Showing papers on "Cavernous sinus published in 2008"
TL;DR: In patients with incomplete tumor removal, radiation therapy is the most effective adjuvant therapy for preventing residual tumor growth and adjunctive postoperative radiotherapy had a marked protective effect against growth of residual tumor.
Abstract: Object Nonfunctioning pituitary adenomas (NFPAs) are benign tumors of the pituitary gland that typically cause visual and/or hormonal dysfunction. Surgery is the treatment of choice, but patients remain at risk for tumor recurrence for several years afterwards. The authors evaluate the early results of surgery and the long-term risk of tumor recurrence in patients with NFPAs. Methods Between 1990 and 2005, 491 previously untreated patients with NFPA underwent surgery at the Universita Vita-Salute. Determinations of recurrence or growth of the residual tumor tissue during the follow-up period were based on neuroradiological criteria. Results Residual tumor after surgery was detected in 173 patients (36.4%). Multivariate analysis showed that invasion of the cavernous sinus, maximum tumor diameter, and absence of tumor apoplexy were associated with an unfavorable surgical outcome. At least 2 sets of follow-up neuroimaging studies were obtained in 436 patients (median follow-up 53 months). Tumors recurred in ...
207 citations
TL;DR: Dural arteriovenous shunts (DAVSs) are abnormal shunts within the dura as discussed by the authors, which occur near the venous sinuses and can occur at any site within the Dura.
Abstract: Dural arteriovenous shunts (DAVSs)are abnormal shunts within the dura. Theoretically, they can occur at any site within the dura, but most frequently they develop near the venous sinuses. Venous drainage may occur into the dural sinuses, into osteodural veins, retrogradely via leptome- ningeal veins toward the cortical cerebral, cerebellar, or perimedullary veins,or any combination thereof. Arterial supply is usually from adjacent branches of the dural arteries, less frequently from osseous branches, while pial supply is rare.
205 citations
TL;DR: The endonasal approach provides a minimally invasive route for removal of pituitary adenomas and other parasellar tumors.
Abstract: THE DIRECT ENDONASAL transsphenoidal approach to the sella with the operating microscope was initially described more than 20 years ago. Herein, we describe the technique, its evolution, and lessons learned over a 10-year period for treating pituitary adenomas and other parasellar pathology. From July 1998 to January 2008, 812 patients underwent a total of 881 operations for a pituitary adenoma (n = 605), Rathke's cleft cyst (n = 59), craniopharyngioma (n = 26), parasellar meningioma (n = 23), chordoma (n = 18), or other pathological condition (n = 81). Of these, 118 operations (13%) included an extended approach to the suprasellar, infrasellar/clival, or cavernous sinus regions. Endoscopic assistance was used in 163 cases (19%) overall, including 36% of the last 200 cases in the series and 18 (72%) of the last 25 extended endonasal cases. Surgical complications included 19 postoperative cerebrospinal fluid leaks (2%), 6 postoperative hematomas (0.7%), 4 carotid artery injuries (0.4%), 4 new permanent neurological deficits (0.4%), 3 cases of bacterial meningitis (0.3%), and 2 deaths (0.2%). The overall complication rate was higher in the first 500 cases in the series and in extended approach cases. Major technical modifications over the 10-year period included increased use of shorter (60-70 mm) endonasal speculums for greater instrument maneuverability and visualization, the micro-Doppler probe for cavernous carotid artery localization, endoscopy for more panoramic visualization, and a graded cerebrospinal fluid leak repair protocol. These changes appear to have collectively and incrementally made the approach safer and more effective. In summary, the endonasal approach provides a minimally invasive route for removal of pituitary adenomas and other parasellar tumors.
166 citations
TL;DR: Progressive and rapid involvement of the cavernous sinus, vascular structures and intracranial contents is the usual evolution of rhinocerebral mucormycosis and in the context of immunosupression, a pattern of nasal cavity, maxillary Sinus, ethmoid cells, and orbit inflammatory lesions should prompt the diagnosis of mucormYcosis.
Abstract: Background and objectives: The purpose of this study was to describe common radiographic patterns that may be useful in predicting the diagnosis of rhinocerebral mucormycosis. Methods: We retrospectively evaluated the imaging and clinical data of four males and one female, 3 to 72 years old, with rhinocerebral mucormycosis. Results: All the patients presented with sinusitis and ophthalmological symptoms. Most of the patients (80%) had isointense lesions relative to brain in T1-weighted images. The signal intensity in T2-weighted images was more variable, with only one (20%) patient showing hyperintensity. A pattern of anatomic involvement affecting the nasal cavity, maxillary sinus, orbit, and ethmoid cells was consistently observed in all five patients (100%). Our series demonstrated a mortality rate of 60%. Conclusion: Progressive and rapid involvement of the cavernous sinus, vascular structures and intracranial contents is the usual evolution of rhinocerebral mucormycosis. In the context of immunosupression, a pattern of nasal cavity, maxillary sinus, ethmoid cells, and orbit inflammatory lesions should prompt the diagnosis of mucormycosis. Multiplanar magnetic resonance imaging shows anatomic involvement, helping in surgery planning. However, the prognosis is grave despite radical surgery and antifungals.
