Abstract: OBJECTIVE: We describe a novel 3-dimensional (3-D) stereoendoscope and discuss our early experience using it to provide improved depth perception during transsphe- noidal pituitary surgery. METHODS: Thirteen patients underwent endonasal endoscopic transsphenoidal surgery. A 6.5-, 4.9-, or 4.0-mm, 0- and 30-degree rigid 3-D stereoendoscope (Visionsense, Ltd., Petach Tikva, Israel) was used in all cases. The endoscope is based on "compound eye" technology, incorporating a microarray of lenses. Patients were followed prospectively and compared with a matched group of patients who underwent endoscopic surgery with a 2-dimensional (2-D) endoscope. Surgeon comfort and/or complaints regarding the endoscope were recorded. RESULTS: The 3-D endoscope was used as the sole method of visualization to remove 10 pituitary adenomas, 1 cystic xanthogranuloma, 1 metastasis, and 1 cavernous sinus hemangioma. Improved depth perception without eye strain or headache was noted by the surgeons. There were no intraoperative complications. All patients without cav- ernous sinus extension (7of 9 patients) had gross tumor removal. There were no sig- nificant differences in operative time, length of stay, or extent of resection compared with cases in which a 2-D endoscope was used. Subjective depth perception was improved compared with standard 2-D scopes. CONCLUSION: In this first reported series of purely 3-D endoscopic transsphenoidal pituitary surgery, we demonstrate subjectively improved depth perception and excellent outcomes with no increase in operative time. Three-dimensional endoscopes may become the standard tool for minimal access neurosurgery.

Abstract: Our aim was to review the imaging findings of relatively common lesions involving the cavernous sinus (CS), such as neoplastic, inflammatory, and vascular ones. The most common are neurogenic tumors and cavernoma. Tumors of the nasopharynx, skull base, and sphenoid sinus may extend to the CS as can perineural and hematogenous metastases. Inflammatory, infective, and granulomatous lesions show linear or nodular enhancement of the meninges of the CS but often have nonspecific MR imaging features. In many of these cases, involvement elsewhere suggests the diagnosis. MR imaging is sensitive for detecting vascular lesions such as carotid cavernous fistulas, aneurysms, and thromboses.

Abstract: Purpose We discuss our experiences with fractionated stereotactic radiotherapy (FSR) in the treatment of cavernous sinus meningiomas. Methods and Materials From 1995 to 2006, we monitored 100 patients diagnosed with cavernous sinus meningiomas; 84 female and 16 male patients were included. The mean patient age was 56 years. The most common symptoms were a reduction in visual acuity (57%), diplopia (50%), exophthalmy (30%), and trigeminal neuralgia (34%). Surgery was initially performed on 26 patients. All patients were treated with FSR. A total of 45 Gy was administered to the lesion, with 5 fractions of 1.8 Gy completed each week. Patient treatment was performed using a Varian Clinac linear accelerator used for cranial treatments and a micro-multileaf collimator. Results No side effects were reported. Mean follow-up period was 33 months, with 20% of patients undergoing follow-up evaluation of more than 4 years later. The tumor control rate at 3 years was 94%. Three patients required microsurgical intervention because FSR proved ineffective. In terms of functional symptoms, an 81% improvement was observed in patients suffering from exophthalmy, with 46% of these patients being restored to full health. A 52% improvement was observed in diplopia, together with a 67% improvement in visual acuity and a 50% improvement in type V neuropathy. Conclusions FSR facilitates tumor control, either as an initial treatment option or in combination with microsurgery. In addition to being a safe procedure with few side effects, FSR offers the significant benefit of superior functional outcomes.

