Localizing Thalamomesencephalic Afferent and Efferent Pupillary Defects.

ABSTRACT: A 42-year-old Algerian man presented for binocular oblique diplopia, hypersomnolence with drop attacks, bilateral hearing loss, and thoracic pain. He had a right thalamomesencephalic hemorrhage due to an underlying cavernous malformation treated with subtotal surgical resection. On neuro-ophthalmic examination, the patient had a left relative afferent pupillary defect and a right oculosympathetic efferent pupillary defect (i.e., Horner syndrome) in addition to other thalamomesencephalic eye and neurologic signs (right fourth nerve palsy, hearing loss, hemiparesis, and thalamic pain). Clinicians should recognize the localizing value of this unique constellation of mesencephalic afferent and efferent pupillary defects.

Intraorbital Arteriovenous Fistula From the Superficial Temporal Artery.

Intraorbital arteriovenous fistula is a rare vascular disease characterized by an acquired arteriovenous communication without direct cavernous sinus involvement. Intraorbital arteriovenous fistula may develop slowly and present similarly to other insidious orbitopathies, such as carotid-cavernous fistula. The authors present a case of a superficial temporal artery to superior ophthalmic vein fistula arising in the absence of trauma or prior surgery. This is the first report of a spontaneous intraorbital arteriovenous fistula arising between these vessels and further describes the rare occurrence of intraorbital arteriovenous fistula.

Fractionated Stereotactic Radiotherapy for Cavernous Venous Malformations of the Orbital Apex.

PURPOSE: The objective of this study was to investigate the efficacy and safety of fractionated stereotactic radiotherapy in the treatment of cavernous venous malformation of the orbital apex. METHODS: The authors reviewed a prospective database from a single center of patients with cavernous venous malformation of the orbital apex who had treatment with fractionated stereotactic radiotherapy. The authors compared the symptoms, visual function and the size of the tumor pre- and posttreatment as well as reviewed the treatment details and the incidence of complications. RESULTS: Six patients received treatment with fractionated stereotactic radiotherapy for cavernous venous malformation involving the orbital apex. The median age was 48 (range, 32-63), and 50% were female. Patients received a dose of 45 to 50.4 Gy in 1.8 to 2 Gy fractions. Median follow up was 33 months (range, 18-66 months). The average tumor volume reduction at posttreatment imaging after 12 months was 63%. All lesions reduced in size postradiotherapy and remained controlled for the duration of follow up. All patients who had proptosis or a visual field defect had an improvement in the symptoms posttreatment. There were no complications of the treatment. CONCLUSION: Fractionated stereotactic radiotherapy appears to be a safe and effective management option for cavernous venous malformation of the orbital apex and leads to a sustained reduction of the volume of the lesion with associated improvement in symptoms and visual function.

Bilateral duplication of the abducens nerve - case study.

The abducens nerve is characterized by a long intracranial course and complex topographical relationships. Anatomical knowledge may help to understand both the etiology and clinical symptoms of abducens nerve palsy. Typically, the single trunk of the abducens nerve travels on both sides. However, occasionally different variants of unilateral or bilateral duplications of the abducens nerve may be observed. The presented paper is a detailed anatomical description of bilateral duplication of the abducens nerve, with atypical appearance of the nerve in the cavernous sinus and normal distribution within the lateral rectus muscle on both sides of one cadaver. On the right side both trunks of the abducens nerve fused within the subarachnoid space and pierced the dura mater together. On the left side both trunks of the duplicated abducens nerve pierced the dura mater separately, entered the petrous apex separately and fused just below the petrosphenoidal ligament. Within the cavernous sinus the nerve divided once again into two filaments, which reunited into one trunk a er crossing the horizontal segment of the intracavernous part of internal carotid artery. The orbital segments of the abducens nerve showed a typical course on both sides. Duplication of the abducens nerve is anatomical variation which should be taken into account during diagnostic and surgical procedures performed within the petroclival region and cavernous sinus.