115 citations
TL;DR: Surgical results obtained in the present series of patients suggest that the extended transsphenoidal approach is safe and effective for removal of adenomas within the cavernous sinus, and may lead to a reevaluation of the role of surgery as the therapeutic strategy for invasive pituitaryAdenomas.
Abstract: Object The authors devised an extended transsphenoidal approach involving a submucosal posterior ethmoidectomy that allows for adequate exposure of the cavernous sinus. To evaluate the adequacy of this approach for removal of adenomas invading the cavernous sinus, the authors retrospectively analyzed the surgical outcomes obtained in treated patients. Methods During a 9-year period, 36 patients with pituitary adenomas extending into the cavernous sinus underwent tumor removal at Kinki University Hospital. In the authors' technique of extended transsphenoidal surgery, the inferior wall of the affected cavernous sinus was entirely exposed, not only to permit safe removal of the tumor but also to secure the petrous portion of the internal carotid artery (ICA). For prevention of intraoperative injury to the cranial nerves, a low-profile pressure sensor was attached on the eyelid to detect eye movements in response to electrical stimulation of the cranial nerves. Results Total or subtotal tumor removal was ach...
88 citations
TL;DR: The cumulative volume and specific locations of coils in the CS correlated with TVE-induced cranial nerve palsy and overpacking appeared to be the predominant cause of CNP; however, for CNP in cases involving smaller coil volumes, an alternative mechanism may be involved.
Abstract: Object Transvenous embolization (TVE) for the treatment of a cavernous sinus (CS) dural arteriovenous fistula (DAVF) occasionally causes cranial nerve palsy (CNP). Overpacking of coils is considered to result in CNP. The purpose of this study was to analyze the association of TVE-induced CNP with the volume and location of coils activated in the CS. Methods Thirty-one patients with CS DAVFs (33 lesions) underwent TVE. Results Cranial nerve palsy occurred or was aggravated in 13 cases (39.4%; CNP group). The cumulative volume of activated coils was significantly greater in the CNP group (0.241 ± 0.172 cm3) than in the non-CNP group (0.119 ± 0.075 cm3; p 0.2 cm3 of coil volume, 77.8% showed immediate aggravation or a new occurrence of CNP after TVE. Five lesions treated with a smaller volume of coils showed a delayed worsening or occurrence of CNP. In cases with induced oculomotor nerve palsy, coils had been densely packed in the superolateral part of the anterior CS. Dense ...
61 citations
TL;DR: MRI findings in seven patients with Tolosa–Hunt syndrome with unilateral painful ophthalmoplegia showed focal‐enhancing masses expanding the ipsilateral cavernous sinus, and magnetic resonance imaging should be the initial screening study in these patients.
Abstract: A review of MRI findings in seven patients with Tolosa-Hunt syndrome was carried out. Seven patients presented with unilateral painful ophthalmoplegia. Magnetic resonance imaging studies were carried out to evaluate the cavernous sinuses and orbits. Coronal fast spin-echo T2-weighted images and fat-saturated T1-weighted coronal and transverse images with and without contrast enhancement were obtained for the cavernous sinuses and orbits. All patients showed focal-enhancing masses expanding the ipsilateral cavernous sinus. In one patient the mass was extending to the orbital apex and intraorbitally. All patients recovered on corticosteroid therapy and resolution of the masses was documented on follow-up MRI studies in five patients. One patient had a relapse of symptoms after discontinuing therapy. Magnetic resonance imaging studies of the cavernous sinus and orbital apex show high sensitivity for the detection and follow up of inflammatory mass lesions in Tolosa-Hunt syndrome. Magnetic resonance imaging should be the initial screening study in these patients.
57 citations
TL;DR: Early management by endoscopic transphenoidal surgery for pituitary abscess is recommended: this technique is safe, with minimal blood loss, short operating time, low morbidity, and brief hospital stay.
