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Pensak ML. The cavernous sinus: An anatomic study with clinical implication. Laryngoscope Investig Otolaryngol 2024; 9:e1226. [PMID: 38525119 PMCID: PMC10960246 DOI: 10.1002/lio2.1226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/21/2024] [Indexed: 03/26/2024] Open
Abstract
Objective The management of lesions involving the cavernous sinus remains a formidable challenge. To optimize care for patients with tumors extending into this skull base region a detailed understanding of the surrounding osteology as well as neural and vascular relationships is requisite. This thesis examines the gross anatomy of the region and highlights important surgical implications drawn from these as well as previously published studies. Methods A review of the historical scientific, anatomic, clinical, and surgical literature extending to the present (1992) relating to the cavernous sinus has been performed and discussed. Additionally, the author has performed and described cadaveric dissections revealing novel details about the macroscopic (dural and neurovascular anatomic relationships) and microscopic structure of the cavernous sinus. A series of cases of cavernous sinus pathologies that were addressed in an interdisciplinary surgical approach at the author's institution is also reported. Results Included in this report is a comprehensive review of the embryology of the cavernous sinus and its associated neurovascular structures. Cadaveric dissections have also revealed novel details about dural/meningeal compartments of the cavernous sinus as well as well as associated arterial, venous, and neural relationships. Microscopic observations also reveal novel fundamental insights into the components and structure of the cavernous sinus. Clinical examples from 20 patients illustrate the critical importance for clinical application of cavernous sinus anatomic knowledge to the surgical treatment of pathologies in this region. Conclusion The cavernous sinus is a tripartite venous osteomeningeal compartment intimately neighboring vital structures including the optic tracts, pituitary gland, cranial nerves III, IV, V, V, VI, and the internal carotid artery. Surgical management of cavernous sinus lesions has and continues to evolve with increasing anatomic and clinical study as well as advancements in diagnostic and surgical methodologies. Level of Evidence NA.
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Affiliation(s)
- Myles L. Pensak
- Department of Otolaryngology—Head and Neck SurgeryUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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2
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Luzzi S, Giotta Lucifero A, Rabski J, Kadri PAS, Al-Mefty O. The Party Wall: Redefining the Indications of Transcranial Approaches for Giant Pituitary Adenomas in Endoscopic Era. Cancers (Basel) 2023; 15:cancers15082235. [PMID: 37190164 DOI: 10.3390/cancers15082235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/14/2023] [Accepted: 03/29/2023] [Indexed: 05/17/2023] Open
Abstract
The evolution of endoscopic trans-sphenoidal surgery raises the question of the role of transcranial surgery for pituitary tumors, particularly with the effectiveness of adjunct irradiation. This narrative review aims to redefine the current indications for the transcranial approaches for giant pituitary adenomas in the endoscopic era. A critical appraisal of the personal series of the senior author (O.A.-M.) was performed to characterize the patient factors and the tumor's pathological anatomy features that endorse a cranial approach. Traditional indications for transcranial approaches include the absent pneumatization of the sphenoid sinus; kissing/ectatic internal carotid arteries; reduced dimensions of the sella; lateral invasion of the cavernous sinus lateral to the carotid artery; dumbbell-shaped tumors caused by severe diaphragm constriction; fibrous/calcified tumor consistency; wide supra-, para-, and retrosellar extension; arterial encasement; brain invasion; coexisting cerebral aneurysms; and separate coexisting pathologies of the sphenoid sinus, especially infections. Residual/recurrent tumors and postoperative pituitary apoplexy after trans-sphenoidal surgery require individualized considerations. Transcranial approaches still have a critical role in giant and complex pituitary adenomas with wide intracranial extension, brain parenchymal involvement, and the encasement of neurovascular structures.
