Sinus pericranii treatment

Sinus pericranii treatment

Accepted guidelines or recommendations concerning the managementdiagnosis, and treatment of sinus pericranii are still lacking.

Angiography plays a crucial role in the classification of SP and choice of the optimal treatment. Only accessory SP is amenable to treatment, whereas dominant SP must be preserved.

Ellis et al describe a simple and unique method for determining whether intracranial venous outflow may be compromised by sinus pericranii treatment. This involves performing catheter angiography while the lesion is temporarily obliterated by external compression. Analysis of intracranial venous outflow in this setting allows visualization of angiographic changes that will occur once the sinus pericranii is permanently obliterated. Thus, the safety of surgical intervention can be more fully appraised using this technique 1).


There were notable improvements following surgical resection for the abnormal venous lesions and several sclerotherapies 2)


Intraoperative hemostasis is essential while sinus pericranii is detached from the craniumHemostatic agents such as bone wax or absorbable gelatin and heat coagulation seem to be useful. However, complicative hemorrhage concerning to the preceded technique has been also reported. To detect minor shunting points between the sinus pericranii and the intracranial veins, the major venous connection can be manually compressed. Intraoperative manual compression of a major venous connection of sinus pericranii can be an option to manage intraoperative bleeding 3).

The endovascular approach is becoming increasingly relevant and has proven to be safe and effective 4).

The surgical treatment involves the resection of the extracranial venous package and ligation of the emissary communicating vein. In some cases of SP, surgical excision is performed for cosmetic reasons. The endovascular technique has been described by transvenous approach combined with direct puncture and the recently endovascular embolization with Onyx 5).


1)

Ellis JA, Mejia Munne JC, Feldstein NA, Meyers PM. Determination of sinus pericranii resectability by external compression during angiography: technical note. J Neurosurg Pediatr. 2015 Oct 16:1-5. [Epub ahead of print] PubMed PMID: 26474103.
2)

Ryu JY, Lee JH, Lee JS, Lee JW, Lee SJ, Lee JM, Lee SY, Huh S, Kim JY, Hwang SK, Chung HY. Combined treatment of surgery and sclerotherapy for sinus pericranii. Arch Craniofac Surg. 2020 Apr;21(2):109-113. doi: 10.7181/acfs.2019.00521. Epub 2020 Apr 20. PMID: 32380811; PMCID: PMC7206457.
3)

Fujimoto Y, Ishibashi R, Maki Y, Kitagawa M, Kinosada M, Kurosaki Y, Ikeda H, Chin M. A Simple Surgical Technique for Pediatric Sinus Pericranii: Intraoperative Manual Compression of a Major Shunting Point. Pediatr Neurosurg. 2021 Mar 29:1-6. doi: 10.1159/000514478. Epub ahead of print. PMID: 33780955.
4)

Pavanello M, Melloni I, Antichi E, Severino M, Ravegnani M, Piatelli G, Cama A, Rossi A, Gandolfo C. Sinus pericranii: diagnosis and management in 21 pediatric patients. J Neurosurg Pediatr. 2015 Jan;15(1):60-70. doi: 10.3171/2014.9.PEDS13641. PubMed PMID: 25360854.
5)

Rangel-Castilla L, Krishna C, Klucznik R, Diaz O. Endovascular embolization with Onyx in the management of sinus pericranii: a case report. Neurosurg Focus. 2009 Nov;27(5):E13. doi: 10.3171/2009.8.FOCUS09170. PubMed PMID: 19877791.

Sphenoid sinus mucosal thickening

Sphenoid sinus mucosal thickening

In pituitary apoplexy etiology, there are reports on the appearance of sphenoid sinus mucosal thickening (SSMT) 1) 2)3).

SSMT is otherwise uncommon with an incidence of up to 7% in asymptomatic individuals. The etiology of SSMT in pituitary apoplexy is unclear and may reflect inflammatory and/or infective changes 4).

