Neurosarcoidosis manifesting as cavernous sinus syndrome in systemic sarcoidosis.

Neurosarcoidosis can manifest in various neurological presentations. The occurrence of cavernous sinus involvement in neurosarcoidosis is rare, which can complicate the diagnostic process. We present a case of neurosarcoidosis demonstrating progressively deteriorating right cavernous sinus syndrome in a woman in her 50s, affecting the oculomotor, abducens and the ophthalmic division of the trigeminal nerves. MRI demonstrated meningeal thickening along the lateral wall of the right cavernous sinus, and a pan-CT scan of the chest, abdomen and pelvis revealed disseminated sarcoidosis involving the lungs and the liver. Histopathological analysis of the liver lesion ultimately confirmed the diagnosis of sarcoidosis. This case underscores the significance of considering neurosarcoidosis as a potential cause of cavernous sinus syndrome. In such cases, early initiation of corticosteroid treatment, with or without steroid-sparing agents, is crucial to prevent disease progression and relapse.

Endoscopic transcavernous approach for functional pituitary adenomas.

BACKGROUND: Invasion of the CS is one of the limiting factors for total resection for PitNet tumors with cure rates less than 30%. Extended approaches may be considered in selective and well-studied cases of secreting adenomas. METHOD: We describe the key steps of the endoscopic transcavernous approach for functional pituitary adenomas with a video illustration. The surgical anatomy is described along with the advantages and limitations of this approach. CONCLUSION: A detailed knowledge of CS anatomy and familiarity with this surgical approach acquired in the laboratory is essential. Proper instrumentation is critical to decrease the risks of vascular injury.

Carotid Cavernous Fistula.

Carotid cavernous fistulae (CCFs) are arteriovenous shunts involving the cavernous sinus. CCFs are defined as direct or indirect. Direct CCFs are treated by deconstructive or reconstructive techniques depending on whether the affected internal carotid artery is required to perfuse the ipsilateral cerebral hemisphere, as determined by a balloon test occlusion. Indirect CCFs, or dural fistulae of the cavernous sinus wall, are most often treated with transvenous embolization. Stereotactic radiosurgery is reserved for cases of indirect CCFs that are not completely obliterated by embolization. Overall, cure rates are high with relatively low complication rates.

Comparative analysis of intraoperative and imaging features of invasive growth in pituitary adenomas.

BACKGROUND: Most pituitary adenomas (PAs), also termed pituitary neuroendocrine tumors, are benign in nature and can be treated effectively by surgical resection, medical treatment, and in special cases by radiotherapy. However, invasive growth can be an important feature of a more aggressive behavior and adverse prognosis. The extension of PAs into the cavernous sinus can be categorized according to the Knosp criteria on magnetic resonance imaging (MRI). Comparative analyses of MRI features and intraoperative findings of invasive growth regarding different clinical factors are still scarce. MATERIALS AND METHODS: We performed a retrospective single-center analysis of 764 PAs that were surgically treated between October 2004 and April 2018. Invasive growth was assessed according to the surgical reports and preoperative MRI (Knosp criteria). Clinical data, such as patient age at diagnosis and gender, histopathological adenoma type, and extent of resection, were collected. RESULTS: Invasive features on MRI were seen in 24.4% (Knosp grades 3A-4, 186/764) of the cases. Intraoperatively, invasion was present in 42.4% (324/764). Complete resection was achieved in 80.0% of adenomas and subtotal resection, in 20.1%. By multivariate analysis, invasion according to intraoperative findings was associated with the sparsely granulated corticotroph (SGCA, P = .0026) and sparsely granulated somatotroph (SGSA, P = .0103) adenoma type as well as age (P = .0287). Radiographic invasion according to Knosp grades 3A-4 correlated with age (P = .0098), SGCAs (P = .0005), SGSAs (P = .0351), and gonadotroph adenomas (P = .0478). Both criteria of invasion correlated with subtotal resection (P = .0001, respectively). CONCLUSIONS: Both intraoperative and radiographic signs of invasive growth are high-risk lesions for incomplete extent of resection and occur more frequently in older patients. A particularly high prevalence of invasion can be found in the SGCA and SGSA types. Cavernous sinus invasion is also more common in gonadotroph adenomas. Usage of the Knosp classification is a valuable preoperative estimation tool.

