Showing papers on "Cavernous sinus published in 1991"

Anterior transpetrosal-transtentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients

Abstract: This report presents a new surgical method and the results in 10 patients with petroclival meningiomas extending into the parasellar region (sphenopetroclival meningiomas). Minimal but effective extradural resection of the anterior petrous bone via a middle fossa craniotomy offered a direct view of the clival area with preservation of the temporal bridging veins and cochlear organs. The dural incision was extended anteriorly to Meckel's cave, and in cases with invasion of the cavernous sinus, Parkinson's triangle was enlarged by mobilization of the trigeminal nerve. This approach offered an excellent view from the mid-clivus to the cavernous sinus. Extra-as well as intradural tumor masses and dural attachments could be cleared under direct view of the pontine surface. The risk of injury to the lower cranial nerve and of retraction damage to the temporal lobe and brain stem were kept minimal by this approach. Total tumor resection was achieved in 7 patients, with no resultant mortality. Eight patients had a satisfactory postsurgical course, extraocular paresis being their main complaint. The extent of tumor resection depended on the degree of tumor adhesion to the carotid artery, and operative morbidity on the degree of tumor invasion of the brain stem. Of the 3 patients in whom subtotal tumor removal was achieved, only one experienced regrowth of the tumor and underwent a second operation during the follow-up period (6 months-6 years).

Cavernous malformations and capillary telangiectasia: a spectrum within a single pathological entity.

Abstract: Cerebral vascular malformations have traditionally been divided into four categories: arteriovenous, venous, cavernous, and capillary telangiectases. A controversy exists about separating the latter two lesions into separate entities. Critics claim the distinction is arbitrary but have been unable to present convincing evidence linking the two types of lesions. We have reviewed the histories of 20 patients with cavernous malformations and have analyzed the clinical, radiographic, and surgical-autopsy data associated with these lesions. In some patients, multiple lesions, including cavernous malformations, capillary telangiectases, and transitional forms between the two, were identified. Based on this analysis, we conclude that capillary telangiectasia and cavernous malformations represent two pathological extremes within the same vascular malformation category and propose grouping them as a single cerebral entity called cerebral capillary malformations.

Petrosal sinus sampling: technique and rationale

Abstract: Bilateral simultaneous sampling of the inferior petrosal sinuses is an extremely sensitive, specific, and accurate test for diagnosing Cushing disease and distinguishing between that entity and the ectopic ACTH syndrome. It is also valuable for lateralizing small hormone-producing adenomas within the pituitary gland. The inferior petrosal sinuses connect the cavernous sinuses with the ipsilateral internal jugular veins. The anatomy of the anastomoses between the inferior petrosal sinus, the internal jugular vein, and the venous plexuses at the base of the skull varies, but it is almost always possible to catheterize the inferior petrosal sinus. In addition, variations in size and anatomy are often present between the two inferior petrosal sinuses in a patient. Advance preparation is required for petrosal sinus sampling. Teamwork is a critical element, and each member of the staff should know what he or she will be doing during the procedure. The samples must be properly labeled, processed, and stored. Specific needles, guide wires, and catheters are recommended for this procedure. The procedure is performed with specific attention to the three areas of potential technical difficulty: catheterization of the common femoral veins, crossing the valve at the base of the left internal jugular vein, and selective catheterization of the inferior petrosal sinuses. There are specific methods for dealing with each of these areas. The sine qua non of correct catheter position in the inferior petrosal sinus is demonstration of reflux of contrast material into the ipsilateral cavernous sinus. Images must always be obtained to document correct catheter position. Special attention must be paid to two points to prevent potential complications: The patient must be given an adequate dose of heparin, and injection of contrast material into the inferior petrosal sinuses and surrounding veins must be done gently and carefully. When the procedure is performed as outlined, both inferior petrosal sinuses can be catheterized in more than 98% of patients. The complication rate is low, and the theoretical risk of major morbidity or death is less than 1% (neither has yet occurred, to our knowledge). The most common complication is groin hematoma.

