Cavernous Research Articles

Skull Base Anatomy Presented in 360° Photogrammetry 3-Dimensional Models.

Realistic 3-dimensional (3D) anatomical models may enhance three-dimensional comprehension of the complex anatomy of the skull base. Such models may be generated by photogrammetry, a technical algorithm for photorealistic surface scanning. This study presents a 360° visualization of key neuroanatomical landmarks of the central skull base. One formaldehyde-fixed head specimen with polymer-injected vessels underwent extensive exocranial and endocranial dissections on the right side after a sagittal cut. Initially, the dissection of the orbital region, cavernous sinus, and paranasal sinuses identified cranial nerves II, III, IV, and VI; their branches; extraocular muscles; and major vessels. Subsequently, the 5 terminal branches of the VII were exposed, along with cranial nerves IX, X, XI, and XII. A retrolabyrinthine approach and neck dissection revealed the entire course of cranial nerve VII, sigmoid sinus, the jugular bulb, and the intracranial and extracranial segments of nerves IX, X, XI, and XII. In addition, the infratemporal fossa, pterygopalatine fossa, and middle ear structures were presented. Finally, the vertebral artery segments (v2-v4) and the internal carotid artery, including the petrosal and cavernous segments, were dissected and documented. The specimen was 3D scanned by photogrammetry 3D, refined with 3D modeling software, and uploaded to virtual reality and web visualization. Seven photorealistic models were created and virtual reality videos demonstrating the relevant anatomy in an immersive environment. The courses of intracranial nerves and the associated vascular and soft tissue anatomy were systematically captured from both intracranial and exocranial viewpoints, creating an accurate 360° virtual depiction of the pertinent anatomy. The 3D 360° photogrammetric models developed in this study may allow a better understanding of essential intracranial and extracranial structures of the skull base. These models facilitate customizable views and represent a valuable, freely accessible resource that complements traditional dissections, photographic atlases, and conventional 3D models.

Septic Thrombophlebitis of Multiple Dural Sinuses Extending to Bilateral Internal Jugular Veins due to Acute Sphenoid Sinusitis: A Case of Lemierre's Syndrome.

Lemierre's syndrome (LS) is a rare and potentially life-threatening condition characterized by septic thrombophlebitis within the head and neck region. The lack of a standardized definition in the literature contributes to its limited evidence base. LS presents with various clinical manifestations, often showing atypical features across different age groups. Early diagnosis of LS is challenging due to its nonspecific nature. Recent evidence highlights significant short- and long-term morbidity risks. Successful management requires a multidisciplinary approach and appropriate antibiotic therapy. While LS is commonly associated with oropharyngeal infections, it can also arise from non-oropharyngeal sources, complicating diagnosis and management. We present a case of LS secondary to acute isolated sphenoid sinusitis in an 86-year-old woman. Imaging revealed multiple metastatic septic thrombophlebitis, including bilateral cavernous, inferior petrosal, right transverse and sigmoid sinuses, and internal jugular veins. Blood cultures grew Streptococcus intermedius, and endoscopic sphenoidotomy identified a fungus ball, with cultures confirming Streptococcus anginosus and Aspergillus fumigatus. The patient demonstrated significant recovery with no complications at follow-up. This case illustrates a complex, multifocal pattern of septic thrombophlebitis, extending to multiple venous structures, highlighting the need for comprehensive imaging and a multidisciplinary approach in diagnosing and managing this rare complication. Early recognition of LS, even in the context of non-oropharyngeal infections, is crucial for optimal treatment and improved outcomes.

