Cavernous Sinus Space Research Articles

Zygomatic Approach to Cavernous Sinus Chordoma: 2-Dimensional Operative Video.

Chordoma is not a benign disease. It grows invasively, has a high rate of local recurrence, metastasizes, and seeds in the surgical field.1 Thus, chordoma should be treated aggressively with radical resection that includes the soft tissue mass and the involved surrounding bone that contains islands of chordoma.2-5 High-dose radiation, commonly by proton beam therapy, is administered after gross total resection for long-term control. About half of chordoma cases occupy the cavernous sinus space and resecting this extension is crucial to obtain radical resection. Fortunately, the cavernous sinus proper extension is the easier part to remove and pre-existing cranial nerves deficit has good chance of recovery. As chordomas originate and are always present extradurally (prior to invading the dura), an extradural access to chordomas is the natural way for radical resection without brain manipulation. The zygomatic approach is key to the middle fossa, cavernous sinus, petrous apex, and infratemporal fossa; it minimizes the depth of field and is highly advantageous in chordoma located mainly lateral to the cavernous carotid artery.6-12 This article demonstrates the advantages of this approach, including the mobilization of the zygomatic arch alleviating temporal lobe retraction, the peeling of the middle fossa dura for exposure of the cavernous sinus, the safe dissection of the trigeminal and oculomotor nerves, and total control of the petrous and cavernous carotid artery. Tumor extensions to the sphenoid sinus, sella, petrous apex, and clivus can be removed. The patient is a 30-yr-old who consented for surgery.

Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification.

OBJECT An important prognostic factor for the surgical outcome and recurrence of a pituitary adenoma is its invasiveness into parasellar tissue, particularly into the space of the cavernous sinus (CS). The aims of this study were to reevaluate the existing parasellar classifications using an endoscopic technique and to evaluate the clinical and radiological outcomes associated with each grade. METHODS The authors investigated 137 pituitary macroadenomas classified radiologically at least on one side as Grade 1 or higher (parasellar extension) and correlated the surgical findings using an endoscopic technique, with special reference to the invasiveness of the tumor into the CS. In each case, postoperative MRI was performed to evaluate the gross-total resection (GTR) rate and the rate of endocrinological remission (ER) in functioning adenomas. RESULTS The authors found a 16% rate of CS invasion during surgery for these macroadenomas. Adenomas radiologically classified as Grade 1 were found to be invasive in 1.5%, and the GTR/ER rate was 83%/88%. For Grade 2 adenomas, the rate of invasion was 9.9%, and the GTR/ER rate was 71%/60%. For Grade 3 adenomas, the rate of invasion was 37.9%, and the GTR/ER rate was 75%/33%. When the superior compartment of the CS (Grade 3A) was involved, the authors found a rate of invasion that was lower (p < 0.001) than that when the inferior compartment was involved (Grade 3B). The rate of invasion in Grade 3A adenomas was 26.5% with a GTR/ER rate of 85%/67%, whereas for Grade 3B adenomas, the rate of surgically observed invasion was 70.6% with a GTR/ER rate of 64%/0%. All of the Grade 4 adenomas were invasive, and the GTR/ER rate was 0%. A comparison of microscopic and endoscopic techniques revealed no difference in adenomas with Grade 1 or 4 parasellar extension. In Grade 2 adenomas, however, the CS was found by the endoscopic technique to be invaded in 9.9% and by microscopic evaluation to be invaded in 88% (p < 0.001); in Grade 3 adenomas, the difference was 37.9% versus 86%, respectively (p = 0.002). Grade 4 adenomas had a statistically significant lower rate of GTR than those of all the other grades. In case of ER only, Grade 1 adenomas had a statistically significant higher rate of remission than did Grade 3B and Grade 4 adenomas. CONCLUSIONS The proposed classification proved that with increasing grades, the likelihood of surgically observed invasion rises and the chance of GTR and ER decreases. The direct endoscopic view confirmed the low rate of invasion of Grade 1 adenomas but showed significantly lower rates of invasion in Grade 2 and 3 adenomas than those previously found using the microscopic technique. In cases in which the intracavernous internal carotid artery was encased (Grade 4), all the adenomas were invasive and the GTR/ER rate was 0%/0%. The authors suggest the addition of Grades 3A and 3B to distinguish the strikingly different outcomes of adenomas invading the superior CS compartments and those invading the inferior CS compartments.

