Abstract: Cavernous transformation of the portal vein is defined as the formation of venous channels within or around a previously thrombosed portal vein. The purpose of this work was to study the hemodynamic consequences of cavernous transformation of the portal vein in a group of afflicted patients by use of Doppler sonography. We wished to study the evolution from portal vein thrombosis to the formation of cavernous transformation, the extent of resulting extrahepatic collateral channels, and the patterns of splanchnic collateral circulation.Seventy-five patients (48 adults and 27 children) with cavernous transformation of the portal vein were studied with color and/or pulsed Doppler sonography. Blood flow in the extrahepatic portal vein, in its segmental branches, in the hepatic veins and artery, and in the splanchnic veins was examined. Collateral pathways were sought. For nine patients with acute thrombosis of the portal vein, serial examinations were performed during the formation of cavernous transformation...

Abstract: The authors describe the method and results of treatment of 12 consecutive patients with carotid-cavernous sinus fistulas (CCFs). Treatment was by embolization via a transvenous approach through the superior ophthalmic vein (SOV). The CCFs (two direct and 10 dural) had previously been treated unsuccessfully or, for mechanical reasons, could not be treated by the standard techniques of endoarterial balloon occlusion, particle or glue embolization of feeding vessels from one or both external carotid arteries, or transvenous occlusion of the fistula via the ipsilateral inferior petrosal sinus. All 12 patients were successfully treated either by advancement of a detachable balloon catheter through the ipsilateral SOV into the cavernous sinus with subsequent inflation and detachment of the balloon (11 patients) or by introduction of multiple thrombogenic coils into the fistula via the ipsilateral SOV (one patient). All patients had complete resolution of symptoms and signs after successful occlusion of the CCF. There were no intraoperative complications; however, one patient required postoperative embolization of a residual posteriorly draining fistula via the ipsilateral external carotid artery, and another developed a persistent abducens nerve paresis that eventually required surgical correction. Ten (83.3%) of the 12 patients underwent cerebral angiography 3 to 6 months after surgery, and none showed evidence of a recurrent fistula. Similarly, none of the 12 patients developed recurrent symptoms and signs suggesting recurrence of the fistula during a follow-up period that ranged from 6 months to 10 years (mean 64 months). It is concluded that the transvenous approach to the cavernous sinus through the SOV is a safe and effective treatment of both direct and dural CCFs that are not amenable to transarterial or other transvenous approaches.

Abstract: The extended anterior subcranial approach differs significantly from more traditional surgical approaches to the skull base in that it allows a broad inferior access to the anterior skull base planes with tumor exposure from below rather than via the transfrontal route The authors initially used the subcranial approach in 1978 for the treatment of high-velocity skull base trauma and certain craniofacial anomalies In 1980 they expanded the indications to include the combined neurosurgical-otolaryngological resection of various skull base tumors Osteotomy of the frontonasoorbital external skeletal frame provides optimum anterior access to the orbital and sphenoethmoidal planes as well as to the nasal and paranasal cavities while avoiding frontal lobe retraction and the external facial incisions characteristic of transcranial and transfacial approaches The improved visualization of the anterior skull base and clival-sphenoidal region facilitates en bloc tumor removal, optic nerve decompression, exposure of the medial aspect of the cavernous sinus, and watertight realignment of the anterior cranial base dura In this report the authors present their experience over the past 13 years with 104 patients who underwent operation via the extended subcranial approach Because extensive frontal lobe manipulation and external facial incisions are avoided with this approach, intensive care unit and overall hospital stay are reduced, related complications are minimized, and postoperative cosmetic appearance is enhanced The extended anterior subcranial method is therefore an excellent alternative to traditional transfacial-transcranial skull base approaches for the removal of selected skull base tumors

