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Background: Cavernous sinus hemangiomas (CSHs) are intracranial extradural benign, well-demarcated neoplasms arising within dural sinuses. The orbital apex and superior orbital fissure (SOF) are common locations for these lesions. Because of the complex anatomy of this area and potential morbidity, SOF CSH surgical management is challenging. Objective: Describe a case of a SOF CSH and review of literature. Material and Methods: We present the case of a 44-year-old female with a 2-month history of right eye visual disturbances. A contrast-enhanced magnetic resonance imaging showed a right orbital apex nodular formation. A pterional craniotomy with a middle fossa mini peeling was performed. Results: Gross total resection was accomplished. No recurrences were observed 2 years after surgery. Conclusion: SOF CSH should be included in a differential diagnosis in cases of space-occupying orbital apex lesions with atypical features. Surgery is the gold standard treatment. Radiosurgery is a valid option for tumor remnants.

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BACKGROUND: Sphenoid wing meningiomas with cavernous sinus invasion (SWMCSI) are challenging tumors. The preservation of quality of life and cranial nerve function is one of the most relevant aspects of treating patients with SWMCSI. METHODS: A retrospective study was conducted for surgery performed between 2008 and 2021, including 36 patients presenting with SWMCSI. The data from surgical intervention, Simpson grade of resection, tumor location, and morbimortality related to the surgery was reviewed. We examined the medical records, operative reports, radiologic examinations, and follow-up information. RESULTS: The group comprised 29 women and 7 men with an average age of 61 years (range, 31-87 years). The mean follow-up period was 75 months (range, 1-170 months). Simpson grade I and II resections were obtained in 80% of cases. The meningiomas were World Health Organization (WHO) grade 1 in 94% of cases, WHO grade 2 in 3%, and WHO grade 3 in 3%. The overall mortality was 5.5%. Permanent cranial nerve deficits occurred in 8% of cases, transient cranial nerve deficits in 22%, cerebrospinal fistula in 16.5%, and hemiparesis in 2.7%. The recurrence/regrowth rate was 14% during the follow-up period. The Karnofsky Performance Status 100 and 90 was 92%. CONCLUSIONS: The surgical treatment of symptomatic SWMCSI is an effective treatment modality with low morbimortality and good long-term control of the disease. Visual impairment is the most common abnormality, affecting preoperative and postoperative quality of life of patients with SWMCSI. Training in the microsurgical laboratory is essential for safe surgical approaches in this area.

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Transorbitary intracranial penetrating traumatic injuries are uncommon in the paediatric population, and may occur in the context of domestic, sporting or school accidents. They can extend to skull base and compromise vascular structures such as cavernous sinus and internal carotid. We present a case of 6 years-old girl that suffered an intracranial transorbital penetrating injury with a wooden pencil that crossed from the medial edge of left orbit, transetmoidal and trans-sphenoidal, entering the right sellar region and leaving its end in contact with carotid artery (cavernous segment). After pre-surgical studies, foreign body removal was performed with endoscopic surgery + endovascular control in case of carotid injury. After removing the foreign body, a CSF fistula occurred and was repaired. Patient recovered adequately, without neurological deficit, without postoperative CSF fistula, without CNS infection or oculomotor alteration.

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PURPOSE: The location of paraclinoid aneurysms is determinant for evaluation of its intradural compartment and risk of SAH after rupture. Advanced MRI techniques have provided clear visualization of the distal dural ring (DDR) to determine whether an aneurysm is intracavernous, transitional or intradural for decision-making. We analyzed the diagnostic accuracy of MRI in predicting whether a paraclinoid aneurysm is intracavernous, transitional or intradural. METHODS: We conducted a prospective cohort between January 2014 and December 2018. Patients with paraclinoid aneurysms underwent 3D fast spin-echo MRI sequence before surgical treatment. The DDR was the landmark for MRI characterization of the aneurysms as follow: (i) Intradural; (ii) Transitional; and (iii) Intracavernous. The MRI sensitivity, specificity, positive and negative likelihood ratios were determined compared to the intraoperative findings. We also evaluated the intertechnique agreement using the Cohen's kappa coefficient (κ) for dichotomous classifications (cavernous vs non-cavernous). RESULTS: Twenty patients were included in the cohort. The accuracy of MRI showed a sensitivity of 86.7% (95%CI:59.5-98.3) and specificity of 90.0% (95%CI:55.5-99.8). Analyzing only patients without history of SAH, accuracy test improved with a sensitivity of 92.3% (95%CI:63.9-99.8) and specificity reached 100% (95%CI: 63-100). Values of Cohen's kappa (κ), intertechnique agreement was considered substantial for dichotomous classifications (κ = 0.754; p < 0.001). For patients without previous SAH, intertechnique agreement was even more coincident for the dichotomous classification (κ = 0.901; p < 0.001). CONCLUSION: 3D fast spin-echo MRI sequence is a reliable and useful technique for determining the location of paraclinoid aneurysms in relation to the cavernous sinus, particularly for patients with no history of SAH.

