Delayed Cranial Nerve Palsy After Coiling of Carotid Cavernous Sinus Aneurysms

Neurosurgery ◽  
2010 ◽  
Vol 66 (6) ◽  
pp. E1215-E1216 ◽  
Author(s):  
David S. Xu ◽  
Michael C. Hurley ◽  
H. Hunt Batjer ◽  
Bernard R. Bendok
Keyword(s):  
Cavernous Sinus ◽  
Cranial Nerve ◽  
Clinical Presentation ◽  
Cranial Neuropathy ◽  
Aneurysm Neck ◽  
Post Procedure ◽  
Cranial Nerve Palsies ◽  
Endovascular Coils ◽  
Healthy Females

Abstract OBJECTIVE Detachable endovascular coils have become a common treatment strategy for carotid cavernous sinus aneurysms (CCAs), but previously unrecognized postprocedure complications may emerge as longer follow-up data are accumulated. In this report, the authors document the first known cases of delayed cranial neuropathy following CCA coiling in 3 patients, all of whom present at least a year postprocedure without aneurysm regrowth. The potential mechanisms underlying this syndrome are discussed as well as their implications on the selection and optimal endovascular management of CCA patients. CLINICAL PRESENTATION Three previously healthy females aged 50, 60, and 62 underwent CCA coiling at our institution and subsequently developed ipsilateral cranial nerve palsies at 56, 28, and 14 months, respectively, post-procedure. At presentation, all 3 patients had a new, recurrent area of flow in their CCA without changes in aneurysm size. INTERVENTION One patient declined further treatment. In the other 2 patients, a stent was placed across the aneurysm neck, and one patient underwent additional coiling. Unfortunately, all 3 patients remained symptomatic at their latest follow-up. Conclusion Because of the intimate anatomic environment of the cavernous sinus, neural elements within it may be particularly susceptible to persistent mass or dynamic effects exacerbated by remnant or recurrent flow across the neck of a coiled aneurysm. These 3 cases prompted the authors to advocate for more aggressive efforts to achieve and maintain CCA occlusion. Furthermore, when such efforts are unsuccessful, consideration of traditional carotid occlusion strategies with or without bypass is warranted.

scholarly journals The medial wall of the cavernous sinus. Part 2: Selective medial wall resection in 50 pituitary adenoma patients

2019 ◽  
Vol 131 (1) ◽  
pp. 131-140 ◽  
Author(s):  
Salomon Cohen-Cohen ◽  
Paul A. Gardner ◽  
Joao T. Alves-Belo ◽  
Huy Q. Truong ◽  
Carl H. Snyderman ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Cavernous Sinus ◽  
Cranial Nerve ◽  
Tumor Resection ◽  
Medial Wall ◽  
Long Term Results ◽  
Fat Graft ◽  
Cranial Nerve Palsies ◽  
Remission Rates

OBJECTIVEPituitary adenomas often invade the medial wall of the cavernous sinus (CS), but this structure is generally not surgically removed because of the risk of vascular and cranial nerve injury. The purpose of this study was to report the surgical outcomes in a large series of cases of invasive pituitary adenoma in which the medial wall of the CS was selectively removed following an anatomically based, stepwise surgical technique.METHODSThe authors’ institutional database was reviewed to identify cases of pituitary adenoma with isolated invasion of the medial wall, based on an intraoperative evaluation, in which patients underwent an endoscopic endonasal approach with selective resection of the medial wall of the CS. Cases with CS invasion beyond the medial wall were excluded. Patient complications, resection, and remission rates were assessed.RESULTSFifty patients were eligible for this study, 15 (30%) with nonfunctional adenomas and 35 (70%) with functional adenomas, including 16 growth hormone–, 10 prolactin-, and 9 adrenocorticotropic hormone (ACTH)–secreting tumors. The average tumor size was 2.3 cm for nonfunctional and 1.3 cm for functional adenomas. Radiographically, 11 cases (22%) were Knosp grade 1, 23 (46%) Knosp grade 2, and 16 (32%) Knosp grade 3. Complete tumor resection, based on intraoperative impression and postoperative MRI, was achieved in all cases. The mean follow-up was 30 months (range 4–64 months) for patients with functional adenomas and 16 months (range 4–30 months) for those with nonfunctional adenomas. At last follow-up, complete biochemical remission (using current criteria) without adjuvant treatment was seen in 34 cases (97%) of functional adenoma. No imaging recurrences were seen in patients who had nonfunctional adenomas. A total of 57 medial walls were removed in 50 patients. Medial wall invasion was histologically confirmed in 93% of nonfunctional adenomas and 83% of functional adenomas. There were no deaths or internal carotid artery injuries, and the average blood loss was 378 ml. Four patients (8%) developed a new, transient cranial nerve palsy, and 2 of these patients required reoperation for blood clot evacuation and fat graft removal. There were no permanent cranial nerve palsies.CONCLUSIONSThe medial wall of the CS can be removed safely and effectively, with minimal morbidity and excellent resection and remission rates. Further follow-up is needed to determine the long-term results of this anatomically based technique, which should only be performed by very experienced endonasal skull base teams.

