ACTA RADIOLOGICA OFFICIAL ORGAN OFTHE RADIOLOGICAL SOCIETIES OF DENMARK, FINLAND, NORWAY AND SWEDEN
Vol. 16 Fasc. 1
DIAGNOSIS
1975 January
ORBITAL PHLEBOGRAPHY IV. The cavernous sinuses and adjacent venous sinuses of the skull base JAN BRISMAR The cavernous sinuses and adjacent basal venous sinuses may be affected in various disorders in and close to the base of the skulL Sufficient information concerning these sinuses may be achieved by carotid angiography only in a minority of cases, and thus, phlebography is often indicated. Two different phlebographic routes to the basal sinuses have been used, the anterior approach via the orbital veins and the posterior via the inferior petrosal sinuses. The technique of angular vein puncture for orbital phlebography introduced by DEJEAN & BOUDET (1951) may also be used for examination of the cavernous sinus (BREGEAT et coll. 1952). This technique was used by several authors (BETOULIERES et coll. 1957, ARSENI et coll. 1965, ARON-RoSA et coll. 1966, 1967) although even the ipsilateral cavernous sinus was not always demonstrated. Frontal vein puncture, introduced by VRITSIOS (1961) and modified by VIGNAUD (1970), has improved the results of orbital phlebography (BRISMAR 1974 a, b, c) as well as of examinations of the cavernous sinus (LLOYD 1972, PISCOL et coll, 1970, TORNOW & PISCOL 1970, ENGEL 1972). Adequate filling of the cavernous sinuses should always be obtained when using this technique, provided that the superior ophthalmic veins were unobstructed From the Section on Neurorad.ology (Director: S. Cronqvist), Department of Diagnostic Radiology (Director: Prof. O. Olsson), University Hospital, S-221 85 Lund, Sweden. Submitted for publication 21 December 1973. 1 - 755831 Acta Radiologica D'agnosis Vol. 16 (1975)
Downloaded from acr.sagepub.com at Harvard Libraries on July 7, 2015
2
JAN BRISMAR
(LLOYD). Bilateral filling of the cavernous sinuses and the adjacent basal sinuses (SHIU et coll. 1968, WAGA et coll. 1970, CLAY et coll. 1972, VIGNAUD et coll. 1972 b) may also be achieved with the method of inferior petrosal sinus catheterization via the internal jugular vein (HANAFEE et colI. 1965). Alternatively, the inferior petrosal sinuses may be catheterized via the femoral vein (TAKAHASHI & TANAKA 1971). These two methods are complementary if the orbital veins or the basal sinuses are occluded. However, in some seven per cent of cases (SHIU et coll.) the anatomy of the inferior petrosal sinus prevents the use of the posterior approach. Furthermore, while no complications have been described in association with the frontal vein puncture, SHIU et coll. in 100 patients examined with inferior petrosal sinus catheterization reported one patient with a lateral medullary syndrome developing during the examination, presumably due to rupture of one of the pontine veins; in two other cases contrast medium extravasated into the subdural space but without any serious consequences. Frontal vein puncture is simpler than inferior petrosal sinus catheterization and may also be performed on out-patients. Thus, the former method seems to be preferable as the primary method of approach. Reports on the normal phlebographic appearanceof the basal sinuses of the skull are partly contradictory and do not always agree with classical anatomic descriptions. Lateral displacement of the cavernous sinus has been used as a sign of pituitary tumors (SHIU et coll., WAGA et coll.), although no normal values for the transverse diameter of the pituitary fossa, as defined by the medial borders of the cavernous sinuses, are given in the literature. As several problems remain regarding phlebography by injection of contrast medium into a frontal vein for examination of disorders in and close to the base of the skull the present investigation was undertaken to: (1) evaluate the value of the method to demonstrate the basal veins of the skull; (2) arrive at a deeper knowledge of the normal phlebographic anatomy of the cavernous sinus and adjacent basal venous sinuses; and (3) determine the normal transverse diameter of the pituitary fossa, as assessed from the medial borders of the cavernous sinuses.
