Abstract: ✓ The increasing use of the transsphenoidal approach to sellar tumors has created a need for more detailed information about the neurovascular relationships of the sphenoid sinus. To better define this anatomy, 25 sphenoid sinuses were examined in cadavers, with attention to the neural and vascular structures in the lateral wall of the sinus. Three structures produced prominent bulges into the lateral wall of the sinus; they were 1) the optic nerves, 2) the carotid arteries, and 3) the maxillary branches of the trigeminal nerve. Over half of these structures had a bone thickness of less than 0.5 mm separating them from the sphenoid sinus, and in a few cases, they were separated by only sinus mucosa and dura. 1) The optic canals protruded into the superolateral part of the sphenoid sinus in all except one side of one specimen. In 4% of the optic nerves, only the optic sheath and sinus mucosa separated the nerves from the sinus, and in 78%, less than a 0.5-mm thickness of bone separated them. 2) The carotid...

Abstract: ✓ The author reports the occlusion of 33 carotid-cavernous fistulas in 31 patients using thrombogenic techniques. In one patient the carotid artery had been occluded previously, in one it was occluded deliberately, and with 31 fistulas it was preserved. There was no mortality and virtually no morbidity.

Abstract: Bilateral intracavernous internal carotid artery aneurysms are described in a 3-year-old child. The etiology was uncertain, although the aneurysms may have been mycotic. As there was clinical and radiological evidence of progressive enlargement of both aneurysms, the more conventional forms of treatment were not applicable. A direct surgical approach was made to both aneurysms with exploration of the intracavernous portion of the internal carotid artery under deep hypothermia and cardiac arrest.

Abstract: Twenty-six patients with painful ophthalmoplegia were classified as having the Tolosa-Hunt syndrome on the basis of their clinical findings and response to steroid therapy. All patients underwent orbital venography, a review of which forms the contents of this investigation. Orbital venography, a review of which forms the contents of this investigation. Orbital venograms were normal in 16 patients and abnormal in 10. The major abnormalities were (1) obstruction of the superior ophthalmic vein in its third segment without displacement; (2) collateral venous flow through small venous channels or collateral veins; and (3) poor opacification of the ipsilateral cavernous sinus.

Abstract: A patient with traumatic bilateral carotid-cavernous fistulae was successfully treated by an entirely extracranial approach. The larger fistula on the left was exposed via a transethmoidal, trans-sphenoidal route and was directly opened and packed while the cavernous carotid artery was stented open by an intraluminal balloon catheter. The balloon catheter provided temporary hemostasis and was removed after the fistula had been packed. The left carotid artery remained patent, and the smaller fistula on the right was subsequently obliterated by a balloon catheter. The fistulae have remained cured, and the left internal carotid artery supplies the cerebral circulation.

Abstract: Seven patients with remittent painful ophthalmoplegia for which no specific local cause was found were seen during a period of five years. One had coincidental rheumatoid arthritis, and another had actinomycosis of the ipsilateral middle ear and contralateral parotid gland. The other five had no evidence of generalised autoimmune disease nor any other systemic disorder, two having separate episodes affecting each side. A history of relapsing and remitting painful ophthalmoplegia is suggestive of the Tolosa-Hunt syndrome, but it is rarely possible to confirm that the lesion in the cavernous sinus is the result of non-specific granulomatous infiltration so that the diagnosis remains one of exclusion. Carotid arteriography may show narrowing of the intracavernous part of the internal carotid artery. Orbital venography may also be helpful, particularly when the carotid arteriogram is normal. We believe that the Tolosa-Hunt syndrome is more common in England than is generally realised, but that its clinical features do not necessarily indicate a single pathological entity. Its recognition is important since the response to steroids, although not specific, is rapid in most patients, and the prognosis for complete recovery is relatively good.

Abstract: In a case of malignant tumor after proton-beam radiotherapy, the course of the ophthalmoplegia was consistent with infiltration of the cavernous sinus. This was confirmed at autopsy.

Abstract: The diagnostic accuracy of CT scanning in the sellar area can be improved by using a rapid high dose (RHD) contrast technique which visualizes the supraclinoid carotid arteries, cavernous sinus and vascular plexus of the infundibulum. The RHD technique is briefly described and the pertinent anatomy discussed and illustrated.

