Epistaxis Related to Internal Carotid Artery Cavernous Sinus Aneurysm

AbstractWhile the so-called pseudoaneurysms can result from arterial injury during trans-sphenoidal surgery or after a trauma, spontaneous aneurysms of cavernous–internal carotid artery (CICA) are rare. Symptoms vary and the differential diagnosis with other, more frequent, sellar lesions is difficult. We describe three cases of misdiagnosed CICA spontaneous aneurysm. In two cases the onset was with neuro-ophthalmological manifestations, classifiable as “cavernous sinus syndrome.” The emergency computed tomography scan did not show CICA aneurysm and the diagnosis was made by surgical exploration. The third patient came to our attention with a sudden severe unilateral epistaxis; endonasal surgery revealed also in this case a CICA aneurysm, eroding the wall and protruding into the sphenoidal sinus. When the onset was with a cavernous sinus syndrome, misdiagnosis exposed two patients to potential serious risk of bleeding, while the patient with epistaxis was treated with embolization, using coils and two balloons. Intracavernous nontraumatic aneurysms are both a diagnostic and therapeutic challenge, because of their heterogeneous onset and risk of rupture, potentially lethal. Intracavernous aneurysms can be managed with radiological follow-up, if asymptomatic or clinically stable, or can be surgically treated with endovascular or microsurgical techniques.

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Internal Carotid Artery Injury in Transsphenoidal Surgery: Tenets for Its Avoidance and Refit—A Clinical Study

Brain Sciences ◽

10.3390/brainsci11010099 ◽

2021 ◽

Vol 11 (1) ◽

pp. 99

Author(s):

Dmitry Usachev ◽

Oleg Sharipov ◽

Ashraf Abdali ◽

Sergei Yakovlev ◽

Vasiliy Lukshin ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Cavernous Sinus ◽

Transsphenoidal Surgery ◽

Internal Carotid ◽

Treatment Options ◽

Carotid Artery Injury ◽

Anatomical Features ◽

Stent Grafting ◽

Internal Carotid Artery Injury

One of the most serious/potentially fatal complications of transsphenoidal surgery (TSS) is internal carotid artery (ICA) injury. Of 6230 patients who underwent TSS, ICA injury occurred in 8 (0.12%). The etiology, possible treatment options, and avoidance of ICA injury were analyzed. ICA injury occurred at two different stages: (1) during the exposure of the sella floor and dural incision over the sella and cavernous sinus and (2) during the resection of the cavernous sinus extension of the tumor. The angiographic collateral blood supply was categorized as good, sufficient, and nonsufficient to help with the decision making for repairing the injury. ICA occlusion with a balloon was performed at the injury site in two cases, microcoils in two patients, microcoils plus a single barrel extra-intracranial high-flow bypass in one case, stent grafting in one case, and no intervention in two cases. The risk of ICA injury diminishes with better preoperative preparation, intraoperative navigation, and ultrasound dopplerography. Reconstructive surgery for closing the defect and restoring the blood flow to the artery should be assessed depending on the site of the injury and the anatomical features of the ICA.

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The So-Called Cavernous Sinus: A Review of the Controversy and Its Implications for Neurosurgeons

Neurosurgery ◽

10.1227/00006123-198211000-00019 ◽

1982 ◽

Vol 11 (5) ◽

pp. 712-717 ◽

Cited By ~ 118

Author(s):

John N. Taptas

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Cavernous Sinus ◽

Internal Carotid ◽

Cranial Nerves ◽

Sella Turcica ◽

Middle Cranial Fossa ◽

Cranial Fossa ◽

Base Of The Skull ◽

Extradural Space

Abstract The so-called cavernous sinus is a venous pathway, an irregular network of veins that is part of the extradural venous network of the base of the skull, not a trabeculated venous channel. This venous pathway, the internal carotid artery, and the oculomotor cranial nerves cross the medial portion of the middle cranial fossa in an extradural space formed on each side of the sella turcica by the diverging aspects of a dural fold. In this space the venous pathway has only neighborhood relations with the internal carotid artery and the cranial nerves. The space itself must be distinguished from the vascular and nervous elements that it contains. The revision of the anatomy of this region has not only theoretical interest but also important clinical implications.