Abstract: Introduction A high-speed power-drilling technique of anterior clinoidectomy has been advocated in all publications on paraclinoid region surgery. The entire shaft of the power drill is exposed in the operative field; thus, all neurovascular structures in proximity to any portion of the full length of the rotating drill bit are at risk for direct mechanical and/or thermal injury. Ultrasonic bone removal has recently been developed to mitigate the potential complications of the traditional power-drilling technique of anterior clinoidectomy. However, ultrasound-related cranial neuropathies are recognized complications of its use, as well as the increased cost of device acquisition and maintenance. Methods A retrospective review of a cerebrovascular/cranial base fellowship-trained neurosurgeon's 45 consecutive cases of anterior clinoidectomy using the "no-drill" technique is presented. Clinical indications have been primarily small to giant aneurysms of the proximal internal carotid artery; however, in addition to ophthalmic segment aneurysms, selected internal carotid artery-posterior communicating artery aneurysms and internal carotid artery bifurcation aneurysms, and other large/giant/complex anterior circulation aneurysms, this surgical series of "no-drill" anterior clinoidectomy includes tuberculum sellae meningiomas, clinoidal meningiomas, cavernous sinus lesions, pituitary macroadenomas with significant suprasellar extension, other perichiasmal lesions (sarcoid), and fibrous dysplasia. A bony opening is made in the mid-to posterior orbital roof after the initial pterional craniotomy. Periorbita is dissected off the bone from inside the orbital compartment. Subsequent piecemeal resection of the medial sphenoid wing, anterior clinoid process, optic canal roof, and optic strut is performed with bone rongeurs of various sizes via the bony window made in the orbital roof. Results No power drilling was used in this surgical series of anterior clinoidectomies. Optimal microsurgical exposure was obtained in all cases to facilitate complete aneurysm clippings and lesionectomies. There were no cases of direct injury to surrounding neurovascular structures from the use of the "no-drill" technique. The surgical technique is presented with illustrative clinical cases and intraoperative photographs, demonstrating the range of applications in anterior and central cranial base neurosurgery. Conclusion Power drilling is generally not necessary for removal of the anterior clinoid process, optic canal roof, and optic strut. Rigorous study of preoperative computed tomographic scans/computed tomographic angiography scans, magnetic resonance imaging scans, and angiograms is essential to identify important anatomic relationships between the anterior clinoid process, optic strut, optic canal roof, and neighboring neurovascular structures. The "no-drill" technique eliminates the risks of direct power-drilling mechanical/ thermal injury and the risks of ultrasound-associated cranial neuropathies. The "no-drill" technique provides a direct, time-efficient, and efficacious approach to the paraclinoid/ parasellar/pericavernous area, using a simplified mechanical route. This technique is applicable to any neurosurgical diagnosis and approach in which anterior clinoidectomy is necessary. It is arguably the gentlest and most efficient method for exposing the paraclinoid/parasellar/pericavernous region.

Abstract: Objective Today, meningiomas with primary or, more commonly, secondary involvement of the cavernous sinus remain a surgical challenge Anatomic research on cadaver specimens, together with the advances made in cranial base and microvascular surgery over the past 2 decades, have made it possible to completely resect lesions within the cavernous sinus However, the technical complexity of some procedures, coupled with the current availability of less-invasive therapeutic options, makes the rate of complications related to surgical extirpation of intracavernous meningiomas unacceptably high, especially regarding permanent neurological morbidity and mortality Currently, indications, timing, and multimodal treatments with surgery and radiotherapy represent the main topics of discussion concerning these lesions Methods One hundred forty-seven patients underwent surgery between 1985 and 2003 The patients were retrospectively divided into 2 groups according to the type of surgical treatment: group A (open sinus surgery) and group B (closed sinus surgery) The mean follow-up time was 97 years Results Early postoperative morbidity and permanent postoperative morbidity showed significant differences between the groups At long-term follow-up, we found no statistical differences in the incidence of recurrences and progressions Only patients treated with postoperative radiation therapy (815%) showed clinicoradiological stability Conclusion Growth control and preservation of neurological functions are the primary goals in the treatment of cavernous sinus meningiomas In most cases, surgery and radiosurgery alone do not reach the primary goals, and unresolved issues remain Therefore, we have developed a treatment algorithm as a guide to the best therapeutic options for the most common presentations of the disease

