Transcavernous Sinus Resection of Parotid Carcinoma with Perineural Invasion to Meckel's Cave and Cavernous Sinus

Li Cai¹Ruben Dammers^2*Elise G. Rushing³Clemens Dirven²Abdel Raouf Kayssi⁴Marian Magaña Ricardo^5*Ali F. Krisht^4*

• ¹Arkansas Neuroscience Institute, CHI St Vincent, Little Rock, United States
• ²Department of Neurosurgery, Center for Complex Microvascular Surgery, Erasmus MC Stroke Center, Erasmus University Medical Center, Erasmus MC, Rotterdam, Netherlands
• ³College of Medicine, University of Arkansas for Medical Sciences, Little Rock, United States
• ⁴department of neurosurgery, Arkansas Neuroscience Institute, CHI St Vincent, Little Rock, United States
• ⁵Department of Neurological Surgery, Hospital Civil de Guadalajara Unidad Hospitalaria Fray Antonio Alcalde, Guadalajara, Mexico

Background: Adenoid cystic carcinoma (ACC) of the salivary glands is a rare but aggressive malignancy known for perineural invasion (PNI), allowing tumor spread along cranial nerves to the skull base, Meckel's cave, and cavernous sinus. Cavernous sinus involvement has traditionally been considered inoperable due to the density of neurovascular structures. Recent advancements in skull base microsurgery and anatomical landmark–guided navigation have enabled radical tumor resection in carefully selected patients. Objective: To describe a tailored pretemporal extradural transcavernous skull base approach, combined with infratemporal fossa exposure, for radical resection of parotid ACC with extensive PNI into Meckel's cave and the cavernous sinus, emphasizing internal carotid artery (ICA) skeletonization, fascicular-level nerve dissection and repair, and precision bone work. Methods: A 54-year-old male with multiple cranial nerve palsies and adenoid cystic carcinoma underwent a modified Dolenc approach. A modified Dolenc pretemporal extradural transcavernous approach was performed without orbitozygomatic osteotomy. Bone removal was limited to V₂–V₃ triangle drilling, exposing the infratemporal fossa and Meckel’s cave. ICA skeletonization was guided by the vidian canal,petrolingual ligament,petroclival ligament, and petrosphenoidal ligament, with intraoperative Doppler confirmation. Fascicular-level neurorrhaphy reconstructed infiltrated V₃ fibers. Multilayer skull base reconstruction with autologous fat grafts provided watertight closure and radioprotection. Results: Gross total resection was achieved with preserved integrity of the ICA and all cranial nerves. No new neurological deficits occurred; preexisting palsies remained stable. Pathology confirmed ACC with extensive PNI; immunohistochemistry was positive for Hematoxylin and eosin, B-catenin, CK-7, and S100. Postoperative MRI verified complete cavernous sinus tumor removal. The patient recovered well and was referred for adjuvant stereotactic radiotherapy. Conclusion: This case demonstrates that even extensive cavernous sinus invasion by parotid ACC can be safely addressed with curative intent through precision-based microsurgery. A modified Dolenc approach with limited bone work and infratemporal extension enables maximal resection while preserving function. Strategic reconstruction optimizes safety for adjuvant radiation. This report adds to the growing evidence supporting aggressive yet function-preserving surgical management of malignant skull base tumors in multidisciplinary oncology programs.