Abstract: Objective To design and assess the quality of a novel lateral retrocanthal endoscopic approach to the lateral cavernous sinus. Design Computer modeling software was used to optimize the geometry of the surgical pathway, which was confirmed on cadaver specimens. We calculated trajectories and surgically accessible areas to the middle fossa while applying a constraint on the amount of soft tissue retraction. Setting Virtual computer model to simulate the surgical approach and cadaver laboratory. Participants The authors. Main Outcome Measures Adequate surgical access to the lateral cavernous sinus and adjacent regions as determined by operations on the cadaver specimens. Additionally, geometric limitations were imposed as determined by the model so that retraction on soft tissue structures was maintained at a clinically safe distance. Results Our calculations revealed adequate access to the lateral cavernous sinus, Meckel cave, orbital apex, and middle fossa floor. Cadaveric testing revealed sufficient access to these areas using <10 mm of orbital retraction. Conclusions Our study validates not only the use of computer simulation to plan operative approaches but the feasibility of the lateral retrocanthal approach to the lateral cavernous sinus.

Abstract: The term “paraclinoid aneurysms”, has been used for aneurysms of the internal carotid artery (ICA) between the cavernous sinus and the posterior communicating artery Due to their complex anatomical relationship at the skull base and because they are frequently large/giant, their surgical treatment remains a challenge Ninety-five patients harboring 106 paraclinoid aneurysms underwent surgery (1990–2010) Age, 11–72 years old Sex, 74:21 female/male Follow-up; 1–192 months (mean = 517 months) Eighty-six patients had single and 9 had multiple paraclinoid aneurysms Sixty-six were ophthalmic, 14 were in the ICA superior wall, 13 in the inferior, 10 in the medial, and 3 in the ICA lateral wall Eleven were giant, 29 were large, and 66 were small Sixty-three patients had ruptured and 32 had unruptured aneurysms Two patients with bilateral aneurysms had bilateral approaches, totaling 97 procedures A total of 982 % of aneurysms were clipped (complete exclusion in 938 %) ICA occlusion occurred in 10 (56 %) There was no patient rebleeding during the follow-up period A good outcome was achieved in 768 %, with better results for unruptured aneurysms, worse results for patients with vasospasm, and with no difference according to size Thirty-six (379 %) patients had transient/permanent postoperative neurological deficits (254 % ruptured vs 625 % unruptured aneurysms) The most frequent deficits were visual impairment and third cranial nerve palsies Operative mortality was 116 %, all in patients presenting with ruptured aneurysms Despite relatively high morbidity/mortality, especially for patients with ruptured aneurysms, microsurgical treatment of paraclinoid aneurysm has high efficacy, with better outcome for unruptured aneurysms and worse outcome for patients with vasospasm

Abstract: Background: Sphenoid wing en plaque meningiomas are a subgroup of meningiomas defined by its particular sheet-like dural involvement and its disproportionately large bone hyperostosis. En plaque meningiomas represent 2-9% of all meningiomas and they are mainly located in the sphenoid wing. Total surgical resection is difficult and therefore these tumors have high recurrence rates.

Abstract: Background In treating cavernous sinus dural arteriovenous fistulae (CSdAVFs), transvenous embolization of the whole affected sinus is usually performed, which may result in the disturbance of normal venous drainage or permanent cranial nerve palsy. Objective To describe superselective shunt occlusion of CSdAVFs. Methods Between July 2005 and August 2011, we had 20 consecutive cases of CSdAVFs. In 14 cases (70%), we could detect the restricted locus of arteriovenous shunts by 3-dimensional rotational angiography and/or superselective arteriography. After navigating the microcatheter to the shunt segment, consecutive superselective arteriovenography was performed to confirm the location of the microcatheter at the proper position. Results In 12 of 14 cases (85.7%) in which the shunt was restricted, coiling only in the small venous pouch or compartment, which was just downstream of the shunt point, led to complete disappearance of the shunt without obliterating the entire sinus. No recurrence or permanent cranial nerve palsy was observed during the follow-up period with a mean of 46 months (range, 3-69 months) in 12 cases treated by superselective shunt occlusion. Conclusion This technique, which enables complete extirpation of shunts by small amounts of coils, is a feasible way to treat CSdAVFs with excellent mid- to long-term results. Understanding of the angioarchitecture by 3-dimensional rotational angiography and consecutive superselective arteriovenography was useful. This method should be considered before sinus packing or mere obliteration of dangerous venous outlets.