Abstract: Objective Different approaches to the skull base have been developed through the sphenoidal sinus. Traditional boundaries of the trans-sphenoidal approach can be extended in antero-posterior and lateral planes. We review our experience with the extended endoscopic endonasal approach in the first 12 cases. Methods We used the extended endoscopic endonasal approach in 12 patients with different lesions of the skull base. This study specifically focuses on the type of lesions, surgical approach, outcome and surgical complications. Results The extended endoscopic endonasal approach was used in 12 patients with the following lesions: 4 invasive adenomas to the cavernous sinus, 2 clival chordomas, 2 craniopharyngiomas, 1 hypothalamic astrocytoma and 3 pituitary adenomas extended upon the tuberculum. Gross total resection was achieved in 8 cases (66.7%) subtotal resection in 3 and just a biopsy could be accomplished in the case of astrocytoma. This last patient developed meningo-encephalitis and died two weeks later. Conclusions The extended endoscopic endonasal approach is a promising minimally invasive alternative for selected cases with sellar, parasellar or clivus lesions. As techniques and technology advance, this approach may become the procedure of choice for most lesions and should be considered an option in the management of the patients with these complex pathologies by skull base surgeons.

Abstract: Cranial Approaches -- Microneurosurgery: Principles, Applications, and Training -- Endoscopy: Principles and Techniques -- Image-Guided Radiosurgery Using the Gamma Knife -- How to Perform Surgery for Intracranial (Convexity) Meningiomas -- The “Dangerous” Intracranial Veins -- How to Perform Subfronto-Orbitonasal Approach for Anterior Cranial Base Surgery -- How to Perform Cranio-Orbital Zygomatic Approaches -- How to Perform Middle Fossa/Sphenoid Wing Approaches -- How to Perform Central Skull Base Approaches -- How to Perform Selective Extradural Anterior Clinoidectomy -- How to Perform Approaches of the Orbit -- How to Perform Transsphenoidal Approaches -- How to Perform Transoral Approaches -- How to Perform Posterior Fossa Approaches -- How to perform transpetrosal approaches -- Vascular Lesions -- Principles of Microneurosurgery for Safe and Fast Surgery -- Surgical Management of Intracranial Aneurysms of the Anterior Circulation -- Intracranial Aneurysms in the Posterior Circulation -- Giant Aneurysms -- Arteriovenous Malformations of the Brain -- Intracranial Cavernomas -- Carotid Endarterectomy -- Brain Revascularization by Extracranial-Intracranial Arterial Bypasses -- Management of Intracranial Venous Pathologies — Potential Role of Venous Stenting -- Traumas, Cerebrospinal Fluid, Infections -- The Glasgow Coma and Outcome Scales: Practical Questions and Answers -- Cranial Trauma in Adults -- Hydrocephalus in Adults (Including Normal Pressure Hydrocephalus Syndrome) -- Arachnoid Cysts -- Brain Infections -- Parasitoses of the Central Nervous System: Hydatidosis -- Parasitoses of the Central Nervous System: Cysticercosis -- Intracranial Tumors -- Classification of Brain Tumors and Corresponding Treatments -- Stereotactic Biopsies for Tumors: Indications, Limits, Diagnosis with Histopathology and other Laboratory Techniques -- Management of (Malignant) Intracranial Gliomas -- Management of Lymphomas -- Management of Anterior Fossa Lesions -- Management of Tumors of Middle Fossa -- Management of Central Skull Base Tumors -- Management of Cavernous Sinus Lesions -- Management of Convexity Meningiomas -- Meningiomas Involving the Major Dural Sinuses: Management of the Sinus Invasion -- Posterior Fossa Meningiomas -- Endoscopic Surgery for Skull Base Meningiomas -- Management of Pituitary Adenomas -- Craniopharyngiomas -- Management of Tumors of the Anterior Third and Lateral Ventricles -- Endoscopic Management of Colloid Cysts -- Management of Pineal Region Tumors -- Epidermoid/Dermoid Cysts -- Tumors of the Fourth Ventricle and Cerebellum in Adults -- Vestibular Schwannomas -- Brainstem Tumors -- Management of Foramen Magnum Tumors -- Radiosurgery for Intracranial Tumors -- Intraoperative Explorations -- Ultrasound-Guided Neurosurgery -- Brain Neuronavigation for Deep-Seated Targets -- Brain Mapping -- Intraoperative Neurophysiology in Neurosurgery -- Pediatrics -- Specificities of, and Changes in, Pediatric Neurosurgery -- Cranial Traumas in Children -- Management of Hydrocephalus in Childhood -- Intracranial Tumors in Childhood -- Nonsyndromic Craniosynostoses -- Management of Lumbosacral Lipomas -- Management of Encephaloceles -- Epilepsy Surgery in Children -- Spine -- Management of Spine Traumas and Spinal Cord Injury -- Approaches to Cervical Spine -- Management of Degenerative Disease of the Cervical Spine -- Management of Lumbar Disc Herniations and Degenerative Diseases of Lumbar Spine -- Management of Lumbar Spondylolisthesis -- Non-Traumatic Extra-Medullary Spinal Cord Compression -- Intramedullary Tumors -- Chiari Malformation -- Syringomyelia -- Infections in Spine -- Functional Neurosurgery -- Stereotactic Techniques -- Selective Thalamotomy -- Targets for Electrical Stimulation in Functional Neurosurgery -- Functional Neurosurgery for Parkinson’s Disease -- Functional Neurosurgery for Dystonias -- Neurosurgical Management of Cancer Pain -- Neurosurgery for Neuropathic Pain -- Microvascular Decompression for Hemifacial Spasm -- Microvascular Decompression for Trigeminal Neuralgia -- Neurosurgery for Trigeminal Neuralgia -- Neurosurgery for Spasticity -- Selective Dorsal Rhizotomy for the Treatment of Childhood Spasticity -- State-of-the-Art of Surgical Therapies for Psychiatric Disorders: Depression -- Neurosurgery for Psychiatric Disorders: Obsessive-Compulsive Disorder -- Neurosurgical Management of Epilepsy in Adults -- Neurophysiology Applied to Neurosurgery -- Neuronal Transplantation: A Review -- Peripheral Nerves -- Management of Nerve Injuries (with Emphasis on Nerve Action Potential (NAP) Recordings) -- Tunnel Compression Syndromes of Median and Ulnar Nerves -- Tumors of the Peripheral Nerves -- Education -- Message from the Chairman of the Education and Training Committee of the WFNS -- What do Young Neurosurgeons Really Need -- The Role of the World Federation of Neurosurgical Societies in the Development of World Neurosurgery -- Epilogue.