[A case of Takayasu arteritis complicated with cavernous sinus syndrome presenting as unilateral optic nerve DWI hyperintensity].

A 47-year-old male patient with a history of Takayasu arteritis presented with prominent symptoms of left eyeball fixation, protrusion, and visual loss. Orbital magnetic resonance imaging revealed hyperintensity on diffusion-weighted imaging of the left optic nerve, with corresponding low signal on apparent diffusion coefficient maps, suggestive of acute infarction of the left optic nerve. Combined with the patient's cranial magnetic resonance imaging findings, the diagnosis of cavernous sinus syndrome was established.

Interventional Embolization of Unilateral Cavernous Sinus With ONXY Glue Combined With Coils for the Treatment of Bilateral Dural Arteriovenous Fistula.

PURPOSE: To summarize the clinical experience of unilateral sponge sinus embolization of cavernous sinus dural arteriovenous fistula (CS DAVF) via jugular vein access with ONXY gel and spring coil intervention. METHODS: The authors retrospectively analyzed the clinical data of 3 patients who were treated with unilateral cavernous sinus embolization for bilateral cavernous sinus dural arteriovenous fistula (CS DAVF) from October 2020 to May 2022 in our department by using transjugular vein access spring coil + ONXY gel interventional embolization. RESULTS: Immediate postoperative angiography suggested that the cavernous sinus fistula was completely embolized in all 3 patients, and cerebral angiography was carried out from 6 to 12 months after the operation and assessed using the Class grading method, and there was no recurrence in any of the 3 patients. CONCLUSIONS: Transvenous access ONXY adhesive combined with spring coil interventional embolization of unilateral cavernous sinus to cure bilateral cavernous sinus dural arteriovenous fistula is feasible, which can avoid the excessive use of spring coils and ONXY adhesive, and it is the key to the effective cure of DAVF in cavernous sinus area and to reduce the complication.

Transorbital neuroendoscopic surgery for treatment of sphenoid wing meningiomas extending to the cavernous sinus: clinical implications and a technical illustration.

OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of transorbital neuroendoscopic surgery (TONES) in the management of sphenoid wing meningiomas (SWMs) with cavernous sinus and orbital invasion. METHODS: The authors conducted a retrospective review of 32 patients with SWMs treated at Gazi University using TONES from October 2019 to May 2023. The study includes clinical applications to elucidate the endoscopic transorbital approach. Surgical techniques focused on safe subtotal resection, aiming to minimize residual tumor volume for subsequent radiosurgery. Data were collected on patient demographics, tumor characteristics, surgical procedures, complications, and postoperative outcomes, including radiological imaging and ophthalmological evaluations. RESULTS: Surgical dissections delineated a three-phase endoscopic transorbital approach: extraorbital, intraorbital, and intracranial. In the clinical application, gross-total resection was not achieved in any patient because of planned postoperative Gamma Knife radiosurgery. The mean follow-up period was 16.3 months. Of 30 patients with preoperative proptosis, 25 experienced postoperative improvement. No new-onset extraocular muscle paresis or visual loss occurred postoperatively. The average hospital stay was 1.15 days, with minimal complications and no significant morbidity or mortality. CONCLUSIONS: Total resection of SWMs invading the cavernous sinus and orbit is associated with substantial risks, particularly cranial nerve deficits. TONES offers a minimally invasive alternative, reducing morbidity compared with transcranial approaches, and represents a significant advancement in the surgical management of SWMs, especially those extending into the cavernous sinus and orbit. The approach provides a safe, effective, and patient-centric approach, prioritizing subtotal resection to minimize neurological deficits while preparing patients for adjunctive radiosurgery. This study positions TONES as a transformative surgical technique, aligning therapeutic efficacy with neurovascular preservation and postoperative recovery.

