Experience with the ultrasonic surgical aspirator in a cavernous hemangioma of the cavernous sinus

Cavernous sinus hemangioma: a fourteen year single institution experience

Cavernous sinus hemangioma (CSH) is a rare extra-axial vascular neoplasm that accounts for 2% to 3% of all cavernous sinus tumors. Their location, propensity for profuse bleeding during surgery, and relationship to complex neurovascular structures are factors which present difficulty in excising these lesions. The authors describe their experience of 22 patients with CSH over 14 years at a tertiary care center. Patients were managed with microsurgical resection using a purely extradural transcavernous approach (13 patients) and with Gamma Knife radiosurgery (GKRS; Elekta AB, Stockholm, Sweden) (nine patients). Retrospective data analysis found headache and visual impairment were the most common presenting complaints, followed by facial hypesthesia and diplopia. All but one patient had complete tumor excision in the surgical series. Transient ophthalmoparesis (complete resolution in 6-8 weeks) was the most common surgical complication. In the GKRS group, marked tumor shrinkage (>50% tumor volume reduction) was achieved in two patients, slight shrinkage in five and no change in two patients, with symptom improvement in the majority of patients. To our knowledge, we describe one of the largest series of CSH managed at a single center. Although microsurgical resection using an extradural transcavernous approach is considered the treatment of choice in CSH and allows complete excision with minimal mortality and long-term morbidity, GKRS is an additional tool for treating residual symptomatic lesions or in patients with associated comorbidities making surgical resection unsuitable.

Intracranial extra-axial cavernous angioma of the cerebellar falx

INTRODUCTION

Intracranial cavernous hemangiomas are benign vascular malformations that can be divided into intra-axial and extra-axial types. Extra-axial cavernous angiomas (or hemangiomas) are rare lesions; intracranially, they arise in relation to the dura mater or at a spinal level mimicking meningiomas. They are very rarely reported in the posterior cranial fossa.

CASE REPORT

The authors report a case of a cavernous angioma that occurred in the cerebellar falx of a 58-year-old man. The lesion was discovered during cranial computed tomography (CT) and magnetic resonance imaging (MRI) examinations. The patient underwent surgery with en-bloc removal of the tumor. No significant intraoperative bleeding or complications occurred during the postoperative course.

CONCLUSION

Intra-axial and extra-axial cavernous angiomas are histopathologically identical lesions, but by the radiological features, it is very difficult to distinguish the extra-axial cavernous angiomas from meningiomas, especially when dural tail sign and calcification are present.

Preoperative Onyx embolization of a giant cavernous malformation involving the dural sinuses

Cavernous malformations (CMs) or hemangiomas arising from within the dural sinuses are rare entities that differ from their parenchymal counterparts in that they are highly vascular lesions. While parenchymal CMs are typically angiographically occult, intrasinus malformations may have large, dural-based arterial feeding vessels that are amenable to preoperative embolization. The novel liquid embolic Onyx (ev3, Inc.) is an ideal agent for the embolization of these lesions. The authors present the first known case of a giant intrasinus CM embolized with Onyx before gross-total resection. The authors report the case of a 9-year-old boy with brief apneic episodes in whom MR imaging revealed a giant CM arising from within the right transverse and sigmoid sinuses and infiltrating the right tentorium cerebelli. At another institution, the patient had undergone 1 prior embolization and 2 unsuccessful attempts at resection. Both surgeries had been complicated by massive blood loss and were aborted. Under the authors' care, the patient underwent preoperative transarterial embolization with Onyx during which a substantial volume of the mass lesion was filled with embolisate. Subsequently, complete circumferential excision of the mass from the tentorium was accomplished with minimal intraoperative blood loss.

Cavernous Hemangioma of the Cavernous Sinus, Skin, and Retina: Hemodynamic Changes after Treatment: Case Report

OBJECTIVE

There are several reports concerning cavernous hemangiomas of the skin and central nervous system. Additional retinal involvement has also been reported.

CLINICAL PRESENTATION

The authors report a 69-year-old woman with a giant extra-axial cavernous hemangioma of the right cavernous sinus involving the supra- and parasellar region, retina, and skin.

INTERVENTION

Shrinkage of its cutaneous part lead to subsequent increase of the volume of the intracranial part. Owing to compression of the optic and the oculomotor nerves, oculomotor disturbances, ptosis, and visual impairment to 0.2 occurred. Via a pterional approach microsurgical removal of the tumor except for a remnant of the intracavernous part was performed.