Abstract: The purpose of this study is to apply contrast-enhanced 3D fast-imaging employing steady-state acquisition (3D-FIESTA) imaging to the evaluation of cranial nerves (CN) in patients with cavernous sinus tumors. Contrast-enhanced 3D-FIESTA images were acquired from ten patients with cavernous sinus tumors with a 3-T unit. In all cases, the trigeminal nerve with tumor involvement was easily identified in the cavernous portions. Although oculomotor and abducens nerves were clearly visualized against the tumor area with intense contrast enhancement, they were hardly identifiable within the area lacking contrast enhancement. The trochlear nerve was visualized in part, but not delineated as a linear structure outside of the lesion. Contrast-enhanced 3D-FIESTA can be useful in the assessment of cranial nerves in and around the cavernous sinus with tumor involvement.

Abstract: Objective : We retrospectively analyzed the surgical outcomes of 42 patients with growth hormone (GH)-secreting pituitary adenoma to evaluate the clinical manifestations and to determine which preoperative factors that significantly influence the remission. Methods : Forty-two patients with GH-secreting pituitary adenoma underwent transsphenoidal surgery (TSS) between 1995 and 2007. The patient group included 23 women and 19 men, with a mean age of 40.2 (range 13-61) years, and a mean follow-up duration of 49.4 (range 3-178) months after the operation. For comparable radiological criteria, we classified parasellar growth into five grades according to the Knosp classification. We analyzed the surgical results of the patients according to the most recent stringent criteria for cure. Results : The overall rate of endocrinological remission in the group of 42 patients after primary TSS was 64% (26 of 42). The remission rate was 67% (8 of 12) for microadenoma and 60% (18 of 30) for macroadenoma. The remission rate was 30% (3 of 10) for the group with cavernous sinus invasion and 72% (23 of 32) for the group with intact cavernous sinus. Cavernous sinus invasion in Knosp grade III and IV was significantly correlated with the remission rate. There was a significant relationship between preoperative mean GH concentration and early postoperative outcome, with most patients in remission having a lower preoperative GH concentration. Conclusion : TSS is thought to be an effective primary treatment for GH-secreting pituitary adenomas according to the most recent criteria of cure. Because the remission rate in cases with cavernous sinus invasion is very low, early detection of the tumor before it extends into the cavernous sinus and a long-term endocrinological and radiological follow-up are necessary in order to improve the remission rate of acromegaly.