Cavernous sinus metastasis in head and neck cancer: Focus on oral squamous cell cancer.

Intracranial metastatic disease is rarely found in head and neck cancer (HNC), in particular, cavernous sinus (CS) involvement is difficult to recognize, because of its rarity, not specific symptoms associated and challenging imaging features. We report our experience in 4 cases, reviewing also the English literature. We analysed data from 21 patients showing that CS metastasis is a dramatic event, with rapid onset, usually starting with neurological manifestations (ophthalmoplegia, headache and trigeminal dysesthesia) and almost unavoidable outcome (DOD in 18/21 patients). Furthermore, we assessed that the diagnostic confirmation could be difficult to perform because of the need for multiple exams and time consuming procedures. Unfortunately, usual antineoplastic therapies seem to be not effective in prolonging survival, also because patients are already weakened by primary tumour treatments. The only option that seems useful in improving outcomes is immunotherapy.

MRI 3D SPACE T2WI for Pituitary Adenoma Cavernous Sinus Invasion Diagnosis.

OBJECTIVE: This study aims to assess the utility of magnetic resonance imaging (MRI) 3D SPACE T2-weighted imaging (T2WI) sequences in evaluating cavernous sinus invasion by pituitary adenomas. METHODS: Data were collected from patients who underwent continuous pituitary MRIexaminations at the Medical Imaging Center of our hospital from October 2019 to February 2021. Eligible cases were evaluated for sagittal and axial T1WI sequences, coronal 3D SPACE T2WI sequences, and sagittal and coronal enhanced T1-weighted imaging (T1WI) sequences using the INFINITT PACS workstation. The Wilcoxon signed-rank test for paired samples and the Mann-Whitney U test for 2 independent samples were used to statistically analyze differences in image quality scores among various groups. In addition, the sensitivity, specificity, positive predictive value, and negative predictive value of each observation index were compared with intraoperative results. RESULTS: 3D SPACE T2WI showed superior cavernous sinus imaging quality compared with contrast enhanced T1WI and T2WI plain scans (P < 0.05). The sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 90.0%, 55.60%, and 100.0%, respectively. The accuracy for pituitary adenoma invasiveness diagnosis based on cavernous sinus medial wall integrity was 94.40%. CONCLUSIONS: The imaging quality of the medial wall of the cavernous sinus on the 3D SPACE T2WI plain scan sequence surpassed that of contrast enhanced T1WI TSE-enhanced scans and T2WI TSE plain scans. The continuous observation of the medial wall of the cavernous sinus using this sequence holds great diagnostic value for assessing cavernous sinus invasion by pituitary adenomas. This strategy is more reliable than traditional MRI observation indicators.

Endoscopic Endonasal Transsphenoidal Transcavernous Transoculomotor Triangle Approach for Resection of an Invasive Pituitary Adenoma Extending Into the Parapeduncular Space Through the Cavernous Sinus.

BACKGROUND AND IMPORTANCE: A subset of invasive pituitary adenomas invade not only the medial wall of the cavernous sinus but can progress superiorly through the cavernous sinus roof at the oculomotor triangle and reach the subarachnoid parapeduncular space. We describe a series of 2 of 3 cases where an endoscopic endonasal approach was used to reach the parapeduncular space through the oculomotor triangle for tumor decompression. Images of the third case are presented. CLINICAL PRESENTATION: Case 1: We present a 2-dimensional surgical video of a recurrent corticotroph adenoma post gamma knife radiotherapy which was invading the left cavernous sinus and extending into the left parapeduncular space. Histopathological examination revealed densely granulated corticotrophin adenoma. The patient had reduction in the serum cortisol level postoperatively and was induced into remission medically. Postoperative third nerve palsy recovered partially, and sixth nerve palsy recovered completely at the 3-month follow-up. Case 2 : A case of recurrent silent corticotrophin adenoma invading the right parapeduncular space through the right cavernous sinus was operated through the same approach as case 1. Only a subtotal excision of the tumor in the cisternal space was possible. The patient developed a complete right third cranial palsy in the immediate postoperative period with near total recovery at the 6-month follow-up. CONCLUSION: Endoscopic endonasal approach to the parapeduncular space through a transcavernous transoculomotor route is reasonably safe and effective, as long as key anatomic landmarks and structures are identified and preserved while using natural tumor corridors to achieve tumor clearance.