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SUMMARY: A comparative study of the morphology of suboccipital cavernous sinus (SCS) using MRI and cast specimens was performed. The present retrospective study analysed the craniocervical magnetic resonance venography (MRV) imaging data of 61 patients. Three-dimensional reconstruction was performed using Mimics 19.0. The SCS left-right diameter(d1), distance from the midline (d2), supero-inferior diameter(d3), anteroposterior diameter (d4), distance from posterior diameter to skin (d5), and diameter of the SCS at different parts (d6-d8) were measured. Comparison between MRV images and cast specimens, the SCS, marginal sinus, anterior condylar vein, and vertebral artery venous plexus were symmetrical and could be bilaterally displayed, whereas the presence of extra condylar vein and posterior condylar vein exhibited different types. The adjacency between the SCS and its communicating vessels and changes in its communicating vessels corresponded well with the MRV images and cast specimens. Many types of the presence of left and right lateral condylar and posterior condylar veins were found in the cast specimens, which could be divided into the bilateral presence of posterior condylar and lateral condylar veins, unilateral presence of posterior condylar veins, and unilateral presence of lateral condylar vein. A total of 61 cases analysed using MRV images revealed the bilateral presence of posterior condylar and lateral condylar veins (77.1 %), the unilateral presence of posterior condylar vein (18.0 %), and the unilateral presence of lateral condylar vein (9.8 %), of which the bilateral presence of posterior condylar and lateral condylar veins accounted for the largest proportion. MRV images and cast specimens of the SCS showed its normal morphological structure and adjacency, thus providing accurate and complete Three-dimensional imaging anatomical data of the SCS and its communicating vascular structures. This study enriches the Chinese SCS imaging anatomy data and may be valuable in clinical practice.

RESUMEN: Se realizó un estudio comparativo de la morfología del seno cavernoso suboccipital (SCS) mediante resonancia magnética y muestras de yeso. El presente estudio retrospectivo analizó los datos de imágenes de venografía por resonancia magnética (RNM) craneocervical de 61 pacientes. La reconstrucción tridimensional se realizó con Mimics 19.0. Se midió: el diámetro izquierdo-derecho del SCS (d1), la distancia desde la línea mediana (d2), el diámetro superoinferior (d3), el diámetro anteroposterior (d4), la distancia desde el diámetro posterior hasta la piel (d5) y el diámetro del SCS en diferentes partes (d6-d8). En la comparación entre las imágenes RNM y las muestras de yeso, el SCS, el seno marginal, la vena condilar anterior y el plexo venoso de la arteria vertebral eran simétricos y se observaron bilateralmente, mientras que la presencia de la vena extracondilar y la vena condilar posterior presentaba tipos diferentes. La proximidad del SCS y sus vasos comunicantes y los cambios en sus vasos comunicantes se correspondieron bien con las imágenes de RNM y los especímenes moldeados. Se encontraron muchos tipos de venas condilares laterales y condilares posteriores izquierda y derecha en las muestras de yeso, que podrían dividirse en presencia bilateral de venas condilares posteriores y condilares laterales, presencia unilateral de venas condilares posteriores y presencia unilateral de venas condilares laterales. Un total de 61 casos analizados mediante imágenes MRV revelaron la presencia bilateral de venas condilares posteriores y condilares laterales (77,1 %), la presencia unilateral de venas condilares posteriores (18,0 %) y la presencia unilateral de venas condilares laterales (9,8 %) de los cuales la presencia bilateral de las venas condilar posterior y condilar lateral representó la mayor proporción. Las imágenes de RNM y las muestras de yeso del SCS mostraron su estructura morfológica y adyacencia normales, lo que proporcionó datos anatómicos de imágenes tridimensionales precisos y completos del SCS y sus estructuras vasculares comunicantes. Este estudio enriquece los datos de anatomía de imágenes de SCS chino y puede ser valioso en la práctica clínica.

