Showing papers on "Cavernous sinus published in 2012"

Carotid-cavernous fistulas

Abstract: Carotid-cavernous fistulas (CCFs) are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. The characteristic clinical features seen in patients with CCFs are the sequelae of hemodynamic dysfunction within the cavernous sinus. Once routinely treated with open surgical procedures, including carotid ligation or trapping and cavernous sinus exploration, endovascular therapy is now the treatment modality of choice in many cases. The authors provide a review of CCFs, detailing the current classification and clinical management of these lesions. Therapeutic options including conservative management, open surgery, endovascular intervention, and radiosurgical therapy are presented. The complications and treatment results as reported in the contemporary literature are also reviewed.

Rhino-orbital-cerebral mucormycosis.

Abstract: This review focuses on sinus, sino-orbital, and rhinocerebral infection caused by the Mucorales. As the traditional term of "rhinocerebral" mucormycosis omits the critical involvement of the eye, the more comprehensive term as rhino-orbital-cerebral mucormycosis (ROCM) is used. The most common underlying illnesses of ROCM are diabetes mellitus, hematological malignancies, hematopoietic stem cell transplantation, and solid organ transplantation. Sporangiospores are deposited in the nasal turbinates and paranasal sinuses in immunocompromised patients. Qualitative and quantitative abnormalities of neutrophils, monocytes and macrophages increase the risk for development of mucormycosis. Altered iron metabolism also is a critical factor in the pathogenesis of patients with diabetes mellitus who are at risk for ROCM. Angioinvasion with thrombosis and tissue necrosis is a key pathophysiological feature of human Mucorales infection. The ethmoid sinus is a critical site from which sinus mucormycosis may extend through the lamina papyracea into the orbit, extraocular muscles, and optic nerve. The brain may be seeded by invasion of the ethmoidal and orbital veins, which drain into the cavernous sinuses. Diplopia and ophthalmoplegia may be the earliest manifestations of cavernous sinus syndrome before changes are apparent on diagnostic imaging modalities. Negative diagnostic imaging does not exclude cavernous sinus mucormycosis. Mucormycosis of the maxillary sinus has a constellation of clinical features that are different from that of ethmoid sinus mucormycosis. A painful black necrotic ulceration may develop on the hard palate, indicating extension from the maxillary sinus into the oral cavity. Orbital apex syndrome is an ominous complication of mucormycosis of the orbit. Once within the orbital compartment, organisms may extend posteriorly to the optic foramen, where the ophthalmic artery, ophthalmic nerve and optic nerve are threatened by invasion, edema, inflammation and necrosis. Early diagnosis of sinus mucormycosis is critical for prevention of extension to orbital and cerebral tissues. Optimal therapy requires a multidisciplinary approach that relies on prompt institution of appropriate antifungal therapy with amphotericin B, reversal of underlying predisposing conditions, and, where possible, surgical debridement of devitalized tissue. Outcomes are highly dependent upon the degree of immunosuppression, site and extent of infection, timeliness of therapy, and type of treatment provided. New modalities for early diagnosis and therapeutic intervention are critically needed for improved outcome of patients with ROCM.

Stereotactic fractionated radiotherapy for cavernous venous malformations (hemangioma) of the orbit.

Abstract: Purpose Cavernous malformations (hemangioma) of the orbit, when symptomatic, can often be treated successfully with complete surgical excision. However, when they involve local structures in their capsule, are situated in the orbital apex, or extend through the superior orbital fissure, the risks of surgery increase significantly. In such cases, alternative treatment modalities can be explored. In this study, the authors report on the use of fractionated stereotactic radiotherapy (SFRT) for the treatment of surgically complicated cavernous malformations. Methods In this retrospective cohort study, the authors reviewed the clinical and radiologic records of 5 patients treated with SFRT over the past 5 years. Results Patients ranged in age from 30 to 65 years, and 3 out of 5 were female. Two cases involved the cavernous sinus, one involved the ophthalmic artery, one involved the posterior ciliary artery, and the last traversed the superior orbital fissure. Four had significant visual field defects. Each was treated with SFRT. A total dose of 4000 cGy divided into 20,200 cGy fractions was applied for 3 cases, while 2 other cases were treated with total doses of 4563 and 4959 cGy divided into 28 × 162 cGy and 29 × 171 cGy fractions, respectively. Rapid resolution of visual field defect was noted by 3 months, and overall tumor shrinkage was on average 60% (range: 32-79%). Follow-up was on average 23.4 months (range: 5-50 months). No complications of treatment were noted. Conclusions For symptomatic cavernous malformations demonstrating anatomical position that may increase risk of surgical excision, SFRT is an effective and safe method to control lesion size and improve visual function.

