Color Doppler Imaging in the Diagnosis and Follow-up of Carotid Cavernous Sinus Fistulas

This report describes color doppler imaging (CDI) in theevaluation and follow-up of nine patients with carotid cavernous sinusfistulas.The orbits and carotid arteries were examined with CDI.In allcases,the diagnosis was confirmed by angiography.CDI clearlydemonstrated the dilated superior ophthalmic veins (SOVs) with retrogradeflow and low resistance arterial doppler waveform in all nine patients (10eyes).After the study of quantitative hemodynamics,we found that directcarotid cavernous sinus fistulas s...

Transvenous Embolization of Carotid Cavernous Fistula by Sequential Occlusion of the Cavernous Sinus

Objective Introduction When we perform transvenous embolization of carotid cavernous fistula, we selectively occluded the venous outflow to the retrograde cortical venous drainage and retrograde ophthalmic venous drainage as the initial steps before the rest of the cavernous sinus. The rationale is to prevent re-diversion of flow into the ophthalmic veins and cortical veins in a subtotally occluded carotid cavernous fistula.Method From 1997 to 2004, a total of 46 patients with carotid cavernous fistula were treated by transvenous embolization using the proposed selective occlusion strategy. There were 6 direct and 40 dural cartoid cavernous fistulae. The embolic agents were Guglielmi detachable coils and fibered platinum coils. Transvenous embolization routes included inferior petrosal sinus (IPS) alone (32 patients), IPS and intercavernous sinus (9 patients), and superior ophthalmic vein (5 patients).Result The follow-up period ranged from 4 months to 7 years. One patient developed retinal hemorrhage due to ophthalic vein thrombosis one week after the embolization procedure. Two patients had transient ophthalmoplegia and 2 patients had symptomatic recurrence of the carotid cavernous fistula during the follow-up. Clinical cure was achieved in 44 patients (96%).Conclusion The sequential occlusion strategy offers a safe and effective method in the transvenous embolization of carotid cavernous fistula.

Application of virtual reality in quantified analyses for cavernous sinus surgical approach

Objective To evaluate the utility of virtual reality system in quantitative comparison for cavernous sinus surgical approach. Methods Image data of CT and MRI scan performed in five adult cadaver heads was inputted into the Destroscope virtual reality system to build 3-D model of cavernous sinus.

Characteristic MR imaging findings and surgical treatment of cavernous hemangiomas in cavernous sinus

Objective To analyze the imaging character and surgical therapy of cavernous hemangiomas in cavernous sinus(CSHs).Methods From 2001 to 2008,13 patients with CSHs were surgically treated in our department. The diameters of CSHs varied from 3. 5 cm to 6. 0 cm. Results All the patients were operated on with no mortality.

Giant cavernous aneurysms occluded by aneurysmal thrombosis,calcification,parent artery occlusion:A case report and review of literature

BACKGROUND Patients with giant intracranial aneurysms(GIAs)are at a high risk of rupture,morbidity,and mortality even after surgical or endovascular treatment.We described a case of a spontaneously occluded GIA secondary to gradual growth of the GIA,continuously progressed aneurysmal thrombosis,complete aneurysmal calcification and complete occlusion of the parent artery-the right internal carotid artery(RICA).CASE SUMMARY A 72-year-old female patient complained of sudden pain in her right eye upon admission to our hospital.She had been diagnosed with a GIA[30 mm(axial)×38 mm(coronal)×28 mm(sagittal)]containing an aneurysmal thrombus located in the cavernous sinus segment of RICA diagnosed by magnetic resonance imaging(MRI),enhanced MRI,and magnetic resonance angiography more than 14 years ago.Later,with slow growth of the cavernous carotid GIA,aneurysmal thrombosis progressed continuously,spontaneous occlusion of the RICA,complete aneurysmal calcification,and occlusion of the GIA occurred gradually.She had no history of subarachnoid hemorrhage but missed the chance for endovascular therapy at an early stage.As a result,she was left with severe permanent sequelae from the injuries to the right cranial nerves Ⅱ,Ⅲ,Ⅳ,V1/V2,and Ⅴ.CONCLUSION The risk of rupture of the cavernous carotid GIAs was relatively low and possibly further be reduced by the stasis flow and spontaneous occlusion of the parent artery internal carotid artery(ICA)induced by the mass effect of the cavernous carotid GIAs and the extremely rare aneurysmal calcification.However,nowadays,it is advisable to recommend early endovascular treatment for the cavernous carotid GIAs to prevent injuries to the surrounding intracranial nerves and occlusion of the ICA,mainly caused by the mass effect of the cavernous carotid GIAs.

