Showing papers on "Cavernous sinus published in 1997"

Endoscopic endonasal transsphenoidal surgery: experience with 50 patients.

Abstract: An endoscope was used in transsphenoidal surgery and eventually replaced the operating microscope as the tool for visualization. This study focuses on 50 patients (28 females and 22 males) with a median age of 38 years (range 14-88 years). Initially, four patients underwent operation via a sublabial-transseptal approach using a rigid endoscope in conjunction with an operating microscope. The 48 subsequent operations were performed through a nostril using only rigid endoscopes. Forty-four patients had pituitary adenomas and six had various other lesions. Thirteen patients had microadenomas, 16 had intrasellar macroadenomas, nine had macroadenomas with suprasellar extension, and six had invasive macroadenomas involving the cavernous sinus. Seven patients had recurrent pituitary adenomas and 25 had hormone-secreting adenomas (eight patients with Cushing's disease and 17 patients with prolactinomas). Among the eight patients with Cushing's disease, seven had resolution of hypercortisolism clinically and chemically. Of the 17 patients with prolactinomas, 10 improved clinically with normal serum prolactin levels, four improved clinically with elevated serum prolactin levels, and three had residual tumors in the cavernous sinus. Among the 19 patients with nonsecreting adenomas, 16 underwent total resection and three subtotal resection leaving residual tumor in the cavernous sinus. Postoperatively, all patients who had undergone endonasal endoscopic surgery had unobstructed nasal airways with minimal discomfort. More than half of the patients required only an overnight hospitalization.

The role of transvenous embolization in the treatment of intracranial dural arteriovenous fistulas.

Abstract: OBJECTIVE: To evaluate the role of transvenous embolization in the treatment of intracranial dural arteriovenous fistulas (DAVFs), including its efficacy and safety. METHODS: We retrospectively studied the charts of 24 patients (21 women and 3 men) treated for an intracranial DAVF since 1990 in whom a transvenous approach was attempted either alone (16 patients) or in combination with arterial embolization (8 patients). There were 12 cavernous sinus, 9 transverse-sigmoid sinus, 2 inferior petrosal sinus, and 1 intradiploic fistulas. Three fistulas were Type I, 12 were Type IIa, and 9 were Type IIa+b, according to the revised Djindjian's classification. Transvenous embolic agents included coils (17 patients), detachable balloons (6 patients), bucrylate (2 patients), and silk sutures (1 patient). RESULTS: Anatomic cure was proven in 21 patients (87.5%). Clinical cure was obtained in 23 cases (96%), as follows: 15 patients with a single transvenous approach, 6 with a combined arteriovenous approach, and 2 with an arterial approach after failure of venous access. There was one persistent cavernous fistula despite coil packing of the cavernous sinus. Complications were as follows: five transient and one permanent sixth nerve palsies in cavernous DAVFs, two transient labyrinthic dysfunctions in transverse sinus DAVFs, and one subarachnoid hemorrhage without sequelae. CONCLUSION: Transvenous embolization is a useful and safe approach in the management of intracranial DAVFs.

The surgical resectability of meningiomas of the cavernous sinus.

Abstract: OBJECTIVE:The optimal management for patients with cavernous sinus meningiomas remains controversial. We attempt to contribute to the ongoing debate of appropriate surgical indications.METHODS:In this retrospective review, 39 patients, including 27 women and 12 men ranging in age from 24 to 73 years