Abstract: Pituitary abscess is a rare entity and the correct diagnosis is still difficult before surgery. More than 210 cases have been reported in the medical literature, mostly in the form of isolated case reports. We report two cases of pituitary abscess treated endoscopically and we review the literature. A 30-year-old woman and a 35-year-old man were admitted with a history of pituitary dysfunction. Patient 1 presented with polyuria, polydipsia, amenorrhea, headache, and visual impairment. Magnetic resonance imaging showed a cystic intra- and supra-sellar lesion with ring enhancement after contrast injection. Patient 2 presented with frontal headache, proptosis, painful ophthalmoplegia, visual impairment, and fever. Eight years before the patient had undergone a transphenoidal surgery for Prolactinoma. Magnetic resonance imaging revealed a sellar lesion extending into the cavernous sinus and carotid artery bilaterally. Both patients underwent endoscopic transnasal-transsphenoidal exploration. Intraoperative diagnosis of pituitary abscess was made. The postoperative courses were uneventful. Antibiotic therapy was performed in both cases. Only three cases of endoscopic treatment of pituitary abscess have been reported in the literature. We recommend early management by endoscopic transphenoidal surgery for pituitary abscess: this technique is safe, with minimal blood loss, short operating time, low morbidity, and brief hospital stay.
56 citations
TL;DR: Progressive contrast “filling in” in the tumors on conventional contrast-enhanced MR images can aid in differentiating between cavernous sinus lesions and suggest the diagnosis of cavernous hemangiomas.
Abstract: BACKGROUND AND PURPOSE: The reported MR imaging characteristics of cavernous sinus cavernous hemangiomas (CSCHs) in the literature are nonspecific. The purpose of our study was to explore dynamic enhancement features of CSCHs on conventional contrast-enhanced MR imaging and to correlate these features with histopathologic subtypes. MATERIALS AND METHODS: Twenty-one patients (8 male and 13 female; age range, 13–63 years; average age, 42.6 years) with surgically confirmed CSCHs were retrospectively investigated. Preoperative MR study was performed in all cases, consisting of T1-weighted axial imaging, T2-weighted axial imaging, T1-weighted sagittal imaging, and contrast-enhanced T1-weighted axial, sagittal, and coronal images. RESULTS: There were 4.8% (1/21) that showed homogeneous enhancement on all 3 contrast-enhanced sequences, whereas 95.2% (20/21) demonstrated heterogeneous enhancement on the first contrast-enhanced sequence. Among the 20 lesions, on subsequent contrast-enhanced sequences, 55.0% (11/20) showed homogeneous enhancement, whereas 35.0% (7/20) of lesions showed progressive contrast “filling in.” The remaining 10% (2/20) exhibited no apparent enhancement changes. The 95.2% (20/21) of lesions with heterogeneous enhancement on the first contrast-enhanced sequence correlated with type B or type C pathologic findings, whereas 4.8% (1/21) with homogeneous enhancement correlated with type A pathologic findings. Among the 20 type B or type C lesions, 80% (16/20) achieved total or near-total resection. CONCLUSION: Progressive contrast “filling in” in the tumors on conventional contrast-enhanced MR images can aid in differentiating between cavernous sinus lesions and suggest the diagnosis of cavernous hemangiomas.
55 citations
TL;DR: A relatively conservative approach to these extensive lesions resulted in good outcome in a majority of patients and both the standard as well as skull base approaches may be utilized for successful removal of giant medial sphenoidal wing meningiomas.
Abstract: Surgical management of giant medial sphenoid meningiomas (≥5 cm in maximum dimension) is extremely challenging due to their intimate relationship with vital neural structures like the optic nerve, cranial nerves of the cavernous sinus and the cavernous internal carotid artery. Their surgical management is presented incorporating a radiological scoring system that predicts the grade of tumour excision. 20 patients of giant medial sphenoidal wing meningioma (maximum tumour dimension range: 5.2 to 9.5 cm; mean maximum dimension = 6.12 ± 1.06 cm) with mainly visual and extraocular movement deficits, and raised intracranial pressure, underwent surgery. A preoperative radiological scoring system (range 1–12) was proposed considering tumour volume (using Kawamoto’s method); extension into the surrounding surgical corridors; extent of cavernous sinus invasion (based on the tumour relationship to the cavernous internal carotid artery); associated hyperostosis and/or >50% calcification; and, associated brain oedema. Both the conventional frontotemporal craniotomy (n = 13) and its extension to orbitozygomatic osteotomy (n = 7) were utilized. The cavernous sinus was explored in 4 patients and the hyperostotic sphenoid ridge drilled in five patients. Total excision was achieved in nine patients; small tumour remnants within the cavernous sinus, interpeduncular fossa or suprasellar cistern were left in eight patients; and less than 10% of tumour was left in three patients. A patient with a completely calcified meningioma died due to myocardial infarction. When the preoperative radiological score was ≥7, there was considerable difficulty in achieving total tumour excision. A mean follow of 17.58 ± 15.05 months revealed improvement in visual acuity/field defects in three, stabilisation in 11, and deterioration of ipsilateral visual acuity in five patients. Symptoms of raised pressure, cognitive dysfunction, aphasia and proptosis showed improvement. A relatively conservative approach to these extensive lesions resulted in good outcome in a majority of our patients. Both the standard as well as skull base approaches may be utilized for successful removal of giant medial sphenoidal wing meningiomas. A preoperative radiological score of ≥7 predicts a greater degree of difficulty in achieving complete surgical extirpation.