Invasive Aspergillus Rhinosinusitis in Patients with Acute Leukemia

Abstract: Invasive aspergillus rhinosinusitis is a potentially lethal complication of chemotherapy-induced neutropenia in patients with acute leukemia. The majority of cases are caused by Aspergillus flavus. The infection is difficult to diagnose early but should be suspected when a neutropenic patient develops persistent fever without a known source, symptoms of rhinitis or sinusitis, cutaneous findings over the nose or sinuses, symptoms and signs of orbital or cavernous sinus disease, or an ulcerating lesion of the hard palate or gingiva. Careful anterior rhinoscopy followed by computed tomography of the sinus helps establish the diagnosis, which should be confirmed by histologic study and culture of biopsied material. Early treatment with aggressive surgery, high-dose amphotericin B and 5-fluorocytosine, and possibly white blood cell transfusions may produce a cure if the patient's bone marrow recovers. Newer antifungal agents offer promise for prophylaxis and treatment of this infection.

Supratentorial dermoid cysts

Abstract: Supratentorial dermoid cysts are rare lesions. In eight cases presented here, the lack of recurrence after subtotal removal of the capsule and the good long-term prognosis are emphasized. This finding is in agreement with the literature. The frequent relationship of these lesions with the cavernous sinus suggests a vascular genesis in the development of intracranial dermoid cysts.

Dorello's canal: a microanatomical study.

Abstract: The microsurgical anatomy of Dorello's canal has been studied in 20 specimens obtained from 10 cadaver heads fixed in formalin. The bow-shaped canal through which courses the abducens nerve before reaching the cavernous sinus is located inside a venous confluence which occupies the space between the dural leaves of the petroclival area. The petrosphenoidal ligament (Gruber's ligament), which forms the posteromedial wall of the canal, appears as a fibrous trabecula surrounded by venous blood. Canal measurements were performed and its anatomical relationship with the sixth cranial nerve is described. Angulations of variable degrees were observed in the course of the nerve inside and outside the canal. The influence of this relatively tortuous course of the abducens nerve upon its vulnerability in some pathological conditions is discussed.

Transarterial platinum coil embolization of carotid-cavernous fistulas.

Abstract: Of the 227 embolization procedures performed by our neurointerventional section for symptomatic carotid-cavernous fistulas over the past 10 years, five involved placement of platinum coils in the cavernous sinus from a transarterial route. In four patients, prior transarterial balloon procedures had failed to produce fistula closure. In the fifth patient, with Ehlers-Danlos syndrome, a prior transvenous embolization attempt was unsuccessful. In three patients, complete closure of the carotid-cavernous fistula was achieved with preservation of the parent artery. In one patient, the earliest treated, a portion of a platinum coil projected through the fistula into the parent artery. To eliminate the risk of clot formation and distal embolization, internal carotid occlusion was performed and tolerated without deficits. In the last patient, closure of the anterior drainage was achieved, but complicated by distal migration of the platinum coils with transient aggravation of ocular symptoms. Attempts to occlude the remaining cortical drainage were unsuccessful with platinum coils; therefore, a balloon was used to obliterate the small remaining fistula. Transarterial platinum coil embolization is an alternative treatment for symptomatic carotid-cavernous fistulas that cannot be closed successfully by other embolization techniques. The development of shorter, more thrombogenic, detachable or retrievable coils may make this technique more promising in the future.

Color Doppler imaging. A new noninvasive technique to diagnose and monitor carotid cavernous sinus fistulas.

Abstract: • Color Doppler imaging is a recent development in ultrasonography that allows for simultaneous two-dimensional structural imaging and Doppler evaluation of blood flow. With this technique, one patient with a traumatic carotid cavernous sinus fistula and two patients with spontaneous dural cavernous arteriovenous malformations were evaluated. Color Doppler imaging demonstrated a dilated superior ophthalmic vein with arterialized blood flow in all three patients. In two cases the diagnosis was confirmed by angiography, and in one of these cases the fistula was occluded with a detachable balloon catheter. Postembolization color Doppler imaging revealed return of normal venous flow in the superior ophthalmic vein. This technique offers a noninvasive means to confirm the clinical diagnosis and to track the hemodynamics of these arteriovenous fistulas. In certain cases, color Doppler imaging may eliminate the need for computed tomography and magnetic resonance imaging in the evaluation of suspected arteriovenous malformations of the orbit.