Double inter-internal carotid artery communication through intercavernous anastomosis and posterior communicating artery associated with multiple intracranial artery segmental agenesis/aplasia.

Segmental internal carotid artery (ICA) and basilar artery (BA) agenesis/aplasia are rare vascular anomalies. We report an extremely rare case of combined ICA, BA, and A1 segmental absence presenting with double inter-ICA collateral communication through the intercavernous anastomosis and posterior communicating arteries. The patient presented with diplopia and transient ischemic attack. The pathogenesis of the anatomic anomalies and clinical symptoms are discussed.

Superficial middle cerebral vein connection to the cavernous sinus is not infrequent in brain arteriovenous malformations: an argument against their congenital origin?

INTRODUCTION: The aim of this study was to test the hypothesis that the superficial middle cerebral vein (SMCV) is frequently absent or fails to connect with the cavernous sinus (CS) in the presence of brain arteriovenous malformations (AVMs), a frequently reported argument for the congenital origin of brain AVMs. METHODS: The SMCV was retrospectively compared between patients with a brain AVM and a control group. The presence or absence of the SMCV, its direct or indirect connection to the CS and its termination in a laterocavernous sinus (LCS), paracavernous sinus (PCS), or directly in the CS was studied on digital subtraction angiography. RESULTS: One hundred twenty-five left or right side carotid angiograms from 70 patients with a brain AVM were compared to 125 angiograms from 74 controls. The SMCV was present in 88 (70.4 %) cases in the brain AVM group and 96 (76.8 %) cases in controls (p = 0.25). The SMCV was connected directly or indirectly to the CS in 65 (52 %) cases in the brain AVM group and 65 (52 %) cases in controls (p = 1). When comparing the subgroup of carotid angiograms ipsilateral to a supratentorial AVM, no statistically significant difference was found with controls. In three of six cases in which a SMCV drained an AVM, the vein terminated directly or indirectly in the CS. CONCLUSIONS: No difference of SMCV presence and direct or indirect connection to the CS was found between patients with AVM and a control group. SMCV anatomy does not support the congenital origin of brain AVMs.

Facial nerve injury as a complication of endovascular treatment for cavernous dural arteriovenous fistula.

Facial nerve injury following endovascular treatment of cavernous dural arteriovenous fistulae may be caused by ischemia from inadvertent embolisation of vasa nervorum, shearing or compressive forces. We report a case of unilateral facial nerve palsy as a complication of cavernous dural arteriovenous fistula embolisation.

Surgical cannulation of the superior ophthalmic vein for the treatment of previously embolized cavernous sinus dural arteriovenous fistulas: serial studies and angiographic follow-up.

OBJECTIVE: The purpose of this study was to evaluate the safety and efficacy of transorbital puncture for the retreatment of previously embolized cavernous sinus dural arteriovenous fistulas (DAVFs) via a superior ophthalmic vein (SOV) approach. MATERIALS AND METHODS: During a 12-year period, 9 consecutive patients with previously embolized cavernous sinus DAVFs underwent retreatment via the transorbital SOV approach. RESULTS: All of the nine cases of previously embolized cavernous sinus DAVFs were successfully embolized. Clinical follow-ups were conducted in all nine cases at the duration of 17-141 months (61.22 ± 39.13 months). No recanalization occurred during the follow-up period. A subtle ptosis appeared in two patients and disappeared in one of the two cases after a 4-year follow-up. One patient suffered from paroxysmal positional vertigo and bruit for nearly 2 years after the treatment, but the follow-up angiography demonstrated no recurrence. One patient had persistent visual impairment caused by the initial venous stasis retinopathy. One patient with a history of a procedure-related transient decrease in visual acuity had it return to the normal level. The remaining four cases had clear improvement in the ocular symptoms and became completely asymptomatic during the follow-up period. No patient worsened or developed new symptoms. CONCLUSION: The approach of surgical cannulation of the SOV for the retreatment of previously embolized cavernous sinus DAVFs was proved feasible and efficient, especially when the transarterial and transfemoral venous approaches were inaccessible. However, if the SOV is not dilated enough or is located deeply in the orbit, transorbital venous puncture access may not be possible.