54 citations
TL;DR: An accurate classification of global medial sphenoid ridge meningiomas is mandatory to gain insight into their clinical behavior and for understanding the long-term efficacy and safety of available treatment options.
Abstract: OBJECTIVE On the basis of contemporary multiplanar imaging, microsurgical observations, and long-term follow-up in 60 consecutive patients with sphenoid ridge meningiomas, we propose a modification to Cushing's classification of these tumors. This article will concentrate on patients from this series with global medial sphenoid ridge tumors. METHODS Data were collected prospectively for 35 patients with global meningiomas arising from the medial portion of the sphenoid ridge that were surgically treated between 1982 and 2002. RESULTS All patients were followed for the entire length of this study (mean, 12.8 yr). The tumor size ranged from 2 to 8 cm (mean, 4.5 cm). Of the 24 patients with purely intradural tumors, four (17%) had Simpson Grade I and 19 had Simpson Grade II resections; 23 (96%) had gross total resections. Of the 11 patients with tumors extending extradurally (i.e., cavernous sinus), one (9%) patient had a Simpson Grade II resection, whereas nine (82%) had Simpson Grade III resections, with the latter being all visible tumor removed except that in the cavernous sinus. One (9%) of these 11 patients had a gross total resection, and 9 (82%) had radical resections, with the latter defined as total removal of all intradural tumor. The overall morbidity rate was 18%. There was no surgical mortality or symptomatic cerebral infarction. CONCLUSION An accurate classification of global medial sphenoid meningiomas is mandatory to gain insight into their clinical behavior and for understanding the long-term efficacy and safety of available treatment options. Primary medial sphenoid ridge tumors consistently involve the unilateral arteries of the anterior cerebral circulation, and therefore, the resection of tumor from around these arteries is the most important operative nuance for their safe excision.
TL;DR: A. terreus sinusitis with orbitocranial extension had never been reported in the literature and is difficult to eradicate using surgical debridement combined with optimal antifungal agents because of the intracranial extension and the relative resistance of conventional antIFungal therapy.
TL;DR: This is the first report of a complete removal of a cavernous sinus hemangioma using an endoscopic transnasal approach, and may be less traumatic than the transcranial route based on the lateral location of the cranial nerves.
Abstract: Objective/Importance: Hemangiomas of the cavernous sinus are rare lesions Complete removal through a transcranial route often causes ocular motor palsies Because the cranial nerves in the cavernous sinus are lateral to the carotid, a medial approach to the cavernous sinus may be less traumatic to the cranial nerves Clinical Presentation: A 50-year-old man with headaches, dizziness, diplopia, and magnetic resonance imaging that demonstrated a right cavernous sinus mass expanding into the sella and sphenoid sinus Intervention: A gross total removal of a cavernous sinus hemangioma was performed through an extended endoscopic transsphenoidal approach Conclusion: This is the first report of a complete removal of a cavernous sinus hemangioma using an endoscopic transnasal approach The endoscopic transnasal approach to the medial cavernous sinus may be less traumatic than the transcranial route based on the lateral location of the cranial nerves
Journal Article•
TL;DR: Selective management with endovascular therapy and manual compression are the effective treatment for dural CCF, however sight-threatening complications can develop after therapy due to progressive ophthalmic vein thrombosis and should be carefully monitored.
Abstract: Objective: To describe the ocular findings, endovascular treatment, and clinical outcome in patients with dural carotid cavernous sinus fistula (CCF). Material and Method: A retrospective evaluation of 80 consecutive patients who underwent examination and treatment for dural CCF between January 1997 and December 2004 was performed. Results: Fifty females and 30 males, with an average age of 49 years (from 6 -80 years) participated in this study. All patients had more than one clinical signs and symptoms including proptosis (84%), arterialization of conjunctival vein (93%), chemosis (42%), cranial nerve palsy (52%), elevated intraocular pressure (51%), and optic neuropathy (13%). Diminished vision was found in 43% of the patients. The degree of visual deficit ranged from 20/40 to no light perception. After angiographic evaluation, patients were classified to CCF Barrow’s type B 14%, type C 15%, and type D 71%. Endovascular treatment by transvenous and/or transarterial embolization was performed in 60 patients (75%). Carotid-angular compression therapy was solely performed in 19 patients (24%) and was used as an adjunct to endovascular treatment in 30 patients (38%).The follow-up period ranged from 6 to 94 months. Clinical cure was achieved in 41 patients (51%) and improvement in 30 patients (38%). Anatomical cure was demonstrated by angiogram in 50 patients (63%). Intra-operative complications were found in three patients including ophthalmic artery occlusion and cerebral infarction. Eight patients experienced transient aggravation of symptoms including increased proptosis, elevation of intraocular pressure, choroidal detachment that required suprachoroidal drainage, and venous stasis retinopathy. Ophthalmic vein thrombosis resulting in central retinal vein occlusion was developed in three patients and finally caused severe visual deficit. There was no operative mortality. Conclusion: Selective management with endovascular therapy and manual compression are the effective treatment for dural CCF. However, sight-threatening complications can develop after therapy due to progressive ophthalmic vein thrombosis and should be carefully monitored. Keywods: Carotid cavernous sinus fistula, Endovascular, Outcome
TL;DR: Whether contrast-enhanced 3D constructive interference in steady state MR imaging is useful to differentiate between paraclinoid and cavernous sinus aneurysms of the internal carotid artery is determined.