Abstract: OBJECTIVE: Hemangiomas are rare but highly vascular tumors that may develop in the cavernous sinus or orbit. These tumors pose diagnostic as well as therapeutic challenges to neurosurgeons during attempted removal. We analyzed our increasing experience using stereotactic radiosurgery (SRS). METHODS: Eight symptomatic patients with hemangiomas underwent SRS between 1988 and 2007. The presenting symptoms included headache, orbital pain, diplopia, ptosis, proptosis and impaired visual acuity. The hemangiomas were located in either the cavernous sinus (7 patients) or the orbit (1 patient). Four patients underwent SRS as primary treatment modality based on clinical and imaging criteria. Four patients had previous microsurgical partial excision or biopsy. The median target volume was 6.8 mL (range, 2.5―18 mL). The median prescription dose delivered to the margin was 14.5 Gy (range, 12.5―19 Gy). The dose to the optic nerve in all patients was less than 9 Gy (range, 4.5―9 Gy). RESULTS: The median follow-up period after SRS was 80 months (range, 40―127 months). Six patients had symptomatic improvement; 2 patients reported persistent diplopia. Follow-up imaging revealed tumor regression in 7 patients and no change in tumor volume in 1 patient. All the patients improved after SRS. CONCLUSION: Our extended experience confirms that SRS is an effective management strategy for symptomatic intracavernous and intraorbital hemangiomas. Our study is the first long-term report on the safety and efficacy of SRS.

Abstract: Objective En plaque sphenoid wing meningiomas are complex tumors involving the sphenoid wing, the orbit, and sometimes the cavernous sinus. Complete removal is difficult, so these tumors have high rates of recurrence and postoperative morbidity. The authors report a series of 71 patients with sphenoid wing meningiomas that were managed surgically. Methods The clinical records of 71 consecutive patients undergoing surgery for sphenoid wing meningiomas at Lariboisiere Hospital, Paris, were prospectively collected in a database during a 20-year period and analyzed for presenting symptoms, surgical technique, clinical outcome, and follow-up. Results Among the 71 patients (mean age, 52. 7 years; range, 12-79 years), 62 were females and 9 were males. The most typical symptoms recorded were proptosis in 61 patients (85.9%), visual impairment in 41 patients (57.7%), and oculomotor paresis in 9 patients (12.7%). Complete removal was achieved in 59 patients (83%). At 6 months of follow-up, magnetic resonance imaging scans revealed residual tumor in 12 patients (9 in the cavernous sinus and 3 around the superior orbital fissure). Mean follow-up was 76.8 months (range, 12-168 months). Tumor recurrence was recorded in 3 of 59 patients (5%) with total macroscopic removal. Among the patients with subtotal resection, tumor progression was observed in 3 of 12 patients (25%; 2 patients with grade III and 1 patient with grade IV resection). Mean time to recurrence was 43.3 months (range, 32-53 months). Conclusion Surgical management of patients with sphenoid wing meningiomas cannot be uniform; it must be tailored on a case-by-case basis. Successful resection requires extensive intra- and extradural surgery. We recommend optic canal decompression in all patients to ameliorate and/or preserve visual function.

Abstract: Cavernous sinus (CS) dural arteriovenous fistulas (DAVFs) rarely cause venous infarction (VI) and/or intracranial hemorrhage (ICH) despite the presence of cortical venous drainage (CVD). The present study investigated the characteristics of CS DAVFs manifesting as VI/ICH. Fifty-four patients treated for CS DAVFs were retrospectively studied. Six patients presented with VI/ICH. Two of the three patients presenting with ICH had CVD only to the superficial sylvian vein (SSV) or the deep sylvian vein (DSV). Three patients presenting with VI had multiple drainages, and angiography of these patients showed a varix on the SSV, drainage into the DSV with agenesis of the second and third segment of basal vein of Rosenthal, and thrombosis of the distal petrosal vein. CS DAVF with CVD only carries higher risk of VI/ICH than multiple drainages. Many CS DAVFs presenting with VI, especially those with drainage into the petrosal vein, have multiple drainages in the early stage. Thrombosis of the inferior and superior petrosal sinuses and superior orbital vein gradually increases pressure of the CVD, and then, VI may occur. In contrast, CS DAVFs with CVD only from the beginning, common in the patients with drainage into the SSVs and DSVs, are likely to cause ICH. Angiographic risk factors causing VI/ICH are CVD only, varix formation, agenesis of the second and third segment of basal vein of Rosenthal, and thrombosis of the superior orbital vein, lateral half of the superior petrosal sinus, and distal CVD.