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Affiliation(s)
- Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Alice Giotta Lucifero
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
| | - Jessica Rabski
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Paulo A S Kadri
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
- Medical School, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, Brazil
| | - Ossama Al-Mefty
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Bonneville JF, Potorac I, Tshibanda L, Martin D, Petrossians P, Beckers A. Demonstration of the inferior intercavernous sinus is closely linked to the extent of pneumatization of the sphenoid sinus: useful information for the pituitary surgeon. Pituitary 2022; 25:861-867. [PMID: 35987843 DOI: 10.1007/s11102-022-01267-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE To study the utility of T2-weighted MRI sequences in the identification of the inferior intercavernous sinus (IICS), a potential source of bleeding during transsphenoidal surgery of pituitary adenomas. METHODS Pituitary sagittal T1W and coronal T2W MRI sequences were analyzed in 237 consecutive patients, after the exclusion of postoperative MRIs and those revealing an empty sella or a pituitary macroadenoma. Sphenoid sinus pneumatization was defined as incomplete (group 1) if it did not reach the nadir of the sella turcica, as complete (group 2) if it extended beyond the nadir of the sella or asymmetric (group 3), when only one side of the sinus was completely pneumatized. RESULTS In Group 2 (70% of the patients), the IICS was rarely visualized on coronal T2W MRI (6/167 patients-3.6%), whereas in Group 1 it was identified in nearly all patients (55/57 patients - 96.5%, p < 0.001). In Group 3, the IICS was only visible above the non-pneumatized part of the sphenoid sinus. CONCLUSIONS The IICS can be identified on coronal T2W images in patients with an incompletely pneumatized sphenoid sinus, but very rarely in patients with a totally pneumatized sinus. This information can help to increase awareness among pituitary surgeons of the need to potentially manage IICS bleeding during transsphenoidal surgery in patients with an incompletely pneumatized sphenoid sinus.
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Affiliation(s)
- Jean-François Bonneville
- Department of Medical Imaging, Centre Hospitalier de Liège, Université de Liège, Domaine Universitaire du Sart Tilman, 4000, Liège, Belgium.
| | - Iulia Potorac
- Department of Endocrinology. Centre Hospitalier de Liège, Université de Liège, Domaine Universitaire du Sart Tilman, 4000, Liège, Belgium
| | - Luaba Tshibanda
- Department of Medical Imaging, Centre Hospitalier de Liège, Université de Liège, Domaine Universitaire du Sart Tilman, 4000, Liège, Belgium
| | - Didier Martin
- Department of Neurosurgery, Centre Hospitalier de Liège, Université de Liège, Domaine Universitaire du Sart Tilman, 4000, Liège, Belgium
| | - Patrick Petrossians
- Department of Endocrinology. Centre Hospitalier de Liège, Université de Liège, Domaine Universitaire du Sart Tilman, 4000, Liège, Belgium
| | - Albert Beckers
- Department of Endocrinology. Centre Hospitalier de Liège, Université de Liège, Domaine Universitaire du Sart Tilman, 4000, Liège, Belgium
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Kosty J, Peterson R, Miriyala S, Banks T, Kandregula S, Dossani RH, Guthikonda B. An anatomic assessment of the intercavernous sinuses and review of the literature. J Neurol Surg B Skull Base 2022; 84:266-271. [PMID: 37187479 PMCID: PMC10171929 DOI: 10.1055/a-1819-0144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/03/2022] [Indexed: 10/18/2022] Open
Abstract
Background
As expanded endoscopic endonasal approaches are gaining popularity, a thorough understanding of the anatomy of the intercavernous sinuses is pertinent to avoid bleeding complications. There have been few studies reporting the presence and dimensions of the anterior (AIS), posterior (PIS), and inferior (IIS) intercavernous sinuses. We performed a cadaveric study to better understand these structures.
Methods
Colored latex was injected into the arterial and venous trees of seventeen cadaveric heads. Dissections assessed the presence and dimensions of the anterior, posterior, and inferior intercavernous sinuses. In an additional 3 specimens, the sellar contents were subjected to histologic analysis.
Results
In thirteen specimens (59%), all three sinuses were identified. In 5 specimens (33%), only the anterior and posterior intercavernous sinuses could be identified, and in one specimen, only an anterior and inferior sinus were identified. An AIS was identified in all 20 (100%) specimens, PIS in 17 (85%), and an IIS in 13 (66)%. In two specimens (10%), the AIS covered the entire face of the sella. Dimensions of the AIS averaged 1.7 x 11.7 x 2.8 mm, PIS averaged 1.5 x 10.8 x 1.7 mm, and IIS averaged 8.7 x 11.8 x 1.0 mm when present.
Conclusion
All examined specimens demonstrated the presence of an anterior intercavernous sinus, and most had a posterior intercavernous sinus. The presence of an inferior intercavernous sinus was more variable. Preoperative awareness of these sinuses is helpful in planning transphenoidal surgery in order to minimize the risk of bleeding.
