A cavernous sinus cavernous hemangioma. Case report

Orbital Cavernous Venous Malformation in a 35-Year-Old Man: A Case Report

In this article we present a case of a 35-year-old patient with a massive 43 × 35 × 34 mm cavernous venous malformation of the left orbit. The orbital lesion was initially observed in 2008 and remained untreated to 2021 due to the patient's refusal to consent to the surgical procedure; which caused the tumor to grow to monstrous dimensions.

Surgical Treatment of Cavernous Sinus Cavernomas: Evidence from Vietnam

Cavernous sinus cavernomas, a rare vascular malformation, represents 3% of all benign cavernous sinus tumors. Both clinical and radiological signs are important for differentiating this condition from other cavernous sinus diseases. The best treatment is radical removal tumor surgery; however, due to the tumor being located in the cavernous sinus, there are many difficulties in the surgery. We report a case of a 35-year-old female who only presented sporadical headache. After serial magnetic resonance imaging acquisitions, a tumor measuring 30 mm in the left cavernous sinus and heterogenous enhencement was observed. Then, the patient underwent an operation with an extradural basal temporal approach. Postoperatively, the tumor was safely gross total removed. The patient developed left oculomotor nerve palsy but fully recovered after 3 months of acupunture treatment, and developed persistent left maxillofacial paresthesia. The surgical treatment for cavernous sinus cavernomas may be considered a best choice regarding safety and efficiency.

Pediatric Intracavernous Sinus Lesions: A Single Institutional Surgical Case Series and Review of the Literature

BACKGROUND

Pediatric intracavernous sinus tumors are exceedingly rare and thus poorly characterized. Their neurosurgical management is challenging and diagnostic, and management guidelines are limited.

OBJECTIVE

To report our institutional experience with the surgical resection of pediatric intracavernous sinus tumors. We also compare and contrast our results with the 14 cases of pediatric intracavernous sinus lesions in the current literature.

METHODS

A retrospective descriptive analysis of consecutive pediatric patients (ages 0-18 yr) presenting to our institution with a diagnosis of an intracavernous sinus lesion was performed. From January 2012 to January 2017, 5 cases were identified. Eleven patients with secondary invasion of the cavernous sinus (2 meningiomas, 7 pituitary adenomas) or dermoid tumors involving the cavernous sinus (2) were not included in our review.

RESULTS

Surgical resection via a frontotemporal orbitozygomatic approach was performed in all cases by a single senior neurosurgeon (M.L.). There were no perioperative or postoperative complications attributable to the surgery or approach. Four of 5 patients remained neurologically stable throughout the perioperative and postoperative period. The fifth patient had a complete resolution of their cranial neuropathies postoperatively. A pathological diagnosis that guided long-term management was obtained in all cases.

CONCLUSION

Neurosurgical management of pediatric cavernous sinus lesions can be safely performed and critically guide future therapies. Surgeon familiarity with cavernous sinus and skull-base anatomy is critical to the successful management of these patients. The benefits of surgery should be balanced against the potential complications and need for a tissue diagnosis in children. The senior author had a significant experience with cavernous sinus approaches in adults prior to initiating use of the approach in the pediatric population.

Multidisciplinary management of an intra-sellar cavernous hemangioma: Case report and review of the literature

Extra-axial cavernous hemangiomas (ECH) are rare vascular lesions with a tendency to grow within the medial structures of the middle cranial fossa. This pathological entity lacks specific symptoms, and falls into the category of differential diagnosis of space occupying lesions in the cavernous sinus (CS) with or without sellar involvement, including those of tumoral, vascular and inflammatory nature. Of note, ECH can also be indolent, and is at times discovered incidentally during autopsy investigations. On radiological studies, ECH with sellar extension are frequently mistaken at first for pituitary adenomas. Total removal of intrasellar-CS ECH is technically demanding and burdened by remarkable morbidity and mortality rates, mostly related to the complex neuroanatomy of the CS-sellar region (i.e., peri and postoperative bleeding, and transitory or permanent nerve palsies, hormonal deficits). Consequently, only a few cases of successful total removal have been reported so far in the literature. Surgical debulking with cranial nerve decompression followed by stereotactic radiosurgery is currently considered the best alternative to total removal when the latter carries excessive perioperative risks. We present a rare case of a mainly located intrasellar ECH extending to the left CS discussing its clinical features and focusing on the most relevant aspects of the surgical management along with a review of the pertinent literature.