The mechanism of thickening of the para sellar dura mater and sphenoid sinus mucosa have been considered to be caused by congestion of dural blood flow because of increased cavernous and circular sinus pressure due to a sudden increase in intrasellar pressure.


A study revealed that age, tumor size, and thickened sphenoid sinus mucosa were strongly related to the occurrence of internal carotid artery stenosis in pituitary apoplexy. Among these factors, age had the potential of being an independent predictor of the condition 5).


Two magnetic resonance imaging (MRI) signs of pituitary apoplexy are the “pituitary ring sign” and “sphenoid sinus mucosal thickening”. The occurrence of both these MRI signs together in patients with ischaemic pituitary apoplexy was investigated. A literature review searching the terms “pituitary ring sign” and “sphenoid sinus mucosal thickening” in the context of pituitary apoplexy from 1990 until the present was performed. To be included in the study, each case had to have ischaemic pituitary apoplexy defined as the acute expansion of a pituitary adenoma or, less commonly, in a non-adenomatous gland, from infarction without hemorrhage or very little hemorrhage and a T1-weighted MRI of the brain with contrast that displayed both “sphenoid sinus mucosal thickening” and a “pituitary ring sign” either on an actual study (the author’s cases) or in a figure in an article from the literature that could be reviewed and clearly illustrate these two signs. Twelve cases of ischaemic pituitary apoplexy were found, all with MRI images that showed both of these signs. Ten cases from the literature (3 of which were published by this author) plus an additional 2 recently evaluated in our hospital, totaled the 12 cases. Thus, 5 of the total 12 cases were evaluated by this author. Of these 12 patients, both headache and visual loss were present in 5 patients, headache alone was indicated in 5 patients (10 of the 12 presented with headache), and no initial symptoms identified in 2 patients (incidentally found non-functioning pituitary adenomas on MRI). These findings indicate that each sign (“pituitary ring sign” and “sphenoid sinus mucosal thickening”) may exist alone with or without pituitary apoplexy, yet both signs together in the appropriate clinical context is a strong predictor of pituitary apoplexy 6).


Arita et al. treated two patients with pituitary apoplexy in whom magnetic resonance (MR) images were obtained before and after the episode. Two days after the apoplectic episodes, MR imaging demonstrated marked thickening of the mucosa of the sphenoid sinus that was absent in the previous studies. The relevance of this change in the sphenoid sinus was investigated. Retrospective evaluations were performed using MR images obtained in 14 consecutive patients with classic pituitary apoplexy characterized by acute onset of severe headache. The mucosa of the sphenoid sinus had thickened predominantly in the compartment just beneath the sella turcica, in nine of 11 patients, as ascertained on MR images obtained within 7 days after the onset of apoplectic symptoms. This condition improved spontaneously in all four patients who did not undergo transsphenoidal surgery. The sphenoid sinus mucosa appeared to be normal on MR images obtained from three patients at the chronic stage (> 3 months after onset). The incidence of sphenoid sinus mucosal thickening during the acute stage was significantly higher in the patients with apoplexy than that in the 100 patients without apoplexy. A histological study conducted in four patients who underwent transsphenoidal surgery during the early stage showed that the subepithelial layer of the sphenoid sinus mucous membrane was obviously swollen. The sphenoid sinus mucosa thickens during the acute stage of pituitary apoplexy. This thickening neither indicates infectious sinusitis nor rules out the choice of the transsphenoidal route for surgery 7).