Abstract: BACKGROUND AND PURPOSE: Differentiation between paraclinoid and cavernous sinus aneurysms of the internal carotid artery (ICA) is critical when considering treatment options. The purpose of this study was to determine whether contrast-enhanced (CE) 3D constructive interference in steady state (CISS) MR imaging is useful to differentiate between paraclinoid and cavernous sinus aneurysms. MATERIALS AND METHODS: This study included 11 aneurysms in 10 consecutive female patients, ranging from 52 to 66 years of age. All aneurysms were adjacent to the anterior clinoid process. After conventional and CE 3D-CISS imaging on a 1.5T MR imaging unit, all patients underwent surgery, and the relationship between the aneurysms and the dura was confirmed. Two neuroradiologists evaluated the location of the aneurysms on CE 3D-CISS images and classified them as intradural, partially intradural, and extradural aneurysms. Operative findings were used as a reference standard. To understand the imaging characteristics, we assessed the boundary and signal intensity of the cavernous sinus, CSF, and carotid artery on the side contralateral to the lesion. RESULTS: Operative findings disclosed that 5 aneurysms were intradural and 6 were extradural. All except 2 were accurately assessed with CE 3D-CISS imaging. One intradural aneurysm adjacent to a large cavernous aneurysm and 1 cavernous giant aneurysm were assessed as partially intradural. On CE 3D-CISS images, the boundary between the CSF, cavernous sinus, and carotid artery was identified by high signal-intensity contrast in all cases. CONCLUSION: CE 3D-CISS MR imaging is useful for the differentiation between paraclinoid and cavernous sinus aneurysms.
TL;DR: A patient with a direct carotid artery-cavernous sinus fistula caused by head trauma in whom a self-expanding covered stent was successfully used to obliterate the fistula is presented.
Abstract: Authors present the case of a patient with a direct carotid artery-cavernous sinus fistula caused by head trauma in whom a self-expanding covered stent was successfully used to obliterate the fistula. However, at the 9-month follow-up an angiogram revealed a complex caroticocavernous fistula that was completely obliterated with Onyx 18 transarterially.
TL;DR: This is the first case of combined treatment using “cold” and radiolabelled octreotide in a pituitary metastasis from a neuroendocrine tumour, and a considerable improvement in quality of life were gradually recorded.
Abstract: Herein we report a rare case of a pituitary metastasis from a neuroendocrine tumour mimicking an adenoma. Moreover, starting from this unusual case, the relevant literature concerning the diagnosis and management of patients with metastasis at pituitary level is reviewed. A 69-year-old woman was admitted to our Unit for severe headache, diplopia, and critical visual field impairment. MRI showed a large pituitary mass compressing the optic chiasm and infiltrating the cavernous sinus. Trans-sphenoidal biopsy revealed a pituitary metastasis from a neuroendocrine tumour, in line with the multiple liver lesions that were already considered metastases from an ileal primary neuroendocrine tumour. In vitro receptor characterisation of both pituitary and liver tissues by immunohistochemistry showed a heterogeneous somatostatin receptor subtype pattern, with a predominant expression of sst2 within the pituitary lesion. However, the liver metastasis receptor profile was completely different from the pituitary. Octreotide LAR was administered first, followed by receptor radiometabolic therapy with radiolabelled somatostatin analogues (90Y-DOTATOC and 177Lu-DOTATATE). After 16 months, MRI showed a significant shrinkage of the sellar mass. Moreover, disappearance of diplopia and visual defects, together with a considerable improvement in quality of life were gradually recorded. To our knowledge, this is the first case of combined treatment using “cold” and radiolabelled octreotide in a pituitary metastasis from a neuroendocrine tumour.
TL;DR: Low-dose Gamma Knife radiosurgery seems to be very effective for management of cavernous sinus hemangiomas, and can be considered as a treatment modality of choice for these lesions.