Magnetic resonance imaging and biological markers in pituitary adenomas with invasion of the cavernous sinus space

The preoperative diagnosis of cavernous sinus invasion remains difficult and controversial, and there are currently no reliable histological or molecular markers that predict pituitary tumour behaviour and response to treatment. We evaluated 45 patients with pituitary adenoma. The results have shown that the sensitivity of MRI for indicating cavernous sinus invasion in this prospective study was 60%, specificity 85%, positive predictive value 83.33%, negative predictive value 62.96%. Forty-five specimens of pituitary adenomas were analyzed for expression of F8, VEGF, Ki-67, c-myc, bcl-2, nm23 and MMP-9 immunoreactivity using immunoperoxidase staining. MVD was assessed using F8-related antigen. The results have shown that MVD of invasive pituitary adenomas was significantly higher than that of noninvasive (P < 0.001). There was an association between the invasion of pituitary adenomas and Ki-67 LI (P = 0.039) or the expression of VEGF (P < 0.001) and MMP-9 (P < 0.001). But c-myc LI and bcl-2 expression have no association with invasiveness of pituitary adenomas (P = 0.061 vs. P = 0.201). On the other hand, there is an inverse relationship between nm23 expression and tumor invasion (P < 0.001). In conclusion, parasellar extension of pituitary adenomas through the medial wall of the cavernous sinus diagnosed at surgery, can be determined by radiology with sensitive gadolinium-enhanced MRI. Although our study has shown that MVD and the expression of VEGF, Ki-67, nm23 and MMP-9 have associations with invasiveness of pituitary adenomas, they are lack of specificity. These markers can only provide some useful informations on the therapeutic strategy of pituitary adenomas.

Magnetic Resonance Imaging and Biological Markers in Pituitary Adenomas with Invasion of the Cavernous Sinus Space

Objective To evaluate the magnetic resonance imaging (MRI) and biological marks in pituitary adenomas with cavernous sinus invasion.Methods The MRI features and intraoperative findings were investigated in 45 patients with pituitary adenoma,and their specimens of pituitary adenomas were analyzed for the expression of F8,Ki-67,VEGF,MMP-9,nm23,c-myc and bcl-2 immunoreactivity using immunoperoxidase staining.MVD was assessed using F8-related antigen.Results The sensitivity of MRI for predicting cavernous sinus invasion was 60%,its specificity 85%,its positive predictive value 83% and negative predictive value 63% in 45 patients with pituitary adenoma.The results of immunoreactivity revealed that MVD,Ki-67 label index (LI),the expression of VEGF and MMP-9 of invasive pituitary adenomas were significantly higher than those of noninvasive (52.52±11.18 vs 34.96±18.69,2.74±2.83 vs 1.25±1.45,4.73±0.64 vs 3.09±1.48 and 3.05±1.04 vs 0.67±0.74,P0.001,=0.039,0.001 and 0.001,respectively).The expression of nm23 of noninvasive pituitary adenomas was significantly higher than that of invasive (4.08±1.18 vs 1.55±1.52,P0.001).But c-myc LI and bcl-2 expression had no association with invasiveness of pituitary adenomas (1.07±1.54 vs 0.35±0.73,P=0.061;2.34±1.75 vs 1.66±1.79,P=0.201,respectively).Conclusion Pituitary adenomas with cavernous sinus invasion can be diagnosed by sensitive gadolinium-enhanced MRI preoperatively.MVD and the expression of Ki-67,VEGF,MMP-9 and nm23 have associations with invasiveness of pituitary adenomas to some extent.These markers may provide some useful information to the treatment of invasive pituitary adenoma.