Transorbital embolization of cavernous sinus dural arterio-venous malformations with surgical exposure and catheterization of the superior ophthalmic vein.

PURPOSE: Cavernous sinus dural arterio-venous malformations (dAVF) represent a pathologic connection between branches of the internal and/or external carotid artery and the cavernous sinus. Standard endovascular approaches for dAVF treatment are transvenous embolization through the inferior petrosal sinus or the facial vein and transarterial embolization. These approaches are not always successful or feasible, and alternative techniques are required. Here, we present a case series of a minimally invasive transorbital approach with surgical exposure and catheterization of the superior ophthalmic vein for transvenous fistula coiling. METHODS: 14 patients with dAVFs (Barrow Type B to D) that were treated at a tertiary care medical center over a period of 13 years were included in the study. Patients with persisting dAVF associated symptoms were selected for this approach when conventional endovascular interventions were not successful or not feasible. The surgical procedure was performed under general anaesthesia. RESULTS: A successful transorbital approach was performed in all 14 cases. In 12 of 14 patients a catheter assisted successful embolization of the fistula was performed using platinum coils with no relevant residual fistula flow. In two cases, a spontaneous thrombosis of the fistula during the surgical procedure required no further embolization. No postoperative therapy-associated complications were observed. CONCLUSION: The described approach is an effective method to embolize dAVFs in selected cases when catheter assisted transvenous and/or transarterial embolization is not successful or not feasible. In this case series we demonstrate an excellent success rate with no therapy-associated major complications.

Multiple dural arteriovenous fistulas involving the cavernous sinus, transverse sinus, sigmoid sinus and spinal drainage: CT angiography findings in 14-year-old boy.

Dural arteriovenous fistulas (DAVF) are rare and constitute 10% to 15% of all intracranial arteriovenous malformations. Only few cases of DAVFs are reported in children. Here is the first case report describing CT angiographic findings in a 14 year old child having multiple DAVFs involving spinal canal, both cavernous and cerebral sinuses.

Arterial spin-labeling imaging at 3-T in dural arteriovenous fistulas of cavernous sinus before and after endovascular treatment.

A 72-year-old man presented with chemosis and ophthalmoplegia due to dural arteriovenous fistulas (DAVF) of the cavernous sinus (CS). Preoperative arterial spin-labeling (ASL) image showed visible vein in the bilateral superior ophthalmic vein (SOV). Endovascular transvenous embolization of the shunting points of the CS-DAVF was performed, and the postoperative angiogram showed complete obliteration of the CS-DAVF. Postoperative ASL showed no visible vein in the bilateral SOV. ASL in CS-DAVF was proved to have shown retrograde venous drainage from the CS-DAVF by comparing ASL before and after treatment.

The treatment of a dural carotid cavernous fistula (CCF) using Onyx via a transorbital approach: a technical note.

We report the successful case of embolisation of a Barrow D (White et al. in Am J Neuroradiol 28:1415-1417, 2007) dural carotid cavernous fistula (CCF) with bilateral external carotid artery and internal carotid arterial supply, using a direct percutaneous transorbital approach with the embolic agent Onyx. In particular, we highlight the properties of Onyx which make it suitable to treat the multi-compartmental nature of CCFs. The patient developed transient complications which may be related to the volume of embolic agent used, and we discuss this point further. This is still a developing technique, and we present our case as a technical note to aid those contemplating embolisation via a transorbital approach with Onyx.

Narrowing of Meckel's cave and cavernous sinus and enlargement of the optic nerve sheath in Pseudotumor Cerebri.