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Affiliation(s)
- Jennifer Kosty
- Neurosurgery, LSU Health Shreveport, Shreveport, United States
| | | | | | - Timothy Banks
- Neurosurgery, LSU Health Shreveport, Shreveport, United States
| | | | - Rimal H Dossani
- Neurosurgery, LSU Health Shreveport, Shreveport, United States
- Neurosurgery, University at Buffalo, Buffalo, United States
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Chenin L, Toussaint P, Lefranc M, Havet E, Peltier J. Microsurgical anatomy of the inferior intercavernous sinus. Surg Radiol Anat 2020; 43:211-218. [PMID: 32975638 DOI: 10.1007/s00276-020-02581-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/15/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Intercavernous sinuses (ICSs) are physiological communications between the cavernous sinuses. The ICSs run between the endosteal and meningeal layers of the dura mater of the sella turcica. Whereas the anterior and posterior ICSs have been frequently described, the inferior ICS (iICS) has been less well studied in the literature; however, poor awareness of the ICS's anatomy can lead to serious problems during transsphenoidal, transsellar surgery. The objective of the present anatomical study was to describe the iICS in detail. METHODS The study was carried out over a 6-month period in a university hospital's anatomy laboratory, using brains extracted from human cadavers. The brains were injected with colored neoprene latex and dissected to study the iICS (presence or absence, shape, diameter, length, distance between inferior and anterior ICSs, distance between inferior and posterior ICSs, relationships, and boundaries). RESULTS Seventeen cadaveric specimens were studied, and an iICS was found in all cases (100%). The shape was variously plexiform (47.1%), filiform (35.3%), or punctiform (17.6%). The mean ± standard deviation diameter and length of the iICS were 3.75 ± 2.90 mm and 11.92 ± 2.96 mm, respectively. The mean iICS-anterior ICS and iICS-posterior ICS distances were 5.36 ± 1.99 mm and 7.03 ± 2.28 mm, respectively. CONCLUSION The iICS has been poorly described in the literature. However, damage to the iICS during transsphenoidal, transsellar surgery could lead to serious vascular complications. A precise radiological assessment appears to be essential for a safe surgical approach.
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Affiliation(s)
- Louis Chenin
- Department of Anatomy and Organogenesis, Faculty of Medicine, Jules Verne University of Picardie, 80000, Amiens, France. .,Department of Neurosurgery, Amiens University Hospital, 80000, Amiens, France.
| | - Patrick Toussaint
- Department of Neurosurgery, Amiens University Hospital, 80000, Amiens, France
| | - Michel Lefranc
- Department of Neurosurgery, Amiens University Hospital, 80000, Amiens, France
| | - Eric Havet
- Department of Anatomy and Organogenesis, Faculty of Medicine, Jules Verne University of Picardie, 80000, Amiens, France
| | - Johann Peltier
- Department of Anatomy and Organogenesis, Faculty of Medicine, Jules Verne University of Picardie, 80000, Amiens, France.,Department of Neurosurgery, Amiens University Hospital, 80000, Amiens, France
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Wahl L, Lockwood JD, Keet K, Henry BM, Gielecki J, Iwanaga J, Bui CJ, Dumont AS, Tubbs RS. The inferior intercavernous sinus: An anatomical study with application to trans-sphenoidal approaches to the pituitary gland. Clin Neurol Neurosurg 2020; 196:106000. [PMID: 32574965 DOI: 10.1016/j.clineuro.2020.106000] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The inferior intercavernous sinus is located below the pituitary gland in the sella turcica. Its presence has been controversial among anatomists because it is not always found on radiological imaging or during cadaveric dissections; however, it is becoming a better-known structure in the neurosurgical and radiological fields, specifically with respect to transsphenoidal surgery. Therefore, the present study was performed to better elucidate this structure at the skull base. PATIENTS AND METHODS Fifty adult, latex injected cadavers underwent dissection. The presence or absence of the inferior cavernous sinus was evaluated and when present, measurements of its width and length were made. Its connections with other intradural venous sinuses were also documented. RESULTS An inferior intercavernous sinus was identified in 26 % of specimens. In all specimens, it communicated with the left and right cavernous sinus. The average width and length were 3 mm and 9.5 mm, respectively. In the sagittal plane, the inferior intercavernous sinus was positioned anteriorly in 31 %, at the nadir of the sella turcica in 38 %, and slightly posterior to the nadir of the sella turcica in 31 %. In two specimens (15.4 %), the sinus was plexiform in its shape. In one specimen a diploic vein connected the basilar venous plexus to the inferior intercavernous sinus on its deep surface. CONCLUSION An improved understanding of the variable anatomy of the inferior intercavernous sinus is important in pathological, surgical, and radiological cases.