Abstract: Optimal management of cavernous sinus hemangiomas remains unclear. Total microsurgical removal of these neoplasms may be extremely difficult due to their rich vascularization. Three cases of cavernous sinus hemangioma treated with low-dose Gamma Knife radiosurgery are presented. Marginal dose varied from 10 to 13 Gy. Treatment planning and radiation dosimetry were done with a goal of conformal and selective coverage of the lesion with 50% prescription isodose line using multiisocenter technique. In all cases significant shrinkage of the neoplasm was marked at 3 months after treatment. Mean volume reduction at 12 months after radiosurgery was 60% (range: 45-75%). In all patients the shrinkage of the neoplasm was accompanied by notable improvement of the preexistent oculomotor nerve palsy. No radiosurgery-related complications were met during follow-up. In conclusion, low-dose Gamma Knife radiosurgery seems to be very effective for management of cavernous sinus hemangiomas, and can be considered as a treatment modality of choice for these lesions.
TL;DR: A previously healthy 10-year-old patient with headache, otalgia, and hearing loss was diagnosed with pachymeningitis and methicillin-resistant Staphylococcus aureus otitis media and bacteremia, which exemplifies an aggressive MRSA intracranial infection that advanced despite antibiotic therapy.
TL;DR: Clival DAVFs can be misdiagnosed as dural cavernous sinus fistulae and the best treatment is transarterial embolization of the dural feeders using liquid embolic agents.
Abstract: Objective Dural arteriovenous fistulae (DAVFs) rarely involve the clivus This report examines the clinical presentation, angiographic findings, endovascular management, and outcome of clival DAVFs Particular attention was given to safety and efficacy of transarterial embolization using liquid embolic agents Methods We reviewed the clinical and radiological data of 10 patients with spontaneous clival DAVFs who were treated endovascularly at the University of California at Los Angeles Medical Center between 1992 and 2006 Results Nine patients presented with ocular symptoms and one patient experienced pulsatile tinnitus Cerebral angiograms showed that these clival DAVFs were supplied by multiple branches of the internal and external carotid arteries The patterns of venous drainage were from the clival veins to the cavernous sinus and superior ophthalmic vein in nine patients and to the inferior petrosal sinus in two patients Six clival DAVFs were embolized transarterially through the clival branches of the ascending pharyngeal artery Onyx 18 (Micro Therapeutics Inc, Irvine, CA) was used in three patients and n-butyl cyanoacrylate was used in three patients Immediate complete angiographic obliteration was achieved in three patients All six patients experienced an angiographic and clinical cure without any complications at 3 months Two patients were incompletely treated using particles and coils for the relief of the symptoms Two other patients were completely treated after the recipient clival venous structures were occluded transvenously with coils Conclusion Clival DAVFs can be misdiagnosed as dural cavernous sinus fistulae The best treatment is transarterial embolization of the dural feeders using liquid embolic agents Transvenous occlusion of the cavernous sinus is unnecessary in most cases
TL;DR: Some recent findings pathways that appear to regulate meningioma growth are reviewed, and potential targets for novel therapies are also discussed.
Abstract: Skull base, including optic nerve, cavernous sinus, clival and foramen magnum tumors represent a major challenge for neurosurgeons and neuro-oncologists. Growth regulatory signaling pathways for these tumors are of increasing interest as potential targets for new chemotherapy. Those differentially activated in various grades of meningiomas are currently being identified as well. This article reviews some recent findings pathways that appear to regulate meningioma growth. Potential targets for novel therapies are also discussed.
TL;DR: The clinical features, pathophysiology, and potential treatment approaches to pituitary tumor-associated headache are summarized.
Abstract: Pituitary tumors come to clinical attention due to endocrine dysfunction, distortion of local structures surrounding the pituitary fossa, or as an incidental finding during neuroimaging for headache. Explanations for pituitary tumor-associated headache include stretching of the dura mater and invasion of pain-producing structures within the cavernous sinus. However, small functional pituitary lesions may present with severe headache without cavernous sinus invasion or suprasellar extension. Prolactinomas and growth hormone-secreting tumors have a high prevalence of rare headache phenotypes with or without autonomic features, suggesting that biochemical abnormalities within the hypothalamo-pituitary axis may play a role in headache. Somatostatin analogues may be highly effective at aborting headache associated with functionally active pituitary lesions, particularly in the case of acromegaly. A proposed mechanism for this is inhibition of nociceptive peptides. This article summarizes the clinical features, pathophysiology, and potential treatment approaches to pituitary tumor-associated headache.
TL;DR: Because Onyx may be injected via a trans venous approach and the microcatheter is easily withdrawn, cavernous sinus via transvenous catheterization and embolization is a safe and efficient way to treat complicated cavernous dural arteriovenous fistulas, especially those for which operations via transarterial approaches have failed.