The suboccipital cavernous sinus

Abstract: The authors studied the microsurgical anatomy of the suboccipital region, concentrating on the third segment (V3) of the vertebral artery (VA), which extends from the transverse foramen of the axis to the dural penetration of the VA, paying particular attention to its loops, branches, supporting fibrous rings, adjacent nerves, and surrounding venous structures. Ten cadaver heads (20 sides) were fixed in formalin, their blood vessels were perfused with colored silicone rubber, and they were dissected under magnification. The authors subdivided the V3 into two parts, the horizontal (V3h) and the vertical (V3v), and studied the anatomical structures topographically, from the superficial to the deep tissues. In two additional specimens, serial histological sections were acquired through the V3 and its encircling elements to elucidate their cross-sectional anatomy. Measurements of surgically and clinically important features were obtained with the aid of an operating microscope. This study reveals an astonishing anatomical resemblance between the suboccipital complex and the cavernous sinus, as follows: venous cushioning; anatomical properties of the V3 and those of the petrous-cavernous internal carotid artery (ICA), namely their loops, branches, supporting fibrous rings, and periarterial autonomic neural plexus; adjacent nerves; and skull base locations. Likewise, a review of the literature showed a related embryological development and functional and pathological features, as well as similar transitional patterns in the arterial walls of the V3 and the petrous-cavernous ICA. Hence, due to its similarity to the cavernous sinus, this suboccipital complex is here named the "suboccipital cavernous sinus." Its role in physiological and pathological conditions as they pertain to various clinical and surgical implications is also discussed.

Nasopharyngeal angiofibromas: selecting a surgical approach

Abstract: Background A review of 16 juvenile nasopharyngeal angiofibromas, managed at the University of Pittsburgh, is presented. Methods A retrospective chart review was done. Surgical approaches and factors affecting recurrence are analyzed. Results Endoscopic transnasal, transpalatal, medial maxillectomy, facial translocation, and infratemporal fossa approaches, with or without craniotomy, were employed. The 37.5% recurrence rate reflects the advanced stage of the tumors. A major risk factor for recurrence was tumor involvement of the cranial base. Conclusions The surgical approach should be selected according to tumor location and effectiveness of embolization. In young patients, the approach should minimize the potential for facial growth retardation. Tumors confined to the nasopharynx, nasal cavity, and paranasal sinuses may be removed endoscopically. Medial maxillectomy is recommended for tumors that extend to the medial infratemporal fossa or medial cavernous sinus. Significant involvement of the infratemporal fossa, cavernous sinus, or middle cranial fossa requires infratemporal fossa or transfacial approaches.© 1997 John Wiley & Sons, Inc. Head Neck19: 391–399, 1997

Embolization of dural cavernous fistulas via superior ophthalmic vein approach.

Abstract: PURPOSE: To present the results of our treatment of dural cavernous sinus fistulas with surgical exposure of the superior ophthalmic vein (SOV), retrograde venous catheterization, and coil embolization of the cavernous sinus. METHODS: Twelve patients with dural cavernous sinus fistulas were treated via a retrograde transvenous SOV approach in our hospital during a 3-year period. All patients had been referred by ophthalmologists because of secondary glaucoma and decreased visual acuity. Angiography showed preferential venous drainage of the dural cavernous sinus fistulas to an enlarged ipsilateral SOV. A total of 13 SOV exposures were performed, one patient with bilateral fistulas required bilateral treatment. The vein was surgically exposed by an ophthalmologist and then catheterized. Platinum coils were delivered through a microcatheter at the fistula site and into the root of the SOV, until there was complete angiographic closure. RESULTS: Catheterization and embolization were successful in 12 of the 13 patients, with complete angiographic occlusion of the fistula. Two patients with bilateral fistulas had transient worsening of symptoms on the contralateral side. Three patients required follow-up angiography. No early complications occurred, and late complications were minor in two cases. All patients except one with long-standing symptoms recovered premorbid visual acuity. At follow-up, 11 (92%) of the 12 embolized fistulas remained occluded. CONCLUSIONS: Retrograde catheterization of the SOV and embolization of the cavernous sinus with coils is a direct, safe, and efficient way to occlude dural cavernous sinus fistulas.