Cavernous Sinus: A Comprehensive Review of its Anatomy, Pathologic Conditions, and Imaging Features

The purpose of this article was to review the anatomy of the cavernous sinus (CS), illustrate numerous lesions that can affect the CS, and emphasize the imaging characteristics for each lesion to further refine the differential diagnoses. The CS, notwithstanding its small size, contains a complicated and crucial network that consists of the carotid artery, the venous plexus, and cranial nerves. The wide-ranging types of pathologies that can involve the CS can be roughly classified as tumoral, congenital, infectious/inflammatory/granulomatous, and vascular. Conditions that affect the CS usually lead to symptoms that are similar to each other; thus, for diagnosis, imaging procedures are required. Radiological evaluations are also required to detect pre- and postoperative CS invasion. Magnetic resonance imaging, which can be supplemented with thin-section contrast-enhanced sequences, is the preferred imaging technique for evaluating the CS. For correct diagnosis of CS lesions and accurate evaluations of CS invasions, it is essential to carefully analyze the anatomical structures within the CS and to acquire precise knowledge about the imaging features of CS lesions, which may frequently overlap.

Gamma knife surgery for a hemangioma of the cavernous sinus in a child

Cavernous sinus (CS) hemangiomas are rare vascular abnormalities that constitute 0.4%-2% of all lesions within the CS. Cavernous sinus hemangiomas are high-flow vascular tumors that tend to hemorrhage profusely during resection, leading to incomplete resection and high morbidity and mortality. While Gamma Knife surgery (GKS) has proven to be an effective treatment of CS hemangiomas in the adult population, few reports of GKS for treatment of CS hemangiomas exist in the pediatric literature. Here, the authors present the first case of a 15-year-old girl with a biopsy-proven CS hemangioma who achieved complete resolution of her symptoms and a complete imaging-defined response following GKS. If suspicion for a CS hemangioma is high in a pediatric patient, GKS may be considered as an effective treatment modality, thus avoiding the morbidities of open resection.

Cardiovascular phenotype in Turner syndrome--integrating cardiology, genetics, and endocrinology

Cardiovascular disease is emerging as a cardinal trait of Turner syndrome, being responsible for half of the 3-fold excess mortality. Turner syndrome has been proposed as an independent risk marker for cardiovascular disease that manifests as congenital heart disease, aortic dilation and dissection, valvular heart disease, hypertension, thromboembolism, myocardial infarction, and stroke. Risk stratification is unfortunately not straightforward because risk markers derived from the general population inadequately identify the subset of females with Turner syndrome who will suffer events. A high prevalence of endocrine disorders adds to the complexity, exacerbating cardiovascular prognosis. Mounting knowledge about the prevalence and interplay of cardiovascular and endocrine disease in Turner syndrome is paralleled by improved understanding of the genetics of the X-chromosome in both normal health and disease. At present in Turner syndrome, this is most advanced for the SHOX gene, which partly explains the growth deficit. This review provides an up-to-date condensation of current state-of-the-art knowledge in Turner syndrome, the main focus being cardiovascular morbidity and mortality. The aim is to provide insight into pathogenesis of Turner syndrome with perspectives to advances in the understanding of genetics of the X-chromosome. The review also incorporates important endocrine features, in order to comprehensively explain the cardiovascular phenotype and to highlight how raised attention to endocrinology and genetics is important in the identification and modification of cardiovascular risk.