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Radiation-induced meningiomas are the most common radiation-induced neoplasms. They exhibit a distinct aggressive clinical behavior as rapid growth, recurrences, multiplicity, and malignant progression are common features.1-4 Atypical histological findings and aberrant cytogenetics are increasingly identified.5-7 Radical resection of aggressive radiation-induced meningiomas is the best treatment option and would offer the best chance for control of the disease. Wide bone and dural margins should be pursued in the resection. Parasellar extension creates significant surgical challenges. Cavernous sinus exploration through the multidirectional axis provided by the cranioorbital zygomatic approach allows radical resection of the tumor, cranial nerve decompression, and carotid artery preservation and control.8-11 This article describes a cavernous sinus radiation-induced meningioma after radiation for Cushing disease. It demonstrates the details of the extra- and intradural exploration and dissection of the neurovascular structures in the cavernous sinus, with proximal and distal control of the carotid artery. However, even after radical resection, recurrence is a common finding in this malignant behavioral radiation-induced tumor. Patient consented for surgery. Image at 9:41 comes from the Science Museum Group, United Kingdom. Refer to the Wellcome blog post (archive). This image is licensed under the CC-BY 4.0 International license.

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Septic cavernous sinus thrombosis is a rare but often debilitating and potentially fatal disease. We describe a case of bilateral orbital cellulitis with rapidly progressing cavernous sinus thrombosis and left sigmoidal sinus thrombosis in an immunocompetent 20-year-old military man who had undergone intensive physical training. The patient presented with rapid painful swollen left eye for 2 days. The examination results were gross proptosis with total ophthalmoplegia. He was treated with intravenous antibiotics and corticosteroid. At 1 week, visual acuity improved to 20/20 OU, with a normal intraocular pressure. There was a significant improvement in proptosis. The ocular motility of the right eye was fully restored, with slight residual ophthalmoplegia in the left eye. There was no residual illness or recurrence of illness at 3 months' follow-up.

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ABSTRACT Septic cavernous sinus thrombosis is a rare but often debilitating and potentially fatal disease. We describe a case of bilateral orbital cellulitis with rapidly progressing cavernous sinus thrombosis and left sigmoidal sinus thrombosis in an immunocompetent 20-year-old military man who had undergone intensive physical training. The patient presented with rapid painful swollen left eye for 2 days. The examination results were gross proptosis with total ophthalmoplegia. He was treated with intravenous antibiotics and corticosteroid. At 1 week, visual acuity improved to 20/20 OU, with a normal intraocular pressure. There was a significant improvement in proptosis. The ocular motility of the right eye was fully restored, with slight residual ophthalmoplegia in the left eye. There was no residual illness or recurrence of illness at 3 months' follow-up.

RESUMO A trombose séptica do seio cavernoso é uma condição rara, mas frequentemente debilitante e potencialmente fatal. Descrevemos um caso de celulite orbital bilateral com progressão rápida para trombose do seio cavernoso e trombose do seio sigmoide esquerdo, em um militar imunocompetente de 20 anos de idade que havia sido submetido a treinamento físico intenso. O paciente apresentou um inchaço rápido e doloroso no olho esquerdo por 2 dias. Os resultados do exame foram proptose macroscópica com oftalmoplegia total. Ele foi tratado com antibióticos intravenosos e costicosteróide. Em 1 semana, a acuidade visual melhorou para 20/20, com pressão intraocular normal. Houve uma melhora significativa na proptose. A motilidade ocular do olho direito foi totalmente restaurada, com leve oftalmoplegia residual no olho esquerdo. Não houve doença residual ou recorrência da doença após três meses de acompanhamento.

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