Treatment for Intracranial Dural Arteriovenous Malformations: A Meta-analysis from the English Language Literature

Abstract: OBJECTIVE: The treatment of intracranial dural arteriovenous malformations (DAVMs) remains problematic. Options include ligature of feeding vessels, endovascular procedures, surgical obliteration, or a combination of the latter two. We conducted a meta-analysis of the English language literature on DAVMs to determine the most effective treatment option related to location and angiographic characteristics. METHODS: The criteria for inclusion were pre- and post-treatment angiography, a description of the type of treatment, and clinical outcome. The analysis included a total of 258 patients, 248 from a review of 223 published articles and 10 from the authors' series. DAVMs were divided into six categories by location, and the results of treatment were compared based on obliteration rates using X 2 analysis. RESULTS: In transverse-sigmoid sinus DAVMs (n = 64), combined therapy (endovascular plus surgical treatment) proved significantly more effective than either therapy alone (P < 0.01). For lesions of the tentorial incisura (n = 66), combined therapy and surgical obliteration alone proved superior to embolization (P < 0.001). For lesions of the cavernous sinus (n = 67), treatment was primarily endovascular, with success rates of 62 to 78% for transarterial and transvenous approaches, respectively. In the anterior fossa (n = 23), surgical obliteration was highly effective, with a success rate of 95 %. The small number of cases in both the superior sagittal sinus (n = 28) and middle fossa (n = 10) regions, precluded any statistical analysis. Finally, simple ligature of feeding vessels produced success rates of only 0 to 8% and can no longer be recommended. CONCLUSION: There is no single ideal treatment for the obliteration of DAVMs. The management of each case is best considered individually. The results of this review serve as a rational starting point for the selection of treatment options.

Transcranial Epidural Approach to Pituitary Tumors Extending beyond the Sella

Abstract: OBJECTIVE: The treatment of residual and/or recurrent pituitary tumors, initially operated on through transsphenoidal and/or transcranial approaches, required a new single approach that would make it possible to excise the tumor from the sella and from the neighboring regions. Surgical complications, such as pneumatocephalus, cerebrospinal fluid leak, mechanical lesion of the internal carotid artery and/or visual apparatus, and failure to remove the tumor completely, supported the need for an approach that would guarantee a much higher rate of completeness of resection of tumors and also avoid the risk of occurrence of complications. This report does not address endocrinological disorders before surgical treatment of pituitary tumors nor is its aim to present the functional efficacy of surgical treatment relating to hormones. METHODS: The anatomic relationships of the sellar and parasellar regions were studied using central cranial base specimens (8). Previous anatomic studies of the triangles of the lateral wall of the cavernous sinus (including anteromedial, paramedial, and Parkinson's triangles) and practical experience dealing with tumors in the region led to the use of the triangular windows as key accesses to the pituitary tumors in the enlarged sella and in the neighboring area(s). RESULTS: During the past 15 years, 210 patients with pituitary tumors extending into the parasellar and other regions beyond the sella were operated on using the transcranial approach. In Group I (consisting of 120 patients), complete removal was achieved in 66.5% of the patients by using the classical approach. Postoperative cerebrospinal fluid leak occurred in 8% and impairment of the visual function in 6% of the patients. With the new approach being used during the last 5 years in Group II (consisting of 90 patients), postoperative impairment of the visual function occurred in only 1 patient and cerebrospinal fluid leak occurred in only 1 other patient. Complete excision was achieved in 92.5% of the patients in Group II. Postoperative improvement of the visual function(s) was achieved for 26% of the patients in Group I and 52% of the patients in Group II. There was no mortality in either the first or the second group. CONCLUSION: The results led to the conclusion that the new approach to pituitary tumors extending beyond the sella (regarding the rate of completeness of the tumor resection) is superior to the previous transcranial approach (6, 8). Using the new approach, the risks of surgical complications can be avoided by preserving, intact, the diaphragm sellae and the dura covering the central cranial base around the sella.

