Endovascular approach to treatment of indirect carotico-cavernous fistulae

The purpose of the study was to assess the cure rate in patients with indirect carotico-cavernous fistula (CCF) treated by transvenous embolisation via the inferior petrosal sinus (IPS) pathway or the superior ophthalmic vein (SOV). Twelve fistulae in 11 patients were treated by transvenous embolisation, eight patients via the IPS and four fistulae in three patients via the SOV. Angiographic cure was defined as complete obliteration of the fistula and clinical cure as total resolution of signs and symptoms. Complete cure was achieved in eight patients with nine fistulae embolised transvenously. Five fistulae were approached via the IPS and four via the SOV. Our preferred method for treatment of indirect CCF is the transvenous route. The IPS approach is technically easier and has fewer potential risks than the SOV approach. However, if the IPS is not patent the SOV can provide good alternative access to the cavernous sinus.     

Transvenous embolization for cavernous dural arteriovenous shunts: about the intracranial venous approach to the cavernous sinus

Recently, the first choice of therapy for cavernous dural arteriovenous shunts (CdAVS) is transvenous embolization. Usually the approach routes for cavernous sinus are the inferior petrosal sinus (IPS), the superior ophthalmic vein (SOV) in most cases and the superior petrosal sinus (SPS) in rare case. But, it is difficult for us to treat patients in whom there are no extracranial veins through which to approach the cavernous sinus, with transvenous embolization. We presented the case in which intracranial transvenous approach to the cavernous sinus and transvenous embolization were performed and in which we achieve good results. In this article, we presented a case with Barrow's type D CdAVS and cortical venous drainage. At first, transarterial embolization was performed to decrease the amount of venous drainage for the purpose of eliminate convulsions and consciousness disturbance. However, cortical venous drainage continued. Moreover bilateral dilated SOVs normalized and bilateral IPSs were not visible, so we decided that it was impossible to carry out the transvenous embolization via extracranial veins. Transvenous embolization to the left cavernous sinus via the intracranial ophthalmic vein between the superior ophthalmic fissure and the inferior ophthalmic fissure after craniotomy was performed. Then, the transvenous embolization to the right cavernous sinus was carried out through the right superficial middle cerebral vein after craniotomy. The results were good and chemosis and bilateral abducens palsy diminished immediately. Trans-intracranial venous embolization for CdVAS is a very useful therapy when no extracranial veins exist for transvenous embolization.     

Delayed abducens nerve palsy after transvenous coil embolization for cavernous sinus dural arteriovenous fistulae

Purpose

Abducens nerve palsy is the most common complication after transvenous embolization (TVE) for cavernous sinus dural arteriovenous fistula. Abducens nerve palsy is reported to have a good prognosis after the symptoms have been alleviated. The purpose of this study was to identify cases of delayed abducens nerve palsy after successful TVE and discuss the physiological mechanisms responsible for this unusual complication.

Methods

Between 1991 and 2012, TVE was performed for 73 patients. The patients were evaluated for clinical symptoms every 12 months during the follow-up period. Patients’ data and information about abducens nerve palsy were obtained from clinical records retrospectively.

Results

Abducens nerve palsy newly developed in 4 (5.5 %) of 73 patients at 3–65 months after TVE. All four patients with delayed abducens nerve palsy were followed up for 8–84 months. However, delayed abducens nerve palsy persisted in all four patients. In these four patients, the shunt points were posterior cavernous sinus. The average coil length used for four patients was 206.5?±?43.1?cm (n?=?4), and the average coil length used for patients without delayed abducens nerve palsy was 112.8?±?38.8?cm (n?=?69).

Conclusion

The possibility of delayed abducens nerve palsy should be kept in mind, especially in the patients who were treated with transvenous coil packing in the posterior part of the cavernous sinus. Furthermore, our results suggest that long-term follow-up care is important for these patients, even after complete neurological and radiological recovery was attained.     

