NEUROCHIRURGIA ADV ANCES

FORT SCHRIT T E

Supplementum ad Fortschritte der Neurologie und Psychiatrie

Heft 6

Neurochirurgia 19 (1976), 239-246 © Georg Thieme Verlag, Stuttgart

Angiographic findings in basal tumours of the anterior and middle cranial fossa G. B. Bradac, J. Schramm, R. S. Simon Department of Neuroradiology and Neurosurgery of the Klinikum Steglitz, Free University of Berlin

Summary

Angiographic findings in tumours located near the skull base in the anterior and middle cranial fossa are described. It is possible to distinguish local and general changes, but in general these will indicate the localisation of the tumour rather than its type. Key-words: angiography intracranial tumour anterior cranial fossa middle cranial fossa

primary, histologically verified tumours near

thc base of the anterior and middle cranial fossa were reviewed for the purpose of this study. Among them were 13 meningiomas, 8 craniopharyngiomas, 7 adenomas and 2 basal tumours (carcinoma of the pharynx and chondroblastoma), as well as 2 cerebral

tumours which we included in this study because they had infiltrated the dura. We local and remote pathological changes in the arterial and venous phase.

observed Zusammenfassung

Angiographische Befunde bei Tumoren nahe der Schädelbasis in der vorderen und mittleren Schädelgrube werden beschrieben. Bei den Befunden werden lokale Zeichen und Fernzeichen unterschieden, diese sind eher typisch für eine be-

stimmte Tumorlokalisation als far eine Tumorart.

1. Local changes

A. Displacements of arteries and veins are well known (Chase and Taveras, 5, 6, Krayenbühl and Yasargil 13), so we will not discuss

them here in detail. Displacement of arteries

In tumours of the skull base there are a

often together with veins in the carotid re-

number of appearances in the carotid angiogram to which little attention has been paid.

gion could be seen in 27 of our 32 cases. In 5 craniopharyngiomas (Fig. 1) displacement of only the veins could be seen (internal cerebral vein, v. septi pellucidi) in the carotid angio-

We have reviewed our material from this point of view. Angiograms of 32 patients with

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240

G. B. Bradac, J. Schramm, R. Simon

Fig. 1: Retrosellar craniopharyngioma

A Carotid angiogram, venous phase: Arch-like shift of septal vein (.-->-) and internal cerebral vein (1>-). The arterial phase was normal B Vertebral angiogram, arterial phase: Stretching and posterior displacement of thalamic perforating arteries

gram, while the arteries were inconspicuous. In these cases displacement of arteries could be seen in the vertebral angiogram. This is dependent on the fact that these tumours had a more retrosellar extension. It should also be mentioned here that the anterior cerebral ar-

diagnostic value. Some examples of vessel-

tery, when taking an oblique course as an

in 13 out of 32 cases. They often originated either from the ophthalmic artery (in 6 meningiomas) or were involved in the supply of the tumour as hypertrophied meningo-hypophyseal branches of the internal carotid artery. Bernasconi and Cassinari (1) were the first to describe hypertrophy of the meningohypophyseal branches in cases of tentorial meningioma. Other authors demonstrated these vessels in meningiomas and in other skull-base tumours (Wickbom and Stattin 26, Stattin 21, Schniirer and Stattin 20, Frugoni et al. 7, Westberg and Ross 25, Westberg 24, Pribram et al. 19, Kriebel/ et al. 15, Kramer and Newton 24, Randa et al. 11, Hatam 12). Our material, too, gave evidence of pathological stains by hypertrophied meningo-hypophyseal branches, not only in 5 meningiomas but also in 1 craniopharyngioma, 2 adenomas and the tumour of the nasopharynx, see Fig.

anatomical variant, can escape displacement

by a medially situated tumour, as already mentioned by Gado and Bull (8). B. We were able to see a direct involement

of the vessel wall in 11 of 32 cases (30 %). This occurred 7 times in meningiomas, once in a chondroblastoma, oligodendroglioma a haemangio-endothelioma, and an adenoma. The carotid siphon and the ophthalmic artery were the most affected by this walling-in process. The anterior cerebral artery and the first

segment of the middle cerebral artery were affected to a lesser degree, and at one time even the pericallosal artery by an extraordinarily large olfactory groove meningioma. When a retrosellar extension exists, the posterior cerebral and basilar artery can also be affected. When this direct involvement has led to a stenosis or occlusion the appearance of a collateral circulation from other vessels is of

wall involvement are visible in Figures 2, 3, 5. C. Pathological stains were seen in all

meningiomas, in 4 of 7 adenomas, in 1 of 8 craniopharyngiomas and in the tumour of the nasopharynx. Pathological vessels were found