De novo formation of a central nervous system cavernous malformation: implications for predicting risk of hemorrhage: Case report and review of the literature

Abstract: The authors present a documented sporadic de novo cavernous malformation of the central nervous system (CNS) in a patient undergoing follow-up magnetic resonance imaging after resection of an acoustic neuroma The authors believe that this is the first report of a de novo cavernous malformation in a patient without a familial history of this disease or a history of treatment with cranial radiation The occurrence of de novo lesions invalidates the common assumption that cavernous malformations are congenital lesions The use of this assumption to calculate bleeding risks retrospectively in patients with cavernous malformations is likely to underestimate the risk of symptomatic hemorrhage significantly Consequently, the de novo formation of cavernous malformations may be more common than appreciated and may explain the higher bleeding rates reported in prospective compared with retrospective studies of these lesions

A new concept in Dorello's canal microanatomy: the petroclival venous confluence

Abstract: The so-called Dorello's canal was studied in 32 specimens (16 human cadaver heads) injected with colored latex and fixed in formalin (28 specimens) or studied with microscopic and ultrastructural methods (four specimens). To avoid the differences usually encountered in the description of this area, the authors preferred to consider a larger space that they have named the petroclival venous confluence (PVC). It was located between two dural layers: inner (or cerebral) and outer (or osteoperiosteal). The PVC was quadrangular on transverse section. The posterior petroclinoid fold and the axial plane below the dural foramen of the abducent nerve (sixth cranial nerve) limited the PVC at the top and bottom, respectively. Its anteroinferior limit was the posterosuperior aspect of the upper clivus and outer layer of the dura mater. Its anterior limit was the vertical plane containing the posterior petroclinoid fold, and its posterior limit was the inner layer of the dura. The PVC was limited laterally by the medial aspect of the petrous bone apex and medially by the virtual sagittal plane extending the medial limit of the inferior petrosal sinus upward. The PVC was a venous space bordered by endothelium and continuous with the cavernous sinus, the basal sinus of the clivus, and the inferior petrosal sinus. There were trabeculations between the two dural layers. The petrosphenoidal ligament of Gruber may be regarded as a larger trabeculation, and it divided the PVC into a superior and an inferior compartment. The abducent nerve generally ran through the inferior compartment, where it was fixed to the surrounding dura mater. This nerve was only separated from venous blood by a meningeal sheath of varying thinness lined with endothelium. The clinical implications of these findings are discussed.

The Surgical Resectability of Meningiomas of the Cavernous Sinus

Abstract: OBJECTIVE The optimal management for patients with cavernous sinus meningiomas remains controversial. We attempt to contribute to the ongoing debate of appropriate surgical indications. METHODS In this retrospective review, 39 patients, including 27 women and 12 men ranging in age from 24 to 73 years (median, 48 yr), underwent surgical treatment for this condition. Completeness of tumor resection, cranial nerve morbidity, general morbidity, and long-term outcome were studied. The cavernous internal carotid artery was partially encased in 15 patients, totally encased in 11 patients, and narrowed by tumor in 13 patients. RESULTS Of eight patients who underwent complete tumor resection, seven had partial encasement of the internal carotid artery. Of 31 patients who underwent subtotal resection, 11 underwent postoperative radiotherapy. There were no deaths in the series. Morbidity was 17.9% for cranial nerves controlling extraocular motor function. Trigeminal nerve function did not improve after surgical treatment. The median follow-up period was 2 years (range, 6 mo-5.3 yr). Symptomatic and radiographic recurrence occurred in two patients who underwent complete tumor resection and in two patients who underwent subtotal resection. CONCLUSION Based on our findings and a review of the literature, we conclude the following: 1) the resectability of meningiomas of the cavernous sinus depends on the degree of internal carotid artery involvement; 2) total excision of cavernous sinus meningiomas is possible but rarely achieved in holocavernous meningiomas; 3) cranial nerve morbidity is significant; and 4) subtotal excision with or without postoperative radiotherapy is an effective short-term oncological strategy.

