Perineural tumor extension through the foramen ovale: evaluation with MR imaging

Perineural tumor extension is a form of metastatic disease in which primary tumors spread along neural pathways and gain access to non-contiguous regions. The treatment and prognosis are altered when perineural extension occurs. Awareness and proper evaluation are critical for the radiologist. The third (mandibular) division of the trigeminal nerve (V3), passing through the skull base via the foramen ovale, is a common route of perineural spread of head and neck lesions. Seven patients with perineural tumor involvement of the mandibular nerve were evaluated with magnetic resonance imaging with use of standard spin-echo pulse sequences emphasizing T1-weighted information. Three patients had adenoid cystic carcinoma, three had squamous cell carcinoma, and one had well-differentiated lymphocytic lymphoma of the orbit. MR imaging signs of perineural involvement included smooth thickening of V3, concentric expansion of the foramen ovale, replacement of the normal trigeminal cistern hypointensity by an isointense mass, lateral bulging of cavernous sinus dural membranes, and atrophy of masticator muscles.     

以眼科症状首诊的鼻咽癌MRI特征

目的 探讨以眼科症状首诊的鼻咽癌患者的MRI表现.方法 回顾性分析经病理证实的22例鼻咽癌患者Ⅲ、Ⅳ和(或)Ⅵ组颅神经侵犯的临床及MRI表现.结果 22例鼻咽癌患者病变均沿眼运动神经走行分布区浸润扩散.22例患者中复视者14例.发生外展神经、动眼神经和滑车神经不全麻痹者分别为12例(16侧)、6例(7侧)和3例(4侧).MRI表现:海绵窦受累表现为增厚型(8例共10侧)或肿块型(14例共16侧);眶上裂扩大4例4侧,眶上裂软组织信号影9例共10侧;眼外肌受累8例共10侧,表现为眼外肌增粗、周围脂肪间隙模糊伴异常强化;10例动态增强扫描显示鼻咽部病变与海绵窦、眶内病变的动态增强扫描曲线一致,均表现为速升平台型.结论 眼运动神经损害是鼻咽癌的首诊症状之一,应用MR检查可以明确诊断.     

Perineural spread of malignant melanoma of the head and neck: clinical and imaging features

BACKGROUND AND PURPOSE: Extension of malignant melanoma along cranial nerves is a little-known complication of malignant melanoma of the head and neck. We describe the clinical and MR imaging findings of perineural spread of malignant melanoma to cranial nerves, emphasizing that this entity occurs more commonly with desmoplastic histology and may have a long latent period following primary diagnosis. METHODS: At two institutions, we identified and retrospectively reviewed eight cases of malignant melanoma of the head and neck that had MR imaging evidence of perineural spread of disease. All patients underwent confirmatory tissue sampling. RESULTS: Seven patients had melanomas of the facial skin or lip, and one patient had a primary sinonasal lesion. By histopathology, these melanomas included five desmoplastic, two mucosal, and one poorly differentiated melanotic spindle-cell tumor. All patients developed symptomatic cranial neuropathy an average of 4.9 years from the time of initial diagnosis. MR imaging demonstrated postgadolinium enhancement of at least one branch of the trigeminal nerve in all cases and of at least one other cranial nerve in five cases. Other findings included abnormal contrast enhancement and soft tissue thickening in the cavernous sinus, Meckel's cave, and/or the cisternal segment of the trigeminal nerve. CONCLUSION: Although perineural spread of disease occurs most commonly with squamous cell carcinoma and adenoid cystic carcinoma, malignant melanoma must also be included in this differential diagnosis, particularly if the patient's pathology is known to be desmoplastic. Similarly, any patient with malignant melanoma of the head and neck who undergoes MR imaging should receive an imaging assessment focused on the likely routes of perineural spread.     