2, 3, 6, 7. It is well known, but it will be

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A

Angiographic findings in basal tumours of the anterior and middle cranial fossa

241

Fig. 3: Recurrent supra- and parasellar meningioma. Carotid angiogram A Arterial phase: Pathological vascularisation Fig. 2: Meningioma

A Carotid angiogram, arterial phase: Tumour supply by meningeo-hypophyseal branches Narrowing of carotid siphon (-->-) and irregularity of the wall of the ophthalmic artery (>-) B Vertebral angiogram, arterial phase: Posterior communicating artery (-->-). Filling of the post-

(

). The tumour is supplied by hypertrophied

meningeo-hypophyseal branches (>-) and ethmoidal branches from the ophthalmic (artery ( >-)

B Capillary phase: Pathological vascularisation of the tumour ( ). Pathological early filling of parietal veins ( < )

stenotic portion (>-) of the carotid siphon with filling of the middle cerebral artery

This can be explained by either direct infiltration or by the sinus acting as a direct

mentioned in brief, that tumours close to the are especially meningiomas skull base sometimes supplied additionally by branches

venous drainage. In 3 cases a doubtful compression of the cavernous sinus was found. In such cases phlebography of the basal veins could be considered as appropriate, as a supplementary examination (Lloyd 17, Lombardi and Passerini 16, Theron and Djindjian 22,

of the external carotid artery. Therefore angio-

graphy of this vessel should be performed routinely. D. Early filling of the cavernous sinus and/

Michalik et al. (18).

or basilar sinus was found in 10 cases. (Fig.

E. As we have reported elsewhere about

4, 7) Two of them proved not to be men-

aspects of venous drainage in tumours of the skull base (Bradac 4), this will need only brief

ingiomas (1 craniopharyngioma, 1 adenoma). 16

Neurochirurgia 19,6

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A

G. B. Bradac, J. Schramm, R. Simon

242 A

;tk,

* Tentorial ridge meningioma. angiogram Fig. 4:

Carotid

A Capillary phase: Early filling of basilar sinus (>) Tumour stain (T). B Venous phase: The drainage of the superficial sylvian veins is not disturbed ( < ). These veins drain normally into the cavernous sinus and

Fig. 5: Same case as in Fig. 4. Vertebral angiogram, arterial phase: Besides the displacement of the vessels, note the tapered deformation of the basilar artery (>)

pterygoid plexus (>). Note the posterior placement of the internal cerebral vein (>)

27, Bradac 4), this will not show on the angiogram. With further extension of the tumour from the para-sellar toward the lateral region, it becomes clear that this detour of the ophthalmic vein can also be blocked, as in 2 of our cases. At the same time, yet independently thereof, a disorder of drainage of the deep sylvian veins may occur. If this is the case, the deep sylvian veins will drain conversely: partly into the superficial sylvian veins and partly into the veins of the territory

dis-

mention here: in 8 cases (4 meningiomas, 2 craniopharyngiomas, 1 adenoma, 1 tumour of

the nasopharynx) a disordered drainage of the superficial sylvian veins became evident. The tumour had either blocked or impeded the normal drainage of these veins into the cavernous sinus and pterygoid plexus. Drainage, therefore, occured via the sphenoparietal sinus into the ophthalmic vein (Fig. 8, 9). As a result, the direction of flow in the ophthalmic vein was then opposite to that in normal cases, i. e. from intracranial to extracranial. Where the superficial sylvian veins

drain differently (Hacker 1, Wolff and Huang

of the internal cerebral vein (Fig. 8, 9). F. Disorders of drainage of the ophthalmic

vein can be divided angiographically into three groups. The following authors have al-