Microsurgical anatomy of the abducens nerve.

Abstract: The aim of this study is to demonstrate and review the detailed microsurgical anatomy of the abducens nerve and surrounding structures along its entire course and to provide its topographic measurements. Ten cadaveric heads were examined using ×3 to ×40 magnification after the arteries and veins were injected with colored silicone. Both sides of each cadaveric head were dissected using different skull base approaches to demonstrate the entire course of the abducens nerve from the pontomedullary sulcus to the lateral rectus muscle. The anatomy of the petroclival area and the cavernous sinus through which the abducens nerve passes are complex due to the high density of critically important neural and vascular structures. The abducens nerve has angulations and fixation points along its course that put the nerve at risk in many clinical situations. From a surgical viewpoint, the petrous tubercle of the petrous apex is an intraoperative landmark to avoid damage to the abducens nerve. The abducens nerve is quite different from the other nerves. No other cranial nerve has a long intradural path with angulations and fixations such as the abducens nerve in petroclival venous confluence. A precise knowledge of the relationship between the abducens nerve and surrounding structures has allowed neurosurgeon to approach the clivus, petroclival area, cavernous sinus, and superior orbital fissure without surgical complications.

Giant anterior clinoidal meningiomas: surgical technique and outcomes.

Abstract: Object Surgery for giant anterior clinoidal meningiomas that invade vital neurovascular structures surrounding the anterior clinoid process is challenging. The authors present their skull base technique for the treatment of giant anterior clinoidal meningiomas, defined here as globular tumors with a maximum diameter of 5 cm or larger, centered around the anterior clinoid process, which is usually hyperostotic. Methods Between 2000 and 2010, the authors performed 23 surgeries in 22 patients with giant anterior clinoidal meningiomas. They used a skull base approach with extradural unroofing of the optic canal, extradural clinoidectomy (Dolenc technique), transdural debulking of the tumor, early optic nerve decompression, and early identification and control of key neurovascular structures. Results The mean age at surgery was 53.8 years. The mean tumor diameter was 59.2 mm (range 50–85 mm) with cavernous sinus involvement in 59.1% (13 of 22 patients). The tumor involved the prechiasmatic segment of the optic...

Prospective evaluation of the characteristics and incidence of adenoma-associated dural invasion in Cushing disease.

Abstract: Object Dural invasion by adrenocorticotropic hormone (ACTH)-secreting adenomas is a significant risk factor for incomplete resection and recurrence in Cushing disease (CD). Since ACTH-producing adenomas are often the smallest of the various types of pituitary tumors at the time of resection, examining their invasion provides the best opportunity to identify the precise sites of early dural invasion by pituitary adenomas. To characterize the incidence and anatomical distribution of dural invasion by ACTH-secreting adenomas, the authors prospectively and systematically analyzed features of dural invasion in patients with CD. Methods The authors prospectively studied consecutive patients with CD undergoing the systematic removal of ACTH-secreting adenoma and histological analysis of the anterior sella dura as well as other sites of dural invasion that were evident at surgery. Clinical, imaging, histological, and operative findings were analyzed. Results Eighty-seven patients with CD (58 females and 29 males)...

Lateral orbital wall approach to the cavernous sinus.

Abstract: Object Lesions of the cavernous sinus remain a technical challenge. The most common surgical approaches involve some variation of the standard frontotemporal craniotomy. Here, the authors describe a surgical approach to access the cavernous sinus that involves the removal of the lateral orbital wall. Methods To achieve exposure of the cavernous sinus, a lateral canthal incision is performed, and the lateral orbital rim and anterior lateral wall are removed, for later replacement at closure. The posterior lateral orbital wall is removed to the region of the superior and inferior orbital fissures. With reflection of the dural covering of the lateral cavernous sinus and removal of the anterior clinoid process, the cavernous sinus is exposed. Results Exposure and details of the procedure were derived from anatomical study in cadavers. After the approach, with removal of the anterior clinoid process, the entire cavernous sinus from the superior orbital fissure anteriorly to the Meckel cave posteriorly is expos...