Abstract: The microsurgical anatomy of the superior orbital fissure was examined in cadaver specimens. The cavernous sinus fills the posterior margin and the orbital contents fill the anterior margin of the fissure. All of the nerves coursing in the walls of the cavernous sinus pass through the superior orbital fissure to reach the orbit. The fissure has a narrow lateral part and a larger medial part. The annular tendon from which the rectus muscles arise is situated in front of the upper half of the medial part of the fissure and is attached to the lateral margin near the junction of the lateral and medial parts. The fissure is divided into three sectors: lateral, central, and inferior. The lateral sector, which corresponds to the narrow lateral part, transmits the trochlear, frontal, and lacrimal nerves and the superior ophthalmic vein, all of which course outside the annular tendon. The central sector, which is situated behind and is aligned with the lateral part of the annular tendon, transmits the superior and inferior divisions of the oculomotor nerve, the abducens and nasociliary nerves, and the sensory and sympathetic roots of the ciliary ganglion, all of which pass through the annular tendon. The inferior sector, which is located below the annular tendon and origin of the inferior rectus muscle, is filled with a posterior extension of the orbital fat and transmits the inferior ophthalmic vein. The relationship and course of the nerves in each sector and the incisions that may be used to open and expose the contents of the fissure are reviewed.

Abstract: A protocol for the treatment of selected intracavernous and proximal internal carotid artery aneurysms is described. Intraoperative angiography is used together with intraoperative balloon occlusion of the internal carotid artery and electroencephalography to optimize the timing of an extracranial-intracranial bypass before occlusion of the carotid artery and to provide intraoperative documentation of graft patency. This protocol has been used successfully in seven patients with complex aneurysms that were unsuitable for other endovascular methods or a direct microsurgical approach. Six aneurysms were located in the cavernous sinus, and one was located on the supraclinoid portion of the internal carotid artery. There were no permanent complications; one patient had a brief episode of dysphasia, which resolved without sequelae.

Abstract: We report a case of unilateral agenesis of the internal carotid artery with intercavernous anastomosis, a rare development anomaly. MR and carotid ultrasound, in association with clinical awareness, can be used to diagnose this condition.

Abstract: Neuropathy of the trigeminal nerve can involve its full course, from its nuclei in the brain stem to its peripheral branches. The nerve can be divided into four segments--brain stem, cistern, the Meckel cave and cavernous sinus, and extracranial--and consideration of the pathologic entities by these locations simplifies the differential diagnosis. Multiple sclerosis, infarct, and glioma are the most common abnormalities in the brain stem leading to trigeminal neuropathy. The most common cisternal cause is neurovascular compression, followed by acoustic and trigeminal schwannomas, meningiomas, epidermoid cysts, lipomas, and metastases. Trigeminal neuropathy arising from the Meckel cave and cavernous sinus is frequently due to meningiomas, trigeminal schwannomas, epidermoid cysts, metastases, pituitary adenomas, and aneurysms. Malignant tumors, which may demonstrate perineural tumor spread, are the most common extracranial cause. Because the clinical findings do not permit accurate lesion localization, magn...

Abstract: The Gamma Knife radiosurgical treatment of 20 patients suffering from trigeminal neuralgia is reported. Eleven patients received radiosurgical treatment with the goal of pain relief. Six had secondary trigeminal neuralgia due to AVM, large cavernous sinus and petrous bone meningiomas, trigeminal neurinoma, or chordoma; 5 others had essential trigeminal neuralgia. Radiosurgical treatment was considered only after the failure of conventional medical and surgical treatment. For the other 9 patients, the control of the tumor was the main objective (four acoustic and one trigeminal neurinoma, one petroclival chordoma, and three tumors of the cavernous sinus: one hemangiopericytoma, one metastasis, one meningioma). We have not been using this method for sufficient time to evaluate long-term results. However, we believe that a large majority of our patients benefited greatly from this technique with a rapid clinical improvement, which is a reflection of the relevance of the chosen target.