Abducens schwannoma inside the cavernous sinus proper: case report

BACKGROUND: Only 2 cases of abducens nerve schwannoma solely inside the cavernous sinus have been reported. In both cases, abducens nerve palsy remained after operation. We report the first case of abducens nerve schwannoma inside the cavernous sinus proper with postoperative recovery from abducens nerve palsy. CASE DESCRIPTION: The patient was a 47-year-old female who developed left abducens and trigeminal nerve palsies. Neuroradiological examination revealed left intra-cavernous sinus tumor. Total removal of the tumor was performed. The location of the tumor was confirmed intraoperatively inside the cavernous sinus itself, with no relation to the trigeminal nerve. Further, the relation of the tumor to one particular nerve fiber within the abducens nerve bundle was confirmed inside the cavernous sinus. After surgery, the patient had transient abducens nerve palsy. It had totally disappeared by 6 months. CONCLUSION: When the tumor origin is just within the spacious cavernous sinus rather than more posterior in the narrow dural tunnel of Dorello's canal, successful preservation of the nerve function is possible postoperatively through a thorough knowledge of the membranous anatomy and careful preoperative study of the radiographic findings.     

Transvenous embolisation of dural carotid-cavernous fistulas by multiple venous routes: a series of 27 cases

Summary.  Background: Transvenous embolisation is an effective option in the treatment of dural carotid-cavernous fistulas (DCCFs). This can be achieved via a number of venous routes.  Method: From 1997 to 2001, 27 patients with DCCFs (15 unilateral and 12 bilateral) were treated by transvenous embolisation with Guglielmi detachable coils and fibered platinum coils. The transvenous embolisation routes included inferior petrosal sinus (IPS) alone (18 patients), IPS and inter-cavernous sinus (6 patients), IPS and clival plexus (1 patient), superior ophthalmic vein (SOV) via facial vein (1 patient) and SOV via superficial temporal vein (1 patient). One patient required further transarterial embolisation with polyvinyl alcohol particles.  Findings: The follow-up period ranged from 4 to 57 months (average 26 months). Two patients had transient ophthalmoplegia and 2 patients had symptomatic recurrence of the DCCF during the follow-up. There was no permanent procedure-related morbidity. Clinical cure was achieved in 26 patients (96%) and complete angiographic obliteration was documented in 24 patients (89%).  Interpretation: DCCFs can be successfully treated by transvenous embolisation via different venous routes. Published online January 14, 2003 Acknowledgments  We thank Lap-Chung Tang for the hand drawings and Dr. Kwok-Hung Lai for computer graphics. We also thank Kwun-Lin Man, Marina Lee and Emily Tin for assistance in the secretarial work.  Correspondence: K.-M. Cheng, Department of Neurosurgery, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong, China.     

Lymphoma of the sphenoid sinus presenting as abducens nerve palsy in a child

Primary sphenoid sinus malignancy with abducens nerve palsy is rare in the paediatric population. We report the first case of bilateral isolated abducens nerve palsy secondary to primary T‐cell anaplastic lymphoma of the sphenoid sinus in the absence of radiological evidence of bony destruction or malignant invasion in an 8‐year‐old boy. This case highlights the importance of understanding surgical anatomy of the sphenoid sinuses and cavernous sinuses, and to maintain a high index of suspicion when a patient is presented with simultaneous palsy of any of the cranial nerves within the cavernous sinus and sphenoid sinus disease, despite possible disparities between clinical features and radiological findings. Prompt surgical exploration and biopsy of sphenoid sinus is imperative to establish the diagnosis and to initiate treatment in order to avoid further progression of disease or other complications.     

Embolisation of indirect carotid-cavernous sinus dural arterio-venous fistulae using the direct superior ophthalmic vein approach

Summary  Indirect carotid-cavernous sinus dural arterio-venous fistulae (cDAVF) can be treated by transarterial and/or transvenous embolisation. This study evaluated patients with cDAVF who underwent transvenous embolisation using the direct superior ophthalmic vein (SOV) approach. Between January 2004 and October 2006, eight cDAVF in seven patients were embolised using direct surgical exposure of the SOV when access to the cDAVF via transarterial or transfemoral venous routes was not feasible. Medical records and imaging studies were retrospectively reviewed. The seven patients consisted of four females and three males from 43 to 65-year-old (mean age, 54.4 years). Six cDAVF lesions were located on the left side and two on the right. All fistulae were successfully embolised and showed clinical improvement. One patient presented after treatment with transient venous congestion on the brain stem, which was relieved by osmotic diuretics and steroids. Direct surgical exposure of the SOV for transvenous embolisation of cDAVF can be effective if the facial vein, inferior petrosal sinus, and internal jugular vein are thrombosed. This approach is easy, safe, and effective when performed by a multidisciplinary team. Correspondence: Jae-Whan Lee, Assistant Professor, Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, 134 Shinchon-dong Seodaemun-gu, Seoul 120-752, Korea.     