Successful surgical treatment of oculomotor palsy due to schwannoma of the cavernous sinus in a 7-year-old girl: a case report.

Oculomotor nerve schwannoma in children not associated with neurofibromatosis is a rare disease, with 26 pediatric cases reported so far. There is no established treatment plan. A 7-year-old girl presented with oculomotor nerve palsy. Surgical reduction of the tumor combined with postoperative gamma knife surgery preserved the oculomotor nerve, improved oculomotor nerve function, and achieved tumor control during the observation period of 20 months. The combination of partial surgical resection and gamma knife surgery as a treatment strategy for oculomotor nerve schwannoma resulted in a good outcome.

Carotid-cavernous fistula: A potential treatable cause of bilateral abducens palsy and conjunctival hyperemia.

OBJECTIVE: Carotid cavernous fistulas (CCFs) represent uncommon and anomalous communications between the carotid artery and the cavernous sinus. MATERIALS AND METHODS: Case report RESULTS: We present the clinical details and successful management of a previously healthy 44-year-old patient who presented with one-month worsening headache, bilateral abducens palsy and conjunctival injection. Imaging modalities including magnetic resonance imaging (MRI) with contrast and digital subtraction angiography (DSA) facilitated the diagnosis of CCF. The patient underwent endovascular coiling of the CCF, leading to neurological recovery and symptom remission. CONCLUSION: This case highlights the importance of promptly CCF diagnosis in patients with multiple cranial nerve palsies and conjunctival hyperemia. Moreover, it emphasizes the efficacy of endovascular coiling in achieving symptom remission.

[Carotid-cavernous fistulas]. / Sinus-cavernosus-Fisteln.

BACKGROUND: Carotid cavernous fistulas (CCFs) are rare but clinically significant vascular anomalies characterized by abnormal connections between the cavernous sinus and arteries. This overview presents a comprehensive analysis of anatomy, classification, clinical presentation, diagnosis, imaging, and therapy of CCFs. The cavernous sinus, a central venous structure in the brain, is of critical importance for understanding CCFs due to its proximity to key structures such as the internal carotid artery and cranial nerves. CLASSIFICATION: CCFs are classified into direct and dural types, with direct fistulas typically being high-flow and dural fistulas being low-flow. The symptomatology varies greatly and can range from noises in the head, diplopia, red eye, tearing, to blurred vision and headaches. The diagnostic assessment requires a combination of detailed medical history, neurological and ophthalmological examination, and the use of imaging techniques. METHODS: In imaging, computed tomography (CT) and magnetic resonance imaging (MRI) are crucial for depicting the anatomical structures and blood vessels, while digital subtraction angiography (DSA) is considered the gold standard for accurate representation of the fistula. The treatment of CCFs is complex and depends on the type of fistula, location, and clinical condition of the patient. CONCLUSION: This overview emphasizes the importance of precise diagnosis and individualized therapy to achieve optimal results and avoid complications. Ongoing developments in medical imaging and treatment techniques will continuously improve the treatment outcomes of patients with CCFs.

Multi-center application of a convolutional neural network for preoperative detection of cavernous sinus invasion in pituitary adenomas.