Abstract: Purpose: The aim of this study was to evaluate the feasibility and safety of the transfacial venous embolization of cavernous or paracavernous dural arteriovenous fistula (DAVF) in which approach via inferior petrosal sinus (IPS) was not feasible. Materials and Methods: We identified the cases of transfacial venous embolization of cavernous sinus (CS) or adjacent dural sinuses from the neurointerventional database of three hospitals. The causes and clinical and angiographic outcomes of transfacial venous embolization were retrospectively evaluated. Results: Twelve patients with CS (n = 11) or lesser wing of sphenoid sinus (LWSS, n = 1) DAVF were attempted to treat by transvenous embolization via ipsilateral (n = 10) or contralateral (n = 2) facial vein. Trans-IPS access to the target lesion was impossible due to chronic occlusion (n = 11) or acute angulation adjacent the target lesion (n = 1). In all twelve cases, it was possible to navigate through facial vein, angular vein, superior ophthalmic vein, and then CS. It was also possible to further navigation to contralateral CS through intercavernous sinus in two cases, and laterally into LWSS in one case. Post-treatment control angiography revealed complete occlusion of the DAVF in eleven cases and partial occlusion in one patient, resulting in complete resolution of presenting symptom in eight and gradually clinical improvement in four patients. There was no treatment-related complication during or after the procedure. Conclusion: In the cavernous or paracavernous DAVF in which trans-IPS approach is not feasible, the facial vein seems to be safe and effective alternative route for transvenous embolization.

Abstract: Object As tumors enlarge, they generally grow along paths of least resistance. For pituitary macroadenomas, extrasellar extension into the suprasellar region, cavernous sinus, or sphenoid sinus may occur. The sphenoid sinus is known to have a variable anatomical configuration, and the authors hypothesize that certain anatomical factors may resist tumor expansion into the sphenoid sinus, thereby directing tumor growth into the suprasellar space. In this paper the authors' goal was to determine if sphenoid anatomy influences pituitary tumor growth. Methods The authors conducted a retrospective analysis of 106 consecutive surgical cases of pituitary macroadenoma. Patient demographics, suprasellar extension, sellar width, and features of the sphenoid intersinus septum were recorded on radiographic review. The chi-square test, t-test, logistic regression, and classification and regression tree analysis were used for statistical analysis. Results Of the 106 patients included in the study, 71 (67%) demonstrated ...

Abstract: Background Direct surgical exposure and cannulation (DSEC) of the superior ophthalmic vein (SOV) can be used as an alternative approach for the endovascular treatment of cavernous sinus dural fistulas (CSDF) that fail conventional endovascular access The aim of this study was to report the techniques, effectiveness and safety of DSEC of the SOV in these cases Methods Between June 2007 and June 2011, nine CSDF in nine patients who presented with ocular signs and symptoms were embolized using DSEC of the SOV when the CSDF could not be treated via the transarterial or transfemoral venous route Results All nine patients were successfully treated by introduction of Onyx in conjunction with detachable coils through the catheterized SOV to the affected cavernous sinus No exposure or catheterization of the SOV proved difficult Symptoms and signs resolved completely in all patients after successful occlusion of the CSDF There were no intraoperative complications All patients underwent follow-up cerebral angiography at least 3 months after treatment, and none showed recurrence of the fistula Conclusion DSEC of the SOV for embolization of a CSDF is a good alternative treatment when conventional venous routes are inaccessible Surgical access to the SOV is direct and can be performed safely The use of Onyx in conjunction with detachable coils is safe and effective for symptomatic CSDF