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Affiliation(s)
- Lauren Wahl
- Department of Cell and Developmental Biology, University of Colorado, Boulder CO, USA
| | - Joseph D Lockwood
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - Kerri Keet
- Division of Clinical Anatomy, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Brandon Michael Henry
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; International Evidence-Based Anatomy Working Group, Krakow, Poland
| | - Jerzy Gielecki
- Department of Radiology, Collegium Medicum, School of Medicine, University of Warmia and Mazury, Olsztyn, Poland; Department of Anatomy, University of Warmia and Mazury, Olsztyn, Poland
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA.
| | - C J Bui
- Department of Neurosurgery, Ochsner Medical Center, New Orleans, LA, USA
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA; Department of Anatomical Sciences, St. George's University, St. George's, West Indies, Grenada; Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA; Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA
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Tentorial Venous Anatomy: Cadaveric and Radiographic Study with Discussion of Origin and Surgical Significance. World Neurosurg 2019; 131:e38-e45. [PMID: 31295599 DOI: 10.1016/j.wneu.2019.06.232] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/28/2019] [Accepted: 06/29/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Described variations of tentorial venous anatomy impact surgical sectioning of the tentorium in skull base approaches; however, described configurations do not consistently explain postoperative complications. To understand the outcomes of 2 clinical cases we studied the tentorial venous anatomy of 2 cadavers. METHODS The venous anatomy of the tentorium isolated in 2 uninjected fresh cadaver head specimens with preserved bridging veins was observed by transillumination before and after methylene blue injection of the dural sinuses and tentorial veins. Our findings in cadavers were applied to explain the clinical and radiologic (magnetic resonance imaging and computed tomographic venography) findings in the 2 cases presented. RESULTS A consistent transtentorial venous system, arising from transverse and straight sinuses, communicating with supra- and infratentorial bridging veins was seen in the cadaver and patient radiography (magnetic resonance imaging and computed tomographic venography). Our first patient had a cerebellar venous infarct from compromise of the venous drainage from the adjacent brain after ligation of a temporal lobe bridging vein to the tentorium. Our second patient suffered no clinical effects from bilateral transverse sinus occlusion due to drainage through the accessory venous system within the tentorium. CONCLUSIONS Herein, we elaborate on transtentorial venous anatomy. These veins, previously reported to obliterate in completed development of the tentorium, remain patent with consistent observed configuration. The same transtentorial venous system was observed in both cases and provided insight to their outcomes. These findings emphasize the importance of the transtentorial venous system physiologically and in surgical approaches.
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Taghipour M, Ghaffarpasand F. Letter to the Editor Regarding “Six Walls of the Cavernous Sinus Identified by Sectioned Images and Three-Dimensional Models: Anatomic Report”. World Neurosurg 2017; 104:1014-1015. [DOI: 10.1016/j.wneu.2017.03.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 03/16/2017] [Indexed: 10/19/2022]
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MITSUHASHI Y, HAYASAKI K, KAWAKAMI T, NAGATA T, KANESHIRO Y, UMABA R, OHATA K. Dural Venous System in the Cavernous Sinus: A Literature Review and Embryological, Functional, and Endovascular Clinical Considerations. Neurol Med Chir (Tokyo) 2016; 56:326-39. [PMID: 27063146 PMCID: PMC4908076 DOI: 10.2176/nmc.ra.2015-0346] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 03/09/2016] [Indexed: 11/22/2022] Open
Abstract
The cavernous sinus (CS) is one of the cranial dural venous sinuses. It differs from other dural sinuses due to its many afferent and efferent venous connections with adjacent structures. It is important to know well about its complex venous anatomy to conduct safe and effective endovascular interventions for the CS. Thus, we reviewed previous literatures concerning the morphological and functional venous anatomy and the embryology of the CS. The CS is a complex of venous channels from embryologically different origins. These venous channels have more or less retained their distinct original roles of venous drainage, even after alterations through the embryological developmental process, and can be categorized into three longitudinal venous axes based on their topological and functional features. Venous channels medial to the internal carotid artery "medial venous axis" carry venous drainage from the skull base, chondrocranium and the hypophysis, with no direct participation in cerebral drainage. Venous channels lateral to the cranial nerves "lateral venous axis" are exclusively for cerebral venous drainage. Venous channels between the internal carotid artery and cranial nerves "intermediate venous axis" contribute to all the venous drainage from adjacent structures, directly from the orbit and membranous skull, indirectly through medial and lateral venous axes from the chondrocranium, the hypophysis, and the brain. This concept of longitudinal venous axes in the CS may be useful during endovascular interventions for the CS considering our better understandings of its functions in venous drainage.