Abstract: Background Treatment of cavernous dural arteriovenous fistulas (DAVF) is usually made by a transarterial approach. However, in many complicated patients, treatments via transarterial approaches can not be achieved, and only an operation via a transvenous approach is feasible. We aimed to study the feasibility of transarterial embolization of cavernous dural arteriovenous fistulas with a combination detachable coils and Onyx to embolize a complicated cavernous DAVF via a transvenous approach. Methods From August 2006 to August 2007, six cases of complicated cavernous DAVF were embolized with a combination of detachable coils and Onyx via a transvenous approach. Three cases were male and the other three were female. Their ages ranged from 36 to 69 years old. The fistula was in the right lateral cavernous sinus in one case, in the left lateral cavernous sinus in another, and in the bilateral cavernous sinus in 4 cases. One fistula was fed by the right internal carotid artery and its meningohypophyseal trunk; one was fed by the branches of the left internal carotid artery and left external carotid artery; four were fed by the branches of the bilateral internal carotid artery and/or the bilateral external carotid artery. One case was drained via one lateral inferior petrosal sinus; three were drained via bilateral inferior petrosal sinuses; one was drained via one lateral ophthalmic and facial veins; one was drained via the inferior petrosal sinus and the ophthalmic and facial veins. Four were embolized via the inferior petrosal sinus, and two were embolized via the ophthalmic and facial veins. Results Among six cases of complicated cavernous DAVF, four were fully embolized with Onyx by a single operation, and two cases were fully embolized with Onyx following two operations. Transient headache was found after operation in all patients, but was cured after several days by the symptomatic treatments. In one case, the first operation via the inferior petrosal sinus was a failure; the feeding branches of the external carotid artery were embolized, and transient facial palsy was appeared after operation. The fistula was fully embolized with Onyx via the inferior petrosal sinus after two months with no complications. One bilateral cavernous sinus DAVF was embolized with Onyx via the inferior petrosal sinus by two operations, and transient abducens nerve palsy occurred after embolization. Conclusions Because Onyx may be injected via a transvenous approach and the microcatheter is easily withdrawn, cavernous sinus via transvenous catheterization and embolization is a safe and efficient way to treat complicated cavernous dural arteriovenous fistulas, especially those for which operations via transarterial approaches have failed, or spontaneous cavernous dural arteriovenous fistulas.
01 Jan 2008
TL;DR: In this paper, the authors evaluated patients with direct superior ophthalmic vein (SOV) exposure for transvenous embolization of dural arterio-venous fistulae.
Abstract: Summary Indirect carotid-cavernous sinus dural arterio-venous fistulae (cDAVF) can be treated by transarterial and=or transvenous embolisation. This study evaluated patients with cDAVF who underwent transvenous embolisation using the direct superior ophthalmic vein (SOV) approach. Between January 2004 and October 2006, eight cDAVF in seven patients were embolised using direct surgical exposure of the SOV when access to the cDAVF via transarterial or transfemoral venous routes was not feasible. Medical records and imaging studies were retrospectively reviewed. The seven patients consisted of four females and three males from 43 to 65year-old (mean age, 54.4 years). Six cDAVF lesions were located on the left side and two on the right. All fistulae were successfully embolised and showed clinical improvement. One patient presented after treatment with transient venous congestion on the brain stem, which was relieved by osmotic diuretics and steroids. Direct surgical exposure of the SOV for transvenous embolisation of cDAVF can be effective if the facial vein, inferior petrosal sinus, and internal jugular vein are thrombosed. This approach is easy, safe, and effective when performed by a multidisciplinary team.
TL;DR: The extradural temporopolar approach offers a relatively safe and wide exposure of the sphenocavernous and petroclival regions and is an advantageous approach to large tumors in these regions and for complex upper basilar artery or superior cerebellar artery aneurysms.
Abstract: Object The extradural temporopolar approach is used for enhanced exposure of the cavernous sinus and petroclival regions in the treatment of complex lesions not amenable to sole treatment via radiosurgical or endovascular methods. The authors' objective was to review the indications, surgical experience, and operative technique in a series of patients who underwent surgery with this approach. Methods The authors conducted a retrospective review to identify patients who underwent a temporopolar approach from 1992 to 2008. An orbitozygomatic craniotomy was frequently used, followed by extradural retraction of the temporal lobe. A sequential progression of bone removal at the anterior and middle skull base, followed by opening the layers of the lateral wall of the cavernous sinus was next performed to safely retract the brain and widen the exposure to the cavernous sinus, interpeduncular fossa, and upper petroclival regions. Results Sixty-six patients were identified and included in the study. The mean patie...
TL;DR: This study evaluated patients with cDAVF who underwent transvenous embolisation using the direct superior ophthalmic vein (SOV) approach and found this approach is easy, safe, and effective when performed by a multidisciplinary team.