A case report on timely surgical intervention in pituitary apoplexy and cavernous sinus invasion

A case report on timely surgical intervention in pituitary apoplexy and cavernous sinus invasion

Incidental paraganglioma of sella : A case report and literature review

Most primary paragangliomas of the head and neck occur in the carotid, jugular body, tympanic ventricle, and vagus nerves. Primary sellar paragangliomas are rare, and their long-term outcomes remain unknown. It is also unclear whether they can be classified as asymptomatic incidentalomas in the sellar region. A 75-year-old man who had been followed up for 15 years for an asymptomatic non-functional pituitary adenoma strongly requested surgery and underwent endoscopic transsphenoidal surgery to remove the tumor. Intraoperatively, the tumor was found to be elastic, harder than the pituitary adenoma, fibrous, and not extremely vascularized. The tumor was excised extracapsularly, although residual tumor tissue remained in the medial part of the bilateral cavernous sinuses. A histopathological assessment revealed negative epithelial markers, positive neuroendocrine markers, and partial positivity for S-100, leading to a diagnosis of paraganglioma. Cervicothoracic and abdominal computed tomography, along with spinal magnetic resonance imaging, revealed no apparent neoplastic lesions. The patient experienced no recurrence for 5 years following the resection. The majority of sellar tumors are pituitary adenomas, craniopharyngiomas, Rathke’s cleft cysts, or metastatic brain tumors. Herein, we present a case of an asymptomatic primary sellar paraganglioma that was successfully resected. The case highlights that paraganglioma can be included among incidentalomas in the sellar region. Routine follow-up should generally be recommended for patients with asymptomatic sellar incidentalomas.

MicroRNA Is Downregulated in Invasive Non-Functioning Pituitary Adenomas.

The study aimed to analyze hsa-miR-16-5p, hsa-miR-143-3p, hsa-miR-423-5p, hsa-miR-137-3p, hsa-miR-489-5p, hsa-miR-520-3p, hsa-miR-486-5p, and hsa-miR-200a-3p expression in the serum of patients with invasive non-functioning pituitary adenomas (NFPAs) and prolactinomas, as candidates for non-invasive biomarkers. The study included 62 patients with NFPAs and 18 with macroprolactinoma who qualified for transsphenoidal surgical resection. MicroRNAs were isolated from serum samples. The expression levels of hsa-miR-16-5p, hsa-miR-143-3p, hsa-miR-423-5p, hsa-miR-137-3p, hsa-miR-489-5p, hsa-miR-520-3p, hsa-miR-486-5p, and hsa-miR-200a-3p were determined using TaqMan MicroRNA assays. The statistical analyses were performed with MedCalc. The total concentration of microRNA was significantly lower in NFPAs than in the CG (p = 0.0419). ROC curve analysis showed that the cutoff point of miRNA lower than 10.73 predicted the PA (sensitivity = 70.0%; specificity = 57.7%; AUC = 0.629; p = 0.052). No correlation between selected miRNAs and tumor type was found: hsa-miR-143-3p (p = 0.4610), hsa-miR-16-5p (p = 0.8767), and hsa-miR-423-5p (p = 0.1459). miRNA expression also did not correlate with invasiveness (cavernous or sphenoid sinus invasion, optic chiasm compression). Although the total expression of microRNA was significantly lower in NFPAs, hsa-miR-16-5p, hsa-miR-143-3p, and hsa-miR-423-5p are not useful as non-invasive biomarkers in patients with invasive non-functioning pituitary adenomas and prolactinomas.

Transorbital Approach to the Cavernous Sinus After an Exenteration.