Abstract: Occlusion or thrombosis of the superior ophthalmic vein or of the cavernous sinus is an unspecific finding that may be secondary to different disorders such as tumours of the skull base or nasopharynx. Sometimes, however, no underlying disorder is found in spite of an extensive clinical and radiological evaluation. Eight such cases are here presented. Similar cases have previously been described, both as examples of the Tolosa-Hunt syndrome and as aseptic cavernous sinus thrombosis. The literature on these two disorders is reviewed and different diagnostic criteria discussed.

Abstract: Background and aim 9 patients with 10 arteriovenous fistulas were treated with Onyx at our institution over a period of 19 months: 4 direct and indirect carotid–cavernous fistulas (CCFs) and 6 dural arteriovenous fistula (DAVFs). Complete occlusion was achieved with no recurrences or permanent complications in our small series. We report hemodynamic instability, including severe bradycardia and asystole, during embolization of DAVF and CCF with Onyx in several patients. These changes were reversible with interruption of Onyx injection and administration of atropine. No recurrence of symptoms after atropine administration was noted as Onyx embolization continued during the same session or during postprocedural 24 h monitoring. No adverse clinical consequences were noted. Results Bradycardia was observed in 4 cases, with a brief asystole in 2 of these patients during transarterial and transvenous Onyx delivery at cavernous sinus and orbital levels. Based on our observation, hemodynamic instability was demonstrated during Onyx injection into the vessels that were in close proximity to the trigeminal nerve or its branches, especially in low-flow/low-volume compartment and may represent a direct effect of dimethyl sulfoxide/Onyx on the trigeminal nerve, resulting in vagal response from trigeminocardiac reflex. Conclusion Proposed measures to prevent this complication include pretreatment with atropine or prophylactic placement of transvenous pacemakers in patients with underlying heart block and patients with contraindications to atropine use.

Abstract: True carotid aneurysms with sphenoid extension and revealed by epistaxis are rare. A review of the literature shows the mortality risk of this pathology and the different therapeutic options. A 41-year-old female presented with a cavernous carotid aneurysm with sphenoid extension revealed by massive epistaxis. We propose a combined treatment of the affected vessel using coils and an uncovered stent. The first stage to stop the hemorrhages and occlude the aneurysm using the coil and the second stage several days later after anticoagulation using the stent to prevent revascularization. This treatment has been shown to be effective in producing immediate hemostasis and stable long-term occlusion.

Abstract: Background Transsphenoidal surgery has been well established as an effective primary treatment for tumours of the sellar region. During the dural opening, the prominent intercavernous sinus poses limitations for this approach and may contribute to incomplete tumour resections.

Abstract: Penetrating non-missile orbito cranial injuries are rare in a civilian pediatric setting. We describe a case of a trans-orbital penetration by a wooden chopstick deep down into the cerebellar vermis detected at neuroradiological examination in a child presenting for head injury. The foreign body was successfully pulled out in one piece surgically.

Abstract: Post-traumatic fistulas between the middle meningeal artery and the cranial venous system are extremely rare. We describe clinical presentation and successful endovascular management of a case of post-traumatic fistula between the middle meningeal artery and the sphenoparietal sinus. A 53-year-old man was admitted with multiple brain contusions and a temporoparietal fracture after a head trauma. On day 3 after trauma he developed unilateral signs of a cavernous sinus syndrome. Digital subtraction angiography showed a fistula between the middle meningeal artery and the sphenoparietal sinus. The fistula was occluded by endovascular coil embolization, resulting in complete remission of the clinical symptoms. A high index of suspicion is necessary to detect subtle signs of venous congestion of the cavernous sinus in an intubated patient. Angiography is the diagnostic modality of choice and should include the selective investigation of the external carotid artery vascular territory. Endovascular therapy provides minimal invasive and definitive treatment of this rare condition.