Cerebral aneurysms with intrasellar extension: a systematic review of clinical, anatomical, and treatment characteristics

Abstract: Object Intrasellar aneurysms are rare lesions that often mimic pituitary tumors, potentially resulting in catastrophic outcomes if they are not appropriately recognized. The authors aimed to characterize the clinical and anatomical details of this poorly defined entity in the modern era of neuroimaging and open/endovascular neurosurgery. Methods A PubMed literature review was conducted to identify all studies reporting noniatrogenic aneurysms with intrasellar extension, as confirmed by CT or MR imaging and angiography. Clinical, anatomical, and treatment characteristics were analyzed. Results Thirty-one studies reporting 40 cases of intrasellar aneurysms were identified. Six patients (15%) presented with aneurysmal rupture. Patients with unruptured aneurysms presented with the following signs and symptoms: headache (61%), visual field cuts/decreased visual acuity (61%), endocrinopathy (57%), symptomatic hyponatremia (21%), and cranial nerve paresis (other than optic nerve) (18%). The most common endocrine...

Surgical results of an endoscopic endonasal approach for clival chordomas

Abstract: The surgical approaches for clival chordomas remain controversial, although the extent of resection is one of the most important factors for long survival rates. Recently an endoscopic endonasal approach in good collaboration with otolaryngologists has attracted major attention as a surgical approach for clival chordomas. We describe our experience with the endoscopic endonasal approach and provide a review of the literature. Between 2008 and 2011, six operations were performed via the endoscopic endonasal approach for clivus chordomas. The mean tumor size was 35 mm in diameter. The tumor location was mainly from the upper to middle clivus. The tumor extended into the cavernous sinus in five cases and intradurally in three cases. A binostril approach was performed in four cases, while a one nostril approach was performed in two cases. Gross total removal was achieved in three cases. The analysis of cases with incomplete resection suggested that residual tumors were observed epidurally and subdurally. The residual on the epidura was observed from the posterior clinoid to the posterior compartment of the cavernous sinus. On the other hand, the residual on the subdural was observed behind the upper part of the pituitary gland. There was no postoperative cerebrospinal fluid (CSF) leakage using vascularized nasoseptal flaps in any of the cases. The endoscopic endonasal transclival approach allows an appropriate extent of resection with acceptable complication rates in comparison with other approaches. In our series, the accomplishment of gross total removal was associated with the relationship between the tumors and surrounding structures, such as the pituitary gland and the cavernous portion of the intracranial carotid artery (ICA).

Endovascular Treatment of Cavernous Sinus Aneurysms

Abstract: BACKGROUND AND PURPOSE: Aneurysms of the cavernous segment of the internal carotid artery generally exhibit a benign clinical course, with mass effect on cranial nerves. Rupture generally leads to carotid cavernous fistula and, rarely, to subarachnoid hemorrhage. In this study we report results of treatment in 85 patients with 86 cavernous sinus aneurysms. MATERIALS AND METHODS: In a 15-year period, 85 patients with 86 cavernous sinus aneurysms were treated. There were 77 women (91%) and 8 men, with a mean age of 55.5 years (range 26–78 years). Presentation was cranial neuropathy in 56, carotid cavernous fistula in 8, and subarachnoid hemorrhage in 1 patient. Twenty-one aneurysms were asymptomatic. Treatment was selective coiling in 31 aneurysms and carotid artery occlusion in 55 aneurysms, 5 after bypass surgery. RESULTS: All 8 cavernous sinus fistulas were closed with coils. There were no complications of coiling and 1 patient had a permanent neurologic complication after carotid artery occlusion (morbidity 1.2%; 95% confidence interval, 0.01 to 6.9%). Clinical and MR imaging follow-up ranged from 3 months to 12 years. In 52 of 56 (93%) patients presenting with symptoms of mass effect, symptoms either were cured (n = 23) or improved (n = 29). All aneurysms were thrombosed after carotid artery occlusion and at latest MR imaging, 34 of 50 aneurysms (68%) were substantially decreased in size or completely obliterated. CONCLUSIONS: In this series, for patients with cavernous sinus aneurysms, a treatment strategy including selective coiling and carotid artery occlusion was safe and effective. Most symptomatic patients (93%) were improved or cured, and most aneurysms (68%) shrank on follow-up.