To describe a novel technique of transorbital access to the lateral wall of the cavernous sinus (CS) after exenteration. Cadaveric dissection study. Seven heads (13 orbits) were dissected after total orbital exenteration. The technique was centered on creation of an osteotomy within the greater wing of sphenoid, bordered by the superior and inferior orbital fissures to access the middle cranial fossa. V2 within the foramen rotundum was used as a guide to enter the interdural plane of the lateral CS wall. Results were expressed as the mean value ±1 SD. The lateral CS wall was precisely visualized with identification of cranial nerves III to V2 back to the anterior portion of the Gasserian ganglion. To enable this level of exposure, the osteotomy created within the greater wing of sphenoid was a triangular window with a height of 12.7 ± 1.5 mm (range 10.0-15.0 mm), bordered superiorly by the superior orbital fissure to a linear dimension of 12.8 ± 2.5 mm (range 8.0-18.0 mm), and inferiorly by the inferior orbital fissure to an extent of 12.1 ± 3.9 mm (range 0.9-15.0 mm). The distances from the orbital apex to the intracavernous cranial nerves V1 and V2, and V3 within the foramen ovale were 22.9 ± 3.6 mm (range 17.0-31.0 mm), 25.2 ± 5.0 mm (range 17.5-36.0 mm), and 27.8 ± 5.9 mm (range 18.0-41.0 mm), respectively. The distance between the orbital apex and anterior Gasserian ganglion approximated the maximum surgical corridor achieved with this technique, which was 31.8 ± 4.8 mm (range 26.0-44.0 mm). The transorbital approach to the lateral CS wall is a feasible corridor of access after exenteration. It provides an alternative interdural pathway, thereby obviating the need for additional transcranial or endonasal access routes. Such a technique is in its infancy and surgical series are required to verify it in the clinical setting.

Repairment of an interrupted oculomotor nerve in the cavernous sinus.

Oculomotor nerve palsy following head trauma can cause eye movement disorders and severe visual problems, but it was considered to have a poor prognosis with a wide range of interventions in the past. However, we performed neuroanastomosis in a patient with isolated oculomotor nerve injury and obtained a satisfactory long-term recovery, although the short-term effect was not obvious. The clinical presentation, surgical management, and functional rehabilitation of this patient are discussed.

Application of Topographical Anatomy of the Trochlear Nerve in Transtentorial Approaches: An Anatomic Study.

Transection of the free edge of tentorium (FET) might be necessary when approaching cavernous sinus lesions, clip placement in certain posterior communicating artery aneurysms, or during transpetrosal and retrosigmoid transtentorial approaches. No anatomic study has investigated the relationship of the trochlear and oculomotor nerve and FET in an attempt to identify a safe zone for such maneuver. Ten embalmed specimens (20 sides) were studied and the following morphometric measurements were taken using digital microcalipers: trochlear (TP) to oculomotor porus (OP), length of the intratentorial segment of cranial nerve (CN) IV, nerve free FET, and distance along the oculomotor (CN III) from its OP to CN III/trochlear (CN IV) crossing and angle between the long-axis petrous ridge and TP (petrotrochlear angle). The CN IV pierced the deep layer of the FET in all cases at a mean distance 8.11 mm (4.43-11.33) posterior to the OP, measured along the FET. CN IV continued within the tentorial edge for a mean of 6.17 mm (3.18-11.33) before entering the cavernous sinus at a mean distance of 1.9 mm (0-5.46 mm) from the posterior-most aspect of the OP. A nerve-free portion of FET was 1.93 mm (mean) (0-5.46). No nerve-free FET segment (<1 mm) was observed in 4 sides (20%), and a nerve-free FET segment <2.00 mm was seen in 55% of cases. The mean distance from OP to the CN III/IV crossing was 10.17 mm (1.00-15.57). The mean petrotrochlear angle was 164.49° (140.01-183.85), and >175° in 4 specimens (20%). Our data confirm presence of the intratentorial segment of CN IV. Transection of the FET carries the lowest risk of CN IV injury if performed < 2 mm or >10 mm posterior to the OP, or posterior to intersection of the FET and a virtual extension of a petrous ridge.

Extended Resection of Cavernous Sinus Medial Wall Improves Remission Rates in Somatotroph Pituitary Neuroendocrine Tumors: A Strategy to Inspect Anatomical Interface.

Extended Resection of Cavernous Sinus Medial Wall Improves Remission Rates in Somatotroph Pituitary Neuroendocrine Tumors: A Strategy to Inspect Anatomical Interface.

Endoscopic transorbital approach for the management of spheno-orbital meningiomas: A systematic review and meta-analysis.