Abstract: Hypophosphatemia with osteomalacia may be due to a neoplasm that produces fibroblast growth factor 23 (FGF-23), which inhibits phosphate reabsorption in the kidneys. Most of these tumors occur in bone or soft tissue and occasionally in the head, although intracranial occurrence is very rare. This report describes a tumor that caused hypophosphatemia and osteomalacia and was located entirely in the right anterior cranial fossa. Radiologically, the tumor resembled a meningioma; histologically, it was a low-grade phosphaturic mesenchymal tumor, mixed connective tissue variant (PMTMCT). After gross-total resection, the patient's symptoms abated and laboratory values normalized. The authors also studied another PMTMCT initially diagnosed as a hemangiopericytoma that involved the left anterior cranial fossa and ethmoid sinus, and reviewed reports of 6 other intracranial tumors that induced osteomalacia, 3 entirely in the anterior cranial fossa, 2 involving the anterior cranial fossa and ethmoid sinus, and 1 in the cavernous sinus. In older children or adults who have hypophosphatemia with osteomalacia and no personal or family history of metabolic, renal, or malabsorptive disease, a neoplasm should be suspected and an imaging workup that includes the brain is warranted, with particular attention to the anterior cranial fossa. Additionally, because there are some overlapping histological features between PMTMCTs and hemangiopericytomas, it may be helpful to assess tumoral FGF-23 expression by reverse transcriptase polymerase chain reaction or immunohistochemical analysis in patients with oncogenic osteomalacia from an intracranial tumor diagnosed as, or resembling, hemangiopericytoma.

Abstract: This study evaluated clinical and neuroradiological results in 13 consecutive patients with spontaneous and traumatic direct carotid cavernous fistulas treated at our center between January 2006 and September 2012. All patients were treated by coiling of the cavernous sinus. Coiling was always performed while a semi-compliant non-detachable balloon was temporarily inflated in the internal carotid artery. This technique (balloon-assisted coiling) permitted a clear visualization of the fistula, facilitated coil positioning and protected the patency of the artery. All patients’ clinical data and radiological examinations were reviewed; nine patients underwent radiological and clinical follow-up, with a mean duration of 3.8 years (range: six months-six years). Overall results at discharge showed a complete occlusion of the fistula in seven patients (7/13, 54%) and a resolution of symptoms in eight patients (8/12, 67%). Radiological follow-up showed complete occlusion of the fistula in all patients (9/9, 100%) and clinical follow-up showed a resolution of symptoms in eight patients (8/9, 89%) and persistent symptoms in one (1/9, 11%). No procedure-related complications occurred. Balloon-assisted coiling of the cavernous sinus for the treatment of direct carotid cavernous fistulas proved an effective and safe technique, both in angiographic and clinical terms, and may be considered a technical improvement.

Abstract: Background The medial wall of the cavernous sinus is believed to play a significant role in determining the direction of growth of pituitary adenomas and in planning pituitary surgery. However, it remains unclear whether there is a dural wall between the pituitary gland and the cavernous sinus. Objective To identify and trace the membranelike structures medial to the cavernous sinus and around the pituitary gland and their relationships with surrounding structures. Methods Sixteen cadavers (7 females and 9 males; age range, 54-89 years; mean age, 77 years) were used in this study and prepared as 16 sets of transverse (5 sets), coronal (2 sets), and sagittal (9 sets) plastinated sections that were examined at both macro- and microscopic levels. Results The pituitary gland was fully enclosed in a fibrous capsule, but the components and thickness of the capsule varied on different aspects of the gland. The meningeal dural layer was sandwiched between the anterosuperior aspect of the gland capsule and the cavernous sinus. Posteroinferiorly, however, this dural layer disappeared as it fused with the capsule. A weblike loose fibrous network connected the capsule, carotid artery, venous plexus, and the dura of the middle cranial fossa. Conclusion The medial wall of the cavernous sinus consists of both the meningeal dura and weblike loose fibrous network, which are located at the anterosuperior and posteroinferior aspects, respectively.