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Affiliation(s)
- Yutaka MITSUHASHI
- Department of Neurosurgery, Ishikiri-Seiki Hospital, Higashiosaka, Osaka
| | - Koji HAYASAKI
- Department of Neurosurgery, Japan Community Health Care Organization, Hoshigaoka Medical Center, Hirakata, Osaka
| | - Taichiro KAWAKAMI
- Department of Neurosurgery, Osaka City University, Graduate School of Medicine, Osaka, Osaka
| | - Takashi NAGATA
- Department of Neurosurgery, Ishikiri-Seiki Hospital, Higashiosaka, Osaka
| | - Yuta KANESHIRO
- Department of Neurosurgery, Japan Community Health Care Organization, Hoshigaoka Medical Center, Hirakata, Osaka
| | - Ryoko UMABA
- Department of Neurosurgery, Osaka Saiseikai Nakatsu Hospital, Osaka, Osaka
| | - Kenji OHATA
- Department of Neurosurgery, Osaka City University, Graduate School of Medicine, Osaka, Osaka
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Prominent Inferior Intercavernous Sinus on Sagittal T1-Weighted Images: A Sign of Intracranial Hypotension. AJR Am J Roentgenol 2016; 206:817-22. [PMID: 27003051 DOI: 10.2214/ajr.15.14872] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to describe the diagnostic accuracy of the dilatation of the inferior intercavernous sinus as a sign of intracranial hypotension and to raise awareness of this anatomic structure, which can be mistaken for a focal pituitary lesion. MATERIALS AND METHODS Sagittal T1-weighted images of 26 patients with intracranial hypotension and 28 control subjects were evaluated to determine the presence of a distended inferior intercavernous sinus. Information about the shape, size, and signal of the inferior intercavernous sinus was also collected. The chi-square test was used to compare both groups. Sensitivity and specificity of the dilatation of the inferior intercavernous sinus as a sign of intracranial hypotension were calculated. RESULTS A visible inferior intercavernous sinus was found in 13 of 26 patients with intracranial hypotension (50%) and in four of 28 control subjects (14.3%). These percentages were significantly different (p = 0.005). There was no significant difference in size of the inferior intercavernous sinus in the intracranial hypotension group (median, 5.86 mm(2); interquartile range, 6.28 mm(2)) compared with the control group (median, 8.25 mm(2); interquartile range, 16.69 mm(2)). Changes in the size of the inferior intercavernous sinus were detected in congruence with the appearance or resolution of intracranial hypotension. CONCLUSION Dilatation of the inferior intercavernous sinus is frequently associated with intracranial hypotension, although it can also be found in the healthy adult as a normal anatomic variant. Recognition of this anatomic structure is important to avoid mistaking it for a focal pituitary lesion.
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Vascular Complications of Intercavernous Sinuses during Transsphenoidal Surgery: An Anatomical Analysis Based on Autopsy and Magnetic Resonance Venography. PLoS One 2015; 10:e0144771. [PMID: 26658152 PMCID: PMC4675535 DOI: 10.1371/journal.pone.0144771] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 11/23/2015] [Indexed: 02/07/2023] Open
Abstract
Purpose Vascular complications induced by intercavernous sinus injury during dural opening in the transsphenoidal surgery may contribute to incomplete tumour resections. Preoperative neuro-imaging is of crucial importance in planning surgical approach. The aim of this study is to correlate the microanatomy of intercavernous sinuses with its contrast-enhanced magnetic resonance venography (CE-MRV). Methods Eighteen human adult cadavers and 24 patients were examined based on autopsy and CE-MRV. Through dissection of the cadavers and CE-MRV, the location, shape, number, diameter and type of intercavernous sinuses were measured and compared. Results Different intercavernous sinuses were identified by their location and shape in all the cadavers and CE-MRV. Compared to the cadavers, CE-MRV revealed 37% of the anterior intercavernous sinus, 48% of the inferior intercavernous sinus, 30% of the posterior intercavernous sinus, 30% of the dorsum sellae sinus and 100% of the basilar sinus. The smaller intercavernous sinuses were not seen in the neuro-images. According to the presence of the anterior and inferior intercavernous sinus, four types of the intercavernous sinuses were identified in cadavers and CE-MRV, and the corresponding operative space in the transsphenoidal surgical approach was implemented. Conclusion The morphology and classification of the cavernous sinus can be identified by CE-MRV, especially for the larger vessels, which cause bleeding more easily. Therefore, CE-MRV provides a reliable measure for individualized preoperative planning during transsphenoidal surgery.