OBJECTIVE: Pseudotumor cerebri (PTC) is a clinical entity of uncertain etiology associated with several subtle findings on magnetic resonance imaging (MRI) including posterior flattening of the globes, enlargement of the optic nerve sheath (ONS), empty sella sign. We aimed to characterize the incidence of and significance of 2 novel MRI findings: narrowing of Meckel's cave and of cavernous sinus. METHODS: Forty-six patients with a condition diagnosed as PTC based on clinical history were retrospectively reviewed, and their MRI studies were assessed for previously reported imaging findings associated with PTC. The maximal diameters of the cavernous sinuses, Meckel's caves, and ONSs were measured along with those of age-matched controls on axial T2-weighted images. RESULTS: The Meckel's caves and cavernous sinuses are significantly (P < 0.01) narrowed in patients (mean diameters: 0.41 and 0.25 cm) versus controls (0.54 and 0.36 cm), respectively. The ONS was enlarged in patients with a mean diameter of 0.65 cm versus 0.54 cm (P < 0.01). Meckel's cave narrowing and ONS enlargement seem to be better indicators of PTC than cavernous sinus narrowing, with sensitivities of 78.3% and 86.9% and specificities of 84.8% and 76.1% versus 60.9% and 76.1%, respectively. CONCLUSIONS: This finding of narrowed Meckel's caves in PTC may be clinically useful as a novel imaging finding seen on routine MRI studies. Optic nerve sheath enlargement is also confirmed as an important finding in PTC.

Transvenous treatment of complex cavernous dural arteriovenous fistulae with Onyx and coils.

Transvenous embolization has become the treatment of choice for such lesions We evaluated Onxy for patients with cavernous dural arteriovenous fistulae (CDAVFs) who underwent transvenous embolization via different transvenous approaches. Case records of six patients with symptomatic CDAVFs, treated between October 2006 and November 2007 were reviewed. A total of seven transvenous procedures were performed in the six patients with CDAVFs. All the patients with CDAVFs of the cavernous sinus were symptom free following embolization. The approach via the internal jugular vein and the inferior petrosal sinus was possible in four of the six patients, with complete occlusion of the fistula. In the remaining two patients, the approach was via the facial vein. Transient bradyarrythmia without morbidity was the only complication in two patients.

Transvenous embolization of cavernous sinus dural arteriovenous fistulas using detachable coils and Glubran 2 acrylic glue via the inferior petrosal sinus approach.

OBJECTIVES: To describe the technique, efficacy, and safety of transvenous embolisation (TVE) of cavernous sinus arteriovenous fistulas (CSDAVFs) via the inferior petrosal sinus (IPS) with detachable coils and acrylic glue. METHODS: Spontaneous unilateral CSDAVFs were confirmed by cerebral angiography in eight patients, with angiographic patency of the ipsilateral IPS in three and angiographic non-visualisation of the ipsilateral IPS in five. There were two patients with complete occlusion of the ipsilateral internal jugular vein (IJV). TVE with detachable coils and acrylic glue were performed through a femoral vein and an IPS approach. RESULTS: TVE viaipsilateral IPS was successfully performed in all eight patients in our group. The number of detachable coils for each patient ranged from 2 to 8 (mean, 5.0). Angiography immediately after TVE showed complete occlusion of the CSCAVFs in seven patients and nearly complete occlusion in one. Complete recovery of clinical symptoms was achieved in all eight patients. No recurrence of clinical symptoms was observed at follow-up. CONCLUSIONS: Transvenous embolisation via an IPS approach is a highly efficient and safe treatment for CSDAVFs. Embolisation with a combination of coils and acrylic glue may help to achieve complete occlusion of fistulas with fewer coils.

Follow-up of endovascular treatment of direct carotid-cavernous fistulas.