Cavernous sinus dural fistulae treated by transvenous approach through the facial vein: report of seven cases and review of the literature

BACKGROUND AND PURPOSE: Dural Carotid Cavernous Fistulas (CCFs) can be treated by transarterial and/or transvenous endovascular techniques. The venous route usually goes through the internal jugular vein (IJV) and the inferior petrosal sinus (IPS) up to the pathologic shunts of the cavernous sinus. In case a thrombosed IPS, catheterization through the obstructed sinus is not always possible and a puncture of the superior ophthalmic vein (SOV) can be performed often after a surgical approach. We report our results in the endovascular transvenous treatment of dural CCFs through the facial vein (retrograde catheterization of the IJV, facial vein, angular vein, SOV, and cavernous sinus). METHODS: A retrospective study of seven patients with a dural CCF treated with transvenous embolization via the facial vein was performed. In five patients, the IPS was thrombosed. In one patient, the IPS was patent, but there was not communication between the cavernous sinus compartment in which the CCF shunts were located and the IPS itself. In the only patient with the CCF draining through permeable IPS, the transvenous route through the IPS permitted the occlusion of the posterior CCF shunts and a second session was performed through the facial vein in order to occlude the shunts of the anterior compartment of the cavernous sinus. The other six patients underwent one embolization session only. RESULTS: In all seven cases, it was possible to navigate through the tortuous junction of the angular vein and the SOV. In one patient with a thrombosed SOV, the venous procedure was interrupted because the catheterization through the occluded SOV failed. In the other six patients, after transvenous catheterization of the cavernous sinus via the facial vein, placement of coils resulted in complete occlusion of the dural CCF with clinical cure in four patients and improvement in two. CONCLUSION: In the endovascular treatment of the dural CCFs, the transfemoral approach via the facial vein provides a valuable alternative to other transvenous routes. Catheterization of the cavernous sinus via the facial vein is usually successful. Although this technique requires caution, it allows a safe and effective treatment of these lesions.     

经面静脉-眼上静脉入路治疗颈动脉海绵窦瘘

目的　评价经面静脉 眼上静脉入路治疗颈动脉海绵窦瘘 (CCF)的有效性。方法 :经股静脉 面静脉 眼上静脉入路到达患侧海绵窦 ,用GDC或EDC ,游离弹簧圈 ,真丝线段等多种栓塞材料填塞海绵窦 ,同时闭塞瘘口。面静脉插管困难者 ,在下颌角附近切开皮肤显露面静脉 ,直视下穿刺面静脉放置相应导管 ,再经眼上静脉到达患侧海绵窦并将其填塞。结果 :经面静脉 眼上静脉入路对 14例、16侧海绵窦进行了栓塞治疗 ,其中 5例为外伤性、直接CCF(A型 ) ,经动脉途径球囊栓塞后复发 ,或微弹簧圈栓塞未能成功 ,或经岩下窦入路未能成功 ,9例为自发性、间接CCF(D型 8例 ,C型 1例 )。 13例经股静脉 面静脉 眼上静脉途径 ,1例通过直视下面静脉穿刺。 11例栓塞治疗后即刻造影显示瘘消失 ,2例残留低流量的岩下窦引流 ,另有 1例在微导管进入面静脉后 ,面静脉痉挛闭塞 ,未能继续进行栓塞治疗 ,造影仍见瘘存在 ,但眼静脉出现明显的造影剂滞留。 1例A型CCF在球囊栓塞后出现外展神经麻痹 ,经面静脉 眼上静脉栓塞后亦无改善。因面静脉痉挛闭塞未能栓塞成功者 ,于术后即感眼部症状加重 ,但第 2天感症状缓解 ,术后第 2 1天症状明显改善 ,造影检查发现瘘口已经消失 ,术后 1个月患者眼部症状完全消失。其他病例在栓塞术后眼部症状明显改善 ,     

Targeted compartmental embolization of cavernous sinus dural arteriovenous fistulae using transfemoral medial and lateral facial vein approaches

There are multiple transvenous approaches for treatment of cavernous dural arteriovenous fistulae (DAVF). The choice of a specific route depends on the compartment of the cavernous sinus involved in the fistula and its venous drainage. We used two different facial vein approaches to treat patients with cavernous DAVF draining directly into the anterior compartment of the cavernous sinus and thence to the superior ophthalmic vein. Other transvenous routes to the sinus were not apparent. Embolization was targeted to the involved compartment with preservation of those not embolized. No major post-procedure ophthalmic venous engorgement occurred. We believe that ideal treatment of cavernous DAVF is targeted transvenous coil deposition, which necessitates detailed knowledge of the anatomy of the facial veins and cavernous sinus compartments.     