Diffuse large B-cell lymphoma within a cavernous hemangioma of the cavernous sinus

Cavernous angiomas or hemangiomas and malignant lymphomas rarely involve the cavernous sinus. We report the case of a 72-year-old man with right circumorbital pain and right oculomotor nerve dysfunction because of a mass in the right cavernous sinus. It was removed via a transsphenoidal approach and histological examination revealed the mass was a cavernous hemangioma containing atypical large B cells in some sinusoidal vessels; no other evidence of lymphoma was detected on (18)F-2-fluoro-2-deoxy-D-glucose positron-emission tomography or bone marrow biopsy. The patient underwent gamma knife radiosurgery (GKS) of the right cavernous sinus, but no systemic chemotherapy was administered. Although good local control was achieved, the patient developed a systemic diffuse large B-cell lymphoma (DLBCL) 1.5 years after the GKS. The atypical lymphocytes of the cavernous hemangioma and biopsied lymph nodes expressed multiple myeloma oncogene-1 protein. This is a rare case of DLBCL occurring within a cavernous sinus that was diagnosed as hemangioma of the cavernous sinus by neuroimaging, surgical findings, and rapid-freezing histological diagnosis. The case indicates a importance of surgical sampling and detailed histopathological analysis.

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.

Are cavernous sinus hemangiomas and cavernous malformations different entities?

Cavernous hemangiomas that occur within the cavernous sinus (CS) are different from cerebral cavernous malformations (CMs) clinically, on imaging studies, and in their response to treatment. Moreover, CMs are true vascular malformations, whereas hemangiomas are benign vascular tumors. Because of these differences, the authors suggest that these two entities be analyzed and grouped separately. Unfortunately, despite these differences, much confusion exists in the literature as to the nature, behavior, and classification of these two distinct lesions. This confusion is exacerbated by subtle histological differences and the inconsistent use of nomenclature. The authors use the term "cavernous malformation" to refer to intraaxial lesions only; they prefer to use the term "cavernous sinus hemangioma" to refer to extraaxial, intradural hemangiomas of the CS.

Intrasellar cavernous hemangioma

Reports of intrasellar cavernous hemangioma are rare. They are usually incidental findings at autopsy, or initially mistaken for pituitary adenoma and treated accordingly. There are no specific symptoms. Cranial nerve palsy has occasionally been reported in patients with cavernous hemangioma, with or without sellar extension. However, intrasellar cavernous hemangioma with extension into the cavernous sinus resulting in oculomotor palsy has not been reported. We present a rare case of intrasellar cavernous hemangioma and discuss the diagnosis and management. Total surgical removal is recommended. However, attempts to resect the parasellar component of the lesion may be associated with high morbidity. Therefore, surgical cranial nerve decompression in the acute stage followed by stereotactic radiosurgery for the residual lesion may be an alternative.

Cavernous hemangioma extending to extracranial, intracranial, and orbital regions

✓ Extraaxial cavernous hemangiomas are rare intracranial lesions that can be located in different cranial compartments. Extension across different tissue planes such as the subcutaneous tissue, skull, orbital cavity, intracranial dura mater, and extracranial trigeminal divisions within the same patient has not been previously reported.

This 32-year-old woman suffered left exophthalmos, left sixth nerve palsy, and trigeminal neuropathy. Magnetic resonance imaging studies revealed an extensive multicompartmental lesion, with enhancement following Gd administration.

A left orbitopterional approach allowed removal of several cavernomatous lesions located in the orbit, frontotemporal dura, and lateral wall of the cavernous sinus. A histologically based diagnosis of extraaxial cavernous hemangioma was made. In the postoperative period the patient experienced a regression of her symptoms.

The authors report on a case of cavernous hemangioma with a unique extension to different intracranial/extracranial compartments. Although radical removal of the lesion was not feasible, partial excision allowed for satisfactory clinical control of the patient's symptoms.

Intracavernous granular cell tumor

BACKGROUND

Granular cell tumors in the central nervous system are quite rare. To date, only 6 cases of granular cell tumor arising from cranial nerves have been reported in the literature. To the best of our knowledge, we present the first case of a predominant intracavernous granular-cell tumor arising from oculomotor nerve.