Abstract: The so called “spontaneous” carotid-cavernous fistulae are mostly dural shunts between the meningeal branches of internal or external carotid arteries and dural veins in the vicinity of cavernous sinus. The spontaneous external carotid-cavernous fistula could be treated by ligation or embolization of branches of external carotid artery. On the other hand, the direct closure of internal carotid-cavernous fistula is quite a challenge to neurosurgeons. Here is a report of a technique for direct closing of a spontaneous internal carotid-cavernous fistula which does not impair internal carotid blood flow. Exposure of cavernous sinus wall is achieved by means of a frontotemporal craniotomy. Operative angiography is performed in order to establish the topographical relationship of internal carotid artery, Parkinson's triangle of the cavernous sinus and fistula. Fine copper on copper compound wire is threaded transdurally into the lumen of the sinus. A direct current (0.2 mA to 2 mA) is applied to the copper wire for 1 to 2 minutes. The closure of fistula is verified by operative angiograms. Our experiences of the three cases suggest that electrothrombosis is an ideal treatment of spontaneous internal carotid-cavernous fistula.

Abstract: It appears that the specific vascular loops are essential for the diagnosis of carotico-cavernous fistulas, so that the ophthalmologist has an important part to play; his opinion on the angiography can also carry weight. The intraocular pressure should also be checked and if glaucoma occurs it should be treated as indicated.

Abstract: Four patients who sustained crushing fractures of the sphenoidal bone had angiographic evidence of venous occlusions of the cavernous area. Signs depended upon the type of basal venous and cavernous anatomy. The diagnosis can be made by demonstrating abrupt cutoff of veins in the cavernous region, preferred retrograde flow of the anterior cavernous sinus, direct venous hemorrhage, and venous stasis.

Abstract: The perifolicular region of the human spleen was studied under the scanning electron microscope. The marginal zone 10 to 50 micron in width was located around the white pulp, and was composed of concentrically arranged reticulum cell networks and intervening lymphocytes, red blood cells and macrophages. The cavernous sinuses 10-150 micron in width were situated between the marginal zone and the red pulp, and were lined by thin, flat endothelia. The perimarginal cavernous sinuses communicated with one another through narrow canals and formed a plexus. Transmural passages of lymphocytes were noted on the side of the white pulp. The perimarginal cavernous sinus plexus was also in communication with the interspaces between reticulum cells in the marginal zone. The human perimarginal cavernous sinus plexus appears to correspond to the marginal sinus in rat and rabbit spleens.

Abstract: The value of the catheter occlusion therapy is analyzed in 92 cases retrospectively, and the indication, and complication risk of these procedures are considered. In the following vessel areas occlusion with different methods have been performed with decreasing frequency; kidneys, pelvis, legs, gastrointestinal tract, external carotid and internal carotid artery. Serious complications have been observed in therapeutic investigations at the head, especially in occlusions of the external carotid artery. In this group embolisation therapy should be performed with strict indication only.

Abstract: A case of mucormycosis in a 45 year-old woman with uncontrolled diabetes is reported. Following dental extractions, the patient presented with total ophthalmoplegia, chemosis and complete sensory loss of the right fifth cranial nerve. Exophthalmus was not present. Although a fungal infection was suspected, administration of Amphotericin B was avoided because of renal insufficiency. After temporary clinical improvement with high doses of antibiotics, signs of right seventh and eighth cranial nerve paralysis and of thrombosis of the right ophthalmic artery developed. The patient expired after six days. Autopsy disclosed extensive mucormycosis with involvement of the nasal cavity and paranasal sinuses, soft tissues and bones of face and orbit, cranial nerves, meninges and base of the brain, as well as mycotic thrombosis of the right cavernous sinus and the internal carotid, ophthalmic and maxillary arteries. The spread of infection is detailed, and the importance of an early diagnosis is stressed.

Abstract: In the reported case unilateral external ophthalmoplegia developed in a young woman, with concomitant pain and anaesthesia in the area innervated by the 1st branch of the trigeminal nerve. After ruling out an expanding lesion of the central nervous system, aneurysm, diabetes, myasthenia, multiple sclerosis and other diseases dexamethasone was administered in a total dose of 30 mg. Complete clinical remission was achieved. In the light of observations and a survey of the peritinent literature it has been accumed that the disease was caused by a non-specific process in the small vessels in the vicinity of the cavernous sinus.

Abstract: Fistulas between the cavernous sinus and the carotid artery occur either after trauma or spontaneously. Unilateral exophthalmos is invariably the most conspicuous symptom. Until recently, treatment consisted of some method of occluding the carotid artery involved. Interventional catheter techniques have since been developed that use either Gelfoam embolization or released balloons. The results seem very promising, but long-term results of these new techniques are not yet available. Carotid-cavernous sinus fistulas may be dural or direct, each requiring a different interventional technique. Theredore, it is essential to determine the type involved by selective internal and external carotid angiography. This paper discusses 19 patients with carotid-cavernous fistulas, four of whom were successfully treated by catheter techniques. Gelfoam embolization was used in one case, and in three cases the fistula was closed with the aid of a balloon.