A case of a hemorrhagic non-functioning pituitary adenoma presenting with abducens nerve palsy

A pituitary adenoma presenting with isolated abducens nerve palsy is an extremely rare occurrence. The authors report a rare case of a hemorrhagic non-functioning pituitary adenoma presenting with isolated abducens nerve palsy. The etiology of isolated abducens nerve palsy by a pituitary tumor is discussed. A 34-year-old male presented with severe headache, vomiting, right-sided ophthalmic pain, and diplopia. On admission, he had right-sided isolated abducens nerve palsy. Magnetic resonance (MR) images demonstrated a less-enhancing intra-and suprasellar mass lesion with intratumoral hemorrhage and right-sided slight cavernous sinus invasion, that exhibited an iso-high mixed intensity on T1-weighted image and a low-high mixed intensity on T2. Cerebral angiogram revealed no abnormality. The pituitary hormone function was within normal range. The tumor was totally resected via the transnasal route. The histological diagnosis was a typical non-functioning pituitary adenoma with hemorrhage. The abducens nerve palsy was completely resolved 7 months after surgery. It was supposed that the isolated abducens nerve palsy was caused by the direct compression of abducens nerve in the cavernous sinus by the extension of a pituitary tumor and hematoma. Pituitary adenoma should be considered in the differential diagnosis of abducens nerve palsy. Early diagnosis and transsphenoidal surgery is recommended to improve the abducens nerve palsy.     

Transvenous embolization in spontaneous direct carotid-cavernous fistula in childhood

Carotid cavernous fistula (CCF) is an abnormal arteriovenous communication in the cavernous sinus. Direct CCF results from a tear in the intracavernous carotid artery. Typically, it has a high flow and usually presents with oculo-orbital venous congestive features such as exophthalmos, chemosis, and sometimes oculomotor or abducens cranial nerve palsy. Indirect CCF generally occurs spontaneously with subtle signs. We report a rare case of spontaneous direct CCF in childhood who did not have the usual history of craniofacial trauma or connective tissue disorder but presented with progressive chemosis and exophthalmos of the right eye. This report aims also to describe the safety and success of transvenous embolization with coils of the superior ophthalmic vein and cavernous sinus through the inferior petrosal sinus.     

Transvenous occlusion of dural cavernous sinus fistulas through the thrombosed inferior petrosal sinus: report of four cases and review of the literature

BACKGROUND: The aim of this study is to describe the technique and results of the endovascular approach through the thrombosed inferior petrosal sinus (IPS) for occlusion of dural cavernous sinus fistulas (DCSFs). METHODS: In four patients presenting with clinically symptomatic DCSFs, the angiogram did not show opacification of the IPS, indicating that it neither drained the arteriovenous fistula nor the cerebral venous outflow. A large volume biplane phlebogram of the jugular bulb was obtained to identify a thrombosed remnant of the IPS. We were able to navigate small hydrophilic catheters and microguide wires through the thrombosed IPS into the ipsi- or contralateral CS. After reaching the fistula site the CS was packed with detachable platinum coils. RESULTS: We were able to reach the fistula site and to achieve a dense packing of coils within the arteriovenous shunting zone in all of the patients. The final angiogram showed subtotal or complete occlusion of the arteriovenous fistula. All four patients recovered completely and showed disappearance of the fistula on follow-up arteriograms. One patient developed a transient sixth nerve palsy. No complications related to the approach were observed. CONCLUSIONS: For endovascular treatment, transvenous occlusion of DCSFs via the IPS is a feasible approach, even when this sinus is partially or completely thrombosed. Gentle handling of recently available, improved hydrophilic microguide wires and microcatheters allows effective and safe catheter navigation into the CS. A phlebogram of the jugular bulb is very useful for identification of a thrombosed IPS.     