Abstract: Background Large and giant medial sphenoid wing meningiomas that are located deeply in the skull base where they are closely bounded by cavernous sinus, optic nerve, and internal carotid artery make the gross resection hard to achieve. Also, this kind of meningiomas is often accompanied by a series of severe complications. Therefore, it was regarded as a formidable challenge to even the most experienced neurosurgeons. This study aimed to investigate the clinical features and management experience of patients with large and giant medial sphenoid wing meningiomas. Methods In this study, 53 patients (33 female and 20 male, mean age of 47.5 years) with large and giant medial sphenoid wing meningiomas were treated surgically between April 2004 to March 2012, with their clinical features analyzed, management experience collected, and treatment results investigated retrospectively. Results In this study, gross total resection (Simpson I and II) was applied in 44 patients (83%). Fifty-three patients had accepted the routine computed tomography scan and magnetic resonance imaging scan as postoperative neuroradiological evaluation. Their performance showed surgical complications of vascular lesions and helped us evaluate patients' conditions, respectively. Meanwhile, the drugs resisting cerebral angiospasm, such as Nimodipine, were infused in every postoperative patient through vein as routine. As a result, 11 patients (21%) were found to have secondary injury of cranial nerves II, III, and IV, and nine patients got recovered during the long-term observing follow-up period. Temporary surgical complications of vascular lesions occurred after surgery, such as cerebral angiospasm, ischemia, and edema; 24 patients (45%) appeared to have infarction and dyskinesia of limbs. Overall, visual ability was improved in 41 patients (77%). No patient died during the process. Conclusions Microsurgical treatment may be the most effective method for the large and giant medial sphenoid wing meningiomas. The surgical strategy should focus on survival and postoperative living quality.

Abstract: Invasive fungal rhinosinusitis (IFRS) is a disease of the paranasal sinuses and nasal cavity that typically affects immunocompromised patients in the acute fulminant form. Early symptoms can often mimic rhinosinusitis, while late symptoms can cause significant morbidity and mortality. Swelling and mucosal thickening can quickly progress to pale or necrotic tissue in the nasal cavity and sinuses, and the disease can rapidly spread and invade the palate, orbit, cavernous sinus, cranial nerves, skull base, carotid artery, and brain. IFRS can be life threatening if left undiagnosed or untreated. While the acute fulminant form of IFRS is the most rapidly progressive and destructive, granulomatous and chronic forms also exist. Diagnosis of IFRS often mandates imaging studies in conjunction with clinical, endoscopic, and histopathological examination. Treatment of IFRS consists of reversing the underlying immunosuppression, antifungal therapy, and aggressive surgical debridement. With early diagnosis and treatment, IFRS can be treated and increase patient survival.

Abstract: Objectives:The aim of this study was to provide the anatomic rationale for a transnasal approach to the orbital apex and cavernous sinus, and to evaluate its applicability and efficiency.Methods:One hundred patients with lesions of the orbital apex, cavernous sinus, optic nerve, clivus, parapharyngeal space, infratemporal fossa, or pterygopalatine fossa were reviewed over a 10-year period. All patients underwent an endoscopic transnasal approach to the orbital apex and cavernous sinus. The surgical technique required a standard endoscopic sinus surgery set. The possible complications were recorded and classified as intraoperative or postoperative.Results:There were complications in 8 cases: 4 intraoperative and 4 postoperative. The intraoperative complications included rupture of the internal carotid artery in 1 patient and cerebrospinal fluid leak in 3 patients. All intraoperative complications were resolved during surgery. The postoperative complications were transitory eyelid ptosis in 2 patients (reso...

Abstract: Background and importance Purely intraorbital arteriovenous fistulas (AVFs), which are rare vascular malformations that clinically mimic carotid-cavernous fistulas (CCFs), involve a fistula from the ophthalmic artery to 1 of the draining ophthalmic veins. We describe a case of an intraorbital AVF treated with transvenous endovascular coil embolization via the inferior petrosal sinus (IPS) route and review the literature on this rare entity. Clinical presentation An 81-year-old woman sought treatment after 7 days of progressive left-sided visual acuity loss, chemosis, and lateral rectus palsy. Magnetic resonance imaging demonstrated dilated vascularity in the left orbit raising suspicions for a CCF. Cerebral angiography showed a purely intraorbital AVF with a fistula between the left ophthalmic artery and superior ophthalmic vein (SOV). Transvenous selective catheterization of the fistula was performed by successfully navigating the ipsilateral IPS to the cavernous sinus and SOV. The fistula was then embolized using detachable coils. The patient was discharged the next day. Three weeks after embolization, her ocular symptoms and findings had resolved. Conclusion Intraorbital AVFs are a rare type of AVF that can be treated by direct surgical ligation, transarterial embolization, or transvenous embolization. We successfully navigated the IPS, which is frequently stenotic or occluded secondary to chronically increased fistulous drainage, and utilized this route to embolize the fistula with detachable coils.