Meningioma is the most common benign tumor in the central nervous system and may arise from the sphenoid wing region. The tumor can involve the cavernous sinus medially, periorbital and orbital apex structures anteriorly, and infratemporal fossa inferiorly. Surgical approaches more currently used include the fronto-temporal approach, the pterional approach, and even the frontotemporal-orbitozygomatic approach. The results of safety and efficacy of Transorbital neuroendoscopic surgery for these cases are still unclear, with scarce literature on the subject. We assessed the safety and efficacy of Endoscopic Transorbital Approach (TOA) for the Management of Spheno-Orbital Meningiomas (SOMs). We searched Medline, Embase, Web of Science databases following PRISMA guidelines. We used single proportion analysis with 95% confidence intervals under a random-effects model, I2 to assess heterogeneity, and Baujat and sensitivity analysis to address high heterogeneity. Eligible studies included those with ≥4 patients treated with endoscopic transorbital approach for the management of spheno-orbital meningioma. Of the 3520 studies initially identified, 9 were selected, involving 216 patients, with a median follow-up of 20 months. For subtotal resection, pooled analysis confirmed a rate of 40% (CI: 24% to 57%) and a total resection rate of 46% (CI: 27% to 65%). The analysis also confirmed a rate of visual deficits of 10% (CI: 0% to 24%). The rate of cerebrospinal fluid leak was 2% (CI: 0% to 5%), and diplopia occurred in 8% of cases (CI: 0% to 18%). ETOA is a safe and minimally invasive approach for spheno-orbital meningiomas, with low complication rates and effective cranial nerve preservation. However, its tumor resection efficacy is inferior to non-minimally invasive techniques, potentially affecting long-term outcomes. Further studies are needed to clarify its role and optimize tumor control in selected cases.

Intraocular hypertension caused by elevated episcleral venous pressure following arteriovenous fistula embolization.

Increased intraocular pressure due to elevated episcleral venous pressure is a recognized complication associated with arteriovenous fistulas, which typically form between the carotid artery and the cavernous sinus. We report a case of a patient who developed paradoxical worsening syndrome a few days after he underwent a two-staged transarterial embolization procedure of a left sided ethmoidal arteriovenous fistula. The patient presented with signs of elevated episcleral venous pressure leading to intraocular hypertension caused by the iatrogenic partial obstruction of the left superior ophthalmic vein.

Repeated stereotactic radiosurgery for residual intracranial dural arteriovenous fistulas

ObjectiveStereotactic radiosurgery (SRS) is widely used for the treatment of intracranial dural arteriovenous fistulas (DAVFs); however, the outcomes of repeated SRS to deal with residual DAVFs are unclear. This study assessed the benefits and potential negative consequences of repeated SRS in patients with residual DAVFs.MethodsThis retrospective study examined all patients who underwent two SRS procedures for DAVFs in a single academic medical center between January 1998 and December 2022. Information related to patient demography, DAVFs characteristics, and clinical outcomes were obtained from medical records. The objective in this study was to obtain a preliminary overview of the results of repeated SRS for DAVFs.ResultsThe study cohort of 19 patients included 14 patients with non-cavernous sinus (NCS) DAVFs and 5 patients with cavernous sinus (CS) DAVFs. The NCS group included 8 patients who were categorized as low-grade (Borden grade 1) and 6 as high-grade (Borden grade 2 or 3). The median follow up duration after the second session of SRS was 37 months. Symptomatic improvement was noted in 16 patients (84.2%) and total obliteration was identified in 11 patients (57.9%). No patient suffered from intracranial hemorrhage after the repeated SRS. One patient (5.3%) experienced symptomatic radiation-induced change mandating temporary course of medical treatment.ConclusionsRepeated SRS appears to be a safe and effective approach to deal with residual DAVFs, resulting in symptomatic improvement and complete radiologic obliteration.

Open vascular treatment after internal carotid artery knife transection: illustrative case.