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Intracranial aspergillosis producing cavernous sinus syndrome and rupture of internal carotid artery

Australasian Radiology ◽

10.1111/j.1440-1673.1994.tb00134.x ◽

1994 ◽

Vol 38 (1) ◽

pp. 72-75 ◽

Cited By ~ 11

Author(s):

ROSS BREADMORE ◽

PATRICIA DESMOND ◽

KENNETH OPESKIN

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Cavernous Sinus ◽

Internal Carotid ◽

Cavernous Sinus Syndrome ◽

Intracranial Aspergillosis

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Behçet's Disease-Associated Aneurysm of the Internal Carotid Artery within the Cavernous Sinus: Report of a Patient

Neuro-Ophthalmology ◽

10.1080/01658100601166243 ◽

2007 ◽

Vol 31 (1) ◽

pp. 19-22

Author(s):

Figen Gökçay ◽

Neşe Çelebisoy ◽

İsmail Oran ◽

Kenan Aksu

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Behçet’S Disease ◽

Cavernous Sinus ◽

Behcet’S Disease ◽

Internal Carotid ◽

Behçet's Disease ◽

Behcet's Disease

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Management of Cavernous Sinus Meningioma Presenting With Cerebrovascular Insufficiency Secondary to Cavernous Carotid Artery Occlusion: Report of 2 Cases

Operative Neurosurgery ◽

10.1093/ons/opy120 ◽

2018 ◽

Vol 16 (4) ◽

pp. 503-513 ◽

Cited By ~ 1

Author(s):

Gmaan Alzhrani ◽

Nicholas Derrico ◽

Hussam Abou-Al-Shaar ◽

William T Couldwell

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Cavernous Sinus ◽

Internal Carotid ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Surgical Removal ◽

Cerebrovascular Insufficiency ◽

Cavernous Sinus Meningioma ◽

Cavernous Carotid Artery

Abstract BACKGROUND Surgical removal of cavernous sinus meningiomas is challenging and associated with high morbidities as a result of the anatomic location and the surrounding neurovascular structures that are often invaded or encased by the tumor. Advances in radiotherapy techniques have led to the adoption of more conservative approaches in the management of cavernous sinus meningioma. Internal carotid artery encasement and invasion has been documented in these cases; however, ischemic presentation secondary to internal carotid artery stenosis or occlusion by meningioma in the region of the cavernous sinus is rare, with only few cases reported in the literature. OBJECTIVE To report our surgical technique and experience with bypass grafting for cavernous sinus meningiomas that invade or narrow the internal carotid artery. METHODS We report 2 patients who presented with signs and symptoms attributed to cavernous carotid artery occlusion secondary to cavernous sinus meningioma in the last 5 yr. Both patients were treated with flow augmentation without surgical intervention for the cavernous sinus meningioma. RESULTS In both cases, the clinical and radiological signs of cerebrovascular insufficiency improved markedly, and the patients’ tumors are currently being monitored. CONCLUSION Although the cerebrovascular insufficiency in this subset of patients is attributed to the occlusion of the cavernous carotid artery caused by the tumor, we propose treating those patients with flow augmentation first with or without radiation therapy when there is a clear imaging feature suggestive of meningioma in the absence of significant cranial nerve deficit.

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Orbital Vascular And Lymphatic Systems

Surgical Anatomy of the Ocular Adnexa ◽

10.1093/oso/9780199744268.003.0013 ◽

2012 ◽

Author(s):

David Jordan ◽

Louise Mawn ◽

Richard L. Anderson

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Cavernous Sinus ◽

Ophthalmic Artery ◽

Internal Carotid ◽

External Carotid Artery ◽

External Carotid ◽

Sympathetic Nerve Fibers ◽

Carotid Canal ◽

Cervical Ganglion

The anatomy of the orbital vascular bed is complex, with tremendous individual variation. The main arterial supply to the orbit is from the ophthalmic artery, a branch of the internal carotid artery. The external carotid artery normally contributes only to a small extent. However, there are a number of orbital branches of the ophthalmic artery that anastomose with adjacent branches from the external carotid artery, creating important anastomotic communications between the internal and external carotid arterial systems. The venous drainage of the orbit occurs mainly via two ophthalmic veins (superior and inferior) that extend to the cavernous sinus, but there are also connections with the pterygoid plexus of veins, as well as some more anteriorly through the angular vein and the infraorbital vein to the facial vein. A working knowledge of the orbital vasculature and lymphatic systems is important during orbital, extraocular, or ocular surgery. Knowing the anatomy of the blood supply helps one avoid injury to the arteries and veins during operative procedures within the orbit or the eyelid. Inadvertent injury to the vasculature not only distorts the anatomy and disrupts a landmark but also prolongs the surgery and might compromise blood flow to an important orbital or ocular structure. Upon entering the cranium, the internal carotid artery passes through the petrous portion of the temporal bone in the carotid canal and enters the cavernous sinus and middle cranial fossa through the superior part of the forame lacerum . It proceeds forward in the cavernous sinus with the abducens nerve along its side. There it is surrounded by sympathetic nerve fibers (the carotid plexus ) derived from the superior cervical ganglion. It then makes an upward S-shaped turn to form the carotid siphon , passing just medial to the oculomotor, trochlear, and ophthalmic nerves (V1). After turning superiorly in the anterior cavernous sinus, the carotid artery perforates the dura at the medial aspect of the anterior clinoid process and turns posteriorly, inferior to the optic nerve.

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