Fractionated proton radiotherapy for benign cavernous sinus meningiomas.

Abstract: Purpose To evaluate the efficacy of fractionated proton radiotherapy for a population of patients with benign cavernous sinus meningiomas. Methods and Materials Between 1991 and 2002, 72 patients were treated at Loma Linda University Medical Center with proton therapy for cavernous sinus meningiomas. Fifty-one patients had biopsy or subtotal resection; 47 had World Health Organization grade 1 pathology. Twenty-one patients had no histologic verification. Twenty-two patients received primary proton therapy; 30 had 1 previous surgery; 20 had more than 1 surgery. The mean gross tumor volume was 27.6 cm 3 ; mean clinical target volume was 52.9 cm 3 . Median total doses for patients with and without histologic verification were 59 and 57 Gy, respectively. Mean and median follow-up periods were 74 months. Results The overall 5-year actuarial control rate was 96%; the control rate was 99% in patients with grade 1 or absent histologic findings and 50% for those with atypical histology. All 21 patients who did not have histologic verification and 46 of 47 patients with histologic confirmation of grade 1 tumor demonstrated disease control at 5 years. Control rates for patients without previous surgery, 1 surgery, and 2 or more surgeries were 95%, 96%, and 95%, respectively. Conclusions Fractionated proton radiotherapy for grade 1 cavernous sinus meningiomas achieves excellent control rates with minimal toxicities, regardless of surgical intervention or use of histologic diagnosis. Disease control for large lesions can be achieved by primary fractionated proton therapy.

Microsurgical anatomy of the abducens nerve

Abstract: Objective To clarify the oriented classification, relationships, and variations of the abducens nerve and provide a detailed description of its microsurgical anatomic features.

Treatment of a traumatic carotid–cavernous fistula by the sole use of a flow diverting stent

Abstract: Direct caroticocavernous fistula (CCF) has traditionally been treated by detachable balloon placement within the affected cavernous sinus. We describe a case of a direct CCF treated solely with flow-diverting stents. These novel devices may offer a simpler and potentially safer vessel-sparing option in this rare condition.

Endoscopic endonasal approaches to the cavernous sinus.

Abstract: Background: Surgical access to the cavernous sinus (CS) has proven a challenge for the skull base surgeon. Traditional approaches include the transcranial route, which broaches the lateral wall of the CS and has a high risk of cranial nerve weakness. A medial approach is more logical but the microscopic transsphenoidal approach has a restricted view. The endoscopic endonasal approach provides an alternative medial approach with improved visualization to that provided with the microscope. We describe our results using this approach for resection of CS tumors. Methods: A retrospective chart review was performed of all patients treated surgically at a tertiary care referral center between January 2004 and February 2011 with a purely endoscopic endonasal approach to the CS. Results: Out of 400 total endoscopic skull base cases, 41 (10.3%) involved the cavernous sinus. The most common approach was the transsphenoidal transsellar approach (31 patients, 75.6%). Other approaches included the tran-sethmoidal transsphenoidal parasellar (4 patients, 9.8%) and transmaxillary transpterygoidal (6 patients, 14.6%). The most common pathology was pituitary macroadenoma (24 patients, 58.5%). Gross total resection was achieved in 18 patients (43.9%). Cerebrospinal fluid (CSF) leak was not encountered in any patient postoperatively. Complications included 1 case of new postoperative VIth nerve palsy, 1 case of intraoperative hemorrhage, 2 cases of persistent diabetes insipidus, and 2 cases of sinusitis. Conclusion: The endoscopic endonasal approach is a safe and effective option for tumor resection in the CS using a medial to lateral route for selected cases. Morbidity is low and a variety of reconstructive options are available. © 2011 ARS-AAOA, LLC.

