Abstract: From 1974-1986, 152 patients with carotid cavernous sinus fistulae (CCF) have been evaluated. Progressive closure of both dural and direct types of CCF have been noted utilizing intermittent external manual compression of the cervical carotid artery and jugular vein. In a group of 71 patients in whom this treatment was attempted, we have observed that 7 of 23 patients (30%) with dural CCF, and 8 of 48 patients (17%) with direct CCF had complete closure of their fistulae with no recurrence either clinically or at angiography done one year later. Closure occurred at varying times, from several minutes to 6 months (mean 41 days) following compression therapy. In those patients with CCF without rapidly progressive visual deterioration, cerebral ischemia, or other complicating factors, we recommend this technique with serial clinical follow-up and angiography before more definitive therapy is employed.

Abstract: The effect of intravenously administered gadolinium DTPA on signal intensity of normal intracranial structures was analyzed in 25 patients. Magnetic resonance (MR) image enhancement with Gd-DTPA differs from image enhancement on computed tomography with aqueous iodinated contrast media. Marked contrast enhancement owing to Gd-DTPA was observed in the pituitary gland, infundibulum, cavernous sinus, cranial nerves, choroid plexus, and nasal mucosa. Enhancement was not visible routinely in the falx cerebri, tentorium cerebelli, dura, or rapidly flowing blood. The efficacy of Gd-DTPA in any individual MR study may be assessed by observing the signal intensity of the pituitary gland, pituitary stalk, or nasal mucosa.

Abstract: From 1974 to 1986, 148 patients with carotid cavernous fistula (CCF) were evaluated for intravascular therapy. Four patients died from hemorrhage before treatment could be instituted and the CCF closed spontaneously in 5. Therapeutic approaches which resulted in complete occlusion in the remaining 139 cases were transarterial in 118, transvenous in 15 and external compression of the carotid artery and jugular vein in 6. The current treatment of choice of the direct CCF is intravascular embolization using detachable balloons, particulate emboli or liquid adhesive agents to occlude the CCF while attempting to preserve the carotid artery. In 15 patients it was technically too difficult to use the transarterial approach. The patients were therefore treated from a transvenous approach including access via the femoral vein, superior ophthalmic vein, intraoperatively from the inferior petrosal sinus or direct puncture of the cavernous sinus. Embolic agents used included detachable silicone balloons, steel minicoils, particulate emboli and isobutyl-2-cyanoacrylate. In 14 of these 15 patients total obliteration was achieved with marked improvement in symptoms. Complications occurred in 3 patients including perforation of the cavernous sinus resulting in subarachnoid hemorrhage, delayed pontine hemorrhage from subtotal occlusion of the fistula and transient increased proptosis.

Abstract: Four cases of high-flow carotid-cavernous sinus fistula (CCF), three of them posttraumatic and one spontaneous, have been treated by a direct surgical approach to the cavernous sinus. The CCF's were obliterated by the introduction into the cavernous sinus of muscle fragments and/or fibrin sealant. In the three cases with a preoperatively patent internal carotid artery (ICA), the CCF was occluded and the ICA flow preserved. One of these also had a posttraumatic false aneurysm that enclosed the two avulsed ends of a transected intracavernous ICA. This was treated by cervical ICA ligation following resolution of the CCF. A fourth patient, who had previously undergone an unsuccessful ICA trapping procedure elsewhere, also obtained a good result. The case histories and the surgical technique are presented. Direct intracavernous obliteration with muscle fragments and fibrin sealant fulfills the criteria for treatment of high-flow CCF's: occlusion of the arteriovenous fistula and preservation of the ICA circulation. While this surgical technique is a therapeutic option in some cases, it appears to have precise indications in others.

Abstract: A report of eight cases of skull base chordoma is given and the related literature reviewed. From disappointing experience with incomplete tumour removal and radiation the conclusion is drawn, that radical tumour removal at the first attempt should be strived for, even if the operative risk seems to be high. Cavernous sinus invasion should not be a reason to omit operation. Loss of function of one eye appears to be justified if radical tumour removal can be achieved. Possibly, the operative strategy can be improved by combining a frontal transbasal with a frontotemporal subtemporal approach, thus creating a chance for preservation of oculomotor function even in patients whose tumour has invaded the cavernous sinus region.

Abstract: Four cases of spontaneous arteriovenous fistula seen in association with fibromuscular dysplasia of the parent artery are presented. In two patients, the fistula was between the carotid artery and cavernous sinus; in two others, the fistula involved the vertebral artery and paravertebral veins. It is postulated that the angiopathy was responsible for the fistula. Treatment by detachable balloon embolization was successful in each case; however, the presence of the fibromuscular dysplasia made treatment more difficult.