CASE PRESENTATION

A 42-year-old man presented with third-nerve paresis and decreased visual acuity on the left side. Magnetic resonance imaging showed a mainly intracavernous mass partially extending to the superior orbital fissure and entrance of the optic canal. Using a pterional craniotomy, the tumor was removed from within the cavernous sinus via combined superior and lateral intradural approach, and optic nerve was also decompressed. Histologically, the tumor was diagnosed as a granular cell tumor.

CONCLUSIONS

Although it is quite rare, granular cell tumor should be included into the differential diagnosis of intracavernous masses because surgical treatment is curative.

Extradural approach for cavernous hemangioma of the cavernous sinus: experience with 13 cases

The clinical, radiological, and surgical issues concerning cavernous hemangiomas located within the dural confines of the cavernous sinus were analyzed on the basis of experience with 13 cases. The feasibility of radical resection by an entirely extradural approach using a basal temporal surgical route to this relatively rare and formidable surgical problem was investigated. Thirteen patients, four males and nine females, with cavernous hemangioma involving the cavernous sinus were treated from 1992 to 2001. The patients were aged from 15 to 55 years. Headaches and deficits of the cranial nerves coursing through the cavernous sinus were the principal symptoms at presentation. Vision was affected in four patients. The radiological features in all patients were similar with a characteristic pattern of extension and encasement of internal carotid artery. The maximum size of the tumor was 28 to 73 mm (mean 44 mm). An entirely extradural route using the basal temporal approach was used successfully in seven cases. Total resection was achieved in 12 patients and partial resection was achieved in one patient. The follow up ranged from 8 months to 9 years (mean 45 months). The outcome of extraocular movements was poor in our series, possibly due to the massive sizes of the tumors encountered. There was no recurrence or growth of the residual tumor and all patients were leading active lives.

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.

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.

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 malformation of the mammillary bodies: neuropsychological implications. Case report

The authors present the first documented case of a cavernous malformation of the mammillary bodies. A 34-year-old woman presented with a 2-month history of headaches and acute memory changes. Magnetic resonance imaging studies demonstrated a retrochiasmatic interpeduncular lesion that was initially thought to be a craniopharyngioma. Operative resection confirmed the diagnosis of a cavernous malformation. This particular case is unique in its destruction of the mammillary bodies and presents further evidence of the relationship of these regions to memory. This report is also the first to document results of pre- and postoperative neuropsychological evaluations that specifically address the memory deficits created by destruction of the mammillary bodies.

Sellar and parasellar extra-axial cavernous hemangiomas

Cavernous hemangiomas can grow extra-axially within dural sinuses, particularly the cavernous sinus and present like tumours. Five cases of cavernous hemangiomas arising within or from the wall of the cavernous sinus are reported. Three of them had an "endophytic" growth within the cavernous sinus with a lateral extension into the middle cranial fossa, a medial extension into the sella and an anterior extension into the superior orbital fissure. Two cases presented with an "exophytic" extension from the sinus wall at the point of entry of the third and fourth cranial nerves respectively. These patterns of growths are best appreciated by MRI. Keeping in mind that these lesions are contained within a pseudocapsule will help in planing surgical strategy. Characteristic MRI findings of cavernous hemangiomas in this location include hypo-intensity on T 1-weighted images, marked hyperintensity on T2-weighted images and Gadolinium enhancement.

Cavernous hemangiomas of the dura mater at the convexity. Report of a case and therapeutical considerations

A rare case of cavernous angioma of the dura mater at the convexity is presented. In comparison with the more common cavernous hemangiomas that arise from dural sinuses, the ones on the convexity have a much better prognosis. They do not seem to be associated with spontaneous hemorrhage, their removal is simpler and, transoperatory bleeding, if it occurs, is scanty. Computerized tomography detects the presence of cavernous angiomas of the convexity in only 70% of the cases, magnetic resonance imaging in 100%.