scholarly journals Lower Cranial Nerve Palsies in the COVID-19 Pandemic: A 10-Case Series of Intensive Care Unit Patients

2021 ◽  
pp. 1-4
Author(s):  
Pierre Decavel ◽  
Olympe Nahmias ◽  
Carine Petit ◽  
Laurent Tatu
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Prone Position ◽  
Cranial Nerve ◽  
Nerve Palsy ◽  
Case Series ◽  
University Hospital ◽  
Cranial Neuropathy ◽  
Lower Cranial Nerve ◽  
Cranial Nerve Palsies

<b><i>Introduction:</i></b> A number of neurological complications of COVID-19 have been identified, including cranial nerve paralyses. We present a series of 10 patients with lower cranial nerve involvement after severe COVID-19 infection requiring hospitalization in an intensive care unit. <b><i>Methods:</i></b> We conducted a retrospective, observational study of patients admitted to the post-intensive care unit (p-ICU) of Besançon University Hospital (France) between March 16 and May 22, 2020. We included patients with confirmed COVID-19 and cranial neuropathy at admission to the p-ICU. All these patients were treated by orotracheal intubation, and all but one underwent prone-position ventilation therapy. <b><i>Results:</i></b> Of the 88 patients admitted to the p-ICU, 10 patients (11%) presented at least 1 cranial nerve palsy. Of these 10 patients, 9 had a hypoglossal nerve palsy and 8 of these also had a deficit in another cranial nerve. The most frequent association was between hypoglossal and vagal palsies (5 patients). None of the patients developed neurological signs related to a global neuropathy. We found no correlation between the intensity of the motor limb weakness and the occurrence of lower cranial nerve palsies. All but 2 of the patients recovered within less than a month. <b><i>Conclusion:</i></b> The mechanical compressive hypothesis, linked to the prone-position ventilation therapy, appears to be the major factor. The direct toxicity of SARS-CoV-2 and the context of immune dysfunction induced by the virus may be involved in a multifactorial etiology.

scholarly journals RARE-31. TREATMENT OUTCOME OF CHILDREN WITH PLEOMORPHIC XANTHOASTROCYTOMA: RETROSPECTIVE ANALYSIS – A SINGLE INSTITUTION EXPERIENCE

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi228-vi228
Author(s):  
Ossama Maher ◽  
Toba Niazi ◽  
Ziad Khatib ◽  
John Ragheb
Keyword(s):  
Local Recurrence ◽  
Retrospective Analysis ◽  
Malignant Transformation ◽  
Cranial Nerve ◽  
Pleomorphic Xanthoastrocytoma ◽  
Braf V600e ◽  
Biological Behavior ◽  
High Local Recurrence Rate ◽  
Cranial Nerve Palsies