Anatomy While the detailed anatomy of the cavernous sinus is still a matter of dispute, especially with respect to the positions of the cranial nerves and the carotid artery in relation to the 'cavernous tissue', the general arrangement of the basal venous sinuses is not a matter of controversy among anatomists (HAFFERL 1969). The nomenclature used in the present report appears in Fig. 1. The cavernous sinuses (CS) are located on each side of the sella turcica, extending from the superior orbital fissure to the apex of the pyramid. The upper and lateral walls of the sinus are formed by the dura, the upper part of the medial wall consists of a septum towards the pituitary fossa while the infero-medial part borders on the lateral surface of the body of the sphenoidal bone. Anteriorly, each cavernous sinus
Downloaded from acr.sagepub.com at Harvard Libraries on July 7, 2015
ORBITAL PHLEBOGRAPHY
3
~"""",,----',"""""---VDS -r-~CI,---
SPHS
,......,M~~~rt--AICS ill'~'---~'""""''i-'-'t--
CS
~-------"~-PICS
i!-----\:"'""\-- PP PDF ~~~~---+.'-I~ BP ~~~---\-t~---~I--
IPS ~.....----f':+-- I J V -......,/-J-f--SPS '---f:-f--- SS
""","+---TS
Fig. 1. Basal venous sinuses. AICS ~ anterior intercavernous sinus, BP ~ basilar plexus, CS ~ cavernous sinus, IJV ~ internal jugular vein, IPS ~ inferior petrosal sinus, PICS ~ posterior intercavernous sinus, POF = plexus of the foramen ovale, PP = pterygoid plexus, SPHS = sphenoparietal sinus, SPS = superior petrosal sinus, SS ~ sigmoid sinus, TS = transverse sinus, VOS = superior ophthalmic vein.
is connected to the superior ophthalmic vein (VOS) which leaves the orbit through the superior orbital fissure and often also to the sphenoparietal sinus (SPHS) that follows the free edge of the smaller sphenoidal wing. The sphenoparietal sinus is often joined by the middle cerebral veins, which, however, may also enter the cavernous sinus separately. The venous plexus of the foramen ovale.. . and adjacent foramina (POF) connects the lateral part of the cavernous sinus with the pterygoid plexus (PP). From the superior posterior part of the cavernous sinus, the superior petrosal sinus (SPS) runs in its sulcus to the sigmoidsinus, while the larger inferior petrosal sinus (IPS) leaves the inferior posterior part of the cavernous sinus, and passes in the sulcus with its name to the anterior part of the jugular foramen, where it empties in the internal jugular vein (IJV). The two cavernous sinuses are interconnected through the anterior (AICS) and posterior intercavernous sinuses (PICS) located in the sellar diaphragm at the anterior and posterior edge of the sella turcica, and through the basilar plexus (BP), which is a venous network on the clivus. This plexus i(also connected with the inferior petrosal sinuses and the deep cervical veins.
Material In order to obtain a 'normal material', patients with a disorder possibly affecting the veins at the base of the skull, or with an intraorbital disorder causing an occlusion of the intraorbital veins, were not included. Examinations without satisfactory technical quality permitting a detailed evaluation of the anatomy of the cavernous sinuses and the adjacent basal sinuses were also excluded. Thus out of the initial
Downloaded from acr.sagepub.com at Harvard Libraries on July 7, 2015
4
JAN BRISMAR
20 examinations
Fig. 2. Distribution of unisatisfactory examinations (hatched) in the total series of 101 examinations 1971-1973.