Difficult cannulation of the superior ophthalmic vein in the treatment of cavernous sinus dural arteriovenous fistula: two case reports

Retrograde cannulation of the superior ophthalmic vein (SOV) is an important route for embolization of cavernous sinus dural arteriovenous fistula (dAVF). We encountered two cases with significant difficulties with cannulation of the SOV. A 66-year-old woman and an 83-year-old woman were referred to our hospital for treatment of cavernous sinus dAVF. Unilateral chemosis and exophthalmos were seen in both patients. At first, transarterial embolization was performed to reduce the flow, then, transvenous embolization was employed for the treatment of cavernous sinus dAVF. The attempts to embolize through a transfemoral route failed owing to a thrombosed or compartmentalized cavernous sinus. Surgical exposure of the SOV and puncture with needle-cannula was tried. However, in both cases, unsuccessful cannulation resulted in uncontrollable bleeding and periorbital swelling. Finally, by using road-mapping SOV was punctured in the deeper part and the fistula was obliterated with detachable coils. Postoperative course was uneventful and their symptoms were improved. Although the SOV is a useful route for cavernous sinus dAVF embolization, the presence of narrowed or tortuous veins can preclude successful cannulation.     

Trigeminal neurinoma presenting abducens nerve palsy as initial symptom: a report of two cases

Two cases of trigeminal neurinoma presenting abducens nerve palsy as initial symptom are reported. Case 1. A 33-year-old female was admitted because of double vision of two months duration. Neurological examination revealed left abducens nerve palsy. CT scan disclosed a left parasellar tumor with a homogeneous enhancement effect. The tumor was subtotally resected by left extradural subtemporal approach, and diagnosed as trigeminal neurinoma. Case 2. A 18-year-old female was admitted because of double vision of one month duration. Neurological examination revealed left mydriasis and left abducens nerve palsy. CT scan disclosed a low density mass in the left cerebellopontine angle region and enhanced parasellar mass. The cystic mass located at the posterior fossa was removed by left retromastoid suboccipital approach, and diagnosed as trigeminal neurinoma. In these two cases, the abducens nerve palsy disappeared within two months postoperatively. The trigeminal neurinoma presenting abducens nerve palsy as initial symptoms is rare. We were able to collect six similar cases from the literature. All of them, including present two cases, were classified as ganglion type. It was suspected that the abducens nerve was compressed by the trigeminal neurinoma at the cavernous sinus, the petrous apex or the posterior fossa.     

Duplication of the abducens nerve at the petroclival region: an anatomic study

OBJECTIVE: During its course between the brainstem and the lateral rectus muscle, the abducens nerve usually travels forward as a single trunk, but it is not uncommon for the nerve to split into two branches. The objective of this study was to establish the incidence and the clinical importance of the duplication of the nerve. METHODS: The study was performed on 100 sides of 50 autopsy materials. In 10 of 11 cases of duplicated abducens nerve, colored latex was injected into the common carotid arteries and the internal jugular veins. The remaining case was used for histological examination. RESULTS: Four of 50 cases had duplicated abducens nerve bilaterally. In seven cases, the duplicated abducens nerve was unilateral. In 9 of these 15 specimens, the abducens nerve emerged from the brainstem as a single trunk, entered the subarachnoid space, split into two branches, merged again in the cavernous sinus, and innervated the lateral rectus muscle as a single trunk. In six specimens, conversely, the abducens nerve exited the pontomedullary sulcus as two separate radices but joined in the cavernous sinus to innervate the lateral rectus muscle. In 13 specimens, both branches of the nerve passed beneath the petrosphenoidal ligament. In two specimens, one of the branches passed under the ligament and the other passed over it. In one of these last two specimens, one branch passed over the petrosphenoidal ligament and the other through a bony canal formed by the petrous apex and the superolateral border of the clivus. In all of the specimens, both branches were wrapped by two layers: an inner layer made up of the arachnoid membrane and an outer layer composed of the dura during its course between their dural openings and the lateral wall of the cavernous segment of the internal carotid artery. This finding was also confirmed by histological examination in one specimen. CONCLUSION: Double abducens nerve is not a rare variation. Keeping such variations in mind could spare us from injuring the VIth cranial nerve during cranial base operations and transvenous endovascular interventions.     