OBJECTIVE: Cavernous sinus invasion (CSI) plays a pivotal role in determining management in pituitary adenomas. The study aimed to develop a Convolutional Neural Network (CNN) model to diagnose CSI in multiple centers. METHODS: A total of 729 cases were retrospectively obtained in five medical centers with (n = 543) or without CSI (n = 186) from January 2011 to December 2021. The CNN model was trained using T1-enhanced MRI from two pituitary centers of excellence (n = 647). The other three municipal centers (n = 82) as the external testing set were imported to evaluate the model performance. The area-under-the-receiver-operating-characteristic-curve values (AUC-ROC) analyses were employed to evaluate predicted performance. Gradient-weighted class activation mapping (Grad-CAM) was used to determine models' regions of interest. RESULTS: The CNN model achieved high diagnostic accuracy (0.89) in identifying CSI in the external testing set, with an AUC-ROC value of 0.92 (95% CI, 0.88-0.97), better than CSI clinical predictor of diameter (AUC-ROC: 0.75), length (AUC-ROC: 0.80), and the three kinds of dichotomizations of the Knosp grading system (AUC-ROC: 0.70-0.82). In cases with Knosp grade 3A (n = 24, CSI rate, 0.35), the accuracy the model accounted for 0.78, with sensitivity and specificity values of 0.72 and 0.78, respectively. According to the Grad-CAM results, the views of the model were confirmed around the sellar region with CSI. CONCLUSIONS: The deep learning model is capable of accurately identifying CSI and satisfactorily able to localize CSI in multicenters.

The learning curve for cavernous sinus surgery illustrated by symptomatic intracavernous aneurysm clipping through a pretemporal transcavernous approach.

OBJECTIVE: The anatomy of the cavernous sinus (CS) has been well studied in the laboratory for decades; however, performing surgery in and around the CS is still a challenge. To reveal the learning curve for CS surgery via the pretemporal transcavernous approach (PTTC), surgical procedures were examined. The authors proposed 4 levels of surgical difficulty in opening the walls of the CS through this approach. Details of the approach were illustrated by surgical videos of symptomatic intracavernous aneurysm clipping. METHODS: Four levels of surgical difficulty were proposed. The higher the level, the more the CS walls were opened. Pathologies corresponding to each level of difficulty in and around the CS were categorized in each level together with explanations. From 2015 to 2021, 5 patients with symptomatic intracavernous aneurysms (diplopia due to compressive cranial neuropathy) underwent the PTTC at the authors' institute and served as representative cases in opening the walls of the CS. All CS cases from 2009 to 2021 were reviewed and categorized to demonstrate the learning curve. RESULTS: Four levels of surgical difficulty are as follows: level 1, a basic Dolenc extradural approach, which involves opening the anterior third of the superior and lateral walls of the CS; level 2, mobilizing the internal carotid artery (ICA) and opening the proximal dural ring to enter the roof of the CS and treat lesions around the clinoid and upper cavernous ICA; level 3, opening the entire aspect of the superior and lateral walls of the CS, which involves opening the oculomotor triangle and peeling the lateral wall of the CS to the tentorial incisura; and level 4, mobilizing cranial nerves III, IV, and V1 to gain access to the supra-/infratrochlear triangles to have proximal ICA control and opening the posterior wall as the last step to enter the posterior fossa. Surgical steps were described and illustrated with surgical videos of symptomatic intracavernous aneurysm clipping. CONCLUSIONS: The learning curve for CS surgery is long. The authors use 4 levels of surgical difficulty to describe applications of the PTTC in CS surgery. This approach serves as an effective workhorse in treating CS pathologies with low morbidity and high success rates when performed by experienced neurosurgeons.

The lateral transorbital approach to the medial sphenoid wing, anterior clinoid, middle fossa, cavernous sinus, and Meckel's cave: target-based classification, approach-related complications, and intermediate-term ocular outcomes.