The Dolenc technique for cavernous sinus exploration (cadaveric prosection) Technical note

Abstract: 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.

Aneurysms of the intracavernous carotid artery: a multidisciplinary approach to treatment

Abstract: ✓ Of 43 cavernous sinus aneurysms diagnosed over 6½ years, 23 fulfilled indications for treatment; of these 19 were treated, eight surgically and 11 with interventional radiological techniques. Six small and two giant aneurysms were treated surgically: four were clipped, two were repaired primarily, and two were trapped with placement of a saphenous-vein bypass graft. Seven large and four giant aneurysms were treated with interventional radiological techniques: in five cases the proximal internal carotid artery (ICA) was sacrificed; one aneurysm was trapped with detachable balloons; and five were embolized with preservation of the ICA lumen. The mean follow-up period was 25 months. At follow-up examination, three patients in the surgical group were asymptomatic, two had improved, and three had worsened. Three of these patients had asymptomatic infarctions apparent on computerized tomography (CT) scans. At follow-up examination, four radiologically treated patients were asymptomatic, five had improved, two...

Management of vascular perforations that occur during neurointerventional procedures.

Abstract: This article describes a number of treatment strategies for the management of perforations that occur during neurointerventional procedures. During the past 5 years, we have performed over 1200 endovascular procedures to treat vascular disorders involving the brain and spinal cord (400 cerebral arteriovenous malformations, 230 tumors, 197 carotid cavernous fistulas, 183 aneurysms, 130 dural fistulas, 80 spinal arteriovenous malformations, 18 vein of Galen aneurysms, and 20 cases of vasospasm). Fifteen patients (1.1%) sustained a vascular perforation as a direct result of these procedures. Among these 15 patients, indications for endovascular treatment were six symptomatic arteriovenous malformations, two spinal cord arteriovenous malformations, two cavernous sinus dural fistulas, one transverse sinus fistula, one case of vasospasm following subarachnoid hemorrhage, one direct carotid cavernous fistula, one vein of Galen malformation, and one ruptured basilar artery aneurysm. The vascular perforations were grouped into three probable mechanisms: mechanical perforation of a normal vessel (six patients), mechanical disruption of a dysplastic vessel or aneurysm (five patients), and fluid overinjection (four patients). Treatment of the perforations included immediate reversal of anticoagulants (12 patients) and direct closure of the perforation site with coils (five patients). In addition, closure of the intravascular compartment adjacent to the perforation was achieved with coils (six patients), liquid adhesives (four patients), balloons (two patients), or particles (two patients). In two patients a detachable balloon was placed transiently across the perforation site for several minutes, deflated, and removed when no further extravasation was noted. Five patients were started on anticonvulsant therapy, two of whom have had a new onset seizure related to the perforation.(ABSTRACT TRUNCATED AT 250 WORDS)

Lymphocytic Hypophysitis with Involvement of the Cavernous Sinus and Hypothalamus

Abstract: Two cases of lymphocytic hypophysitis are reported, in which hypothalamic involvement causing diabetes insipidus was a prominent clinical feature. In one case, a man had clinical and radiological evidence of the involvement of the cavernous sinus. This represents the second reported case of a man with lymphocytic hypophysitis. A transsphenoidal biopsy established the diagnosis in both cases. Neither the involvement of the cavernous sinus nor permanent diabetes insipidus has been reported previously. A review of the literature is provided.