Deterioration of Ocular Motor Dysfunction After Transvenous Embolization of Dural Arteriovenous Fistula Involving the Cavernous Sinus

Summary  We treated 9 patients with the dural arteriovenous fistula involving the cavernous sinus by transvenous embolization. Two patients experienced deterioration of oculo-motor dysfunction after transvenous embolization. We can speculate about two different kind of causes by which patients symptoms deteriorated according to the result of intrasinus pressure recorded during the embolization [1]: high intrasinus pressure caused by the obliteration of the drainage pathway resulted in cranial nerve palsy in one case [2]; implanted coils directly compressed the cranial nerve in another case. Fortunately our cases recovered, but some kind of preventative measures may be needed in similar cases.     

Trans-arterial embolisation therapy of dural carotid–cavernous fistulae using low concentration n-butyl-cyanoacrylate

Background  Trans-venous embolisation has been accepted as the preferred treatment for dural carotid–cavernous fistulae (DCCF). However, such an approach is not always feasible. In this circumstance, trans-arterial embolisation with low concentration n-butyl-cyanoacrylate glue (NBCA) may be a feasible alternative. We report our results and experience of this method for DCCF. Materials and methods  Five patients with DCCF were treated by trans-arterial embolisation using low concentration NBCA by wedging the microcatheter into the main feeding artery. All five lesions were associated with venous drainage into the superior ophthalmic vein. The inferior petrosal sinus was patent in one patient and thrombosed in four. Additional venous drainage into the Sylvian vein and the superior petrosal sinus was observed in two patients. Findings  The definitive NBCA injection was performed via the branches of the middle meningeal artery in three patients and accessory meningeal artery as well as ascending pharyngeal artery in two patients. Four patients showed complete obliteration of the DCCF on the post-embolisation angiogram, and follow-up studies showed clinical cure or improvement and successful obliteration of the DCCF. One patient had a residual DCCF after the procedure, but showed complete obliteration and clinical cure at 5-month follow-up. Glue penetrated into the Sylvian vein in one patient during the procedure without sequelae. Two patients had transient worsening of ocular symptoms after the procedure. Conclusions  Trans-arterial embolisation with low concentration NBCA using a wedged microcatheter technique is still a safe and effective treatment for DCCF when the transvenous approach is not feasible. However, care must be taken to prevent inadvertent arterial and venous embolisation. An erratum to this article can be found at     

A case of high flow CCF with congestive hemorrhage

The authors report a case of high flow CCF with intracerebral hemorrhage during treatment with endovascular coil embolization. A 52-year-old woman had been in good health until a sudden onset of orbital bruit and left orbital tinnitus occurred. Conjunctival chemosis and diplopia caused by left abducens palsy gradually progressed. Left internal carotid arteriography revealed a carotid-cavernous sinus fistula with direct high-flow shunt. The fistula drained into the superior orbital vein, inferior petrosal sinus, intercavernous sinus and sphenoparietal sinus with significant cortical reflux. The attempt at transarterial balloon occlusion failed. Then transvenous coil embolization was performed. During the course of endovascular treatment, follow up CT depicted intracerebral hemorrhage. Intracerebral hemorrhage was asymptomatic and thought to be caused by venous hypertension from cortical reflux. The patient underwent direct occlusion of the left sphenoparietal sinus for prevention of further hemorrhage via craniotomy. Lastly, the cavernous sinus was completely occluded by transvenous coil embolization. The signs and symptoms resolved 3 months after the procedures.     