The role of stereotactic radiosurgery in cavernous sinus hemangiomas: a systematic review and meta-analysis

Abstract: Cavernous sinus hemangioma is a rare and complex vascular tumor. A direct microsurgical approach usually results in massive hemorrhage. Stereotactic radiosurgery has emerged as a treatment alternative to microsurgery. To conduct a meta-analysis assessing the effect and complications of stereotactic radiosurgery in cavernous sinus hemangioma, a systematic review and meta-analysis of all cases of cavernous hemangioma in the cavernous sinus treated with stereotactic radiosurgery was performed. The search revealed ten papers with a total enrollment of 59 patients. Tumor size ranged from 1.5-51.4 cm(3) (mean 9.6 cm(3)). The mean follow-up period was 49.2 months (range 6-156 months). The most recent MR images demonstrated remarkable tumor shrinkage in 40 patients (67.8%), partial shrinkage in 15 patients (25.4%), and no change in four patients (6.8%). There was no significant correlation between lesion volume and tumor shrinkage. Patients with remarkable tumor shrinkage received higher doses than those with partial or no change tumor shrinkage (P = 0.031). Thirteen patients (22.0%) had no cranial nerve impairments before stereotactic radiosurgery. Among those 46 patients with cranial nerve impairments before stereotactic radiosurgery, complete resolution was achieved in seven patients and improvement in 28, and these impairments remained essentially unchanged in 11 patients. Only one patient had additional trigeminal nerve disturbance. There is no statistical significance in tumor control between patients treated with or without surgery (P = 0.091). The meta-analysis suggests stereotactic radiosurgery avoids the complications associated with attempted microsurgical resection. Stereotactic radiosurgery is an alternative for cavernous sinus hemangiomas confirmed by typical imaging.

Percutaneous biopsy of lesions in the cavernous sinus region through the foramen ovale: diagnostic accuracy and limits in 50 patients.

Abstract: Object The cavernous sinus and surrounding regions—specifically the Meckel cave, posterior sector of the cavernous sinus itself, and the upper part of the petroclival region—are the location of a large variety of lesions that require individual consideration regarding treatment strategy. These regions may be reached for biopsy by a percutaneous needle inserted through the foramen ovale. The aim of this retrospective study was to evaluate the diagnostic accuracy of percutaneous biopsy in a consecutive series of 50 patients referred for surgery between 1991 and 2010. Methods Seven biopsies (14%) were unproductive and 43 (86%) were productive, among which 28 lesions subsequently underwent histopathological examination during a second (open) surgery. To evaluate the diagnostic accuracy of the procedure, results from surgery were compared with those from the biopsy. Results Sensitivity of the percutaneous biopsy was 0.83 (95% CI 0.52–0.98), specificity was 1 (95% CI 0.79–1), and κ coefficient was 0.81. Conclus...

Virtual reality surgical anatomy of the sphenoid sinus and adjacent structures by the transnasal approach

Abstract: Objective To examine the three-dimensional virtual anatomical features of the sphenoid sinus and adjacent structures during virtual surgery and explore their relevance to actual transsphenoidal surgery. Methods CT images of the sphenoid sinus and surrounding structures from 28 Chinese adult patients were measured using a 16-slice helical CT scanner. Image analysis was performed using the volume-rendering method. Two experienced neurosurgeons wearing stereoscopic glasses performed virtual transsphenoidal surgery by the transnasal approach. Results The virtual anatomical features of the sphenoid sinus and the adjacent structures during virtual surgery were described. The distance from the sphenopalatine foramen to the left and right sphenoid ostium was 10.1 ± 2.7 mm and 10.5 ± 3.2 mm, respectively, to the left and right sphenoidal crest 12.9 ± 2.0 mm and 12.8 ± 2.2 mm, respectively, and to the left and right uncinate process 24.0 ± 1.9 mm and 23.9 ± 2.0 mm, respectively. The distance from the uncinate process to the medial and lateral edge of the most prominent part of the anterior bend of the cavernous internal carotid artery (ICA) was 33.7 ± 3.7 mm and 34.8 ± 3.7 mm, respectively, and the angle between the two lines was 9.7 ± 1.9°. Conclusion The study provides virtual anatomical information about the sphenoid sinus and important surrounding structures that is essential for successful real life transsphenoidal surgery.