Abstract BACKGROUND Pleomorphic xanthoastrocytoma (PXA) and anaplastic pleomorphic xanthoastrocytoma (APXA) are two types of rare astrocytomas in pediatrics. There is limited literature reporting their outcomes. METHODS A retrospective analysis of pediatric patients with diagnosis of PXA and APXA treated at Nicklaus Children’s Hospital was conducted using descriptive measures. RESULTS A chart review of patients with brain tumors from 2001 to 2019 revealed that 13 patients (median age 6 years, range 2–17 years) were diagnosed with non-metastatic PXA (n=12) and APXA (n=1). Six patients (46%) were male. Clinical presentation included seizures (n=8), headaches (n=2) cranial nerve palsies (n=2). Diagnostic imaging showed tumor in the temporal lobe (n=5), parietal lobe (n=2), temporoparietal lobe (n=2), frontal lobe (n=1), occipital lobe (n=1), others (n=2). BRAF V600E mutation were identified in three of five analyzed tumors including PXA (n=4) and APXA (n=1). Surgical intervention consisted of gross total resection (n=8) and near/subtotal resection (n=5). Ten patients (76%) required a second surgery (median 2; range 1–4) due to local recurrence. The median time to recurrence was 3 years (range 6 months - 7 years). Three patients (23%) had malignant transformation of PXA, which occurred three to eight years from the initial surgery; one of them also had extensive spinal metastasis. Focal radiation was given to six patients (46%) due to multiple recurrence (n=2), malignant transformation (n=3), APXA (n=1). At a median follow up of 8 years (range 3 to 20 years), eight patients remain alive, three patients had lost to follow up, two patients died from progressive disease. Long-term sequelae varied as follows; seizures (n=5), motor weakness (n=4), cranial nerve palsies (n=2), and learning disability (n=1). CONCLUSION PXA is associated with high local recurrence rate and uncommonly malignant transformation to APXA in pediatrics, which requires close follow-up due to unpredictable biological behavior of these tumors.

Radiosurgical Management of Benign Cavernous Sinus Tumors: Dose Profiles and Acute Complications

Neurosurgery ◽  
2001 ◽  
Vol 48 (5) ◽  
pp. 1022-1032 ◽  
Author(s):  
Joseph C.T. Chen ◽  
Steven L. Giannotta ◽  
Cheng Yu ◽  
Zbigniew Petrovich ◽  
Michael L. Levy ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Pituitary Adenoma ◽  
Radiation Dose ◽  
Cavernous Sinus ◽  
Cranial Nerve ◽  
Cranial Nerve Palsy ◽  
Nerve Palsy ◽  
Tumor Volume ◽  
Grade Iii

Abstract OBJECTIVE Radiosurgery has emerged as an alternative treatment modality for cranial base tumors in patients deemed not suited for primary surgical extirpation, patients with recurrent or residual tumor after open surgery, or patients who refuse surgical treatment. We review our short-term experience with radiosurgical management of cavernous sinus region tumors with the Leksell gamma knife. METHODS From August 1994 to February 1999, 69 patients with cavernous sinus lesions were treated in 72 separate treatment sessions. The tumor type distribution was 29 pituitary adenomas, 35 meningiomas, 4 schwannomas, and 1 paraganglioma. The median follow-up was 122 weeks. Lesions were stratified according to a five-level surgical grade. The grade distribution of the tumors was as follows: Grade I, 13; Grade II, 21; Grade III, 19; Grade IV, 12; Grade V, 4. Median tumor volume was 4.7 cm3. The median radiation dose was 15 Gy to the 50% isodose line. Median maximal radiation dose was 30 Gy. RESULTS Analysis of tumor characteristics and radiation dose to optic nerve and pontine structures revealed a significant correlation between distance and dose. Much lower correlation coefficients were found between tumor volume and dose. One lesion in this series had evidence of transient progression and later regression on follow-up radiographic studies. No other lesions in this series were demonstrated to have exhibited progression. Complications after radiosurgical treatment were uncommon. Two patients had cranial nerve deficits after treatment. One patient with a surgical Grade III pituitary adenoma had VIth cranial nerve palsy 25 months after radiosurgical treatment that spontaneously resolved 10 months later. A patient with a bilateral pituitary adenoma experienced bilateral VIth cranial nerve palsy 3 months after treatment that had not resolved at 35 months after treatment. Six patients with preoperative cranial nerve deficits experienced resolution or improvement of their deficits after treatment. One patient with a prolactin-secreting adenoma experienced normalization of endocrine function with return of menses. CONCLUSION Radiosurgical treatment represents an important advance in the management of cavernous sinus tumors, with low risk of neurological deficit in comparison with open surgical treatment, even in patients with high surgical grades.