Abstract: An orbitozygomatic infratemporal approach for the removal of large neoplasms involving the lateral skull base is described. This approach, involves a unilateral frontotemporal incision extended inferiorly to the neck, a lateral facial flap reflected anteriorly. Transection of the zygoma is followed by its reflection inferolaterally with the temporalis muscle. This exposure provides excellent visualization of both the intradural and extradural aspects of the anterior portion of the cavernous sinus, allowing an aggressive resection of neoplasms in this region. Experience with this procedure in the management of 15 patients is reported here. There was one postoperative death due to pneumonia and septicemia. The morbidities included wound infection, meningitis, CSF leakage and cranial nerve palsy. All the surviving patients, are living independently and have returned to their previous occupations.

Abstract: OBJECTIVE: We report a rare case of internal carotid artery pseudoaneurysm owing to rhinocerebral mucormycosis and review 40 reported cases from 1980 to present. CLINICAL PRESENTATION: A 38-year-old Caucasian man presented with a 3-day history of headache, diplopia, and numbness in the distribution of the left ophthalmic and maxillary branches of the trigeminal nerve. A complete left cavernous syndrome was discovered upon neurological examination. Magnetic resonance imaging scans revealed an inflammatory process involving the paranasal sinuses with extension into the left cavernous sinus, temporal fossa, and petrous bone. INTERVENTION: The patient was immediately treated with amphotericin B, atorvastatin, and daily hyperbaric oxygen sessions before surgical intervention. The patient underwent endovascular treatment of the associated mycotic pseudoaneurysm after carotid test occlusion in addition to a radical bilateral debridement of the paranasal sinuses and infratemporal and temporal fossa. CONCLUSION: Aggressive multimodal therapy is imperative for late-stage rhinocerebral mucormycosis. Extensive resection of infected tissue combined with amphotericin B, atorvastatin, and hyperbaric oxygen seems to be the best course of management. If the internal carotid artery is involved, endovascular intervention is clearly an option to attain this goal. Further research and longer follow-up periods are required to better understand the long-term implications of endovascular coiling and hyperbaric oxygen therapy for rhinocerebral mucormycosis.

Abstract: Endovascular occlusion via the transvenous route is the favored treatment method for dural carotid-cavernous fistulas (CCFs). Ethylene vinyl alcohol copolymer (Onyx), recently approved for treatment of arteriovenous malformations, has advantages over conventional liquid embolic agents in its nonadhesive nature, which allows for longer injections with decreased risk of catheter retention. We report the use of Onyx in the successful transarterial embolization of a dural CCF fed by arterial branches of the internal and external carotid arteries (Barrow type D) after multiple failed attempts to access the cavernous sinus transvenously. Transarterial Onyx embolization could be a valuable option in transarterial treatment of CCFs when venous access is difficult.

Abstract: Aim The aim of this article is to describe the microsurgical anatomy of the cavernous sinus, the triangles, and the osseous relationships in the region with special attention to the relationships important in surgical approaches on the intracavernous structures. Material and methods Fifty cavernous sinuses obtained from twenty-five cadaver heads were studied in detail using magnification. Stepwise dissections of the cavernous sinuses performed to demonstrate the intradural and extradural routes, anatomy of the triangles and osseous relationships in the region. Results The main branches of the intracavernous portion of the carotid artery were the meningohypophyseal, the inferior cavernous sinus, and McConnell;s capsular artery . The main branches of the meningohypophyseal trunk were the tentorial, the dorsal meningeal, and the inferior hypophyseal artery. There were variations of the main branches of the meningohypophyseal trunk. The sixth cranial may splite into rootlets as it passes lateral to the carotid artery. There were size and shape variation of the triangles. Conclusion Aprecise understanding of the bony relationships, the anatomy of the triangels and neurovascular content of the cavernous sinus, together with the use of cranial base and microsurgical techniques are necessary for safer surgery. Asingle approach is not capable of providing exposure of all parts of the sinus.