Multiple dural arteriovenous fistulas of the cranium and spine

Abstract: Dural arteriovenous fistulas are acquired lesions that usually involve the dura around the cavernous sinus. The transverse, sigmoid, and superior sagittal sinuses may be affected occasionally. With the exception of bilateral cavernous sinus dural arteriovenous fistulas, the simultaneous occurrence of dural arteriovenous fistulas at two locations is rare. Among 105 patients evaluated for dural arteriovenous fistulas, we identified seven patients with fistulas at two sites. The age of the patients ranged from 27 to 74 years. Presentation was related to hemorrhage in three patients, loss of vision in four, and a bruit and headaches in one. Patients were treated with combined surgical and endovascular techniques. All treated lesions were completely closed with no mortality or permanent morbidity. The presence of multiple fistulas must be considered in patients being evaluated for dural arteriovenous fistulas. Patients with multiple fistulas usually present with life-threatening hemorrhages or acute neurologic decline; the risk factor for hemorrhages, including those related to venous outflow obstruction, is high in patients with multiple dural arteriovenous fistulas.

Treatment of dural carotid-cavernous fistulas via the superior ophthalmic vein.

Abstract: Symptomatic patients with dural carotid-cavernous fistulas often require treatment. Traditional therapies, which often are not completely successful, include manual common carotid artery compression and embolization via transarterial routes. This report describes four symptomatic patients with spontaneous dural carotid-cavernous fistulas who were treated unsuccessfully with transarterial embolotherapy and subsequently treated successfully by having a detachable balloon introduced into the cavernous sinus via the superior ophthalmic vein, which was surgically exposed. The fistulas resolved without complications. Treatment of dural carotid-cavernous fistulas by means of the transvenous approach via the superior ophthalmic vein may be of benefit in selected patients.

Pituitary adenomas with parasellar invasion.

Abstract: Pituitary adenomas with extension into the parasellar space, the so called “cavernous sinus” can be demonstrated best using MRI. To improve the delineation from the venous compartments the use of unenhanced and enhanced MRI scans is essential. In 25 pituitary adenomas with surgically proven infiltration into the space of the cavernous sinus we correlated the MRI findings with our surgical observations. When the adenoma encases the intracavernous internal carotid artery or reaches as far as to the lateral aspect of the artery, invasion was present in all cases. The critical area where invasion could not be predicted from MRI is the distance between the medial and the lateral aspect of the intracavernous internal carotid artery. By measurement with the monoclonal antibody KI-67 it could be shown, that pituitary adenomas infiltrating the parasellar space have a statistically significant higher growth rate (p < 0.001), compared to non-invasive adenomas. This is of special interest, because surgical cure becomes unlikely, when invasion into the space of the cavernous sinus is present.

Complications of Transsphenoidal Surgery

Abstract: The complications of transsphenoidal surgery may be divided into a number of categories, based both on anatomic structures and on systems that may be involved.

Giant carotid-ophthalmic artery aneurysms: direct clipping utilizing the “trapping-evacuation” technique

Abstract: The authors have devised a "trapping-evacuation" technique to facilitate direct clipping of giant aneurysms in the paraophthalmic region of the internal carotid artery (ICA). The giant aneurysm is collapsed by first trapping the aneurysm by temporary occlusion of the cervical common carotid and external carotid arteries, along with temporary clipping of the intracranial ICA distal to the aneurysm. Thereafter, intra-aneurysmal blood is simultaneously aspirated through a catheter placed in the cervical ICA. Exposure of the proximal end of the aneurysm neck is mandatory for successful clipping. This is accomplished by extensive unroofing of the optic canal, removal of the anterior clinoid process, opening of the anterior part of the cavernous sinus, and exposure of the most proximal intradural (C2) and genu (C3) portions of the ICA. Four cases of giant aneurysms of the paraophthalmic ICA were successfully treated by this technique and the postoperative outcome was good in all cases. Preoperative magnetic resonance imaging for evaluation of the anatomical details, balloon occlusion test of the ICA, and intraoperative measurement of cortical blood flow were important to the success of the operation. Intraoperative digital subtraction angiography via the catheter placed in the cervical ICA was useful in confirming successful clipping.