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Analysis of the intercavernous sinuses using multidetector computed tomography digital subtraction venography (CT-DSV). Clin Neurol Neurosurg 2015; 131:31-4. [PMID: 25679483 DOI: 10.1016/j.clineuro.2015.01.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 01/20/2015] [Accepted: 01/22/2015] [Indexed: 11/22/2022]
Abstract
PURPOSES The intercavernous sinuses (ICSs) connect both sides of the cavernous sinus. Knowledge of the ICSs is useful when employing the endoscopic endonasal transsphenoidal approach. Although there were some studies concerning the anatomy of ICSs using cadavers, there is no well-recognized method of the radiological evaluation of the ICSs. Therefore, we evaluate the ICSs using computed tomography digital subtraction venography (CT-DSV) in the cases of unruptured aneurysm that had the normal sellae anatomy. METHODS We retrospectively analyzed 97 cases of unruptured cerebral aneurysm that had normal parasellar and sellar anatomy except for the aneurysms. The analysis was performed using the multi-planar reconstruction images obtained by CT-DSV in these cases. RESULTS The anterior ICS (AICS), inferior ICS (IICS) and posterior ICS (PICS) were detected in 51 cases (52.6%), 28 cases (28.9%) and 76 cases (78.4%) respectively. In the cases older than 51 years old, the AICS was detected significantly less often than in those younger than 50 years old. CONCLUSIONS The CT-DSV images directly reflected the blood flow. Most of the past research on the ICSs was obtained using cadavers, which could therefore not directly assess the normal human blood flow. The present study showed the usefulness of CT-DSV for evaluating the ICSs and to understand the normal anatomy of the ICSs.
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Oyama K, Fukuhara N, Taguchi M, Takeshita A, Takeuchi Y, Yamada S. Transsphenoidal cyst cisternostomy with a keyhole dural opening for sellar arachnoid cysts: technical note. Neurosurg Rev 2013; 37:261-7; discussion 267. [PMID: 23999887 DOI: 10.1007/s10143-013-0496-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 06/06/2013] [Accepted: 07/27/2013] [Indexed: 10/26/2022]
Abstract
A less invasive transsphenoidal approach with a keyhole dural opening for intrasellar arachnoid cysts is described. This approach was used to address seven sellar cystic lesions with suprasellar extension; they were six intrasellar arachnoid cysts (IACs) and one Rathke's cleft cyst (RCC). In all cases, preoperative MRI revealed cerebrospinal fluid (CSF) intensity on both T1- and T2-weighted images. On preoperative contrast-enhanced MRI, five of the six IACs manifested posterior displacement of the flattened pituitary gland toward the dorsum sellae; one of the six IACs and the RCC exhibited a flattened pituitary gland on the anterior surface of the cyst. Wide cyst cisternostomy through a keyhole dural opening was carried out safely using a microscope with the support of a thin angled endoscope (30° and/or 70°, diameter 2.7 mm). As we aimed to avoid iatrogenic injury of the pituitary function, we found it difficult to obtain a sufficiently wide and precise opening of the cyst wall when the pituitary gland was located on the anterior surface of the cyst wall. Our approach facilitates safe cyst cisternostomy as wide as that obtainable by transcranial manipulation. In addition, CSF leakage is prevented by dural plasty using the fascia lata and stitching with 6-0 monofilament sutures. This technique can be adapted to address various sellar cystic lesions. However, as the posterior or anterior displacement of the normal pituitary gland in the presence of IACs or RCCs, respectively, affects the width of the cyst opening, our technique is more suitable for IACs than RCCs.
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Affiliation(s)
- Kenichi Oyama
- Department of Hypothalamic & Pituitary Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato, Tokyo, 1058470, Japan,
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Aquini MG, Marrone AC, Schneider FL. Intercavernous venous communications in the human skull base. Skull Base Surg 2011; 4:145-50. [PMID: 17171164 PMCID: PMC1661802 DOI: 10.1055/s-2008-1058966] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The intercavernous communications of the skull base were studied in 32 sphenoid blocks using electrolytic decalcification techniques, vascular filling, x-rays, and serial anatomical sections. In this study four intercavernous connections were found: anterior intercavernous sinus (AIS), posterior intercavernous sinus (PIS), inferior intercavernous sinus (IIS), and basilar plexus (BP). The AIS was present in 100% of the cases, with diameters ranging from 0.57 mm to 5.43 mm; in 17 cases (53.12%) it took up the whole anterior wall of the hypophyseal fossa. The PIS was also detected in 100% of the cases, and its diameters ranged from 0.71 mm to 4.14 mm. The IIS was identified in 31 cases (96.9%), assuming three different forms: plexuslike, venous lake, and mixed. The BP was found in 100% of the material analyzed; in 23 cases (71.9%) it proved to be the widest intercavernous communication.In 12 cases of this series the hypophysis was completely enveloped by venous structures, except at the level of the sellar diaphragm.