Although penetrating, nonmissile, traumatic cranial injuries with associated vascular injuries make up a small portion of all traumatic brain injuries, they can pose a unique challenge to the neurosurgeon. Recently, less invasive, endovascular treatment options have shown promise, but there remains a need for experience with open vascular treatment in certain circumstances. The authors describe the importance of careful surgical planning for open vascular repair of an internal carotid artery (ICA) transection injury after traumatic knife cranial penetration. The authors present the case of a 21-year-old Brazilian male, victim of domestic assault by knife, which penetrated the temporal bone, anterior temporal lobe, cranial nerves, cavernous sinus, and right ICA. Digital subtraction angiography showed right ICA occlusion with associated thrombosis of cervical through clinoidal segments, with adequate collateral perfusion. The authors performed a pterional craniotomy for clip ligation of the clinoidal segment of the ICA, with safe removal of the knife and a favorable patient outcome. The authors describe a technical case illustration, accompanied by a surgical video and cadaver and anatomical illustration. This case highlights the importance of detailed knowledge of cerebrovascular and skull base anatomy and preservation of complex open vascular neurosurgical techniques, especially in settings where endovascular treatment is not a feasible option. https://thejns.org/doi/10.3171/CASE2532.

Non-aggressive, sinus-type greater sphenoid wing dural arteriovenous fistula with shunt point in the laterocavernous sinus mimicking a cavernous sinus dural arteriovenous fistula converted to aggressive, non-sinus-type.

Sphenoid wing dural arteriovenous fistulae (DAVFs) are rare. Although the imaging findings of greater sphenoid wing DAVFs may resemble those of cavernous sinus DAVFs (CSDAVFs), their respective presentations differ. Benign CSDAVFs rarely convert to the aggressive type. Conversely, as greater sphenoid wing DAVFs are often of the aggressive type, with intracranial cortical venous reflux and varices, treatment is recommended. Sphenoid wing DAVFs tend to be of the non-sinus type, and transarterial embolisation is often an effective endovascular treatment. We present a case of an asymptomatic greater sphenoid wing DAVF mimicking a CSDAVF that converted from a non-aggressive sinus-type to an aggressive non-sinus-type due to compartmentalisation and thrombotic occlusion. Transarterial embolisation with Onyx and a transarterial venous coil resulted in complete disappearance of the DAVF. Greater sphenoid wing DAVFs can be misdiagnosed as CSDAVFs and require accurate imaging evaluation and careful follow-up, even in asymptomatic or non-aggressive cases.

Clinical characteristics and pathological features of growth hormone-secreting pituitary adenoma combined with hyperprolactinemia.

Large-scale reports on growth hormone-secreting pituitary adenomas (GHPA) with hyperprolactinemia (HPRL) remain limited. The relationship between clinical characteristics and pathological subtypes of GHPA patients, based on the 2022 classification of pituitary neuroendocrine tumors (PitNET), has rarely been elucidated. This study aims to enhance the understanding of clinicopathological features in GHPA and clarify differences between patients with and without HPRL. We retrospectively collected the clinical data of 810 patients diagnosed with GHPA. The clinical and pathological characteristics were compared between the HPRL and non-HPRL groups. Patients were categorized according to 2022 pathological classification and their differences were compared. Compared to the non-HPRL group, the HPRL group exhibited more visual acuity/field impairment and galactorrhea and had higher GH levels. The tumor volume (TV) in the HPRL group was significantly larger, with more severe cavernous sinus invasion and optic chiasm compression, and a higher proportion of mammosomatotroph PitNETs. The most common pathological types of GHPA included sparsely granulated somatotroph PitNETs (46.19%), mammosomatotroph PitNETs (17.37%), and plurihormonal PitNETs (17.80%). Patients with immature PIT-1 lineage PitNETs had the lowest biochemical remission rate and highest tumor residual/recurrence rate. The symptoms of galactorrhea and visual acuity/field impairment contribute to early diagnosis in GHPA patients with HPRL. Although TV is larger and invasiveness is greater, HPRL does not significantly affect the biochemical remission rate. Nearly half of GHPA cases are sparsely granulated somatotroph PitNETs, which are often associated with poor tumor outcomes, highlighting the critical role of pathological type in predicting clinical prognosis.