Turner syndrome and occlusion of the internal carotid artery

A 2-year-old girl with Turner syndrome was admitted with left hemiplegia and left facial palsy. Serial cranial computed tomographic scan demonstrated multiple cerebral infarctions in the right putamen and right medial cortical areas. Single photon emission computed tomographic scan revealed hypoperfusion from the right frontal to the right temporal area. Right carotid angiography showed narrowing and occlusion of the right internal carotid artery at the sphenoidal portion. Collateral circulation was not detected between the external and internal carotid arteries. Left carotid angiography revealed that the left anterior artery was narrow, and that the left internal carotid artery provided blood to the right internal carotid artery through the anterior communicating artery. These findings suggested that the cerebrovascular abnormality might be due to congenital hypoplasia of arteries in this patient. The unusual combination of cerebral infarction and Turner syndrome was reported.

Intracranial cavernous angioma

We report 14 cases of intracranial cavernous angioma, analyzing the clinical features, with special reference to the risk of bleeding, radiological images and treatment in these and in 153 published cases, 167 in all. Cerebral hemorrhage occurred in 44%: typical (intraparenchymal or subarachnoid) in 24.6%, and masked by epilepsy, headache or neurological deficits in 19.2%. In patients with the typical hemorrhagic pattern posthemorrhagic mortality was 12.2%. Of the patients who had a hemorrhage 42.5% were left with more or less disabling neurological deficits, and 16.4% had a rebleed. In discussing treatment we consider four groups of intracranial cavernous angioma: A) symptomatic in a zone of low surgical risk; B) asymptomatic with low surgical risk; C) symptomatic with high surgical risk; D) asymptomatic with high surgical risk. The treatment is surgical, except in the high risk asymptomatic variety, best followed initially with sequential CT scan and MRI and then considered for surgery if the lesion becomes symptomatic, increases in size or presents neuroradiological signs of bleeding.

Development of resistance to antitumor chloroethylnitrosoureas in vitro in brain tumor cells

Rat brain tumor cell lines (9L, C6-1, C6-2), human brain tumor cells (T98G), and HeLa S3 cells were studied to assess their acquired resistance to the chloroethylnitrosoureas (CENUs), 1-(4-amino-2-methyl-5-pyrimidinyl)methyl-3-(2-chloroethyl)-3-nitrosourea hydrochloride (ACNU) and methyl-6-[3-(2-chloroethyl)-3-nitrosoureido]-6-deoxy-alpha-D-glucopyr anosid e (MCNU), after 10 repeated exposures of a panel of different drug concentrations. Assay end-point was colony-forming ability after 24-h drug exposure. Intrinsic resistance was tested at the 10% survival dose (SD10) and C6-1, T98G, and HeLa S3 cell lines were 3 to 16 times more resistant to ACNU than 9L and C6-2 cell lines. After repeated exposures to ACNU, 9L and C6-2 cells acquired 2- and 5-fold resistance to ACNU respectively, whereas C6-1 and T98G cells retained a resistance almost equivalent to the respective parent cells. HeLa S3 cells also acquired resistance to ACNU, as evidenced by a 3.5-fold increase. The SD10 of the cells to MCNU ranged from 4.3 microM (C6-2 cells) to 151.7 microM (T98G cells). After long-term exposure to MCNU, all five cell lines became significantly resistant compared to their respective parent cells. The easily obtained acquired resistance to CENUs suggests a clinical disadvantage of continual and repeated adjuvant monochemotherapy with these agents.

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.