Abstract: Intraosseous arteriovenous malformation (AVM) in the craniofacial region is rare. When it occurs, it is predominantly located in the mandible and maxilla. We encountered a 43-year-old woman with Klippel-Trenaunay syndrome affecting the right lower extremity who presented with a left orbital chemosis and proptosis mimicking the cavernous sinus dural arteriovenous fistula. Computed tomography angiography revealed an intraosseous AVM of the sphenoid bone. The patient's symptoms were completely relieved after embolization with Onyx. We report an extremely rare case of intraosseous AVM involving the sphenoid bone, associated with Klippel-Trenaunay syndrome.

Abstract: BACKGROUND AND PURPOSE: Normal hemodynamic features of the superior petrosal sinus and their relationships to the SPS drainage from cavernous sinus dural arteriovenous fistulas are not well known. We investigated normal hemodynamic features of the SPS on cerebral angiography as well as the frequency and types of the SPS drainage from CSDAVFs. MATERIALS AND METHODS: We evaluated 119 patients who underwent cerebral angiography by focusing on visualization and hemodynamic status of the SPS. We also reviewed selective angiography in 25 consecutive patients with CSDAVFs; we were especially interested in the presence of drainage routes through the SPS from CSDAVFs. RESULTS: In 119 patients (238 sides), the SPS was segmentally (anterior segment, 37 sides; posterior segment, 82 sides) or totally (116 sides) demonstrated. It was demonstrated on carotid angiography in 11 sides (4.6%), receiving blood from the basal vein of Rosenthal or sphenopetrosal sinus, and on vertebral angiography in 235 sides (98.7%), receiving blood from the petrosal vein. No SPSs were demonstrated with venous drainage from the cavernous sinus. SPS drainage was found in 7 of 25 patients (28%) with CSDAVFs. CSDAVFs drained through the anterior segment of SPS into the petrosal vein without draining to the posterior segment in 3 of 7 patients (12%). CONCLUSIONS: The SPS normally works as the drainage route receiving blood from the anterior cerebellar and brain stem venous systems. The variation of hemodynamic features would be related to the relatively lower frequency and 2 different types of SPS drainage from CSDAVFs.

Abstract: This study aimed to propose an alternative treatment for carotid cavernous fistula (CCF) using the balloon-assisted sinus coiling (BASC) technique and to describe this procedure in detail. Under general anesthesia, we performed the BASC procedure to treat five patients with traumatic CCF. Percutaneous access was obtained via the right femoral artery, and a 7F sheath was inserted, or alternatively, a bifemoral 6F approach was accomplished. A microcatheter was inserted into the cavernous sinus over a 0.014-inch microwire through the fistulous point; the microcatheter was placed distal from the fistula point, and a “U-turn” maneuver was performed. Through the same carotid access, a compliant balloon was advanced to cross the point of the fistula and cover the whole carotid tear. Large coils were inserted using the microcatheter in the cavernous sinus. Coils filled the adjacent cavernous sinus, respecting the balloon. Immediate complete angiographic resolution was achieved, and an early angiographic control (mean = 2.6 months) indicated complete stability without recanalization. The clinical follow-up has been uneventful without any recurrence (mean = 15.2 months). An endovascular approach is optimal for direct CCF. Because the detachable balloon has been withdrawn from the market, covered stenting requires antiplatelet therapy and its patency is unconfirmed, but cavernous sinus coiling remains an excellent treatment option. Currently, there is no detailed description of the BASC procedure. We provide detailed angiograms with suitable descriptions of the exact fistula point, and venous drainage pathways. Familiarity with these devices makes this technique effective, easy and safe.