OBJECTIVE: The lateral transorbital approach (LTOA) is a relatively new minimal access skull base approach suited for addressing paramedian pathology of the anterior and middle fossa. The authors define target zones for this approach and describe a series of cases with detailed measurements of visual outcomes, including those obtained with exophthalmometry. METHODS: The authors performed a retrospective analysis of a consecutive series of LTOA patients. Seven target zones were identified: 1) the orbit, 2) the lesser sphenoid wing and anterior clinoid, 3) the middle fossa, 4) the lateral wall of the cavernous sinus and Meckel's cave, 5) the infratemporal fossa, 6) the petrous apex, and 7) the anterior fossa. The authors used volumetric analyses of preoperative and postoperative MR and CT imaging data to calculate the volume of bone and tumor removed and to provide detailed ophthalmological, neurological, and cosmetic outcomes. RESULTS: Of the 20 patients in this cohort, pathology was in zone 2 (n = 10), zone 4 (n = 6), zone 3 (n = 2), zone 1 (n = 1), and zone 5 (n = 1). Pathology was meningioma (n = 10), schwannoma (n = 2), metastasis (n = 2), epidermoid (n = 1), dermoid (n = 1), encephalocele (n = 1), adenoma (n = 1), glioblastoma (n = 1), and inflammatory lesion (n = 1). The goal was gross-total resection (GTR) in 9 patients, all of whom achieved GTR. Subtotal resection (STR) was the goal in 8 patients (5 spheno-orbital meningiomas, 1 giant cavernous sinus/Meckel's cave schwannoma, 1 cavernous sinus prolactinoma, and 1 cavernous sinus dermoid), 7 of whom achieved STR and 1 of whom achieved GTR. The goal was biopsy in 2 patient and repair of encephalocele in 1. Visual acuity was stable or improved in 18 patients and worse in 2. Transient early postoperative diplopia, ptosis, eyelid swelling, and peri-orbital numbness were common. All 9 patients with preoperative diplopia improved at their last follow-up. Seven of 8 patients with preoperative exophthalmos improved after surgery (average correction of 64%). There were no cases of clinically significant (> 2 mm) postoperative enophthalmos. The most frequent postoperative complaint was peri-orbital numbness (40%). There was 1 CSF leak. Most patients were satisfied with their ocular (84%-100% of patients provided positive satisfaction-related responses) and cosmetic (75%-100%) outcomes. CONCLUSIONS: The LTOA is a safe minimal access approach to a variety of paramedian anterior skull base pathologies in several locations. Early follow-up revealed excellent resolution of exophthalmos with little risk of clinically significant enophthalmos. Transient diplopia, ptosis, and peri-orbital numbness were common but improved. Careful case selection is critical to ensure good outcome.

Cavernous Sinus Syndrome Caused by Noninvasive Fungal Maxillary Sinusitis.

It is rare that cavernous sinus complications are caused by maxillary sinus lesions because the locations of these lesions are some distant from each other. The authors describe an unusual presentation that the primary lesion was located in the maxillary sinus and triggered cavernous sinus syndrome and optic nerve symptoms. The most likely possibility was that the infection traveled retrograde along the vascular plexus. Removal of maxillary sinus lesions and establishment ventilation may achieve source control.

Paradoxical worsening of ocular symptoms after transvenous embolization of cavernous sinus dural arteriovenous fistula due to coil-induced perifocal inflammation: A case report.