Abstract: The management of vascular injury to the internal carotid artery (ICA) is controversial. We undertook a retrospective review of 14 patients with blunt injuries to the ICA and found three types of ICA injury, often presenting with delayed symptomatology. Six patients had intraluminal arterial stenosis or obstruction and were treated with anticoagulants. Five patients had pseudoaneurysms. Three of these were treated with balloon occlusion of the ICA above and below the orifice of the aneurysm, one with aneurysmorrhaphy, and one with resection and interposition vein graft. Three patients sustained a carotid cavernous fistula and were treated by balloon occlusion of the fistula while patency of the ICA was maintained. Treatment rendered all patients either asymptomatic or with residual deficits only. Angiography is essential to anatomically delineate the injury. The vascular surgeon, the neurosurgeon, and the interventional radiologist all make important contributions to the successful treatment of patients with blunt ICA injuries.

Abstract: Cavernous sinus thrombosis is an important but difficult clinical diagnosis to confirm by most imaging modalities. 1,2 Until the advent of highfield magnetic resonance imaging (MRI), the imaging method of choice for evaluating thrombus formation in the cavernous sinus was transarterial or intravenous digital subtraction angiography. This article discusses the MRI findings in the diagnosis of cavernous sinus thrombosis. REPORT OF A CASE A 73-year-old woman noticed pain around her left eye ten days before examination. Over the next four days, her left upper eyelid drooped, and she experienced double vision. She was hospitalized elsewhere, and computed tomography (CT) showed a mass in the left anterior cavernous sinus. A cerebral arteriogram was normal. The patient was treated with systemic corticosteroids (prednisone, 80 mg/d), with no resolution of the pain or ocular motility disturbance. Five years prior to admission, the patient had an episode of painful ophthalmoplegia that was described

Abstract: Seven patients with intracavernous aneurysms were treated by proximal balloon occlusion of the carotid artery, with no attempt to preserve carotid blood flow. After a 15-minute occlusion trial, two balloons were detached proximal to the neck of these aneurysms. Major clinical improvement occurred in six patients and no procedure-related complications were encountered (the follow-up period was 4-14 months). Because these aneurysms arise proximal to major collateral pathways, proximal carotid occlusions via endovascular techniques are simple and safe and carry with them little risk of thromboembolism.

Abstract: To the Editor. —Several authors have emphasized the relatively benign clinical course of spontaneous carotidcavernous fistulas compared with that of traumatic fistulas. We herein report the occurrence of a central retinal vein occlusion in a patient who was being followed up for a spontaneous carotid-cavernous fistula. Report of a Case. —A 68-year-old obese but otherwise healthy woman developed redness of her right eye and diplopia in April 1984. One month later, she was found to have a visual acuity of 20/30 OD and 20/25 OS. The right eye showed 6 mm of proptosis and dilated tortuous conjunctival vessels. Paresis of the right sixth nerve was present, with an esotropia of 30 diopters, and there was limitation of abduction to just beyond the midline. Intraocular pressures were 28 mm Hg OD and 18 mm Hg OS. The fundi were normal. Orbital auscultation revealed a bruit. A diagnosis of spontaneous carotid-cavernous fistula

Abstract: We utilized low-field magnetic resonance imaging (MRI) to evaluate 12 patients with head and neck lesions and suspected skull base or facial bone destruction. All except one had high resolution computed tomography (CT). MRI was performed on a 0.15 tesla (low-field) resistive unit, with routinely good resolution due mainly to the use of specially designed rf receiver coils (surface coils). T1 and T2 weighted spin echo images were performed in all cases. In three instances axial, coronal, and sagittal images were done. All CTs were done with high resolution techniques on state-of-the-art equipment. Comparison of the CT and MR images (at low-field strength) showed that MRI's main strength lies in its freedom to perform images in any plane and to visualize intracranial lesions with early brain involvement. Otherwise, the two modalities are comparable. Bone destruction seen on CT was always detectable on MRI, although CT is clearly superior in resolving bone detail. MRI is recommended when direct coronal CT scans are not obtainable to evaluate superiad tumor extension. The improved visualization of nasopharyngeal soft tissue and cavernous sinus region is likely to make MRI the examination of first choice in evaluating lesions of the nasopharynx, skull base, and cavernous sinus.

Abstract: A carotid-cavernous fistula recurred 16 years after a Hamby procedure. The recurrence was manifested by subarachnoid hemorrhage originating from dilated draining pial veins. The fistula was closed with a balloon catheter introduced through a patent remnant of the cervical carotid artery. Patients who have previously undergone Hamby trapping and embolization should be reassessed for an occult fistula that could predispose them to intracranial bleeding.

Abstract: Painful ophthalmoplegia, or Tolosa-Hunt syndrome, is due to nonspecific inflammation of the cavernous sinus. We report two cases of the Tolosa-Hunt syndrome, which, on high resolution fourth-generation CT scan, showed an abnormality in the cavernous sinus consisting of an enhancing soft tissue mass. Both the clinical findings and the CT lesion resolved after high-dosage corticosteroid therapy.

Abstract: Distant metastases from late stages of carcinoma of the vocal cords can occur. Such metastatic deposit can occur in unusual sites. In this report, we are presenting a patient with spread to the cavernous sinus. Radiation therapy was of palliative value.