Cerebral cavernous malformations (cavernomas) in the pediatric age-group

Cavernomas are vascular malformations composed of a compact mass of sinusoidal-type vessels that are immediately contiguous with one another and have no intervening parenchyma. Cavernous malformations were previously held to be a rare pathology occurring predominantly in adults. New neuroradiological techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) demonstrate, on the contrary, that these lesions are also more frequent during childhood than was previously thought. In our institution we observed 17 cases of cavernous malformations in patients aged between 18 months and 16 years, 16 of whom were diagnosed after 1982. In 4 of these cases there was a documented familial history; in 2 multiple malformations were present. The most common site was the subcortical frontal region, but in 1 case the malformation was located in the pineal region. The most frequent (in 12 cases) initial symptom was hemorrhage, with the characteristics of an intracerebral hematoma. In 4 cases the initial symptom consisted of epileptic fits and 2 of these patients subsequently suffered hemorrhage. In one case the symptoms observed were those of an expansile process. All our patients underwent cerebral angiography and only in 1 case did this show a vascular abnormality. CT, performed in 16 patients, gave positive results in all cases. MRI, performed in 12 patients, gave highly significant images in all cases. Radical surgical removal of the malformation was performed in 15 of the 17 patients, and the results can be considered excellent in the majority of cases. Cavernous malformations are, therefore, more frequent lesions than had previously been thought, especially in pediatric patients.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Large cavernous haemangioma of the pituitary fossa: a case report

A large pituitary fossa cavernous haemangioma in a 48-year-old male is presented. The rarity of this lesion is stressed. The relevant literature is reviewed.

Extra-axial cavernous hemangiomas involving the dural sinuses

Extra-axial cavernous hemangiomas are rare lesions previously associated with unacceptable mortality and morbidity rates that precluded surgical resection. The authors analyze the clinical presentation, surgical results, and histology of eight intrasinus cavernous hemangiomas: six located in the cavernous sinus, one in the petrosal sinus, and one in the torcula. Magnetic resonance imaging is the best radiographic test for surgical planning. Successful tumor removal was achieved in six cases with no mortality and low morbidity. In the remaining two patients, only subtotal resection was achieved because of massive hemorrhage in one and the misdiagnosis of a pituitary adenoma leading to a transsphenoidal approach in the other. For hemangiomas arising within the cavernous sinus, extradural removal of the sphenoid bone facilitated preservation of the neurovascular structures. Since the clinical and histological characteristics of these lesions are distinct from intra-axial cavernous hemangiomas, a more appropriate term may be "sinus cavernoma" to indicate that these lesions are primarily intrasinus in origin.

Cerebral cavernous angioma in children

Cerebral cavernous angioma is a rare vascular malformation at any age and is very rare in childhood. In the literature available to us, we have been able to trace only 50 cases, to which we have added the 6 cases from our own series. The incidence in pediatric group is higher at 0-2 years (26.8%) and at 13-16 years (35.7%). The clinical onset shows epilepsy in 45.4% of cases, hemorrhagic syndrome in 27.3%, intracranial hypertension in 16.4%, and focal neurological deficits in 10.9%. Furthermore, we discuss the neuroradiological features (CT, angiography, and MRI) and the therapy of pediatric cavernous angioma.

Pedal hemangioma (venous malformation) occurring in Turner's syndrome: an additional manifestation of the syndrome

Two infants with Turner's syndrome and an unusual vascular tumor or malformation of the feet are described. In one child, the lesion developed in the dorsal metacarpal area, whereas in the other, the lesion was located in a bilaterally symmetrical distribution over the dorsum of the feet. Both lesions were characterized by a proliferation of tortuous, thick-walled veins with imperfectly formed muscular walls. Redundancy of the endothelial lining leading to intimal "webs" and intraluminal vascular channels was prominent. The similarity of these two lesions clinically and histologically suggests that they do not represent a fortuitous occurrence, but an additional manifestation of Turner's syndrome. Furthermore, their existence indicates that the vascular abnormality in Turner's syndrome may be more generalized than previously recognized and may include abnormalities of peripheral blood vessels in addition to those of the heart and aorta.

Cavernous hemangiomas in children

Cavernous angiomas are histologically benign hamartomas, showing no potential for metastasis. Clinically, patients present with convulsions, hemorrhage, or signs of mass effect. Although many cases exhibit ossification on X-ray, the main means of diagnosis is computed tomography. This, in turn, has led to earlier diagnoses being made in much younger patients. Early diagnosis is a matter of urgency as patients are otherwise exposed to the continuing threat of rupture. As cavernous angiomas are operable, the prognosis is usually good.