-40. doi:10.1007/s00276-007-0280-7 - Pubmed
- 5. Yasuda A, Campero A, Martins C, Rhoton A, de Oliveira E, Ribas G. Microsurgical Anatomy and Approaches to the Cavernous Sinus. Neurosurgery. 2008;62(6):SHC1240-63. doi:10.1227/01.neu.0000333790.90972.59 - Pubmed
- 6. Kawase T, van Loveren H, Keller J, Tew J. Meningeal Architecture of the Cavernous Sinus: Clinical and Surgical Implications. Neurosurgery. 1996;39(3):527-35. doi:10.1097/00006123-199609000-00019 - Pubmed
Incoming Links
Articles:
- Dorello canal
- Inferior petrosal sinus
- Dura mater
- Pituitary fossa
- Internal carotid artery venous plexus of Rektorzik
- Zurich pituitary score
- Pterygopalatine fossa
- Suboccipital cavernous sinus
- Superior ophthalmic vein
- Foramen Vesalii
- Ophthalmic artery
- Abducens nerve
- Vein of Galen aneurysmal malformation
- Tuberculous pachymeningitis
- Superior petrosal sinus
- Superior orbital fissure
- Blunt cerebrovascular injury
- Dural arteriovenous fistula
- Cavernous sinus contents (mnemonic)
- Cavernous sinus syndrome
Cases:
- Caroticocavernous fistula
- Fat in cavernous system
- Bilateral cavernous segments internal carotid artery aneurysms
- Pituitary macroadenoma with apoplexy
- Trigeminal amyloidoma
- Normal MRI orbits
- Idiopathic intracranial hypertension
- Bilateral indirect carotid cavernous fistula
- Fat in normal cavernous sinus
- Meningioma - cavernous sinus
- Cavernous sinus fat
- Cavernous sinus (Gray's illustration)
- Bilateral plexiform neurofibromas of the trigeminal and facial nerves - NF1
- Internal carotid artery aneurysm
- Idiopathic intracranial hypertension
- Cavernous sinus thrombosis
- Cavernous sinus arachnoid cyst
- En plaque meningioma with associated CPA / frontal convexity meningiomas
- Tolosa-Hunt syndrome
- Tuberculous meningitis with subarachnoid spinal involvement
Multiple choice questions:
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