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-a-

Angiographic findings in basal tumours of the anterior and middle cranial fossa

243

Pituitary adenoma: Carotid angiogram, arterial phase (magnification): Stretching of the carotid siphon ( ). Supply of the tumour by Fig. 6:

hypertrophied meningeo-hypophyseal vessels (-->-)

ready concerned themselves with this problem (Bradac et al. 2, Theron and Djindjian 22, Hacker and Porrero 10, Tommy and Piscol 23). The most important criteria of these disorders are: the involvement of the ophthalmic vein already described, as a drainage

Fig. 7: Intra- and suprasellar craniopharyngioma. Carotid angiogram A arterial phase: Supply of the tumour by men-

route for the superficial sylvian veins resulting

ingeo-hypophyseal trunk (--->-)

from the blockage of the cavernous sinuspterygoid plexus, together with reversal of flow in the ophthalmic vein (Fig.8, 9). Sec-

B Late arterial phase: Early filling of the basilar

ondly,this reversal of flow in the ophthalmic vein may occur after direct infiltration of the cavernous sinus by the tumour (Bradac et al. 2). Thirdly, the ophthalmic vein may appear normal as far as the direction of flow is concerned (i. e. filling externally to internally), but may then be cut off shortly before reach-

arterial phase, especially in the parieto-occipi-

ing the cavernous sinus.

2. Distant or general changes

sinus (-4.)

tal region, which we were able to see in 4 cases. Early filling of the parietal veins was found in 6 cases. In a previous study, we made a detailed report about the concept of early parietal veins (Bradac et al. 3). At that time, we were able to demonstrate that these

symptoms occur in various lesions of the parietal region. The early occurrence of parietal veins with lesions near the base of the skull indicates that this finding is unspecific not only as regards the type of lesion,

We divided these into two categories. A disturbance of circulation with a prolonged 16*

but also its localisation. The parietal region is apparently an area of special sensitivity, a

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A

244

G. B. Bradac, J. Schramm, R. Simon

region that permits recognition of circulatory disorders, although it is not itself directly involved in the tumour growth (Fig.3, 10).

Conclusions: In tumours near the skull base several angiographic findings are noted which are of diagnostic value. In nearly all cases displacement of arte-

found. Often the vessel walls are

directly involved as indicated by irregularity, stenosis or even occlusion. Pathological vessels originate in arteries at the base of the skull, mostly from the carotid and the ophthalmic artery. In addition to arterial displacement in a number of cases, a displacement of deep veins can be seen. A venous shift can be of special significance if it is the only pathological sign. Impairment of the dynamics of sylvian

and superior ophthalmic vein drainage can frequently be seen.

The drainage of the superficial sylvian veins ( is

Fig. 8: Olfactory meningioma with lateral extension. Carotid angiogram, lateral view A capillary and B venous phase:

The drainage of the sylvian veins is disturbed:

)

diverted by opening of collaterals into the

superior ophthalmic vein (i>-). Partial filling of the cavernous sinus (>-). The drainage of the deep sylvian veins (.-->-) is also disturbed, they drain partly into the superficial sylvian vein ) and partly into the system of the internal cerebral vein (ci)

Fig. 9: Same case as in Fig. 8. Carotid angiogram, ap-view A capillary and B venous phase: The superficial sylvian veins ( ) drain into the the superior ophthalmic vein (!--->-). The deep sylvian veins (insular and striatal veins) (. -) drain partly into the superficial sylvian vein (1.- ) and partly into the system of the internal cerebral vein (ci.). Partial filling of the cavernous sinus (-->)

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ries is

245

B

-"I

Fig. 10: Suprasellar hypophyseal adenoma. Carotid angiogram

A arterial phase: slight elevation of the anterior cerebral artery pericallosal artery B Capillary phase: disturbed circula-

tion in the parieto-occipital region: prolonged arterial filling ) filling of vein (

(

); early

Occasionally early filling of the basilar and cavernous sinus can be demonstrated.

parieto-occipital region or an early filling of

These structures are either directly infiltrated

All these signs can be encountered in isolation or in various combinations. In general, all these signs can be found in all types of tumour. They indicate the localisation but not necessarily the type of tumour.

by the tumour or serve as draining veins of the tumour.

In about 30 % of cases, peripherally located disturbances of circulation were seen: either a prolonged arterial phase in the

the parietal veins.

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Prof. Dr. G. B. Bradac, Neuroradiologie, Klinikum Steglitz der FU Berlin, Hindenburgdamm 30, 3000 Berlin 45

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