Invasive sinus aspergillosis with mycotic aneurysm of the vertebral artery and subarachnoid hemorrhage – Case report

Invasive sinus aspergillosis is a rare life-threatening condition usually found in immunocompromised patients. The fungus spreads from paranasal sinuses into the central nervous system by direct extension or through blood vessels. Perineural spread is an uncommon mechanism of spread in invasive aspergillosis. A mycotic aneurysm is a dangerous complication of invasive sinus aspergillosis because of its insidious development and is often diagnosed only post-mortem after causing fatal intracranial hemorrhage. Intracranial vascular complications of invasive sinus aspergillosis require prompt recognition and treatment and should always be considered when a diagnosis of CNS aspergillosis is made. We present a case of invasive sinus aspergillosis in an apparently immunocompetent patient that manifested with a brain abscess, perineural spread of the infection, and mycotic aneurysm of the vertebral artery with subsequent rupture and fatal subarachnoid hemorrhage. This case highlights the possibility of perineural spread and hemorrhagic complications in invasive cerebral aspergillosis.     

Cavernous sinus lesions

The cavernous sinus is a complex structure susceptible to a wide variety of vascular, neoplastic and inflammatory pathologies. Vascular pathologies include ICA aneurysms, carotid-cavernous fistulas, cavernous sinus thrombosis, and cavernous hemangioma. Neoplasms that involve the cavernous sinus include pituitary adenoma, meningioma, schwannoma, lymphoma, perineural tumor spread, metastases, and direct tumor invasion. Infectious and inflammatory diseases include Tolosa-Hunt syndrome, sarcoidosis, granulomatosis with polyangiitis, IgG-4 related disease and invasive fungal infections. In this article, we review the clinical and imaging findings of a number of pathologies involving the cavernous sinus, focusing on key features that can narrow the differential diagnosis and, in some cases, support a particular diagnosis.     

Tolosa-Hunt syndrome: MR imaging features in 15 patients with 20 episodes of painful ophthalmoplegia

Purpose

(a) To assess MR features in patients with Tolosa-Hunt syndrome (THS) and to (b) correlate MR findings with criteria derived from previously reported pathologic observations.

Methods

Fifteen patients with twenty episodes of painful ophthalmoplegia prospectively selected according to International Headache Society (IHS) standards underwent MR examinations focused on the cavernous sinus. Initial examinations in 20 and follow-up MR images in 17 episodes were retrospectively reviewed by 3 independent observers.

Results

The primary criteria: an enhancing soft tissue lesion within the cavernous sinus, increase in size and lateral bulging of the anterior cavernous sinus contour were consistently present in 15 initial episodes and in 5 recurrences (20/20). Agreement among observers was 100%. The secondary criteria: internal carotid artery narrowing in 7 patients, extension towards the superior orbital fissure in 13 and orbital apex involvement in 8 patients were unanimously agreed upon in 87.5%, 86.6% and 80%. Complete resolution of findings was observed on follow-up studies.

Conclusion

In patients with THS the MR features conform to previously reported pathologic findings. MR features are evocative of THS when an increase in size and bulging of the dural contour of the anterior CS supplemented by carotid artery involvement and extension towards the orbit are present. Resolution of findings within 6 months is required to support the diagnosis.     

18F-FDG PET,contrast CT and MRI to comprehensively diagnose and assess rare perineural spread of squamous cell carcinoma to the greater auricular nerve

We present a case of a 78-year-old male with a primary parotid squamous cell carcinoma which spread via the left facial, trigeminal and greater auricular nerves. The patient presented with left facial droop and paraesthesia. Initial MRI scans demonstrated involvement of the trigeminal and facial nerves with no sign of a primary lesion. Abnormal enhancement within the left parotid substance on FDG PET-CT demonstrated the primary malignancy which was confirmed on histology by core biopsy. There was also focal avidity along the course of the left greater auricular nerve consistent with perineural infiltration, extending from the posterior aspect of the parotid to the left cervical plexus at C2/C3. To our knowledge, this is the second case of squamous cell carcinoma perineural spread to the greater auricular nerve imaged on FDG PET-CT scanning. This case highlights the importance of multimodality imaging correlation in the workup of primary head and neck malignancies and associated perineural spread, which is essential in adjuvant radiation therapy planning to reduce local recurrence, improve prognosis and overall survival.     

Imaging of perineural tumor spread from palatal carcinoma.