Ocular symptoms usually completely resolve after successful transvenous embolization of cavernous sinus dural arteriovenous fistulas (CS-dAVFs). Herein, we report a case of CS-dAVF in which sinus packing of the superior ophthalmic vein (SOV) caused coil-induced inflammation in orbital tissue, leading to deteriorating ocular symptoms. A 73-year-old woman presented with right-eye exophthalmos and chemosis. Cerebral angiography demonstrated right CS-dAVF, which retrogradely drained into the right SOV. We conducted sinus packing with coils via the right inferior petrosal sinus, resulting in obliteration of the shunts. One day after sinus packing, right exophthalmos and chemosis progressed, suggesting dAVF recurrence. However, no residual angiographic shunts were observed. Orbital magnetic resonance imaging (MRI) revealed edema in intraorbital tissue and gadolinium contrast enhancement of SOV wall. We presumed that the coils in SOV induced perifocal inflammation at the venous wall and surrounding orbital tissue, leading to aggravation of ocular symptoms. Following steroid therapy for 2 months, ocular symptoms and contrast enhancement on orbital MRI significantly improved without anticoagulant treatment. Posttreatment paradoxical worsening of ocular symptoms could be caused by coil-induced inflammation of the SOV wall near the orbital tissue. Steroid therapy could be effective in reducing orbital inflammatory reactions.

Role of Cavernous Sinus Extension and MRI T2 Hypointensity in the Extent of Resection following Trans-Sphenoidal Surgery for Giant Pituitary Adenomas.

Background: Giant pituitary adenomas (GPA) pose a significant neurosurgical challenge. In this study, we present an experience of 60 consecutive patients with GPA operated by trans-sphenoidal surgery (microscopic/endoscopic). Objective: The aim of this study was to elucidate preoperative factors predicting extent of resection (EOR) following transsphenoidal surgery for GPA. Materials and Methods: The study was a retrospective evaluation of 60 adult patients (>18 years) with GPA operated over a decade. The patients were analyzed for their clinical presentation, EOR, radiology, visual outcome, endocrinological outcome, and complications. Results: The mean age of the cohort was 41.5 ± 13.3 years, mean tumor volume was 38.2 ± 19.1 cm3, and mean follow-up was 30.6 ± 21.7 months. Improvement in vision was seen in forty patients (66.7%), while another 16 (26.7%) had stable vision as prior to surgery. Duration of visual symptoms was found to be statistically significantly associated with postoperative improvement of vision (P = 0.001). Twenty-four patients (40.0%) underwent subtotal resection (STR), while the remaining 36 patients (60.0%) underwent either gross total or near-total resection. Factors associated with STR were retrosellar (P = 0.04), subfrontal (P = 0.02), Knosp 3,4 cavernous sinus extension (P = 0.03), and MRI T2 hypointensity (P = 0.02). During follow-up, eight patients (13.3%) had radiological evidence of growth of residual tumor. Conclusions: Most cases of GPA can be adequately handled by trans-sphenoidal surgery. The presence of retrosellar, subfrontal, cavernous sinus extensions, and T2 hypointensity should alert the surgeon for likelihood of STR, postoperative residual tumor hemorrhage and need for second-stage endonasal or transcranial surgery. However, utilization of extended endoscopic route has allowed good debulking of tumors having subfrontal and parasellar extensions, which was not possible previously using traditional microscopic transsphenoidal surgery.

Embolization of Cavernous Sinus Dural Arteriovenous Fistula with Liquid Materials Under Transarterial Balloon Protection.

AIM: To analyze the clinical and angiographic outcomes of interventional embolization under transarterial balloon protection technique in patients with cavernous sinus dural arteriovenous fistulas. MATERIAL AND METHODS: In a single-center cohort of 30 patients undergoing cavernous sinus dural arteriovenous fistulas embolization under balloon protection. We collected their clinical symptoms, complications, mid-term follow-up angiographic results, and long-term clinical outcomes for the baseline characteristics. RESULTS: Thirty patients with 31 lesions were included in this study. Immediate applications of angiographies after embolization indicated that complete obliteration occurred in 29 lesions (93.5% of 31 lesions). Two cases with permanent trigeminal nerve palsy were treated by arterial approach. Onyx dispersed into the internal carotid artery in one process, and salvage stent implantation was performed to prevent parent artery occlusion. CONCLUSION: Interventional embolization with intra-arterial balloon protection is effective and safe with rarely occurring complications.