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15
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Loumiotis I, Cloft HJ, Lanzino G. Intercavernous sinus dural arteriovenous fistula successfully treated with transvenous embolization. a case report. Interv Neuroradiol 2011; 17:208-11. [PMID: 21696660 DOI: 10.1177/159101991101700211] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Accepted: 03/11/2011] [Indexed: 11/17/2022] Open
Abstract
The venous sinuses commonly found in the margins of the diaphragm and sella are venous interconnections between the bilateral cavernous dural sinuses and are termed intercavernous communications or intercavernous sinuses. They form a venous ring, a single "circular sinus" that extends throughout the skull base. We report the first case to our knowledge of an intercavernous sinus fistula. We emphasize the importance of thorough knowledge of lesion characteristics before considering any interventional procedure.An 84-year-old woman presented with alarming progressive orbital symptoms for one month affecting her left eye. A cerebral angiogram showed an intercavernous sinus fistula supplied by internal and external carotid arterial branches.Transvenous embolization through retrograde catheterization of the right inferior petrosal sinus allowed complete coil occlusion of the lesion. Cerebral angiography confirmed the absence of residual blood flow through the fistula.This report represents the first case of an intercavernous sinus dural arteriovenous fistula successfully treated with transvenous embolization. A detailed awareness of the regional anatomy is essential for treatment approach and favorable outcomes.
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Affiliation(s)
- I Loumiotis
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.
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16
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Syed MI, Chin A, Clark L. Life-threatening epistaxis from a rare treatable cause. Am J Emerg Med 2007; 25:116-8. [PMID: 17157707 DOI: 10.1016/j.ajem.2006.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Accepted: 05/13/2006] [Indexed: 11/18/2022] Open
Affiliation(s)
- Mohammed Iqbal Syed
- Southern General Hospital, South Glasgow University Hospitals National Health Service Trust, Glasgow, UK.
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17
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Kitano M, Taneda M. Extended transsphenoidal approach with submucosal posterior ethmoidectomy for parasellar tumors. Technical note. J Neurosurg 2001; 94:999-1004. [PMID: 11409533 DOI: 10.3171/jns.2001.94.6.0999] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors have developed an extended transsphenoidal approach with submucosal posterior ethmoidectomy for resection of tumors located in the cavernous sinus or the suprasellar region that are difficult to remove via the conventional transsphenoidal approach. Surgery was performed using this approach in 14 patients with large pituitary adenomas, three patients with craniopharyngiomas, and one patient with a meningioma of the tuberculum sellae. The submucosal dissection of the nasal septum used in the conventional transsphenoidal approach was extended to the superior lateral wall of the nasal cavity to expose the bony surface of the superior turbinate lying under the nasal mucosa. Submucosal posterior ethmoidectomy widened the area visualized through the conventional transsphenoidal approach both superiorly and laterally. This provided a safer and less invasive access to lesions in the cavernous sinus or the suprasellar region through the sphenoid sinus. Using this approach the authors encountered no postoperative complications, such as olfactory disturbance, cranial nerve palsy, or arterial injury. In this article the authors present the surgical methods used in this approach.
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Affiliation(s)
- M Kitano
- Department of Neurosurgery, Kinki University School of Medicine, Osaka-Sayama, Osaka, Japan.
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18
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Ettl A, Zwrtek K, Daxer A, Salomonowitz E. Anatomy of the orbital apex and cavernous sinus on high-resolution magnetic resonance images. Surv Ophthalmol 2000; 44:303-23. [PMID: 10667437 DOI: 10.1016/s0039-6257(99)00115-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Diseases of the orbital apex and cavernous sinus usually present with involvement of multiple cranial nerves, corresponding to the complex anatomy of the region. In nontraumatic disorders, magnetic resonance imaging is the diagnostic modality of choice. However, its capabilities can be fully used only with thorough knowledge of the complicated topographic relationships in this region. This article describes the imaging anatomy of the cranio-orbital junction and adjacent subarachnoid spaces. High-resolution magnetic resonance images of normal subjects are presented, and the results are compared with findings reported in the literature. The following anatomic structures can be visualized on high-resolution magnetic resonance images: extraocular muscles and corresponding connective tissue, major orbital and cerebral arteries, ophthalmic veins, cavernous sinus, and all sensory and motor cranial nerves of the eye along their intraorbital and intracranial course.
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Affiliation(s)
- A Ettl
- Department of Neuro-Ophthalmology, General Hospital, St. Pölten, Austria.