Carcinomas of the hard or soft palate are known to spread perineurally along palatine branches of the maxillary nerve. Imaging of perineural tumor spread from the palate has been underemphasized in the imaging literature. We report the findings from eight patients in whom spread from primary cancers of the palate was seen along the palatine nerves. Indications of perineural spread include enlargement or excessive enhancement of a nerve, or abnormal density/signal intensity, enhancement, or widening of the pterygopalatine fossa, cavernous sinus, or Meckel''s cave.     

Rhinocerebral mucormycosis: MR manifestations

Magnetic resonance (MR) examinations of three patients with rhinocerebral mucormycosis are reviewed. The clinical course is outlined and the MR characteristics are analyzed in light of the known pathology. The major MR findings include sinus and orbital disease followed by deep facial extension. Involvement of basal portions of the hemispheres, brain stem, and hypothalamus occurred rapidly following ipsilateral facial or orbital invasion in all three cases. Regions of intracerebral inflammation were hyperintense compared with normal parenchyma on T2-weighted and proton density-weighted images. Septic cavernous sinus and internal carotid artery thrombosis was diagnosed by MR in one case. Magnetic resonance demonstrated partial resolution of intracerebral abnormalities that accompanied clinical improvement in the one surviving patient.     

Carotid cavernous fistulae: indications for urgent treatment

Angiographic and clinical data from 155 patients with carotid cavernous fistulae were retrospectively reviewed to determine angiographic features associated with increased risk of morbidity and mortality. These features included presence of a pseudoaneurysm, large varix of the cavernous sinus, venous drainage to cortical veins, and thrombosis of venous outflow pathways distant from the fistula. Clinical signs and symptoms that characterized a hazardous carotid cavernous fistula included increased intracranial pressure, rapidly progressive proptosis, diminished visual acuity, hemorrhage, and transient ischemic attacks. Cortical venous drainage from the carotid cavernous fistula is secondary to occlusion or absence of the normal venous outflow pathways and is associated with signs and symptoms of increased intracranial pressure and an increased risk of intraparenchymal hemorrhage. Angiographic demonstration of a cavernous sinus varix, with extension of the sinus into the subarachnoid space, is associated with an increased risk of fatal subarachnoid hemorrhage. Identification of these high-risk features provides a basis for making decisions about treatment.     

Embolization of branches arising from the cavernous portion of the internal carotid artery

Seven patients with vascular disease (four with cavernous and two with transverse sinus dural fistulas and one with a facial arteriovenous malformation, all supplied primarily from cavernous branches of the internal carotid artery) underwent subselective catheterization and embolization. Ten branches were catheterized (seven meningohypophyseal trunks and three inferolateral trunks) and eight branches were embolized. The embolic agents were as follows: polyvinyl alcohol particles in five, hypertonic glucose in two, and liquid adhesive in one. All four cavernous sinus dural fistulas were occluded after embolization. In the two transverse sinus fistulas, the goal of embolization was to obliterate the tentorial supply prior to surgery. This goal was achieved in both cases. In the remaining patient, who had a large facial arteriovenous malformation and recurrent epistaxis, the embolization obliterated the cavernous supply to the nasal cavity and the patient remains hemorrhage-free. Despite one complication, which occurred in the first case when a thrombus formed and dislodged, resulting in an embolic stroke, this study shows that subselective catheterization and embolization can obliterate lesions of the branches arising from the cavernous internal carotid artery.     

Cranial nerve assessment in cavernous sinus tumors with contrast-enhanced 3D fast-imaging employing steady-state acquisition MR imaging

Introduction  The purpose of this study is to apply contrast-enhanced 3D fast-imaging employing steady-state acquisition (3D-FIESTA) imaging to the evaluation of cranial nerves (CN) in patients with cavernous sinus tumors. Methods  Contrast-enhanced 3D-FIESTA images were acquired from ten patients with cavernous sinus tumors with a 3-T unit. Results  In all cases, the trigeminal nerve with tumor involvement was easily identified in the cavernous portions. Although oculomotor and abducens nerves were clearly visualized against the tumor area with intense contrast enhancement, they were hardly identifiable within the area lacking contrast enhancement. The trochlear nerve was visualized in part, but not delineated as a linear structure outside of the lesion. Conclusions  Contrast-enhanced 3D-FIESTA can be useful in the assessment of cranial nerves in and around the cavernous sinus with tumor involvement.     