Abstract: BACKGROUND: This report presents our 15-year experience with Gamma Knife radiosurgery (GKS) for the treatment of 321 patients with dural arteriovenous fistulas (DAVFs) in different locations. METHODS: The most common locations of DAVFs were the cavernous sinus (206 cases) and transverse-sigmoid sinus (72 cases), which together accounted for 86.6 % of cases. In all, 54 patients had undergone embolization or surgery prior to radiosurgery, and the other patients underwent GKS as the primary treatment. During GKS, radiation was confined to the involved sinus wall, which was considered the true nidus of the DAVF. Target volume ranged from 0.8 to 52 cm(3). Marginal and maximum doses to the nidus ranged from 14 to 25 Gy and from 25 to 36 Gy, respectively. RESULTS: The mean follow-up time was 28 months (range 2-149 months). In 264 of 321 patients (82 %) available for follow-up study, 173 (66 %) showed complete obliteration of DAVFs with symptomatic resolution, 87 (33 %) had partial obliteration, 2 (0.8 %) had stationary status, 1 (0.4 %) had progression, and 1 (0.4 %) died from a new hemorrhagic episode. Complications were found in only two (0.8 %) patients, one with venous hemorrhage and one with focal brain edema after GKS. CONCLUSIONS: GKS is a safe, effective treatment for DAVFs. It provides a minimally invasive therapeutic option for patients who harbor less-aggressive DAVFs but who suffer from intolerable clinical symptoms. For some aggressive DAVFs with extensive venous hypertension or hemorrhage, multimodal treatment with combined embolization or surgery is necessary.

Abstract: Background The abducens nerve, cranial nerve VI (CNVI), is the medial-most nerve in the cavernous sinus. Its close proximity to the sphenoid sinus makes it susceptible to injury, invasion, or compression from a sphenoid pathology leading to horizontal gaze diplopia. A wide range of literature describes myriad causes for CNVI palsy, but there is a lack of references that point to paranasal sinus pathology as an etiology, as well as the prognosis and timeline for resolution. Here, we describe a series of patients that presented with CNVI palsy, their management, and prognosis for recovery. This study was designed to evaluate and understand prognostic factors predicting disease course and likelihood of resolution in patients with abducens nerve palsy. Methods A multi-institutional retrospective review was performed of all patients presenting with CNVI palsy between 2009 and 2012. The demographic data, radiological features, treatment regimens, and disease courses were analyzed. Results Fifteen patients at four institutions were identified. Seven patients had neoplasms originating from the paranasal sinuses, three suffered from allergic fungal sinusitis, three patients had invasive fungal sinusitis, one patient had fibrous skull base dysplasia, and one had chronic bacterial sinusitis. The average follow-up time from presentation was 9 months (range, 1-16 months). Thirteen patients underwent surgery, three received chemotherapy, and four had radiation therapy. CNVI palsy resolved in 50% of the cases, with an average time to resolution of 6 weeks (range, 2-12 weeks). Conclusion Paranasal sinus pathology is a rare cause of CNVI palsy. A number of factors may help to predict prognosis in these patients. Masses compressing, but not destroying or invading, the cavernous sinus had optimal posttreatment outcomes with full resolution occurring as early as 2 weeks. Destructive lesions that invaded CNVI and its vasculature, i.e., invasive fungus, were negative indicators for recovery. Knowledge of factors that affect recovery can help clinicians predict disease course and prognosis for resolution of the defect.

Abstract: Objective Tumours in the clival region are difficult to remove surgically. Before the 1970s, clival tumours had very high mortality and morbidity rates. Methods An anatomic dissection was performed on 24 spheno-occipital bone blocks obtained from 28 adult cadavers. The internal carotid artery, paraclival carotid tubercle, sixth cranial nerve and dorsum sellae in the upper clival region were analyzed qualitatively and quantitatively. For the histological evaluation, 4 samples were decalcified and sagittal sections were cut. From the eight blocks obtained, 32 incisions were made in the axial plane, and the tissue was analyzed. Results Using microscopy, a clival recess was clearly identified in 15 of the 24 (62.5%) samples. Paraclival carotid tubercles were observed in 19 (79.16%) of the samples. In the upper clival and petroclival region, the sixth cranial nerve had directional changes at the dural porus, the petrous apex and the lateral wall of the cavernous segment of the internal carotid artery. At the dorsum sellae level, the distance between the medial surfaces of both internal carotid arteries was a mean of 15.33 ± 2.12 mm. This distance at the pharyngeal tubercle was a mean of 38.95 ± 4.67 mm. On all the histological sections, the distance of the sixth cranial nerve from the dural porus to the cavernous sinus was within the basilar plexus, along with the subarachnoid membranes around it. On the petrous apex level, the sixth cranial nerve was fixed to the petrous apex and the internal carotid artery with connective tissue formed by dense collagen fibres. The sixth cranial nerve and the internal carotid artery are tightly surrounded by dense collagen connective tissue, and the relative proximity between the carotids on the dorsum sellae level can be easily damaged during the transsphenoidal–transclival approach. Similarly, due to the ligamentous fixation on the dural porus and the petrous apex surfaces, there is a high risk of injury to the carotid artery and sixth cranial nerve. Conclusion This study determines the relationship between the sixth cranial nerve and the internal carotid artery at the upper clivus and to provide morphologic details that is essential for the risks of transclival surgery.