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19
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Panasci DJ, Nelson PK. MR IMAGING AND MR ANGIOGRAPHY IN THE DIAGNOSIS OF DURAL ARTERIOVENOUS FISTULAS. Magn Reson Imaging Clin N Am 1995. [DOI: 10.1016/s1064-9689(21)00259-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Bhatoe HS, Suryanarayana KV, Gill HS. Recurrent massive epistaxis due to traumatic intracavernous internal carotid artery aneurysm. J Laryngol Otol 1995; 109:650-2. [PMID: 7561475 DOI: 10.1017/s0022215100130932] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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.
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Affiliation(s)
- H S Bhatoe
- Department of Neurosurgery, Command Hospital (SC), Pune, Maharashtra, India
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21
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Abstract
The study of the venous channels in the cavernous sinus in 48 sphenoid bones was performed. Thirty-eight bones were electrolyticly decalcified, subsequently embedded in gelatin, and cut in 1 mm thick slices. Microdissection of the other ten specimens complemented the analysis. Every specimen had the venous structure arranged as a plexus, however, although the channels were variable in number, form, and diameter, the two sides were quite symmetrical. Channels of smaller diameter predominated anteriorly. There was no demonstrable muscular layer in these vessels; the endothelial lining was easily visualized. Fatty tissue separated the venous channels from each other and from arteries and nerves. The distance from the carotid artery and the lateral wall increased anteriorly, but there were significant veins between these two structures in only 35% of the cases. In about one third of specimens the oculomotor nerve was placed over the carotid artery. The abducens nerve was found to be intimately related to the lateral wall without any venous channels between them in 92% of the specimens.
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22
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Microsurgical Resection of Tumors Involving the Cavernous Sinus: Possibilities and Limitations. ACTA ACUST UNITED AC 1989. [DOI: 10.1007/978-3-642-74279-8_27] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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Abstract
The case of a Turner's syndrome patient with an intracavernous hemangioma is presented. The rarity of this lesion is stressed, as is surgical removal without postoperative deficit, the role of estrogens in the pathogenesis, and the clinical and radiological findings.
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Abstract
Dural shunts are vascular communications in which blood flows through small meningeal branches of the carotid arteries to enter the venous circulation near the cavernous sinus. The features of 10 patients with dural shunts are described. Most of these patients were postmenopausal women with dilated episcleral vessels, unilateral elevation of intraocular pressure, and exophthalmos. Pain or discomfort was common and ptosis or limited eye movement was usually present. These findings were characteristically more mild than those associated with carotid-cavernous sinus fistulas. CT scans usually showed enlargement of the extraocular muscles and the superior ophthalmic vein. Arteriography visualized partial or complete occlusion of intracranial venous drainage posterior to the cavernous sinus in all patients. Vascular dynamics of dural shunts are reviewed, and it is suggested that many of these communications may be congenital and that the onset of clinical abnormalities may be associated with the occurrence of intracranial venous thrombosis. Most patients eventually had resolution of their clinical abnormalities without treatment, and in some cases this improvement occurred soon after carotid arteriography.
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Delvert JC, Théron J, Laffont J, Jan M, Santini JJ, Gouazé A. Bases anatomiques de l'exploration radiologique des sinus intercaverneux à la recherche des expansions intra-sellaires. ACTA ACUST UNITED AC 1979. [DOI: 10.1007/bf01654586] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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McGrath P. The cavernous sinus: an anatomical survey. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1977; 47:601-13. [PMID: 273404 DOI: 10.1111/j.1445-2197.1977.tb06591.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
An anatomical survey of the cavernous sinus in 16 adult cadavera has been made, based on serial sections cut at 15 micron in the coronal and sagittal planes. Certain aspects of the survey are of particular interest: (1) the oculomotor, trochlear, and ophthalmic nerves do not run in the lateral dural wall of the cavernous sinus; (2) venous sinuses of the cavernous sinus flow freely in a medial direction both anterior and posterior to the dorsum sellae; (3) trabeculae in the form of collections of fine areolar tissue extend between the vascular and neural elements. The amount present is variable; (4) the horizontal section of the internal carotid artery within the cavernous sinus runs a variable course in relation to the hypophysis and the lateral dural wall; (5) the oculomotor nerve lies within a meningeal envelope as far anteriorly as the tip of the anterior clinoid process; (6) the ophthalmic nerve communicates with the oculomotor, trochlear, and abducent nerves in the anterior part of the cavernous sinus; (7) the abducent nerve may lie within a meningeal envelope in the posterior part of the cavernous sinus; (8) the greater part of the sympathetic nerve plexus around the vertical part of the internal carotid artery passes into the abducent and ophthalmic nerves. Sympathetic fibres pass into the sheaths surrounding the oculomotor and trochlear nerves. Sympathetic ganglia are suspended from the ophthalmic nerve.
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