Endoscopic transsphenoidal approach to pituitary adenomas invading the cavernous sinus

Background Surgery of pituitary adenomas invading cavernous sinus has always been thought as a challenge due to the complex anatomical structures and high risk of complications. The purpose of this study was to evaluate endoscopic trarssphenoidal approach to pituitary adenomas invading cavernous sinus.Methods The clinical data of 22 patients who admitted to Xuanwu Hospital with pituitary adenomas invading cavernous sinus were analyzed retrospectively. All patients underwent endoscopic transsphenoidal surgery. To expose the surgical field sufficiently, the opening of sellar floor was exceeded the bone overlying the invaded cavernous sinus, and synthetic dura was used to repair and strengthen the sella floor for preventing the leak of cerebrospinal fluid.Results Among 22 patients, total resection was achieved in 14, subtotal resection in 5, and partial resection in 3; no patient underwent insufficient resection. Visual symptoms improved in 7 of 9 patients. In one patient diplopia disappeared.Headache was relieved to various extents in all patients. No serious complications were found. Patient＇s hospital stay ranged from 7 to 20 days.Conclusion These data suggest that the endoscopic transsphenoid approach is a safe, minimally invasive, and efficient surgical technique, which might be an important therapeutic strategy for the pituitary adenoms invading cavernous sinus.

Therapeutic embolization of cavernous sinus dural arteriovenous fistulas via transvenous approach

Objective To describe the transvenous catheterization technique for the treatment of cavernous sinus dural arteriovenous fistulas (CSdAVFs), including its indications, complications and efficacy.Methods Eight patients with symptomatic CSdAVFs were treated by endovascular embolization with platinum coils, via the inferior petrosal sinus (IPS) in 6 patients, and via the Sylvian vein after surgical exposure in other 2 patients.Results Complete angiographic resolution of the fistula was obtained in six patients immediately after the procedures, and a complete resolution of symptoms and signs was achieved in all patients. The residual fistulas in two patients disappeared completely in the follow-up angiography.Conclusion Transvenous embolization is a useful and safe approach in the management of CSdAVFs.

Transvenous treatment of a complex cavernous sinus dural arteriovenous fistula secondary to balloon embolization of a traumatic carotid-cavernous fistula

Although recurrent traumatic carotid-cavernous fistula （CCF） and its treatment have beenreported sporadically,^1 a complex cavernous sinus dural arteriovenous fistula （DAVF） secondary to balloon embolization of a direct traumatic CCF is rare. In 2005, we treated such a case via transvenous approach using coils and N-buty-2- cyanoacrylate （NBCA）. The causes of recurrent cavernous sinus DAVF and its endovascular approach are discussed.

Internal carotid artery agenesis with stenosed intercavernous anastomosis:a case report

We report a rare case of internal carotid artery agenesis with stenosed intercavernous anastomosis. A 59-year- old male patient presented with a new infarction in the left basal ganglia. Magnetic resonance angiography and cerebral angiography showed that the right internal carotid artery disappeared from the origin to the foramen lacerum segment, and there was an anastomotic artery with severe stenosis passed through the floor of the sella and in front of the cavernous sinus. The right A1 segment of the anterior cerebral artery was absent and A2 segment was supplied by the normal contralateral internal carotid artery via the anterior communicating artery.

Effects of castration and testosterone replacement on veno-occlusion during penile erection in the rat

Aim: To determine if androgens directly regulate veno-occlusion or if androgens act indirectly to maintain the penilestructures which control outflow. Methods: Using CASTRATE and TESTO rats, measurement was made of meanarterial pressure (MAP), intracavernosal pressure (CCP), and intracavernosal flow (CCF) during erection resultingfrom stimulation of the autonomic innervation of the penis. CCP and CCF were also measured during saline infusioninto the cavernosal sinuses before and after treatment with sodium nitroprusside (SNP, a nitric oxide donor drag) tofully relax cavernosal smooth muscle. Penile tissue was also collected to measure the content of α actin and proline andhydroxyproline to determine if brief withdrawal of androgenic support led to changes in the number of smooth musclecells or the collagen content of the tissue. Results: Infusion of saline into the cavernosal sinuses demonstrated thatveno-occlusion was defective in CASTRATE rats while reno-occlusion was fully functional in TESTO animals.Furthermore, veno-occlusion could be induced in CASTRATE rats if they were first treated with SNP. Thisobservation suggests that failure of veno-occlusion in the CASTRATE rats is due to a deficiency in the production of NOresulting in a reduction in the degree of relaxation of the penile smooth muscle. The measurements of smooth muscleα actin and proline and hydroxyproline content of collagen showed that both were unaffected by castration and that thebasic structure of the penis did not degenerate after one week without androgenic support. Conclusion: Theseresults can be interpreted to mean that androgens control the veno-occlusive mechanism indirectly via a NO dependentmechanism and not by maintaining the structures of the penis which are essential to reno-occlusion.

