{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,21]],"date-time":"2026-07-21T21:55:10Z","timestamp":1784670910027,"version":"3.55.0"},"reference-count":35,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"1","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2024,1,1]]},"abstract":"<jats:sec>\n<jats:title>OBJECTIVE<\/jats:title>\n<jats:p>The anatomy of the cavernous sinus (CS) has been well studied in the laboratory for decades; however, performing surgery in and around the CS is still a challenge. To reveal the learning curve for CS surgery via the pretemporal transcavernous approach (PTTC), surgical procedures were examined. The authors proposed 4 levels of surgical difficulty in opening the walls of the CS through this approach. Details of the approach were illustrated by surgical videos of symptomatic intracavernous aneurysm clipping.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>METHODS<\/jats:title>\n<jats:p>Four levels of surgical difficulty were proposed. The higher the level, the more the CS walls were opened. Pathologies corresponding to each level of difficulty in and around the CS were categorized in each level together with explanations. From 2015 to 2021, 5 patients with symptomatic intracavernous aneurysms (diplopia due to compressive cranial neuropathy) underwent the PTTC at the authors\u2019 institute and served as representative cases in opening the walls of the CS. All CS cases from 2009 to 2021 were reviewed and categorized to demonstrate the learning curve.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>RESULTS<\/jats:title>\n<jats:p>Four levels of surgical difficulty are as follows: level 1, a basic Dolenc extradural approach, which involves opening the anterior third of the superior and lateral walls of the CS; level 2, mobilizing the internal carotid artery (ICA) and opening the proximal dural ring to enter the roof of the CS and treat lesions around the clinoid and upper cavernous ICA; level 3, opening the entire aspect of the superior and lateral walls of the CS, which involves opening the oculomotor triangle and peeling the lateral wall of the CS to the tentorial incisura; and level 4, mobilizing cranial nerves III, IV, and V1 to gain access to the supra-\/infratrochlear triangles to have proximal ICA control and opening the posterior wall as the last step to enter the posterior fossa. Surgical steps were described and illustrated with surgical videos of symptomatic intracavernous aneurysm clipping.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>CONCLUSIONS<\/jats:title>\n<jats:p>The learning curve for CS surgery is long. The authors use 4 levels of surgical difficulty to describe applications of the PTTC in CS surgery. This approach serves as an effective workhorse in treating CS pathologies with low morbidity and high success rates when performed by experienced neurosurgeons.<\/jats:p>\n<\/jats:sec>","DOI":"10.3171\/2023.5.jns2328","type":"journal-article","created":{"date-parts":[[2023,7,22]],"date-time":"2023-07-22T14:48:51Z","timestamp":1690037331000},"page":"183-193","source":"Crossref","is-referenced-by-count":5,"title":["The learning curve for cavernous sinus surgery illustrated by symptomatic intracavernous aneurysm clipping through a pretemporal transcavernous approach"],"prefix":"10.3171","volume":"140","author":[{"given":"Chih-Hsiang","family":"Liao","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung;"},{"name":"Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung;"},{"name":"Institute of Medicine, Chung Shan Medical University, Taichung;"},{"name":"School of Medicine, Taipei Medical University, Taipei;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chun-Fu","family":"Lin","sequence":"additional","affiliation":[{"name":"Division of General Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei;"},{"name":"School of Medicine, National Yang Ming Chiao Tung University, Taipei;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jui-To","family":"Wang","sequence":"additional","affiliation":[{"name":"Division of General Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei;"},{"name":"School of Medicine, National Yang Ming Chiao Tung University, Taipei;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wei-Hsin","family":"Wang","sequence":"additional","affiliation":[{"name":"Division of General Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei;"},{"name":"School of Medicine, National Yang Ming Chiao Tung University, Taipei;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shao-Ching","family":"Chen","sequence":"additional","affiliation":[{"name":"Department of Surgery, Division of Neurosurgery, Cheng Hsin General Hospital, Taipei;"},{"name":"Institute of Neuroscience, National Yang Ming Chiao Tung University, Taipei; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sanford P. C.","family":"Hsu","sequence":"additional","affiliation":[{"name":"Division of General Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei;"},{"name":"School of Medicine, National Yang Ming Chiao Tung University, Taipei;"},{"name":"Institute of Biophotonics, National Yang Ming Chiao Tung University, Taipei, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"6","key":"b1","series-title":"J Neurosurg","first-page":"824","article-title":"Direct microsurgical repair of intracavernous vascular lesions","volume":"58","author":"Dolenc V","year":"1983","unstructured":"Dolenc V. Direct microsurgical repair of intracavernous vascular lesions. J Neurosurg. 1983;58(6):824\u2013831."},{"key":"b2","series-title":"Acta Neurochir Suppl","first-page":"99","article-title":"Extradural approach to intracavernous ICA aneurysms","volume":"72","author":"Dolenc VV","year":"1999","unstructured":"Dolenc VV. 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J Neurosurg. 2016;124(4):1107\u20131113."},{"issue":"4","key":"b30","series-title":"J Neurosurg","first-page":"1376","article-title":"Aneurysms with persistent filling after failed treatment with the Pipeline embolization device","volume":"130","author":"Daou B","year":"2019","unstructured":"Daou B, Atallah E, Chalouhi N,  Aneurysms with persistent filling after failed treatment with the Pipeline embolization device. 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Oper Neurosurg (Hagerstown). 2017;13(4):492\u2013502."},{"issue":"1","key":"b32","series-title":"Neurointervention","first-page":"23","article-title":"Flow diverter treatment for non-ruptured carotid aneurysms: efficacy and safety","volume":"18","author":"L\u00f3pez-Callejas O","year":"2023","unstructured":"L\u00f3pez-Callejas O, Ortiz-Giraldo AF, Vera DD,  Flow diverter treatment for non-ruptured carotid aneurysms: efficacy and safety. Neurointervention. 2023;18(1):23\u201329."},{"key":"b33","series-title":"J Cerebrovasc Endovasc Neurosurg","article-title":"Analysis of reported adverse events of pipeline stents for intracranial aneurysms using the FDA MAUDE database","author":"Porwal MH","unstructured":"Porwal MH, Kumar D, Thalner S, Hedayat HS, Sinson GP. Analysis of reported adverse events of pipeline stents for intracranial aneurysms using the FDA MAUDE database. J Cerebrovasc Endovasc Neurosurg. Published online February 15, 2023. doi:10.7461\/jcen.2023.E2022.10.010"},{"issue":"24","key":"b34","series-title":"J Neurosurg Case Lessons","first-page":"CASE22352","article-title":"Bilateral blindness following flow diverter placement in a giant thrombosed cavernous carotid aneurysm: illustrative case","volume":"4","author":"Misra BK","year":"2022","unstructured":"Misra BK, Khandhar AV, Pradhan R. Bilateral blindness following flow diverter placement in a giant thrombosed cavernous carotid aneurysm: illustrative case. J Neurosurg Case Lessons. 2022;4(24):CASE22352."},{"issue":"2","key":"b35","series-title":"J Neurointerv Surg","first-page":"166","article-title":"Transient in-stent stenosis at mid-term angiographic follow-up in patients treated with SILK flow diverter stents: incidence, clinical significance and long-term follow-up","volume":"11","author":"Essbaiheen F","year":"2019","unstructured":"Essbaiheen F, AlQahtani H, Almansoori TM,  Transient in-stent stenosis at mid-term angiographic follow-up in patients treated with SILK flow diverter stents: incidence, clinical significance and long-term follow-up. 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