Abstract: The purpose of this study was to compare ACTH levels in unstimulated samples obtained from the cavernous sinuses (CS) to unstimulated and CRH-stimulated samples obtained from the inferior petrosal sinuses (IPS) in 15 patients with surgically proven Cushing's disease. After unstimulated samples were obtained through 5-French catheters placed in both IPS, tracker catheters were introduced into both cavernous sinuses, and unstimulated samples were obtained within 5 min of the initial set. The Tracker catheters were removed, CRH was administered, and CRH-stimulated samples were obtained from the IPS. We compared the central to peripheral ACTH ratios in unstimulated samples from the cavernous sinuses to unstimulated and CRH-stimulated samples from the IPS as a basis for distinguishing pituitary from ectopic ACTH production. In addition, we compared the ability of the intercavernous and interpetrosal ACTH ratios to correctly predict the site of the microadenoma. Unstimulated levels of ACTH in the cavernous sinu...

Abstract: A small craniectomy in the infratemporal fossa incorporating the foramen ovale was used to resect 4 large trigeminal neurinomas. The tumour extended from the posterior cranial fossa and involved Meckel's cave and the lateral wall of the cavernous sinus in each instance. The dural sheath around the mandibular nerve and Gasserian ganglion was opened to expose the entire lesion.

Abstract: Pituitary adenomas generally are regarded as benign tumours, but a part of them can invade the cavernous sinus and recur. We examined 43 pituitary adenomas for the following factors: tumour volume, endocrinological function, cavernous sinus invasion, and growth rates examined by using anti-proliferating cell nuclear antigen (PCNA) and MIB1 (a novel anti-Ki-67) as markers. There was significant correlation between PCNA- and MIB1-positive cell rates and PCNA- and MIB1-positive cell rates were higher in the three cases with rapid regrowth than in the other cases. Staining was stronger and more distinct for MIB1 than for anti-PCNA; thus, MIB1-positive cells were easily distinguished by their intense immunoreactivity. MIB1 may be useful for detecting those rare cases with rapid regrowth even when initially regarded as benign tumours. Adenomas with cavernous sinus invasion were significantly larger than those demonstrating no invasion. However, no significant difference was found in the frequency of PCNA- or MIB1-positive cells between adenomas with and without cavernous sinus invasion. These findings suggest that cavernous sinus invasion and growth rate are independent biological factors. Therefore, cavernous sinus invasion may be due to chemical factors produced by the tumour itself rather than as a result of rapid tumour growth.

Abstract: Thirty-four consecutive patients with intracranial meningiomas underwent 35 resections aided by an interactive surgical navigation system (ISN; “frameless stereotaxy”). System capabilities include real-time display of wand location, orientation, and relationship to nearby structures using multiplanar and three-dimensional presentation of magnetic resonance imaging (MRI) and/or computed tomography (CT) data obtained perioperatively. There were 16 patients with convexity tumors, five patients with sphenoid wing tumors, five patients with falx or parasagittal tumors, and eight patients with skull base tumors (two each: petroclival, cavernous sinus, olfactory groove, and planum sphenoidale).The ISN system was used to locate a minimal craniotomy (i.e., trephine) in 11 (32%) patients, to optimize bone flap design in 13 (38%) patients, to identify the location of parasagittal draining veins in five (15%) patients, and to locate the carotid or basilar arteries in 11 (32%) patients. The techniques provided limited...

Abstract: This report describes a patient with pituitary-dependent Cushing's disease who had a preoperative ACTH gradient to the left at the level of the cavernous sinus. Intraoperatively, an adenoma was found entirely within the left cavernous sinus, with no direct connection to the pituitary gland. To our knowledge, such a tumor has not been reported previously. This case has implications for the diagnosis, treatment, and follow-up of patients with pituitary-dependent Cushing's disease. The presence of an entirely extrasellar ACTH-releasing adenoma in the cavernous sinus could explain why pituitary-dependent Cushing's disease may persist postoperatively, even after total hypophysectomy. The diagnosis of an intracavernous tumor can be established by cavernous sinus venography. An extrasellar intracavernous adenoma can be diagnosed intraoperatively after careful negative exploration of the sellar contents followed by incision of the cavernous sinus on the side of the ACTH gradient established by venous sampling.