Dermoid Tumor of the Lateral Wall of the Cavernous Sinus

Abstract: Background: Congenital intracranial dermoid tumors are very rare. The location of these dermoid lesions in the cavernous sinus and the complexity of the operative procedure for these lesions have been noted by several authors. Dermoid tumors originating in the cavernous sinus are usually interdural, and thus blurred vision is an uncommon presentation. Case Description: Herein we report the first incidental case of a cavernous sinus dermoid cyst in a 21-year-old woman. Conclusions: A literature review was done and the possible treatments and approaches for this lesion are discussed. We consider that surgical treatment is indicated in most incidental cavernous sinus dermoid lesions due to the possible symptoms related to compression or rupture leading to chemical meningitis.

Transcortical Venous Approach for Direct Embolization of a Cavernous Sinus Dural Arteriovenous Fistula: Technical Case Report

Abstract: BACKGROUND AND IMPORTANCE Dural arteriovenous fistulas (dAVFs) represent 10% to 15% of all intracranial arteriovenous malformations. Most often, embolization is accomplished with transfemoral catheter techniques. We present a case in which embolization of a cavernous sinus dAVF was made possible through transcranial cannulation of a cortical draining vein. CLINICAL PRESENTATION An 82-year-old woman presented with diplopia, left sixth cranial nerve palsy, intraocular hypertension, and bilateral chemosis. Angiography revealed a complex cavernous dAVF with cortical venous reflux, supplied by both external carotid arteries and the left meningohypophyseal trunk. Percutaneous transvenous access failed, and only partial occlusion was achieved by transarterial embolization. A frontotemporal craniotomy was performed to access the superficial middle cerebral vein in the left sylvian fissure. Under fluoroscopic guidance, a microcatheter was advanced through this vein to the floor of the middle cranial fossa and into the dAVF, permitting coil occlusion. CONCLUSION This transcranial vein technique may be a useful adjunct in dAVF therapy when percutaneous transarterial or transvenous approaches fail or are not possible.

Endoscopic endonasal middle clinoidectomy: anatomic, radiological, and technical note.

Abstract: Background The middle clinoid is an osseous prominence that arises from the body of the sphenoid bone at the anterolateral margin of the sella. Objective To illustrate the radiological and surgical anatomy of the middle clinoid and describe the technical nuances for endonasal endoscopic middle clinoid removal. Methods The fine-cut head CT-angiogram scans of 100 patients and 50 anatomic specimens were examined. The middle clinoid was categorized as: absent, small, prominent, or caroticoclinoidal ring. Ten colored silicon-injected anatomic specimens were used to study the surgical anatomy for the endonasal middle clinoidectomy. Extensive surgical experience allowed for intraoperative observations regarding the surgical anatomy of the middle clinoid and the technical nuances for its removal. Results The middle clinoid was identifiable in 60% of scans (bilateral in 35%), and 20% had at least one caroticoclinoidal ring (bilateral in 6%). When present, the middle clinoid is located at the transition between the intracavernous internal carotid artery (ICA) and paraclinoidal ICA, and covers the anteromedial roof of the cavernous sinus. Endonasal removal of the middle clinoid improves access to the parasellar region. The middle clinoidectomy is completed exposing the following structures sequentially: sellar dura, anterior wall of the cavernous sinus, dura of the lateral tuberculum sella, and paraclinoidal ICA. When a caroticoclinoidal ring is identified, progressive reduction of the middle clinoid can be achieved without fracturing the ring. Conclusion Recognition of the middle clinoid and caroticoclinoidal ring on preoperative imaging is critical for surgical planning and middle clinoid removal in endonasal skull base surgery.