Management of Intracavernous Tumours: An 11-Year Experience

Abstract: Seventy-one patients with tumours involving the cavernous sinus (CS) were operated upon between 1979 and 1989. Fifty-four patients underwent a direct approach to the CS. The average age of these latter patients was 47 (9–69) years. The lesions included 51 benign tumours (26 meningiomas, 16 [7 invasive] pituitary adenomas, 3 trigeminal neurinomas, one chordoma, one chondroma, one craniopharyngioma, one epidermoid tumour, and one cavernous haemangioma), and 3 malignant tumours (one chondrosarcoma, one adenoid cystic carcinoma and one metastatic adenocarcinoma).

Pathways of parasympathetic and sensory cerebrovascular nerves in monkeys.

Abstract: Using immunohistochemistry, we studied the origins and pathways of parasympathetic and sensory nerve fibers to the pial arteries in four squirrel monkeys. Following its application to the surface of the middle cerebral artery, the retrograde axonal tracer True Blue accumulated in parasympathetic neurons of the sphenopalatine ganglion and the internal carotid ganglion. The latter is strategically located where the internal carotid artery enters the cranium. Fibers from the sphenopalatine ganglion reach the internal carotid artery in the cavernous sinus region after running as rami orbitales. Before reaching the internal carotid artery, the fibers bypass aberrant sphenopalatine ganglia, with the most distant, the cavernous ganglion, being located in the cavernous sinus region. True Blue also accumulated in sensory neurons of the ophthalmic and maxillary divisions of the trigeminal ganglion and in sensory neurons of the internal carotid ganglion. Fibers from the ophthalmic division of the trigeminal ganglion reach the internal carotid artery as a branch through the cavernous sinus, bypassing the cavernous ganglion. Fibers from the maxillary division also bypass the cavernous ganglion after reaching it via a recurrent branch of the orbitociliary nerve. Thus, the cavernous ganglion forms a confluence zone for parasympathetic and sensory fibers in the region. In addition, parasympathetic and sensory fibers leave the confluence zone to follow the abducent and trochlear nerves backward to the basilar artery and tentorium cerebelli, respectively. Clinical implications are discussed.

Localization of lesions of the oculomotor nerve: recent concepts.

Abstract: The anatomic features of the third cranial nerve (the oculomotor nerve) and the localization of lesions that affect it are reviewed. Recent considerations of the organization of the oculomotor fascicles in the ventral mesencephalon, the superior and inferior divisional palsies localized proximal to the cavernous sinus, and the possibility of the localization of ischemic oculomotor palsies to the mesencephalon rather than a peripheral site are emphasized. The characteristic manifestations of nuclear lesions (unilateral palsy of the third cranial nerve, weakness of the ipsilateral and contralateral superior rectus muscles, and bilateral incomplete ptosis) are described, as are other variations of nuclear involvement. Although proptosis is typically associated with orbital masses, it may also result from lesions of the cavernous sinus or (rarely) an intracranial lesion. Metastatic orbital tumors often are the first evidence of systemic spread in patients with cancer; infiltrative and mass lesions are the most common. Aberrant regeneration of the oculomotor nerve may occur months to years after the occurrence of an oculomotor lesion.

The clinical importance of the inferolateral trunk of the internal carotid artery.

Abstract: The inferolateral trunk (ILT) of the internal carotid artery (ICA) is a branch that arises inferiorly from the C4 segment of the cavernous ICA. It provides blood supply to the 3rd, 4th, and 6th cranial nerves, as well as to the gasserian ganglion. The ILT anastomoses to branches of the internal maxillary artery, providing collateral circulation between the external carotid artery and the ICA systems. Retinal and cerebral emboli can arise from the external carotid artery system and travel via the ILT to the ICA. Cranial nerve palsies may result after occlusion of the ILT. We present the cases of four patients who had iatrogenic neurological dysfunction subsequent to intravascular procedures that involved the ILT. These cases provide further clinical confirmation of the importance of this blood vessel. A 5th case involving iatrogenic occlusion of the ILT and no neurological deficit is also presented, demonstrating that the ILT is not the sole blood supply of the cranial nerves in the cavernous sinus.

Improved access to lesions of the central skull base by mobilization of the zygoma: experience with 54 cases.