Determinants of Recurrence in Intracranial Meningioma: A Decade of Experience with Surgical and Pathological Correlations in Bandung, Indonesia

Background: Intracranial meningiomas are common primary central nervous system tumors, mostly benign, yet recurrence remains a significant clinical challenge influencing patient prognosis. Understanding the characteristics and determinants of recurrence, particularly in specific populations, is crucial. Data on recurrent meningioma from developing countries like Indonesia are limited. This study aimed to describe the clinicopathological features and surgical management experience of recurrent intracranial meningiomas over a 10-year period at a tertiary referral hospital in Bandung, Indonesia. Methods: A retrospective analysis was conducted on all adult patients (≥18 years) surgically treated for recurrent intracranial meningioma at the Department of Neurosurgery, Dr. Hasan Sadikin General Hospital, Bandung, between January 2012 and December 2022. Patients with incomplete records were excluded. Data collected included demographics, clinical presentation, radiological findings (tumor location, bone infiltration, tumor invasion), surgical history (number of resections, time to recurrence), and histopathological results. Descriptive statistics were used for analysis. Results: Twenty-eight patients met the inclusion criteria. The cohort was predominantly female (n=24, 85.7%) with a median age of 46 years (range 26-67). The most common presenting symptoms were protrusion (n=11, 39.3%) and headache (n=7, 25.0%). Tumors were most frequently located in the parietal (n=10, 35.7%) and sphenoorbital (n=9, 32.1%) regions. Significant bone infiltration was observed in 75.0% (n=21) of cases. Tumor invasion into adjacent structures occurred in 21.4% (n=6), most commonly involving the cavernous sinus (n=2, 7.1% of total / 33.3% of invaded). The median time to recurrence detection was 36 months (range 6-144). Most patients (n=22, 78.6%) underwent two tumor removal surgeries during the study period. Based on available histopathology (n=17), meningothelial (n=10, 35.7% of total / 58.8% of available) and transitional (n=3, 10.7% of total / 17.6% of available) subtypes were the most common WHO Grade 1 diagnoses. One case each of atypical (Grade 2) and malignant (Grade 3) meningioma were identified. Conclusion: Recurrent intracranial meningiomas predominantly affected middle-aged females, often presenting with symptoms related to mass effect in parietal and sphenoorbital locations. High rates of bone infiltration and significant tumor invasion, particularly involving the cavernous sinus, were characteristic features. Recurrence was typically diagnosed within 3 years, with meningothelial and transitional subtypes being the most frequent histologies observed in this recurrent group. These findings underscore the complex nature of meningioma recurrence and highlight the need for tailored management strategies and long-term surveillance, particularly in cases with high-risk features like bone and sinus invasion.

Deep Temporal Muscle Pedicled Flap: A Novel Reconstruction Technique Following Transorbital Approach, Anatomic Study, and Surgical Implications.

The temporalis muscle flap has historically been used for repairing defects from orbital procedures and is commonly used in cranial, oral, and facial reconstructions. However, its application for reconstructing the skull base after a transorbital approach has not been explored. Reconstruction after a transorbital intradural approach is still object of preclinical and clinical investigation, with various techniques emerging recently. This study introduces a novel method suitable for extensive resections of the skull base, including intradural resections of the anterior, middle, and posterior cranial fossae.The study aimed to investigate the feasibility of rotating a vascularized myofascial flap from the anterior third of the temporalis muscle onto the skull base, exploring its extension into the middle cranial fossa after drilling the greater wing of the sphenoid. Six endoscopic dissections were performed on formalin-fixed heads to illustrate the feasibility of preparing a deep fascia flap from the temporalis muscle. Red silicone latex was injected into the external carotid artery to confirm the vascular integrity of the deep temporal branches of the maxillary artery. The deep temporalis myofascial flap offers a large, well-vascularized tissue that can be easily rotated to cover skull base defects after transorbital approaches. Its coverage extends from the middle and anterior cranial fossae to the infratemporal fossa and the lateral wall of the cavernous sinus. It also effectively covers dural defects at the temporal pole. With an appropriate temporal bony window and sufficient exposure, it is feasible to endoscopically prepare a rotation flap from the anterior third of the temporalis muscle, minimizing the need for resecting the lateral orbital margin. This approach is a favorable alternative to traditional reconstruction techniques, offering quick setup in a single operative procedure. Future studies are needed to confirm minimal donor site morbidity regarding masticatory function.