CONCLUSION

Hemodynamic connection between cutaneous, retinal, and intracranial hemangiomas should be considered.

Extradural transcavernous approach to cavernous sinus hemangiomas

OBJECTIVE

Cavernous sinus hemangiomas (CSHs) are uncommon lesions and comprise fewer than 1% of all parasellar masses. Because of their location, propensity for profuse bleeding during surgery, and relationship to complex neurovascular structures, they are notoriously difficult to excise.

CLINICAL PRESENTATION

The authors describe their experience with seven cases of CSHs. Headache and visual impairment were the most common presenting complaints, followed by facial hypesthesia and diplopia. Computed tomographic scans revealed iso- to hyperdense expansile lesions in the region of the cavernous sinus and middle cranial fossa. Magnetic resonance imaging scans revealed hypo- to isointense lesions on T1-weighted images and markedly hyperintense lesions on T2-weighted images, with marked homogeneous enhancement after contrast administration.

INTERVENTION

All CSHs were treated by a purely extradural transcavernous approach. This involved reduction of sphenoid ridge, exposure of the superior orbital fissure, drilling of the anterior clinoid process, coagulation and division of the middle meningeal artery, and peeling of the meningeal layer of the lateral wall of the cavernous sinus from the inner membranous layer. The cranial nerves in the lateral wall of the cavernous sinus were exposed (Cranial Nerves III and IV, as well as V1, V2, and V3). The tumor was accessed through its maximum bulge through either the lateral or anterolateral triangle. The tumor was removed via rapid decompression, coagulation of the feeder from the meningohypophyseal trunk, and dissection along the cranial nerves. All but one patient had complete tumor excision. Transient ophthalmoparesis (complete resolution in 6-8 wk) was the most common surgical complication.

CONCLUSION

To our knowledge, we describe one of the largest series of pure extradural transcavernous approaches to CSHs. CSHs are uncommon but challenging cranial base lesions. The extradural transcavernous approach allows complete excision with minimal mortality or long-term morbidity.

Merits of intralesional fibrin glue injection in surgery for the cavernous sinus cavernous hemangiomas

✓ In planning surgical treatment for extraaxial cavernous hemangiomas, care should be taken to control severe tumor bleeding. The authors present a case of a large cavernous hemangioma of the cavernous sinus, which was completely removed with the aid of multiple intratumoral injections of fibrin glue. This novel method is very effective for preventing excessive blood loss during surgery for this type of lesion.

Intratumoral injection of plastic adhesive material for removal of cavernous sinus hemangioma. Technical note

The authors present a case in which a cavernous sinus (CS) hemangioma was totally removed following intratumoral injection of a plastic fixation material. This unique method is extremely useful for the removal of CS hemangiomas, which often feature massive intraoperative bleeding as an unsolved problem.

Cavernous angioma as a rare neuroradiologic finding in the cavernous sinus

We report the case of a 56-year-old female with a pathologically confirmed cavernous angioma of the cavernous sinus. There are only a few reports on cavernous sinus angiomas in the literature. In contrast to typical intracerebral cavernous angiomas, these lesions are characterized by strong contrast enhancement on computed tomography and magnetic resonance imaging. In spite of the problematic location within the cavernous sinus, these angiomas can be completely resected without additional neurologic deficits. The clinical course of the patient and the unusual neuroradiologic imaging findings, as well as the cases from the literature are discussed.

Cavernous hemangiomas in the cavernous sinus

OBJECTIVE

Cavernous hemangiomas located within the cavernous sinus are rare vascular tumors that are very difficult to remove because of severe intraoperative bleeding. The purpose of this study was to analyze the clinical, neuroimaging, and pathological features and the surgical treatment of these tumors.

METHODS

Ten patients with cavernous hemangiomas in the cavernous sinus who were surgically treated from August 1985 to October 1997, in our hospital, were retrospectively studied.

RESULTS

Among the 10 patients, total tumor removal was performed in four cases, partial removal in two cases, and tumor biopsies in four cases. The four patients who underwent total tumor removal experienced uneventful postoperative courses, with no postoperative neurological deficits for one patient, no new neurological deficits for two patients, and complete ophthalmoplegia and diminished sensation in the distribution of Cranial Nerve V1 for one patient. The two patients who underwent partial removal developed complete ophthalmoplegia and diminished sensation in the distribution of Cranial Nerve V1 after surgery, and one of them experienced contralateral paralysis. All four patients who underwent tumor biopsies experienced severe intraoperative tumor bleeding; one exhibited Cranial Nerve III, IV, and VI injuries after surgery.