Surgery of tumors invading the cavernous sinus

Potential injury to neurovascular structures within the cavernous sinus often prohibits total removal of various cranial base tumors. This report discusses the rationale of direct cavernous sinus surgery and describes a surgical technique refinement as evolved from experience in 18 histologically benign operative cases. The nature of tumor extension mandated entry to the sinus, either through the superior or lateral wall or both. The operative microscope facilitated dissecting and preserving the carotid artery and cranial nerves transversing the sinus. Venous bleeding was controlled by packing. There was one death unrelated to cavernous sinus surgery. Five patients, however, had complications related to cavernous sinus surgery, including hemiplegia in one patient and cranial nerve palsy in four.     

Abducens nerve paralysis: a potential presentation of sphenoid sinus cancer

The sphenoid sinus is the paranasal sinus most commonly implicated when cranial neuropathies are present. Two patients presenting with sixth nerve paralysis secondary to sphenoid sinus involvement are presented. One patient had a primary sphenoid sinus tumor, and the other a metastasis from a bronchogenic carcinoma. Of the two patients, one carried the diagnosis of idiopathic sixth nerve paresis and had had a normal sinus x-ray film and CAT scan done previously. Even in the absence of positive radiographic findings, the high clinical suspicion of sinus malignancy must be maintained in patients manifesting abducens nerve paralysis. In these patients, the petrous apex and cavernous sinus "silent area" must be diligently evaluated. For the patient to have any chance for palliation or potential cure, the tumor must be diagnosed as soon as possible.     

Meningovenous structures of the petroclival region: clinical importance for surgery and intravascular surgery

OBJECTIVE: The goals of this investigation were to perform a detailed analysis of petroclival microanatomic features, to investigate the course of the abducens nerve in the petroclival region, and to identify potential causes of injury to neurovascular structures when anterior transpetrosal or transvenous endovascular approaches are used to treat pathological lesions in the petroclival region. METHODS: Petroclival microanatomic features were studied bilaterally in seven cadaveric head specimens, which were injected with colored silicone before microdissection. Another cadaveric head was used for histological section analyses. RESULTS: A lateral or medial location of the abducens nerve dural entrance porus, relative to the midline, was correlated with the course and angulation of the abducens nerve in the petroclival region. The angulation of the abducens nerve was greater and the nerve was closer to the petrous ridge in the lateral type, compared with the medial type. The abducens nerve exhibited three changes in direction, which represented the angulations in the petroclival region, at the dural entrance porus, the petrous apex, and the lateral wall of the internal carotid artery. The abducens nerve was covered by the dural sleeve and the arachnoid membrane, which became attenuated between the second and third angulation points. The abducens nerve was anastomosed with the sympathetic plexus and fixed by connective tissue extensions to the lateral wall of the internal carotid artery and the medial wall of Meckel's cave at the third angulation point. There were two types of trabeculations inside the sinuses around the petroclival region (tough and delicate). CONCLUSION: The petroclival part of the abducens nerve was protected in a dural sleeve accompanied by the arachnoid membrane. Therefore, the risk of abducens nerve injury during petrous apex resection via the anterior transpetrosal approach, with the use of the transvenous route through the inferior petrosal sinus to the cavernous sinus, should be lower than expected. The presence of two anatomic variations in the course of the abducens nerve, in addition to findings regarding nerve angulation and tethering points, may explain the relationships between adjacent structures and the susceptibility to nerve injury with either surgical or endovascular approaches. Venous anatomic variations may account for previously reported cases of subarachnoid hemorrhage with the endovascular approach.     

Cavernous sinus chondroma. Case report and review of the literature

Chondromas of the base of the skull are most commonly found in the parasellar and sellar regions, and present varying degrees of involvment of the cavernous sinus.However, those confined mainly to the cavernous sinus are rare, and only a few cases have been reported. A 50 year old man experienced left hemifacial pain followed by left abducens nerve palsy. Computerized tomography and magnetic resonance image depicted a well circumscribed mass in the left cavernous sinus. A pterional craniotomy was performed to approach this lesion intradurally. The tumour was subtotally removed Histologically the mass was diagnosed as a mature chondroma. Postoperatively, the left hemifacial pain disappeared and the diplopia improved from the first postoperative day. Successfull removal of lesions in the cavernous sinus requires individualisation of the case as well as choosing the correct surgical approach for the certain patient.