Abstract: A 55-year-old man reported a severe headache of 3 days' duration, left ptosis and left lid swelling before examination. The ocular examination revealed left eye proptosis, severe edema of the left bulbar conjunctiva and lid, increasing intraocular pressure of the left eye and ptosis on the left side with decreased extraocular movement. The right eye was normal. Hematologic studies indicated mild inflammation. An enhanced computed tomography scan revealed proptosis of the left globe and enlargement of the superior ophthalmic vein and cavernous sinus of the left side. Angiography revealed an area of interrupted blood flow in the left cavernous sinus. Enhanced magnetic resonance imaging (MRI) with Gd-DTPA revealed a low-intensity area that was suspected to be a blood clot in the enlarged left cavernous sinus. This case indicates the efficacy of enhanced MRI examination in the early diagnosis of cavernous sinus thrombosis.

Abstract: PURPOSE: To correlate computed tomographic (CT) or magnetic resonance (MR) images with dissections of normal inferior petrosal sinuses (IPS). MATERIALS AND METHODS: Postmortem dissection was performed in 12 individuals, one of whom had undergone CT and MR imaging 3 months before death. Seven patients underwent IPS venography, CT, and MR imaging. One hundred sixteen patients with normal IPS underwent MR imaging; 40, CT and MR imaging; and two, CT, MR imaging, and arteriography. RESULTS: Images showed that the IPS and basilar plexus formed conspicuous, enhanced structures that provide much of the border between the clivus and cerebrospinal fluid. Axial, cross-sectional IPS dimensions were as large as 9 x 16 mm. The larger sinuses were contained by deep grooves of bone that sometimes showed marked cortical thinning. Sixty-nine (39%) of the 175 individuals studied had markedly asymmetric IPS. CONCLUSION: CT and MR images showed that normal IPS and basilar plexus vary in size and are frequently asymmetric. Thi...

Abstract: A case of intracavernous sinus cavernous haemangioma is reported. The tumour was totally resected en masse. The management of the lesion and technical issues concerning the surgery are discussed.

Abstract: Traumatic internal carotid artery aneurysm presenting with epistaxis is rare. Epistaxis often occurs after a delay of weeks to months following head injury. The present case had bouts of recurrent massive epistaxis nearly four months after head injury. Diagnosis was made after carotid angiography. Epistaxis ceased after ipsilateral carotid ligation.

Abstract: Ameloblastomas are histologically benign tumors derived from the odontogenic apparatus. Although these tumors are locally invasive, they rarely invade the paranasal sinuses, orbits, or intracranial cavity, and, thus, they rarely produce ophthalmologic signs and symptoms. In this report, we describe the neuro-ophthalmologic features of three patients with chronically aggressive ameloblastoma. Two of the patients developed a progressive and recurrent orbital apex and cavernous sinus syndromes. One of these patients is, to our knowledge, the first patient described with orbital and cavernous simus involvement by an ameloblastoma initially arising in the mandible. The other is only the second case described with bilateral orbital involvement. The third patient in this series developed a trigeminal sensory neuropathy as the only sign of the tumor. Although ameloblastomas are benign, slowly growing tumors, they may, often over a long period of time, cause significant neuro-ophthalmologic and orbital manifestutions that can only be partially ameliorated by surgery.

Abstract: A modification of the previously described transcochlear approach to extra- and intradural petroclival and clivai lesions is described in this report. It is an approach from the middle cranial fossa. It involves unroofing and depression of the external ear canal, removal of the glenoid cavity of the temporo-mandibular joint, exentration of the middle ear ossicles, posterior mobilization of labryrinthine and tympanic segments of the facial nerve, and drilling of the petrous bone from an entirely lateral perspective. An extensive and low exposure of the petroclival region, posterior aspect of the cavernous sinus, upper and mid clivus and the cerebellopontine angle is obtained. The anterior surface of the brain stem upto the pontomedullary junction is exposed with minimal or no retraction of the temporal lobe of the brain. The vein of Labbe and sigmoid sinus drainage is unhampered. Anterior and posterior extension of the exposure is possible. Only a limited mastoidectomy and labyrinthectomy, necessary to facilitate exposure and mobilization of the facial nerve is necessary. The inferior limit of the exposure is set by the dome of the jugular bulb. Hearing is sacrificed.