Abstract: Sinonasal tumors can invade into the critical structures of the anterior and central skull base. Although the determination of precise tumor histology is difficult with imaging, radiology is important in helping differentiate malignant from benign disease. Imaging helps to map the anatomical extent of intracranial and intraorbital tumor, which has important implications for staging, treatment and prognosis. Imaging also helps to facilitate and plan for craniofacial or endoscopic surgical approaches and radiation planning. This paper will review the locoregional invasion patterns for sinonasal tumors, with emphasis on their imaging features. The authors will discuss the implications for staging, resection potential, choice and details of radiotherapy with or without chemotherapy and prognosis. The imaging assessment of structures and compartments that are critical to the skull base team are highlighted: orbit, cavernous sinus, anterior cranial fossa dura/intracranial tumor, lateral frontal sinus, vascular tumor encasement, perineural tumor spread and tumor effect on the surrounding bony structures.

Abstract: Purpose To evaluate preoperative magnetic resonance imaging (MRI) criteria for their ability to predict the complete removal of parasellar pituitary macroadenoma on the 3-month postoperative MRI Methods Dedicated pre- and postoperative pituitary MRI studies were reviewed in 49 patients who had undergone transsphenoidal surgery for macroadenomas with potential unilateral parasellar involvement Twelve preoperative MRI findings and postoperative MRI outcomes were statistically compared Results Depiction of the inferolateral (positive predictive value [PPV]: 06; negative predictive value [NPV], 092) and lateral (PPV: 065; NPV: 085) compartments of the cavernous sinus and the percentage of intracavernous carotid artery encasement (PPV: 063; NPV, 10 for Conclusion The preoperative MR imaging features that are useful in predicting the complete removal of the parasellar component of a pituitary adenoma as assessed by postoperative MRI are (1) depiction of the lateral and inferolateral compartment of the cavernous sinus and (2) decreasing encasement of the intracavernous carotid artery

Abstract: Endoscopic endonasal transsphenoidal approach (EETA) is an effective and relatively safe to remove pituitary adenomas and other sellar region tumors. One of the most serious complications of transsphenoidal surgery is damage to the cavernous segment of the internal carotid artery, which by different authors occurs at 0 to 3.8%. In the period from 2005 to March 2013 in Burdenko neurosurgical institute 3,000 patients with pituitary adenomas were operated by standard endoscopic transsphenoidal approach. Damage to the internal carotid artery (ICA) occurred in 4 patients, which amounted to 0.13%. To all patients with damage of the ICA angiography was performed in which identified one case of occlusion of the ICA and three cases of false aneurysm formation. Three patients underwent endovascular treatment. Damage to the internal carotid artery may be associated with the wrong orientation in the surgical wound, or excessively aggressive manipulations in the cavernous sinus. Damage to the cavernous segment of the ICA during transsphenoidal surgery is a rare but potentially fatal complication. Extremely important is the correct localization of the middle line and ICA using navigation systems and Doppler ultrasound.

Abstract: Carotid-cavernous sinus fistula is an arteriovenous fistula between the internal carotid artery and the cavernous sinus, and is usually caused by a traumatic tear or a ruptured aneurysm of the cavernous segment of the internal carotid artery. We describe a rare case of delayed intracranial haemorrhage and carotid-cavernous sinus fistula that presented 3 weeks after fracture of the facial bones. The patient developed orbital apex syndrome including ptosis of upper eyelid, pulsatile exophthalmos, chemosis, loss of ocular motility, monocular blindness on the right, and numbness of the right infraorbital region. After transcatheter intra-arterial embolisation, the ptosis and chemosis improved.