CONCLUSION

The features of prominent hyperintensity in T2-weighted scans, with well-defined borders in enhancing magnetic resonance imaging scans, or marked enhancement in computed tomographic and magnetic resonance imaging scans, with no tumor blush in angiographic analyses, facilitate the diagnosis of these tumors. These tumors can be divided into two subgroups on the basis of intraoperative findings and pathological features. We do not recommend division and piecemeal removal of the tumor during surgery if the main supplies of the tumor have not been interrupted.

Cavernous hemangiomas in the cavernous sinus. Case reports

BACKGROUND

Extra-axial cavernous hemangiomas are rare and have a propensity to develop within the cavernous sinus. Total removal of these vascular tumors is difficult due to the risk of severe intraoperative bleeding and the complicated neurovascular structures of the cavernous sinus. Only a small number of cases have been reported to be successfully totally removed.

METHODS

Retrospective studies were done in three cases of extraaxial cavernous hemangiomas located in the cavernous sinus. All three patients presented with clinical symptoms common to other tumors located in the region, such as headache and impairment of cranial nerve function. Their preoperative MRI results showed significant hyperintensity on T2-weighted images and marked enhancement with gadolinium-DTPA that delineated a sharp tumor margin.

RESULTS

All three patients underwent total tumor removal, with an uneventful postoperative course. There was no postoperative neurological deficit in one patient, and a complete ophthalmoplegia and diminished sensation in the V1 distribution in two patients. Three months after operation, follow-up MRI or CT scan showed no residual tumor.

CONCLUSION

Surgical resection of these lesions was possible but difficult because of severe bleeding. Avoiding piecemeal removal before the main feeding arteries are interrupted can minimize intraoperative bleeding.

Integration of a variable action suction adapter into ultrasonic aspirators

PURPOSE

Use of ultrasonic aspirators has become a mainstay in the neurosurgical armamentarium. The handpiece design and ultrasonic parameters have evolved to maximize its safe and efficacious use. Despite these modifications, continuous suction through the tip of the aspirator can result in neurovascular damage, especially when the aspirator is working in the cavernous sinus region or cerebellopontine angle.

CONCEPT

We describe the integration of a variable suction adapter into the existing handpiece of an ultrasonic aspirator to minimize potential injury from the continuous forceful suction normally associated with the use of these devices.

RATIONALE

The integration of such an adapter can reduce the potential for suction injury to cranial nerves or microvascular structures or smaller-caliber arteries and veins.

DISCUSSION

This variable action suction adapter can decrease suction injuries to cranial nerves or the microvasculature.

Efficacy of induced hypotension in the surgical treatment of large cavernous sinus cavernomas

OBJECT

Cavernous sinus cavernomas are rare lesions associated with high rates of intraoperative mortality and morbidity resulting from profuse bleeding. In this paper, the authors report their experience in treating five patients with histologically confirmed cavernous sinus cavernomas and describe the efficacy of induced hypotension in facilitating excision of the lesion.

METHODS

All five patients were women ranging in age from 25 to 54 years, with an average age of 42 years. The mass was small in one and large (>3 cm in diameter) in four. In one patient with a large mass, cardiac arrest occurred after the craniotomy, and remarkable reduction in the size of the cavernoma was evident on postmortem examination. The other three large lesions were successfully removed piecemeal after induction of hypotension (60-80 mm Hg systolic pressure), which remarkably reduced the mass and the bleeding during surgery. In the remaining patient, who had a small lesion, the cavernoma was removed in one piece.

CONCLUSIONS

Cavernous sinus cavernoma can be thought of as a cluster of sinusoidal cavities, the size of which varies depending on the systemic blood pressure. During surgery, reduction of the mass and control of bleeding from the cavernoma can be achieved by inducing hypotension, which enables the safe excision of this lesion. This technique should be considered by surgeons resecting a cavernous sinus tumor, especially when cavernoma is suspected.

Cavernoma of the cavernous sinus: case report

BACKGROUND

The authors report a case of extra-axial cerebral cavernoma localized at the level of the cavernous sinus. This pathology is extremely rare, therefore, differential diagnosis with tumors such as meningioma is often difficult. During recent years, surgical indications for these lesions, congenital and rarely hereditary, have become more definite due to the considerable progress made in neuroradiologic and microsurgic techniques as well as better anatomic knowledge of this region.