Abstract: A carotid-cavernous fistula developed in a 62-year-old woman during an attempt at embolization of a skull base meningioma. The cause is thought to be perforation by the guide wire during catheterization of the meningohypophyseal trunk at the sharp bend at its origin.

Abstract: A patient with head injury presented with computed tomography findings of a diffuse severe infarction of the left cerebral hemisphere in which the cerebral hemodynamics can be evaluated by transcranial Doppler sonography. Serial angiograms revealed a carotid-cavernous fistula, with a complete steal phenomenon. The unusual complication of a traumatic carotid-cavernous fistula is discussed.

Abstract: A 27-year-old man with a traumatic direct dural arteriovenous fistula (DAVF) was treated using embolisation microcoils. He had suffered blunt trauma to the head while drunk and was aware of no neurological deficit. A few days after the accident, however, he noticed a bruit in the right temple. Angiography demonstrated a direct DAVF fed by the right middle meningeal artery and draining into a right temporal dural vein and the ipsilateral cavernous sinus. A Tracker-18 catheter was passed without difficulty through the fistula and the draining vein was then embolised from distal to proximal with microcoils, and finally the fistula was occluded with microcoils, resulting in total obliteration of the fistula. Immediately after the embolisation, the patient could no longer hear the bruit. Thus, when a microcatheter can be introduced into the draining vein, microcoils can be used as emboli in the treatment of direct DAVF.

Abstract: The pterional approach is commonly employed in surgery of the anterior circulation and upper basilar artery aneurysms, as well as for the tumors of orbital, retroorbital, sellar, chiasmatic, subfrontal and prepontine areas and lesions around the sella especially for lesions behind the clivus. Also tumors arising from the medial sphenoid ridge, the superior orbital fissure, the anteromedial temporal surface, or the cavernous sinus region are approached through a pterional exposure. The surgical technique is based on the experience, training and observation of the neurosurgeon. One technique is not necessarily better than another. Regardless of the surgical technique, the end results depend on a rigorous, methodical, systematic, and step-by-step approach to the target, securing it with minimal injury to surrounding structures. In this study, we have analyzed the intraoperative anatomical findings of the Sylvian vein and fissure, lenticulostriatal artery, olfactory nerve, and recurrent artery of Heubner and showed the surgical pitfalls in 700 patients with different diagnoses that were operated on with the pterional approach. The findings were recorded during surgical interventions and through the slides and videotapes of the operations. Also, we have stressed the preservation of the frontotemporal branch of the facial nerve, the delicate retraction of frontal lobe, the cottonoid retraction in temporal lobe and the preservation of olfactory nerve functions.

Abstract: Intracranial cavernous vascular malformations are variously known as cavernous angiomas, cavernous hemangiomas or, more simply, cavernomas.

Abstract: In three patients with histiocytosis X of bone with orbital involvement, CT scans were reviewed. Consistent findings included a destructive lesion of the lateral wall of the orbit with a large soft-tissue component that extended into the extraconal space, the ocular adnexa, and the infratemporal fossa. The greater wing of the sphenoid was eroded in all cases, with epidural extension into the middle cranial fossa. Cavernous sinus involvement and a second bone lesion were seen in two patients.

Abstract: In the last ten years three patients presented with a subacute syndrome characterized by unilateral frontal headache, ipsilateral external ophthalmoplegia, Va or Vb hypoesthesia and peripheral facial palsy. In all of them, plain X-ray and/or CT revealed a nasopharyngeal mass. Orbital venography failed to fill the superior orbital vein ipsilateral to the ophthalmoplegia, suggesting a unilateral cavernous sinus pathology. Biopsy demonstrated lymphoid hyperplasia. Two patients recovered spontaneously, and in one, steroid treatment resulted in fast pain relief and progressing complete disappearance of the mass. In one patient a high titer of Epstein-Barr viral antibodies was detected.