Meningiomas involving the cavernous sinus: histological factors affecting the degree of resection

Abstract: Despite advances in the surgical treatment of meningiomas located at the skull base, surgery for meningiomas involving the cavernous sinus remains controversial. The controversy centers on whether complete resection of such a meningioma is possible while preserving cranial nerve function. To evaluate this question, the authors examined six patients with benign meningiomas involving the cavernous sinus. The pathological features of these tumors were evaluated and compared with the normal histoarchitecture of the cavernous sinus. The tendency of these tumors to be infiltrative is evident and this seems to occur along connective tissue planes within the cavernous sinus. This invasiveness can be explained by the peculiar structure of this region. The trigeminal nerve and ganglion seem to be particularly prone to invasion; this does not correlate with the degree of preoperative impairment of nerve function. Internal carotid artery invasion occurs frequently and can be seen even when there is no narrowing of the artery on arteriography. The pituitary gland can also be invaded by the tumor, which penetrates the thin dural barrier.

Transmaxillary approach to the anterior cavernous sinus: a microanatomic study.

Abstract: Objective Several approaches to expose the anterior cavernous sinus have been used, such as frontotemporal, orbitofrontal, anterior subtemporal, and various transfacial approaches. In an effort to gain exposure to the anterior cavernous sinus without necessitating a craniotomy or wide transfacial exposure, the authors in the present study have developed a transmaxillary approach to the cavernous sinus. Methods The approach was developed using data obtained by performing 24 cadaveric dissections. Using a sublabial incision to expose the maxilla, maxillotomy is performed and the course of the infraorbital nerve is identified as a guide to the maxillary branch of the trigeminal nerve. After an osteotomy of the posterior sinus wall and pterygoid plate, the foramen rotundum is identified, which lies a mean of 10 mm from the posterior wall of the maxilla. A superomedial enlargement of the foramen rotundum is then undertaken to ultimately expose the anterior cavernous sinus. Results This technique offers access to all cavernous cranial nerves, as well as the entire course of the anterior loop of the internal carotid artery to the origin of the ophthalmic artery. With a mean operative range of 38 mm from the posterior wall of the maxilla to the anterior loop of the internal carotid artery, this approach offers adequate exposure with a short operative distance. Conclusion The approach may be useful in limited exposure of tumors of the anterior cavernous sinus and some intracavernous vascular lesions.

Contralateral and ipsilateral microsurgical approaches to carotid-ophthalmic aneurysms.

Abstract: Objective The vicinity of carotid-ophthalmic aneurysms to the roof of the cavernous sinus, to the anterior clinoid process, and to the optic nerve or the optic chiasm requires well-defined surgical techniques. Although microsurgical techniques with ipsilateral direct approaches to these aneurysms have been described in detail, studies about contralateral strategies for the microsurgical treatment of carotid-ophthalmic aneurysms are rare and are mainly confined to case reports. The aim of this study is to describe how to decide on the ipsilateral and contralateral microsurgical approaches to such aneurysms and to demonstrate the surgical techniques for the ipsilateral and contralateral exposure of carotid-ophthalmic aneurysms. Methods In a series of 51 patients with 58 aneurysms of the ophthalmic segment of the internal carotid artery, nine patients with 10 aneurysms (4 large aneurysms, 6 small aneurysms) were treated via a contralateral microsurgical approach after careful preoperative planning. Preoperative planning was based on the analysis of clinical and radiographic data, including cranial computed tomography, magnetic resonance imaging, magnetic resonance angiography, and conventional cerebral angiography. Results The postoperative results were good in 38 (75%) of the patients, fair in 2 (4%), and poor in 3 (6%); 8 (15%) of the patients died after surgery. The postoperative follow-up was 4 months to 10 years. Postoperatively, 15 of 19 patients with uni- or bilateral visual deficits or visual field defects improved, 3 of the 19 patients experienced postoperative impairment of visual function, and 1 of the 19 patients had an unchanged visual field deficit. Visual impairment or unchanged visual function was observed in patients who underwent ipsilateral approaches, which was possibly caused by inappropriate intraoperative retraction of the optic nerve or chiasm. In all patients presenting with preoperative visual deficits who were treated via contralateral approaches, visual function improved in the postoperative course. Conclusion Giant carotid-ophthalmic aneurysms that are eligible for surgical treatment as well as small and large aneurysms dislocating the optic nerve or the chiasm superomedially or medially should be approached via ipsilateral craniotomies. It is recommended that small and large aneurysms of the carotid-ophthalmic segment originating medially, superomedially, or superiorly, displacing the optic nerve or the chiasm superiorly, superolaterally, or laterally, be approached via contralateral craniotomies.