Complicated Fusobacterium necrophorum mastoiditis–More than meets the eye

Otitis media is common in children and Fusobacterium species are an emerging causative pathogen.These species have virulence factors which increase the risk of complicated otitis media.We discuss a case of F.necrophorum infection resulting in significant intracranial disease to highlight the epidemiology of these infections,risk factors for complicated disease and signs and symptoms to guide diagnosis and investigation.

Transvenous embolization of cavernous dural arteriovenous fistula:report of 28 cases

Background Usually, cavernous dural arteriovenous fistula can be treated via transarterial approaches. However, in many complicated patients, transvenous approaches are superior to the transarterial ones because of the difficulties during a transarterial operation. In this study, we retrospectively analyzed the outcomes of 28 patients with cavernous dural arteriovenous fistula treated by transvenous embolization. Methods From September 2001 to December 2005, 28 patients with 31 cavernous dural arteriovenous fistulae were treated with transvenous embolization in Beijing Tiantan Hospital. The involved cavernous sinuses were catheterized via the femoral vein-inferior petrosal sinus approach or the femoral-facial-superior ophthalmic vein approach, and embolized with coils （GDC, EDC, Matrix, Orbit or free coil） or coils plus silk. The patients were followed up for 3 to 26 months. Results All the 31 cavernous sinuses in the 28 patients were successfully embolized. Complete angiographic obliteration of the fistulae was achieved immediately in 25 patients. Residual shunting was observed in the other 3, who had drainage through the pterygoid plexus （2 patients） or the inferior petrosal sinus （1） after the operation. Headache and vomiting were the most common symptoms after the embolization. In 3 patients, who achieved complete angiographic obliteration immediately, the left oculomotor nerve palsy remained unchanged after the operation. Transient abducens nerve palsy was encountered in 1. In 1 patient, the occular symptoms were improved after the operation, but recurred 4 days later, and then disappeared spontaneously after 5 days. During the follow-up, no patient had recurrence. Three months after the operation, angiography was performed on the 3 patients with residual shunting. Two of them had angiographic cure, the other had residual drainage through the pterygoid plexus. Conclusions Transvenous catheterization and embolization of the cavernous sinus is a safe and efficient way to treat complicated cavernous dural arteriovenous fistulae. It is an alternative to the patients with spontaneous cavernous dural arteriovenous fistulae or those in whom transarterial embolization failed.

Invasive sphenoid sinus aspergillosis mimicking sellar tumor: a report of 4 cases and systematic literature review

Background:Invasive sphenoid sinus aspergillosis is a rare but life-threatening condition usually found in immunocompromised patients.When involving cavernous sinus and surrounding structures,patients are frequently misdiagnosed with a neoplasm or sellar abscess.Timely diagnosis and intervention are crucial to patients’outcomes.The objective of this study is to review cases of invasive sphenoid sinus aspergillosis to describe disease manifestations,imaging features,treatment,and outcome.Case presentation:We describe four patients with invasive sphenoid sinus aspergillosis misdiagnosed as sellar tumors preoperatively.The mass was completely removed in three patients and partially removed in one patient microscopically.Pathological examinations confirmed Aspergillus in all cases.All four patients received anti-fungal agents postoperatively.There was no recurrence at the time of each patient’s follow-up date.One patient with complete resection was lost to follow-up while the other three patients’neurologic function improved.Additionally,we performed a systematic review regarding invasive sphenoid sinus aspergillosis of existing English literature.Conclusion:With regard to clinical symptoms,headache,vision impairment,and ophthalmoplegia were observed in over half of the patients in the literature.A sellar mass with bone destruction on CT and involvement of cavernous sinus is highly suggestive of invasive fungal sphenoid sinusitis.Immediate surgical removal of the lesion is recommended for invasive sphenoid sinus aspergillosis to preserve nerve function and increase the likelihood of survival.