Abstract: Indirect carotid-cavernous sinus dural arterio-venous fistulae (cDAVF) can be treated by transarterial and/or transvenous embolisation. This study evaluated patients with cDAVF who underwent transvenous embolisation using the direct superior ophthalmic vein (SOV) approach. Between January 2004 and October 2006, eight cDAVF in seven patients were embolised using direct surgical exposure of the SOV when access to the cDAVF via transarterial or transfemoral venous routes was not feasible. Medical records and imaging studies were retrospectively reviewed. The seven patients consisted of four females and three males from 43 to 65-year-old (mean age, 54.4 years). Six cDAVF lesions were located on the left side and two on the right. All fistulae were successfully embolised and showed clinical improvement. One patient presented after treatment with transient venous congestion on the brain stem, which was relieved by osmotic diuretics and steroids. Direct surgical exposure of the SOV for transvenous embolisation of cDAVF can be effective if the facial vein, inferior petrosal sinus, and internal jugular vein are thrombosed. This approach is easy, safe, and effective when performed by a multidisciplinary team.
TL;DR: A modification of a commercially available prototype three-dimensional skull base model made by a selective laser sintering method and incorporating surface details and inner bony structures such as the inner ear structures and air cells provides a good educational tool for training in skull base surgery.
Abstract: Experience with dissection of the cavernous sinus and the temporal bone is essential for training in skull base surgery, but the opportunities for cadaver dissection are very limited. A modification of a commercially available prototype three-dimensional (3D) skull base model, made by a selective laser sintering method and incorporating surface details and inner bony structures such as the inner ear structures and air cells, is proposed to include artificial dura mater, cranial nerves, venous sinuses, and the internal carotid artery for such surgical training. The transpetrosal approach and epidural cavernous sinus surgery (Dolenc's technique) were performed on this modified model using a high speed drill or ultrasonic bone curette under an operating microscope. The model could be dissected in almost the same way as a real cadaver. The modified 3D skull base model provides a good educational tool for training in skull base surgery.
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TL;DR: This study indicates that dural sinus thrombosis, which is generally considered as a causative factor ofDAVF, is less likely to precede the detection of DAVF, and in Japan, a higher number of cases of cavernous sinus lesions are detected, indicating racial difference in the presentation ofDAF.
Abstract: Dural arteriovenous fistula (DAVF) is generally recognized as an acquired lesion; however, its epidemiology, etiology, and natural history are yet to be completely elucidated. Recently, an epidemiological survey of the detected DAVF cases in Japan between 1998 and 2002 was conducted. The detection rate of DAVF per 100,000 adults per year is 0.29 for DAVF. Furthermore, unlike Europe and North America where cases of transverse-sigmoid sinus DAVF are predominantly detected, in Japan, a higher number of cases of cavernous sinus lesions are detected, indicating racial difference in the presentation of DAVF. Our study indicates that dural sinus thrombosis, which is generally considered as a causative factor of DAVF, is less likely to precede the detection of DAVF. A possible mechanism underlying the formation of DAVF is as follows: subtle changes, including minor trauma, cause the formation of an abnormal arteriovenous shunt in the dura and promote progressive steno-occlusive change in its venous drainage.
TL;DR: The case of a dermoids cyst that was embedded in the lateral wall of the cavernous sinus is described and the literature relating to related cavernous dermoid lesions is reviewed.
Journal Article•
TL;DR: In this paper, an endonasal transsphenoidal approach and a transcranial micro-surgical approach were used to compare the neurovascular relationships in the lateral wall of the cavernous sinus.
Abstract: OBJECTIVE: To provide a comparative description of the endoscopic and microsurgical anatomic features of the blood supply to the cranial nerves in the lateral wall of the cavernous sinus. METHODS: Twenty-four cavernous sinuses were dissected in 12 adult cadaveric beads Endoscopic observations were made with 0 and 45 degree, 4-mm rod-lens endoscupes. The lateral wall of the cavernous sinus was exposed through an endonasal transsphescope with possible magnification ranging from 4x to 40x through a lateral transcranial approach. Neurovascular relationships in the lateral wall of the cavemous sinus were noted, and the endoscopic and microsurgical perspectives were compared. RESULTS: The neurovascular relationships in the laterla wall of the cavernous sinus that are visible by the endonasal transsphenoidal approach but not visible by the transcranial microsurgical approach are as follows between the oculomotor nerve and the tentorial the ophthalmic nerve and the interolateral trunk, and between the abducens nerve and the inferolateral trunk. The neurovascular relationships visible by the nanscranial micro-surgical approach but not visible by the transphenoidal endoscopic approach are as between the proximal segment of the trochlear nerve and the superoproximal artery. a better understanding of the neurovascular relationships in the cavernous sinus lateral wall. This information could be relevant for preservation of the blood supply to the nerves during surgery in or around the eavernous sinus.