Sinonasal undifferentiated carcinoma: CT and MR imaging of an uncommon neoplasm of the nasal cavity.

Abstract: PURPOSE: To determine the computed tomographic (CT) and magnetic resonance (MR) imaging appearance of sinonasal undifferentiated carcinoma. MATERIALS AND METHODS: Findings from 11 patients with histopathologically proved sinonasal undifferentiated carcinoma were retrospectively reviewed. All 11 patients had undergone CT, and six of them had undergone MR imaging. RESULTS: The tumors usually were large (larger than 4 cm in maximum dimension in eight patients), had poorly defined margins, and arose within the ethmoid sinuses and superior nasal cavity. The aggressive nature of the tumor was demonstrated by bone destruction (n = 10) and by invasion of adjacent structures, including paranasal sinuses (n = 10), anterior fossa (n = 7), orbits (n = 4), pterygopalatine fossa (n = 2), parapharyngeal space (n = 1), and cavernous sinus (n = 1). On contrast material-enhanced CT scans, all tumors were enhanced to varying degrees. They tended to be noncalcified (n = 10) and often caused sinus obstruction (n = 10). MR sig...

Vein of Galen Aneurysmal Malformation

Abstract: Over the past 10 years, written contributions on cerebral arteriovenous malformations (CAVM) in children have evolved from anecdotal case reports to short series, offering a better understanding of the disease, the therapeutic strategies and the results of various managements (Ventureyra 1987; Gerosa 1981; Fond 1988; Hoffman 1982; Johnston 1987; Lasjaunias 1995–1996; Maheut 1987; Mori 1980; So 1978; Raimondi 1987; Seidenwurm 1991). Historical contributions from the neurosurgical point of view have demonstrated limitations in the management of these difficult lesions and relinquished them to interventional neuroradiology.

Treatment of post-traumatic carotico-cavernous fistulae using electrolytically detachable coils: technical aspects and preliminary experience

Abstract: We treated six patients with post-traumatic cavernous carotid fistulae by electrothrombosis using Guglielmi's new electrolytically detachable coils. The transarterial endovascular route was chosen in five and the transvenous in one case. Exophthalmos, chemosis and/or an audible bruit disappeared immediately after therapy or in the following month in all patients suffering from these symptoms. Third and sixth cranial nerve palsies resolved in three of four patients. Clinical results were excellent in three, good in two and fair in one. In this last patient massive thrombosis of an enormously dilatated superior ophthalmic vein occurred after treatment of a giant longstanding fistula, leading to unilateral visual impairment and increased sixth nerve palsy. In our first patient the intracavernous carotid artery was occluded by balloons after coil embolisation because of improper coil position and the fear of possible thromboembolic events. Angiographic cure was demonstrated in all cases by angiograms 1-6 months after therapy. The characteristics of these new coils are easy use, manoeuvreability and retrievability. They conform ideally to the shape of the vessel lumen to be obliterated and produce practically no trauma to the vessel walls. Furthermore, they can be positioned in the sinus close to the orifice of the fistula. In the last two cases partial occlusion of the fistula was sufficient to initiate the process of complete thrombosis, and delayed, complete occlusion was observed after 1 month. In our opinion this new device is not only a major contribution to treatment of intracranial aneurysms, but may also improve the results of treatment of carotico-cavernous fistulae.