1)

Agrawal B, Dziurzynski K, Salamat MS, Baskaya M. The temporal association of sphenoid sinus mucosal thickening on MR imaging with pituitary apoplexy. Turk Neurosurg. 2012;22(6):785-90. doi: 10.5137/1019-5149.JTN.4273-11.1. PMID: 23208917.
2)

Liu JK, Couldwell WT. Pituitary apoplexy in the magnetic resonance imaging era: clinical significance of sphenoid sinus mucosal thickening. J Neurosurg. 2006 Jun;104(6):892-8. doi: 10.3171/jns.2006.104.6.892. PMID: 16776332.
3) , 7)

Arita K, Kurisu K, Tominaga A, Sugiyama K, Ikawa F, Yoshioka H, Sumida M, Kanou Y, Yajin K, Ogawa R. Thickening of sphenoid sinus mucosa during the acute stage of pituitary apoplexy. J Neurosurg. 2001 Nov;95(5):897-901. doi: 10.3171/jns.2001.95.5.0897. PMID: 11702884.
4)

Waqar M, McCreary R, Kearney T, Karabatsou K, Gnanalingham KK. Sphenoid sinus mucosal thickening in the acute phase of pituitary apoplexy. Pituitary. 2017 Aug;20(4):441-449. doi: 10.1007/s11102-017-0804-z. PMID: 28421421; PMCID: PMC5508043.
5)

Teramoto S, Tahara S, Kondo A, Morita A. Key Factors Related to Internal Carotid Artery Stenosis Associated with Pituitary Apoplexy. World Neurosurg. 2021 Feb 7:S1878-8750(21)00186-8. doi: 10.1016/j.wneu.2021.02.005. Epub ahead of print. PMID: 33567365.
6)

Vaphiades MS. Pituitary Ring Sign Plus Sphenoid Sinus Mucosal Thickening: Neuroimaging Signs of Pituitary Apoplexy. Neuroophthalmology. 2017 Aug 9;41(6):306-309. doi: 10.1080/01658107.2017.1349807. PMID: 29344069; PMCID: PMC5764063.

Cavernous sinus hemangioma Gamma Knife surgery

Cavernous sinus hemangioma Gamma Knife surgery

A study aimed to evaluate the efficacy of Gamma Knife surgery (GKS) on cavernous sinus hemangioma and to analyze the temporal volume change.

Cho et al. retrospectively reviewed the clinical data of 26 cavernous sinus hemangioma patients who were treated with GKS between 2001 and 2017. Before GKS, 11 patients (42.3%) had cranial neuropathies and 5 patients (19.2%) complained of headache, whereas 10 patients (38.5%) were initially asymptomatic. The mean pre-GKS mass volume was 9.3 mL (range, 0.5-31.6 mL), and the margin dose ranged from 13 to 15 Gy according to the mass volume and the proximity to the optic pathway. All cranial neuropathy patients and half of headache patients showed clinical improvement. All 26 patients achieved mass control; remarkable responses (less than 1/3 of the initial mass volume) were shown in 19 patients (73.1%) and moderate responses (more than 1/3 and less than 2/3) in 7 patients (26.9%). The mean final mass volume after GKS was 1.8 mL (range, 0-12.6 mL). The mean mass volume at 6 months after GKS was 45% (range, 5-80%) compared to the mass volume before GKS and 21% (range, 0-70%) at 12 months. The higher radiation dose tended to induce more rapid and greater volume reduction. No treatment-related complication was observed during the follow-up period. GKS could be an effective and safe therapeutic strategy for CSCH. GKS induced very rapid volume reduction compared to other benign brain tumors 1).


An international multicenter study was conducted to review outcome data in 31 patients with CSH. Eleven patients had initial microsurgery before SRS, and the other 20 patients (64.5%) underwent Gamma Knife SRS as the primary management for their CSH. Median age at the time of radiosurgery was 47 years, and 77.4% of patients had cranial nerve dysfunction before SRS. Patients received a median tumor margin dose of 12.6 Gy (range 12-19 Gy) at a median isodose of 55%. RESULTS Tumor regression was confirmed by imaging in all 31 patients, and all patients had greater than 50% reduction in tumor volume at 6 months post-SRS. No patient had delayed tumor growth, new cranial neuropathy, visual function deterioration, adverse radiation effects, or hypopituitarism after SRS. Twenty-four patients had presented with cranial nerve disorders before SRS, and 6 (25%) of them had gradual improvement. Four (66.7%) of the 6 patients with orbital symptoms had symptomatic relief at the last follow-up. CONCLUSIONS Stereotactic radiosurgery was effective in reducing the volume of CSH and attaining long-term tumor control in all patients at a median of 40 months. The authors’ experience suggests that SRS is a reasonable primary and adjuvant treatment modality for patients in whom a CSH is diagnosed. 2).