Acromegaly due to an ectopic pituitary adenoma in the clivus: case report and review of literature

Abstract: Pituitary adenomas rarely originate outside the sella turcica. Ectopic locations include the suprasellar region, sphenoid sinus, cavernous sinus and clivus. We describe a 50-year-old female who presented with clinical signs and biochemical evidence of acromegaly. Pituitary MRI demonstrated a 2 mm hypointense lesion on the right side of the pituitary gland. However upon drilling of the upper clival bone to expose the sella during endoscopic transsphenoidal surgery, soft tumor-like tissue was encountered within the clivus. Exploration of the sella, including the area of hypointensity noted on preoperative imaging, did not identify any other abnormality. Immunohistochemical examination of the fully resected tumor demonstrated growth hormone immunoreactivity. Failed preoperative diagnosis of this rare ectopic GH-producing tumor was compounded by the presence of a misleading pituitary abnormality consistent with a microadenoma. The epidemiology and pertinent literature of this uncommon condition is discussed.

Cavernous sinus medial wall: dural or fibrous layer? Systematic review of the literature

Abstract: The cavernous sinus (CS) has one of the most complex anatomical networks of the skull base and because of the diversity of its contents is involved in many pathological processes. Nevertheless, anatomical literature concerning the CS is still controversial, so a systematic literature review was performed to find out the microanatomy of the medial wall of the CS and its clinical importance on sellar pathologies. Experimental studies from English-language literature between 1996 and 2010 were identified in MEDLINE, LILACS, and Cochrane databases. After analysis, two tables were prepared exhibiting the major points of each article. Fourteen experimental studies were included in the tables. Four studies concluded that the medial wall of the CS is composed of a loose, fibrous structure, and the remaining ten presumed that the medial wall is formed by a dural layer that constitutes the lateral wall of the sella. The lack of definition standards and of methodological criteria led to variation in the results among different studies. Thus, this hindered results comparison, possibly explaining the different observations.

Angioarchitecture and treatment modalities in posttraumatic carotid cavernous fistulae.

Abstract: Posttraumatic carotid cavernous fistulae are abnormal direct hole communications between the intracavernous carotid artery and the cavernous sinus that can result from both blunt and penetrating trauma. They can be challenging lesions to treat and a variety of modalities and approaches have been proposed since endovascular treatment has become the standard treatment. An analysis of the angioarchitecture of 32 consecutive patients treated in our service demonstrated that seven could be classified as small hole, eight medium and 17 large. Different size fistulae required varying endovascular tools. Small fistulae were best treated using coils and large and medium lesions with balloons. Large lesions were more likely to require multiple tools in order to achieve closure and had a lower chance of ipsilateral carotid preservation. All patients in the series were cured with a carotid preservation rate of 66%. There was no permanent morbidity associated with endovascular treatment.

Gamma Knife radiosurgery of cavernous sinus meningiomas: an institutional review.

Abstract: Introduction Stereotactic radiosurgery offers a unique and effective means of controlling cavernous sinus meningiomas with a low rate of complications. Methods We retrospectively reviewed all cavernous sinus meningiomas treated with Gamma Knife (GK) radiosurgery between November 2003 and April 2011 at our institution. Results Thirty patients were treated, four were lost to follow- up. Presenting symptoms included: headache (9), trigeminal nerve dysesthesias/paresthesias (13), abducens nerve palsy (11), oculomotor nerve palsy (8), Horner's syndrome (2), blurred vision (9), and relative afferent pupillary defect (1). One patient was asymptomatic with documented tumor growth. Treatment planning consisted of MRI and CT in 17 of 30 patients (56.7%), the remainder were planned with MRI alone (44.3%). There were 8 males (26.7%) and 22 females (73.3%). Twelve patients had previous surgical debulking prior to radiosurgery. Average diameter and volume at time of radiosurgery was 3.4 cm and 7.9 cm3 respectively. Average dose at the 50% isodose line was 13.5 Gy. Follow-up was available in 26 patients. Average follow-up was 36.1 months. Mean age 55.1 years. Tumor size post GK decreased in 9 patients (34.6%), remained stable in 15 patients (57.7%), and continued to grow in 2 (7.7%). Minor transient complications occurred in 12 patients, all resolving. Serious permanent complications occurred in 5 patients: new onset trigeminal neuropathic pain (2), frame related occipital neuralgia (1), worsening of pre-GK seizures (1), and panhypopituitarism (1). Conclusion GK offers an effective treatment method for halting meningioma progression in the cavernous sinus, with an acceptable permanent complication rate.