Direct surgery of carotid cavernous fistulae and dural arteriovenous malformations of the cavernous sinus

Abstract: OBJECTIVE: To save the patency of the internal carotid artery (ICA) during the treatment of carotid cavernous fistulae or cavernous sinus dural arteriovenous malformations, direct surgery of the cavernous sinus after failure of endovascular treatment was attempted in this study. METHODS: A total of 78 patients with carotid cavernous fistulae or cavernous sinus dural arteriovenous malformations were treated. Obliteration of the fistulous rent and preservation of the ICA were the therapeutic goals. All patients, except one in whom acute bleeding occurred, received endovascular treatment as the first treatment. In 18 (23.4%) of these 77 patients, it was not possible to obliterate the fistulous rents without sacrificing the ICAs. The 18 patients and the 1 patient with acute bleeding underwent direct surgery to open the cavernous sinus. RESULTS: Various methods, including suturing or clipping the fistulae, sealing the fistulae with fascia and acrylate glue, and packing the cavernous sinus were applied. In each of three complicated cases, the cavernous segment of the ICA was trapped and an intracranial bypass from the petrous segment to the supraclinoid segment was performed. There was no mortality, and the most common morbidity was transient oculomotor palsy, which occurred in eight patients. Follow-up angiography revealed that the ICAs or bypass grafts were thrombosed in 5 of the 19 patients who had undergone surgery. CONCLUSION: In this series, the overall ICA patency rate of patients who underwent embolization and surgery was 94%, and the obliteration rate of the fistulae was 100%. Direct surgery of the cavernous sinus as a complimentary treatment of embolization can increase the preservation rate of the ICA.

The extradural approach to lesions involving the cavernous sinus.

Abstract: We report our experience with five lesions exclusively involving the entire cavernous sinus in which an essentially extradural surgical approach was used. There were two cases of cavernous haemangioma, two cases of meningioma and one case of fungal granuloma. The dural cover of the superior orbital fissure, and mandibular and maxillary divisions of the fifth nerve was dissected along with the dura of the lateral wall of the cavernous sinus. The presence of a relatively large intracavernous bulge due to the tumour assisted in this dissection. The contents of the cavernous sinus were exposed from an anterolateral, lateral and inferior approach. Through the corridor available between the splayed out cranial nerves, a radical resection of the tumour was accomplished in each case. The technical advantages of this approach are discussed in light of the anatomy of the dural configuration of the lateral wall of the cavernous sinus.

Pterygopalatine fossa and maxillary nerve infiltration in nasopharyngeal carcinoma

Abstract: Background Nasopharyngeal carcinoma (NPC) may infiltrate the pterygopalatine fossa (PPF) and the maxillary nerve. This study illustrates involvement of the naxillary nerve in the PPF with perineural spread to the cavernous sinus. Methods One hundred and fourteen patients with proven NPC were studied using magnetic resonance imaging (MRI) and computed tomography (CT). The images were retrospectively reviewed for PPF infiltration and maxillary nerve involvement. Results Seventeen (15%) patients showed infiltration of the PPF. Four patients had maxillary nerve involvement and a perineural spread to the cavernous sinus. Of the 17 patients with PPF infiltration, 8 (47%) patients showed hypoesthesia in the distribution of the infraorbital nerve. All 4 patients with contrast-enhancement of the maxillary nerve exhibited infraorbital neuropathy. Conclusion Infiltration of the maxillary nerve in the PPF with intracranial spread is uncommon but should be suspected in patients with infraorbital neuropathy. This is important as it affects both prognosis and radiation treatment planning. © 1997 John Wiley & Sons, Inc. Head Neck19: 121–125, 1997.

Percutaneous biopsy of cavernous sinus tumors through the foramen ovale.