Radiosurgery for Hemangiomas of the Cavernous Sinus and Orbit: Technical Case Report

Neurosurgery ◽  
2000 ◽  
Vol 47 (3) ◽  
pp. 778-783 ◽  
Author(s):  
Todd P. Thompson ◽  
L. Dade Lunsford ◽  
John C. Flickinger
Keyword(s):  
Cavernous Sinus ◽  
Management Strategy ◽  
Tumor Volume ◽  
Clinical Presentation ◽  
Gamma Knife Radiosurgery ◽  
Symptomatic Improvement ◽  
Vascular Tumors ◽  
Effective Management ◽  
Ocular Symptoms

ABSTRACT OBJECTIVE AND IMPORTANCE Hemangiomas of neurosurgical interest are histologically benign vascular tumors that most often occur in the orbit or cavernous sinus. Hemangiomas can be diagnosed by their characteristic radiographic and angiographic appearance and their tendency to bleed excessively during attempted removal. Intracranial or intraorbital hemangiomas require treatment when they become symptomatic. CLINICAL PRESENTATION We report four hemangioma patients who presented with ocular symptoms or signs, such as orbital pain, ophthalmoplegia, proptosis, or impaired visual acuity. Before our evaluation, two patients had each had incomplete resections aborted because of excessive blood loss, one patient had undergone a nondiagnostic transsphenoidal biopsy, and one patient had had an unsuccessful embolization. INTERVENTION All four patients were treated with gamma knife radiosurgery. Tumors received a minimal tumor dose that ranged from 14 to 19 Gy. Follow-up evaluations were performed 6 to 24 months after radiosurgery and revealed a reduction in tumor volume in three patients and no tumor progression in the fourth. All patients had symptomatic improvement, but one had persistent diplopia. CONCLUSION In this early experience, stereotactic radiosurgery proved to be an effective management strategy that avoided the potentially serious complications associated with surgery or embolization of cavernous sinus hemangiomas.

scholarly journals A Rare Case of Tolosa-Hunt-Like Syndrome in a Poorly Controlled Diabetes Mellitus

2016 ◽  
Vol 2016 ◽  
pp. 1-4 ◽  
Author(s):  
Glenmore Lasam ◽  
Sakshi Kapur
Keyword(s):  
Diabetes Mellitus ◽  
Cavernous Sinus ◽  
Cranial Nerve ◽  
Rare Case ◽  
Tight Glycemic Control ◽  
Eighth Cranial Nerve ◽  
Diagnostic Investigation ◽  
Hunt Syndrome ◽  
Cranial Nerve Palsies ◽  
The Right

We report a case of a 50-year-old female with diabetes mellitus who presented with progressive second, third, fifth, sixth, and eighth cranial nerve palsy. Diagnostic investigation revealed hyperglycemic state, and brain imaging showed a right cavernous sinus enhancement suggestive of and consistent with Tolosa-Hunt syndrome. The patient was started on steroids with tight glycemic control for eight weeks; subsequently, the cranial nerve palsies resolved as well as documented resolution of the right cavernous sinus enhancement.