Abstract: One hundred and twenty-eight lesions of the cavernous sinus were diagnosed and treated by endovascular embolization alone or combined with postembolization surgery. All patients presented with acute or subacute cavernous sinus syndrome. A complete angiographic evaluation included bilateral internal and external carotid and vertebral angiography. A total of 88 carotid-cavernous (c-c) fistulae (68 traumatic and 20 spontaneous) and 40 giant aneurysms were demonstrated. A complete anatomic cure or satisfactory clinical improvement was seen in 67 of 68 traumatic fistulae, in 14 of 20 spontaneous c-c fistulae and in 38 of 40 giant intracavernous aneurysms. An overall 15 per cent immediate and 2.7 per cent long-term morbidity with one death was observed. The technical and clinical complications involving endovascular therapy of each specific intracavernous vascular lesion are analyzed.

Abstract: A left ophthalmoplegia and right hemiplegia were due to thrombosis of an intracavernous aneurysm with occlusion of the left internal carotid artery. Ophthalmoplegia with contralateral hemiplegia is probably a rare syndrome. Thrombosis of an intracavernous aneurysm is probably a rare cause of occlusion of the internal carotid artery.

Abstract: Idiopathic dural arteriovenous malformation which occurs in the posterior fossa uses predominantly transverse and sigmoid sinuses. Cavernous sinus comes next and others are rather rare. However, we have recently experienced such a rare case which was operated on and cured completely. The malformation was fed through the anterior ethmoid artery and drained to the cortical vein. The case was a 36-year-old male and admitted in our clinic for having headache and nausea as the chief complaints. He was diagnosed subarachnoid hemorrhage due to the following findings: CT scans showed a high density zone localized in the sylvian vallecula. Cerebrospinal fluid obtained by a lumbar puncture was found to be bloody. No neurological abnormality other than neck stiffness and positive Kernig's sign was observed. Under study of right carotid arteriography, dural AVM was evident. The anterior ethmoidal artery which branched out from the ophthalmic artery fed the AVM. The cortical vein which ran on the surface of the frontal base was its drainer via a small nidus. There was no abnormality seen on a left carotid arteriogram. Surgery was proceeded with the right frontal craniectomy in extra- and intradural approach. At first, anterior ethmoidal artery was cut at the cribriform plate extradurally. After dura was incised, both the nidus and drainer were coagulated intradurally. The nidus was located at inner surface of the dura. The arachnoid hemorrhage was thought to be caused by rupture of this drainer.(ABSTRACT TRUNCATED AT 250 WORDS)

Abstract: A case study of 2 patients with venous congestion of the orbit due to different etiologies is presented. Both the children demonstrated orbital pain, proptosis, chemosis and conjunctival injection. In one case early diagnosis left to complete recovery by conservative treatment in a patient with a pyogenic cavernous sinus thrombosis. In the other case a traumatic carotid sinus cavernous fistula could be treated successfully using transvasculary navigated detachable balloons.

Abstract: A 30-year-old man with a giant fusiform aneurysm of the intracavernous segment of the right carotid artery, clinically revealed by right painful ophthalmoplegia with exophthalmos, was treated by closure of the carotid artery in the neck with two paediatric Gianturco coils. The aneurysm, which had already shown partial spontaneous intraluminal thrombosis on CT and angiography, was no longer filled and its volume progressively decreased, with almost complete recovery of the oculomotor deficits. Serial CT and angiography performed seven months after treatment demonstrated the reduction in size of the aneurysm, its exclusion from the circulation and a good supply of the intracranial vascular bed, without the necessity of an extracranial-intracranial by-pass.

Abstract: The sphenoid sinus is the paranasal sinus most commonly implicated when cranial neuropathies are present. Two patients presenting with sixth nerve paralysis secondary to sphenoid sinus involvement are presented. One patient had a primary sphenoid sinus tumor, and the other a metastasis from a bronchogenic carcinoma. Of the two patients, one carried the diagnosis of idiopathic sixth nerve paresis and had had a normal sinus x-ray film and CAT scan done previously. Even in the absence of positive radiographic findings, the high clinical suspicion of sinus malignancy must be maintained in patients manifesting abducens nerve paralysis. In these patients, the petrous apex and cavernous sinus "silent area" must be diligently evaluated. For the patient to have any chance for palliation or potential cure, the tumor must be diagnosed as soon as possible.

Abstract: The exit-zone, the intracisternal course, the course in the sidewall of the cavernous sinus and inside the orbit were measured at 91 head-halves. Included are measurements of the length of the area nervosa, its nerve fibers and its distance to the total extracerebral length of the IVth nerve is estimated. The results are discussed with earlier investigations and some clinical approaches and neurophysiological methods are given.

Abstract: Dynamic pituitary CT scan is of major benefit for diagnosis of the smallest pituitary lesions. In 1982, the pituitary dynamic CT technique was suggested in view of the inadequacy of conventional techniques, even using high-resolution systems, for demonstration of the smallest intrasellar adenomas. Visualization of the pituitary capillary bed with this technique is today as fundamental for diagnosis of intrasellar lesions as was demonstration of the calcified pineal gland or internal cerebral vein for identification of the midline of the brain. A brief review of pituitary blood supply is necessary to understand the utility of the dynamic scan (Fig. 3.1).