Abstract: OBJECTIVE : We present a new application to the widely used Hartel percutaneous route through the foramen ovale to the parasellar region to obtain aspiration biopsies of lesions arising from or invading the posterolateral part of the cavernous sinus. METHODS : Thirteen patients with cavernous sinus lesions that were diagnosed using imaging underwent aspiration biopsy by this route. Nine of them were subsequently operated on, and two will undergo surgery in the near future. For the remaining two, surgical removal of the tumor was not indicated. One of these two patients had a meningioma without any related symptoms and no growth revealed by repeated computed tomographic scans, and the other was diagnosed as having a nasopharyngeal carcinoma and consequently received radiotherapy. RESULTS : The accuracy of diagnosis with this technique was 84%. There was no complication related to the procedure. Having knowledge of the pathological diagnosis before determining the correct treatment helped to define the most appropriate strategy. CONCLUSION : We suggest that aspiration biopsy procedures through the foramen ovale be performed in cavernous sinus tumors before making any decision to indicate open surgical, radiosurgical, and/or radiotherapeutic treatments.

Direct Microsurgery of Dural Arteriovenous Malformation Type Carotid-Cavernous Sinus Fistulas: Indications, Technique, and Results

Abstract: Objective There is a subgroup of patients with Barrow Type D carotid-cavernous sinus fistulas (CCFs) who have progressive neurological deficits despite endovascular attempts at obliteration. To effectively arrest the progression of neurological deficits, especially visual loss, these patients require direct operative intervention. We have used a direct approach to such lesions, which comprehensively occludes all fistulous connections of the CCF. Methods We present a series of nine patients with Type D CCFs for which attempts at endovascular embolization failed and that, because of persistent symptoms, required surgical intervention. These lesions characteristically had extensive multiple external carotid artery feeders, often bilateral, in addition to the internal carotid artery feeders. The operative approach used was a combined extra- and intradural full exposure of the cavernous sinus and its contents, with identification and direct obliteration of all arterial input and selective ablation of the venous outflow from the cavernous sinus. Results All nine patients experienced resolution of their symptoms, and complete ablation of the lesions, as demonstrated by postoperative angiography, was achieved. Transient diplopia and trigeminal hypesthesia was observed in all nine patients, which resolved by 6 months postoperatively. One patient suffered from a temporary hemiparesis and another from permanent hemiparesis. There were no deaths related to surgery in this series. Conclusions Patients with Type D CCFs who have persistent, progressive neurological deficits after failed endovascular attempts at obliteration may be treated by a direct surgical approach to ablate the fistulas. The pertinent anatomic concepts, indications for surgery, and operative techniques that are different from previously described methods are discussed.

False aneurysms of the intracavernous carotid artery — Report of 7 cases

Abstract: We present 7 cases of false intracavernous carotid artery aneurysms. Four occurred after trauma and three were caused iatrogenically. Two of the latter occurred in patients with pituitary adenomas, one after transsphenoidal microsurgery and the other after yttrium [YI90] seed implantation into the sella. The third iatrogenic aneurysm was seen shortly after transcavernous tumour surgery.

Acute exophthalmos during treatment of a cavernous sinus-dural fistula through the superior ophthalmic vein.

Abstract: We read with interest the article by Goldberg et al 1 in the June 1996 issue of theArchivesand would like to comment on the importance of ophthalmologic monitoring during the procedure to detect and treat vision-threatening increases in orbital pressure. We recently treated a 35-year-old white man with a spontaneous cavernous sinus-dural fistula. An arteriogram demonstrated poor venous access through the usual transcutaneous approaches. We were asked to provide access for a superior ophthalmic vein cannulation. An anterior orbitotomy was performed while the patient was under general anesthesia, and the superior ophthalmic vein was isolated. A micropuncture introducer (4F Micropuncture Introducer, Cook Corp, Bloomington, Ind) was introduced. A microcatheter (Tracker-18, Target Therapeutics, Fremont, Calif) was placed through the introducer into the posterior cavernous sinus. Platinum microcoils were passed into the sinus. Approximately 1 hour after commencement of the procedure, increasing exophthalmos of the right eye was noted, along