Transsphenoidal approach to infrasellar tumors involving the cavernous sinus

1990 ◽  
Vol 73 (4) ◽  
pp. 513-517 ◽  
Author(s):  
Nobuo Hashimoto ◽  
Haruhiko Kikuchi
Keyword(s):  
Cavernous Sinus ◽  
Cranial Nerve ◽  
Cranial Nerves ◽  
Transsphenoidal Approach ◽  
Skull Base Tumors ◽  
Content Type ◽  
Operating Field ◽  
Cranial Nerve Palsies ◽  
Operative Complications ◽  
Fine Print

✓ The authors review their 2-year experience with a rhinoseptal transsphenoidal approach to skull-base tumors of various pathologies involving both the sphenoid and cavernous sinuses. Eight patients with cranial nerve palsies attributable to compression of the contents of the cavernous sinus and/or optic canal are included in this report. Among these patients, a total of 17 cranial nerves were affected. Postoperative normalization was achieved in eight nerves, significant improvement in seven nerves, and no improvement in two nerves. There were no operative complications of aggravation of cranial nerve palsies in this series. In spite of the limited operating field, the results demonstrate the effectiveness and safety of this approach. The authors recommend that this approach be considered before more aggressive surgery is undertaken.

scholarly journals Tolosa-Hunt Syndrome: A Case Report and Review of the Literature

2013 ◽  
Vol 29 (2) ◽  
pp. 130-133
Author(s):  
Md Rafiqul Islam ◽  
Hasan Zahidur Rahman ◽  
Akm Anwar Ullah ◽  
Md Amir Hossain ◽  
- Md Ziauddin
Keyword(s):  
Cavernous Sinus ◽  
Trigeminal Nerve ◽  
Cranial Nerve ◽  
Motor Nerve ◽  
Pathological Process ◽  
Sensory Loss ◽  
Oral Steroid ◽  
Superior Orbital Fissure ◽  
Hunt Syndrome ◽  
Cranial Nerve Palsies

Tolosa-Hunt Syndrome is a painful ophthalmoplegia which is characterized by periorbital or hemicranial pain, with ipsilateral ocular motor nerve palsies, oculosympathetic paralysis, sensory loss in the distribution of the ophthalmic and occasionally the maxillary division of the trigeminal nerve. Various combinations of these cranial nerve palsies may occur, localising the pathological process to the region of the cavernous sinus/superior orbital fissure. We report the case of a patient presented with severe pain in the right side of face which was periorbital with ipsilateral 3rd,4th, 6th cranial nerve palsies along with ophthalmic and maxillary division of trigeminal nerve involvement. MRI of orbit showed hypo-intense lesion in right cavernous sinus extending to right superior orbital fissure (suggestive of granulomatous infiltration). After taking oral steroid her pain was relieved quickly and cranial nerve palsies reversed within one week. Azathioprin was added and she was completely cured of within next three months. Bangladesh Journal of Neuroscience 2013; Vol. 29 (2) : 130-133

Cranial neuropathy following curative chemotherapy and radiotherapy for carcinoma of the nasopharynx

2000 ◽  
Vol 114 (4) ◽  
pp. 308-310 ◽  
Author(s):  
Matt Y. Kang ◽  
John M. Holland ◽  
Kenneth R. Stevens
Keyword(s):  
Head And Neck ◽  
Cranial Nerve ◽  
Hypoglossal Nerve ◽  
Cranial Nerves ◽  
Nasopharyngeal Cancer ◽  
Concurrent Chemotherapy ◽  
Cranial Neuropathy ◽  
Tumour Control ◽  
Cranial Nerve Palsies ◽  
Head And Neck Radiotherapy

Cranial nerve damage following head and neck radiotherapy is an unusual event. Cranial neuropathy following concurrent chemotherapy and radiotherapy is unreported. The authors report a case of a 54-year-old man treated with curative chemotherapy and radiotherapy for a stage III nasopharyngeal carcinoma who developed an unilateral hypoglossal nerve palsy five years after therapy. Follow-up examination and magnetic resonance imaging (MRI) show no evidence of recurrent disease. Hypoglossal nerve injury occurring after head and neck radiotherapy is an indirect effect due to progressive soft tissue fibrosis and loss of vascularity. This process develops over years leading to nerve entrapment and permanent damage. Cranial nerve palsies, including damage to the hypoglossal nerve, can develop years after therapy with no evidence of tumour recurrence. Chemotherapy and radiotherapy have improved progression-free and overall survival in advanced nasopharyngeal cancer. As more patients achieve long-term tumour control following chemotherapy and radiotherapy, we must be cognizant of potential late injury to cranial nerves.

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