Orbital Venous Drainage into the Anterior Cavernous Sinus Space; Microanatomic Relationships

Orbital Venous Drainage into the Anterior Cavernous Sinus Space; Microanatomic Relationships

Orbital Venous Drainage into the Anterior Cavernous Sinus Space; Microanatomic Relationships

Microsurgical anatomy and relationships in the region of the superior orbital fissure and anterior part of the cavernous sinus were studied, with special attention to the venous structures. Microanatomic dissections were performed in 24 specimens from human cadavers, fixed in formalin, with the aid of a microdrill and operating microscope. A protocol of dissection was developed, enabling plane-by-plane exposure of the cranial nerves passing from the cavernous sinus to the superior orbital fissure and farther, on disclosure of the junction between the ophthalmic veins and the anterior cavernous sinus space. The main draining vessel was the superior ophthalmic vein. The inferior ophthalmic vein was much thinner and it was identified in 91.7% of cases. These two vessels fused together to form a common venous confluence approximately 5 mm in length that entered the anterior cavernous sinus space in its anterior or anteroinferior aspect. The shape of this venous drain varied greatly, from that of a typical vein to that of a venous lake. The latter was characterized by a relatively narrow opening into the anterior cavernous sinus space and lacunar widening of the vessel in its central part. No case of a separate entrance of the superior and inferior ophthalmic veins into the anterior cavernous sinus space was encountered. The anterior cavernous sinus space was described as a slit-like venous chamber located in front of the anterior genu of the intracavernous segment of the internal carotid artery. The anteroposterior diameter of this space was 3.2 +/- 0.4 mm; it was filled with blood, and no venous structures inside this space were observed. The knowledge of the anatomic details described may be useful for elaborating surgical approaches to this region and for planning the treatment of carotid-cavernous fistulas.

Orbital Venous Drainage into the Anterior Cavernous Sinus Space; Microanatomic Relationships

Orbital Venous Drainage into the Anterior Cavernous Sinus Space; Microanatomic Relationships

Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings.

We present 25 pituitary adenomas that were confirmed surgically to have invaded the cavernous sinus space. The surgical results are compared with the preoperative magnetic resonance imaging findings. For comparable radiological criteria, we classified parasellar growth into five grades. This proposed classification is based on coronal sections of unenhanced and gadolinium diethylene-triamine-pentaacetic acid enhanced magnetic resonance imaging scans, with the readily detectable internal carotid artery serving as the radiological landmark. The anatomical, radiological, and surgical conditions of each grade are considered. Grades 0, 1, 2, and 3 are distinguished from each other by a medial tangent, the intercarotid line--through the cross-sectional centers--and a lateral tangent on the intra- and supracavernous internal carotid arteries. Grade 0 represents the normal condition, and Grade 4 corresponds to the total encasement of the intracavernous carotid artery. According to this classification, surgically proven invasion of the cavernous sinus space was present in all Grade 4 and Grade 3 cases and in all but one of the Grade 2 cases; no invasion was present in Grade 0 and Grade 1 cases. Therefore, the critical area where invasion of the cavernous sinus space becomes very likely and can be proven surgically is located between the intercarotid line and the lateral tangent, which is represented by our Grade 2. We also measured tumor growth rates, using the monoclonal antibody KI-67, which shows a statistically higher proliferation rate (P < 0.001) in adenomas with surgically observed invasion into the cavernous sinus space, as compared with noninvasive adenomas.

Pituitary Adenomas with Invasion of the Cavernous Sinus Space

Pituitary Adenomas with Invasion of the Cavernous Sinus Space

The anterior cavernous sinus space

The anterior cavernous sinus space is the venous space anterior to the cavernous carotid artery. It is tetrahedral in shape with the anterior apex at the superior orbital fissure. The superomedial wall is formed by the base of the anterior clinoid process. The inferomedial wall is formed by the sphenoid bone. The lateral wall consists of two layers of dura with the oculomotor, trochlear, ophthalmic and abducens nerves in the inner layer. Medially, the posterior wall consists of the cavernous carotid artery. Laterally, it communicates with the lateral cavernous sinus space. Paraclinoid and carotid cave aneurysms may occupy this space and its microanatomy is important in the surgery of these aneurysms.