INTRODUCTION: Direct carotid-cavernous fistula (CCF) is a direct communication between the internal carotid artery (ICA) and the cavernous sinus. Some patients treated with detachable balloons develop pseudoaneurysms or present with a true aneurysm recanalization in the cavernous ICA with poorly known long-term radiological and clinical progression. The objective of the present study was to evaluate the long-term clinical and radiological progression of patients treated with detachable balloons. METHODS: The present study evaluated 13 patients previously treated for direct CCF by an endovascular approach. RESULTS: The follow-up period ranged between 19 and 128 months. Ophthalmological evaluation demonstrated alterations in eight patients (61.5%). All of these alterations were already present from the moment of the treatment and displayed no signs of progression. Cranial magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) were performed in all patients, and 11 pseudoaneurysms were demonstrated in ten of the 11 patients in whom ICA patency had been preserved. Five patients were submitted for cerebral digital subtraction angiography (DSA) to characterize the pseudoaneurysms previously observed on MRA studies, with no significant differences in morphology, size, aneurismal neck, and number of lesions. CONCLUSION: Endovascular treatment of direct CCF with detachable balloons has been shown to be a long-term effective and stable therapeutic method. The authors found asymptomatic pseudoaneurysms in 91% of cases where the ICA patency was preserved. MRI and MRA demonstrated an accuracy similar to that of DSA in the diagnosis of pseudoaneurysms of cavernous ICA.

Clinical and angiographic characteristics of cavernous sinus dural arteriovenous fistulas manifesting as venous infarction and/or intracranial hemorrhage.

INTRODUCTION: Cavernous sinus (CS) dural arteriovenous fistulas (DAVFs) rarely cause venous infarction (VI) and/or intracranial hemorrhage (ICH) despite the presence of cortical venous drainage (CVD). The present study investigated the characteristics of CS DAVFs manifesting as VI/ICH. MATERIALS AND METHODS: Fifty-four patients treated for CS DAVFs were retrospectively studied. RESULTS: Six patients presented with VI/ICH. Two of the three patients presenting with ICH had CVD only to the superficial sylvian vein (SSV) or the deep sylvian vein (DSV). Three patients presenting with VI had multiple drainages, and angiography of these patients showed a varix on the SSV, drainage into the DSV with agenesis of the second and third segment of basal vein of Rosenthal, and thrombosis of the distal petrosal vein. CS DAVF with CVD only carries higher risk of VI/ICH than multiple drainages. Many CS DAVFs presenting with VI, especially those with drainage into the petrosal vein, have multiple drainages in the early stage. Thrombosis of the inferior and superior petrosal sinuses and superior orbital vein gradually increases pressure of the CVD, and then, VI may occur. In contrast, CS DAVFs with CVD only from the beginning, common in the patients with drainage into the SSVs and DSVs, are likely to cause ICH. CONCLUSION: Angiographic risk factors causing VI/ICH are CVD only, varix formation, agenesis of the second and third segment of basal vein of Rosenthal, and thrombosis of the superior orbital vein, lateral half of the superior petrosal sinus, and distal CVD.

Minimally invasive approaches to treating chemosis of the eyes from unusual dural arteriovenous fistulae.

Chemosis of the eyes is usually attributed to carotid cavernous sinus dural arteriovenous fistulae. Herein, we reviewed unusual cases in which chemosis of the eyes originated from dural ateriovenous fistulae (dAVFs) that were distinctly different from carotid cavernous sinus fistulae. Cases in which ocular symptoms were related to increased intracranial pressure either due to sinus thrombosis or cortical venous drainage without involvement of superior or inferior ophthalmic veins were excluded in this review. Several different types of dural AVFs were associated with chemosis, and these included dAVFs harboring a feeding artery from branches of the external carotid artery directly draining to the superior ophthalmic vein or cavernous sinus via the superior petrous sinus, posterior fossa dAVFs draining via the inferior petrous sinus and cavernous sinus to the ophthalmic vein, a fistula between the ophthalmic artery or branches of the internal carotid artery and inferior ophthalmic vein, or tentorial fistula with a drainage vein to the cavernous sinus via the vein of Galen. This study reviews the symptomatology, treatment options, and cerebrovascular abnormalities observed for these unusual dAVF's with chemosis.