Mucoepidermoid carcinoma of the parotid gland with invasion of the jugular foramen region: A case report.

Mucoepidermoid carcinoma of the parotid gland, being the most prevalent malignant neoplasm among salivary gland tumors, represents the leading incidence rate among primary parotid malignancies. This pathological entity predominantly affects young and middle-aged females, typically presenting as a painless parotid mass. Due to its variable disease progression and nonspecific clinical manifestations, preoperative misdiagnosis as a benign tumor is frequently encountered. However, when parotid mucoepidermoid carcinoma progresses to involve the jugular foramen region, a complex anatomical structure, the diagnostic and therapeutic challenges are significantly amplified. This case report presents a 56-year-old male patient with difficulties in closing his right eye and deviation of the mouth corner for 1 year, along with coughing while drinking water and hoarseness for 2 months. After multiple misdiagnoses and ineffective treatments, the patient was admitted to our hospital with a suspected diagnosis of jugular foramen syndrome. Radiological examinations revealed abnormal enhancement in the right parotid gland, cavernous sinus, and petrous bone of the right temporal bone, with surrounding bone destruction. Surgical pathology confirmed the diagnosis of mucoepidermoid carcinoma of the parotid gland, with intermediate grade and nerve invasion. The tumor had also invaded the jugular foramen region. The patient underwent skull base lesion resection via the infratemporal fossa approach, parotidectomy, cervical lymph node dissection, abdominal fat filling, and external auditory canal closure. And he was treated with postoperative radiotherapy and chemotherapy. After 1 year and 4 months of follow-up, there was no recurrence of the tumor. The patient presented with significant deglutition-related aspiration, prompting surgical intervention to enhance quality of life. Following vocal cord augmentation performed in our department, the patient demonstrated marked improvement in both aspiration symptoms and vocal quality. This case highlights the importance of detailed differential diagnosis and a comprehensive understanding of the jugular foramen region in avoiding misdiagnosis and ensuring timely treatment.

Gruber’s ligament is a part of the dura mater: An anatomical and histological study of Dorello’s canal relevant to skull base surgery

Objective Many studies have focused on Gruber’s ligament and Dorello’s canal. However, only scant studies have analyzed these structures via histological analysis. Furthermore, the histology studies for these structures did not sufficiently evaluate them and their surrounding anatomical relationships. Therefore, this study aims to assess the comprehensive morphology of Gruber’s ligament and Dorello’s canal. Methods: Histological observation in coronal and sagittal sections and microsurgical observations (using both conventional and inferior approaches) were conducted on Gruber’s ligament, Dorello’s canal, and related structures. Results Histological observation revealed that the only extension of the dura was found between the petrous apex and the clivus. Microsurgical dissection using the conventional approach identified a fibrous band, whereas the inferior approach did not reveal any distinct connective tissue other than dura. Our multidirectional approach demonstrated that Gruber’s ligament is part of the dura between the petrous apex and clivus. The petrous apex end was artificially separated from the dura along the medial wall of the cavernous sinus. The previously reported variations of Gruber’s ligament, such as duplication or absence, can now be explained by our findings. Conclusions Gruber’s ligament is simply a part of the dura at the skull base. The extension of the dura between the petrous apex and clivus, which forms part of a mesh-like structure rather than a distinct ligament, traditionally has been termed Gruber’s ligament.

Multiple Cavernous Sinus Arteriovenous Fistulas.

Patients with bilateral cavernous sinus combined with dural arteriovenous fistula in the intercavernous sinus area are very rare. Cavernous sinus dural arteriovenous fistula is mostly associated with venous thrombosis and venous hypertension. It can be treated curatively by the venous route.