METHODS

This 49-year-old man was admitted with a 1-year history of diplopia. Cranial computed tomography (CT) scan with contrast medium, performed prior to admission, showed an expansive lesion at the level of the right cavernous sinus. Preoperative neuroradiologic diagnosis, after cerebral magnetic resonance imaging (MRI) with gadolinium enhancement and cerebral panangiography, was probable cavernoma. The lesion was totally removed via a fronto-orbito-temporo-zygomatic craniotomy.

RESULTS

Postoperatively, the patient had a right oculomotor nerve palsy. This spontaneously resolved 8 months after surgery; diplopia also completely disappeared. Early postoperative control MRI scans with gadolinium on the 2nd postoperative day and 3 months after operation confirmed total removal of the lesion.

CONCLUSIONS

The clinical onset and neuroradiologic aspect of these lesions and the fact that they rarely involve the cavernous sinus, may sometimes make preoperative diagnosis of cavernous sinus cavernoma difficult. Nevertheless, given the routine use of microsurgical techniques and improved anatomic knowledge of this delicate region, the treatment of choice is surgery. However, when doubts exist regarding achievement of total removal, radiosurgery is still a valid therapeutic tool.

Extracerebral cavernous angiomas of the cavernous sinus in the middle fossa

Intracranial extracerebral cavernous angiomas (ECCAs) share the same histologic features as intracerebral lesions, but their clinical picture is different. Surgical treatment of ECCAs of the cavernous sinus remains a challenge for the neurosurgeon because of a high mortality and morbidity due to uncontrollable and massive hemorrhage.

METHODS

We have experienced seven patients with ECCAs of the cavernous sinus between 1982 and 1994. All cases were verified histologically during surgery and two were totally resected during the first surgical attempt. Six of seven patients were female. The mean age at diagnosis was 54.5 years (range; 43 to 71 years).

RESULTS

Computed tomography showed a round or dumbbell-shaped mass in the area of the cavernous sinus. Magnetic resonance imaging revealed a low to isointense mass lesion on the T1-weighted image. Only one of our patients showed a minimal amount of vascular staining on angiography. The total excision of these malformations was difficult because intraoperative bleeding could be profuse. In one case, radiation therapy induced a reduction in the size of the tumor after failure of surgical removal.

CONCLUSIONS

In planning surgical strategy for ECCAs, care should be taken to control the massive bleeding. Radiation therapy is helpful to suppress the tumor growth.

Response of cavernous sinus hemangioma to radiotherapy: a case report

The author reports a case of a histologically proven cavernous hemangioma of the cavernous sinus and middle fossa, which was treated by radiotherapy. This very rare lesion represents a formidable challenge to the neurosurgeon and its excision has been associated with a considerable mortality rate. The significant reduction in the size of tumor of our patient after radiotherapy and the corresponding improvement in her clinical condition provide further evidence in support of the use of radiotherapy as the first line treatment modality after the histological confirmation of a cavernous sinus hemangioma. Surgery should be reserved for tumors that fail to respond to radiotherapy or recur after an initial good response to radiotherapy.

Cavernous sinus hemangiomas: a series, a review, and an hypothesis

Cavernous sinus hemangiomas represent 3% of all benign cavernous sinus tumors. They are dangerous tumors because of the risk of excessive bleeding, but they are easier to dissect from surrounding structures than meningiomas because of the presence of a pseudocapsule. Three cases where total excision was achieved with minimal blood loss, without stroke, and with preservation of cranial nerve function in 2 cases are reported, and 50 cases from the literature are reviewed. Hemangiomas can be distinguished preoperatively from over one-half of meningiomas by their marked hyperintensity on T2-weighted magnetic resonance imaging. They arise within the cavernous sinus and extend laterally by dissecting between the two layers of dura lining the floor of the middle fossa. Cranial nerves III, IV, and V remained stretched over the tumor surface within the overlying dura, whereas cranial nerve VI is found within the tumor and is the most difficult cranial nerve to preserve. Principles for successful and safe excision include preoperative assessment of the safety of temporary or permanent carotid artery occlusion, obtaining early proximal carotid artery control, carefully developing the plane between the dura and the tumor pseudocapsule, early devascularization of the tumor, and avoiding "piecemeal" tumor resection. A few cases demonstrated tumor shrinkage with radiation therapy which should be considered for patients with incomplete tumor excision or who are too ill to undergo surgery.

Magnetic resonance imaging of cavernous sinus cavernous hemangiomas

Radiological findings of surgically verified cavernous hemangiomas of the cavernous sinus are presented with special reference to the appearance in magnetic resonance imaging. Differences in radiological features of the cavernous sinus cavernous hemangiomas and intracerebral cavernous hemangiomas are discussed.