Cavernous sinus invasion by pituitary adenomas

One hundred ninety-eight surgically explored pituitary adenomas were evaluated preoperatively by high-resolution computed tomography (CT). At surgery, evidence of direct cavernous sinus invasion was demonstrated in 19. CT findings in these cases included cavernous sinus expansion (17 patients) and visible encasement of the internal carotid artery (14 patients). The invasive tumor often enhanced to a lesser degree than the cavernous sinuses and ipsilateral internal carotid artery. Intracavernous cranial nerve compression, obliteration, or displacement (14 patients), invasion of the lateral wall of the cavernous sinus (seven patients), and diffuse bone destruction (seven cases) were other findings. Magnetic resonance imaging in three patients provided excellent demonstration of intracavernous internal carotid artery encasement, but displacement and obliteration of intracavernous cranial nerves was not shown as well as it was with CT. Histologically, only three patients showed anaplastic features and only one of them had distant metastases. There was no correlation between histologic features, hormone assays, and invasiveness. This experience indicates any type of pituitary adenoma, regardless of its endocrinologic activity, can invade the cavernous sinus. Cavernous sinus involvement makes complete surgical removal difficult. Preoperative recognition of invasive behavior of these tumors has prognostic value and aids in designing appropriate management. CT is the most useful technique generally available for evaluation and follow-up.     

Leptomeningeal carcinomatosis from perineural invasion of a lip squamous cell carcinoma

Perineural invasion resulting in leptomeningeal carcinomatosis is a rare, but well-recognized phenomenon in head and neck carcinomas. We report the rare case of a patient with a squamous cell carcinoma of the lip resulting in leptomeningeal carcinomatosis and review the relevant published work. A 51-year-old man presented with progressive facial paraesthesia after treatment for a recurrent squamous cell carcinoma of the lower lip. Cavernous sinus involvement was confirmed on MRI and he received stereotactic radiotherapy. He subsequently developed progressive lower limb neurological signs. An MRI showed multiple enhancing leptomeningeal nodules in the cervical and lumbar spine consistent with leptomeningeal carcinomatosis. Whole spine radiotherapy and dexamethasone resulted in short-term stabilization of symptoms only and he rapidly succumbed to progressive neurological disease. To our knowledge, this is the first published report of a squamous cell carcinoma of the lip resulting in leptomeningeal disease of the cauda equina. It illustrates the potential aggressive natural history of squamous cell carcinomas with perineural invasion.     

Perineural spread of nasopharyngeal carcinoma: radiological and CT demonstration

Perineural spread is well known to be the most insidious form of tumour spread of a number of head and neck malignancies. However, perineural extension of nasopharyngeal carcinoma (NC) is a poorly recognized event. Four cases of perineural metastases from NC have been detected with pluridirectional tomography and CT. In 3 cases involvement of the Vidian nerve (nervus canalis pterygoidei) and pterygoid canal was observed. In a fourth patient, invasion of one pterygopalatine fossa and perineural spread along ipsilateral maxillary nerve with enlargement and erosion of the foramen rotundum was demonstrated. Radiological diagnosis of clinically unsuspected perineural tumour spread is important because it markedly influences treatment planning and prognosis of NC.     

Cerebrofacial venous metameric syndrome—spectrum of imaging findings

Cerebrofacial venous metameric syndrome (CVMS) is a complex craniofacial vascular malformation disorder in which patients have a constellation of venous vascular malformations affecting soft tissues, bone, dura, and neural structures including the eye and brain. It is hypothesized that a somatic mutation responsible for the venous abnormalities occurred prior to migration of the neural crest cells, and because of this, facial, osseous, and cerebral involvement typically follows a segmental or “metameric” distribution. The most commonly recognized form of CVMS is Sturge-Weber syndrome. However, a wide spectrum of CVMS phenotypical presentations exist with various metameric distributions of slow-flow vascular lesions including facial venous vascular malformations, developmental venous anomalies, venous angiomas, cavernous malformations (cavernomas), dural sinus malformations, and maybe even vascular tumors such as cavernous hemangiomas. Awareness of the various manifestations as described herewith is important for treatment and screening purposes.     

CT observations pertinent to septic cavernous sinus thrombosis

The use of high-resolution computed tomography (CT) is described in four patients with septic cavernous sinus thrombosis. In all patients CT findings included multiple irregular filling defects in the enhancing cavernous sinus. Unilateral or bilateral inflammatory changes in the orbital soft tissues were also present. Enlargement of the superior ophthalmic vein due to extension of thrombophlebitis was noted in three patients.