Abstract: Improved access to lesions at the medial end of the sphenoid wing or in the interpeduncular cistern after mobilization of the zygoma has been a subject of growing interest in recent years. This study describes the operative technique we have adopted and records our experience with 55 operations in 54 patients who underwent the procedure in the past 3 years. Seven patients had vascular lesions, 44 had tumors, and 3 had miscellaneous lesions. The majority of the tumors were medial meningiomas, and particular note is made of those arising from the cavernous sinus with respect to their resectability. Sixteen of these tumors were encountered, and total excision was possible in 11 cases. Access to the infratemporal fossa is facilitated, and in 2 cases we were able to excise completely trigeminal neuromas that had extended there. The extra maneuver adds little to the overall operating time, and complications relating to it are uncommon, mild in degree, and usually self-limiting. We conclude that the operation is extremely valuable in appropriate circumstances.

Advances in the treatment of complex cerebrovascular disorders by interventional neurovascular techniques.

Abstract: Treatment of complex cerebrovascular disorders, including intracranial aneurysms, carotid cavernous sinus fistulas, vertebral fistulas, arteriovenous malformations, atherosclerosis of brachiocephalic vessels, and arterial vasospasm, is being performed in selected cases by interventional neurovascular techniques. Recent advances in microballoon technology, permanent solidifying polymers, newer embolic agents, high-resolution digital subtraction angiography with road-mapping technique, and steerable micro-guide wires and catheters have greatly improved access in the distal intracranial circulation and markedly reduced the morbidity associated with these procedures. Interventional neuroradiology is emerging as an important adjunct to neurosurgery for selected cerebrovascular disorders.

Sixth nerve schwannomas. Report of two cases.

Abstract: ✓ Two cases of sixth cranial nerve schwannoma are presented with a review of four other cases from the literature. The clinical spectrum, neuroradiological findings, and surgical outcome of the six cases are discussed. There are two distinct clinical presentations for sixth cranial nerve schwannomas. Type I sixth nerve schwannomas present with sixth nerve palsy and diplopia and arise from the cavernous sinus. In contrast, type II sixth nerve schwannomas have a more severe presentation with obstructive hydrocephalus, raised intracranial pressure, sixth nerve palsy, and diplopia. This type arises along the course of the sixth cranial nerve in the prepontine area. Cavernous sinus involvement in either type may preclude total surgical excision and indicate an increased possibility for recurrence.

Management of tumours involving the cavernous sinus.

Abstract: The operative experience with 137 tumours of the cavernous sinus at the University of Pittsburgh during the past 7 years is reported. The importance of the normal and tumour-infiltrated cavernous sinus anatomy and imaging is delineated. 63% of the tumours are benign, primarily meningiomas, for which an anatomical grading system is presented. The various operative approaches to the cavernous sinus are described. 88% of the meningiomas were totally resected. There was a 1.5% operative mortality and 1.5% severe morbidity rate. Initial ipsilateral opthalmoplegia progressively improved in the majority of patients. For all patients with at least 6 months of follow up of benign tumours, the intracavernous tumour recurrence rate was 3% and total recurrence rate was 6%.

Dilated intercavernous sinuses: an MR sign of carotid-cavernous and carotid-dural fistulas.

Abstract: Dilated venous channels traversing the sella and connecting the two cavernous sinuses were seen on contrast-enhanced MR images in four patients with angiographically proved carotid fistulas. The anatomy and variations of these so-called intercavernous sinuses are discussed and are demonstrated in Latex-injected anatomic specimens. Direct visualization of the intercavernous sinuses on contrast-enhanced MR images may serve as an ancillary sign for the diagnosis of carotid-cavernous or carotid-dural fistulas near the sella.

Magnetic resonance imaging of cavernous sinus cavernous hemangiomas.

Abstract: Radiological findings of surgically verified cavernous hemangiomas of the cavernous sinus are presented with special reference to the appearance in magnetic resonance imaging. Differences in radiological features of the cavernous sinus cavernous hemangiomas and intracerebral cavernous hemangiomas are discussed.