Between August 2011 and April 2014, 7 patients with CSHs underwent GKS. GKS was performed as the sole treatment option in 5 patients, whilst partial resection had been performed previously in 1 patient and biopsy had been performed in 1 patient. The mean volume of the tumors at the time of GKS was 12.5±10.2 cm3 (range, 5.3-33.2 cm3), and the median prescription of peripheral dose was 14.0 Gy (range, 10.0-15.0 Gy). The mean follow-up period was 20 months (range, 6-40 months). At the last follow-up, the lesion volume had decreased in all patients, and all cranial neuropathies observed prior to GKS had improved. There were no radiation-induced neuropathies or complications during the follow-up period. GKS appears to be an effective and safe treatment modality for the management of CSHs 3).


A retrospective analysis of 7 patients with CS hemangiomas treated by GKS between 1993 and 2008. Data from 84 CS meningiomas treated during the same period were also analyzed for comparison. The patients underwent follow-up magnetic resonance imaging at 6-month intervals. Data on clinical and imaging changes after radiosurgery were analyzed.

Six months after GKS, magnetic resonance imaging revealed an average of 72% tumor volume reduction (range, 56%-83%). After 1 year, tumor volume decreased 80% (range, 69%-90%) compared with the pre-GKS volume. Three patients had > 5 years of follow-up, which showed the tumor volume further decreased by 90% of the original size. The average tumor volume reduction was 82%. In contrast, tumor volume reduction of the 84 cavernous sinus meningiomas after GKS was only 29% (P < .001 by Mann-Whitney U test). Before treatment, 6 patients had various degrees of ophthalmoplegia. After GKS, 5 improved markedly within 6 months. Two patients who suffered from poor vision improved after radiosurgery.

GKS is an effective and safe treatment modality for CS hemangiomas with long-term treatment effect. Considering the high risks involved in microsurgery, GKS may serve as the primary treatment choice for CS hemangiomas 4).


1)

Cho JM, Sung KS, Jung IH, Chang WS, Jung HH, Chang JH. Temporal Volume Change of Cavernous Sinus Cavernous Hemangiomas after Gamma Knife Surgery. Yonsei Med J. 2020 Nov;61(11):976-980. doi: 10.3349/ymj.2020.61.11.976. PMID: 33107242.
2)

Lee CC, Sheehan JP, Kano H, Akpinar B, Martinez-Alvarez R, Martinez-Moreno N, Guo WY, Lunsford LD, Liu KD. Gamma Knife radiosurgery for hemangioma of the cavernous sinus. J Neurosurg. 2017 May;126(5):1498-1505. doi: 10.3171/2016.4.JNS152097. Epub 2016 Jun 24. PMID: 27341049.
3)

Xu Q, Shen J, Feng Y, Zhan R. Gamma Knife radiosurgery for the treatment of cavernous sinus hemangiomas. Oncol Lett. 2016 Feb;11(2):1545-1548. doi: 10.3892/ol.2015.4053. Epub 2015 Dec 23. PMID: 26893777; PMCID: PMC4734249.
4)

Chou CW, Wu HM, Huang CI, Chung WY, Guo WY, Shih YH, Lee LS, Pan DH. Gamma knife surgery for cavernous hemangiomas in the cavernous sinus. Neurosurgery. 2010 Sep;67(3):611-6; discussion 616. doi: 10.1227/01.NEU.0000378026.23116.E6. PMID: 20647963.
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