1971
1972
1973
material of 101 examinations in 94 patients there remained 26 patients, 10 females and 16 males, constituting the 'normal material'. The relevant veins and sinuses were included in the projections used with the following exceptions: in the axial view in one patient the petrosal sinuses and the jugular veins were not included, and in another patient not the jugular veins. The number of examinations remaining for an analysis of the anatomy of these veins thus amounted to 25 and 24, respectively. Four children were included in the 'normal material' (age: one day, four months, two years and four years). The oldest patient was 71 years of age. Method and technical results A complete examination of the cavernous sinuses is included in the technique for orbital phlebography used by the present author. It has been described in detail previously (BRISMAR 1974 a), to which report the reader is referred. Measurements of the transverse diameter of the pituitary fossa, were performed on the axial films without correction for magnification. The film-focus distance was about 100 em, and the head of the patient rested on the automatic film changer. During the latter part of this series, linear angio-tomography has also been performed in the a.p. projection in several cases. The examinations have been classified as adequate or incomplete. Those with only fragmentary or unilateral demonstration of the cavernous sinus and its drainage and those without an axial view have been assigned to the incomplete ones. As the examination technique was gradually worked out during the series, incomplete examinations were more common at the beginning and due to too slow injection of contrast medium, defective external compression, or absence of adequate views. Among the last 70 examinations, only four were classified as incomplete. In one of these, the injection of contrast medium was partly perivascular; in another the collaterals over the midline in the forehead were underdeveloped; in the third case
Downloaded from acr.sagepub.com at Harvard Libraries on July 7, 2015
ORBITAL PHLEBOGRAPHY
5
Table Incidence of filling of basal venous sinuses in the 'normal material'. SPHS~sphenoparietal sinus, CS ~ cavernous sinus, AICS = anterior and PICS =posterior intercavernous sinuses, BP = basilar plexus, POF~plexus of the foramen ovale, H'S'
Vol. 16 Fasc. 1
DIAGNOSIS
1975 January
ORBITAL PHLEBOGRAPHY IV. The cavernous sinuses and adjacent venous sinuses of the skull base JAN BRISMAR The cavernous sinuses and adjacent basal venous sinuses may be affected in various disorders in and close to the base of the skulL Sufficient information concerning these sinuses may be achieved by carotid angiography only in a minority of cases, and thus, phlebography is often indicated. Two different phlebographic routes to the basal sinuses have been used, the anterior approach via the orbital veins and the posterior via the inferior petrosal sinuses. The technique of angular vein puncture for orbital phlebography introduced by DEJEAN & BOUDET (1951) may also be used for examination of the cavernous sinus (BREGEAT et coll. 1952). This technique was used by several authors (BETOULIERES et coll. 1957, ARSENI et coll. 1965, ARON-RoSA et coll. 1966, 1967) although even the ipsilateral cavernous sinus was not always demonstrated. Frontal vein puncture, introduced by VRITSIOS (1961) and modified by VIGNAUD (1970), has improved the results of orbital phlebography (BRISMAR 1974 a, b, c) as well as of examinations of the cavernous sinus (LLOYD 1972, PISCOL et coll, 1970, TORNOW & PISCOL 1970, ENGEL 1972). Adequate filling of the cavernous sinuses should always be obtained when using this technique, provided that the superior ophthalmic veins were unobstructed From the Section on Neurorad.ology (Director: S. Cronqvist), Department of Diagnostic Radiology (Director: Prof. O. Olsson), University Hospital, S-221 85 Lund, Sweden. Submitted for publication 21 December 1973. 1 - 755831 Acta Radiologica D'agnosis Vol. 16 (1975)
Downloaded from acr.sagepub.com at Harvard Libraries on July 7, 2015
2
JAN BRISMAR
(LLOYD). Bilateral filling of the cavernous sinuses and the adjacent basal sinuses (SHIU et coll. 1968, WAGA et coll. 1970, CLAY et coll. 1972, VIGNAUD et coll. 1972 b) may also be achieved with the method of inferior petrosal sinus catheterization via the internal jugular vein (HANAFEE et colI. 1965). Alternatively, the inferior petrosal sinuses may be catheterized via the femoral vein (TAKAHASHI & TANAKA 1971). These two methods are complementary if the orbital veins or the basal sinuses are occluded. However, in some seven per cent of cases (SHIU et coll.) the anatomy of the inferior petrosal sinus prevents the use of the posterior approach. Furthermore, while no complications have been described in association with the frontal vein puncture, SHIU et coll. in 100 patients examined with inferior petrosal sinus catheterization reported one patient with a lateral medullary syndrome developing during the examination, presumably due to rupture of one of the pontine veins; in two other cases contrast medium extravasated into the subdural space but without any serious consequences. Frontal vein puncture is simpler than inferior petrosal sinus catheterization and may also be performed on out-patients. Thus, the former method seems to be preferable as the primary method of approach. Reports on the normal phlebographic appearanceof the basal sinuses of the skull are partly contradictory and do not always agree with classical anatomic descriptions. Lateral displacement of the cavernous sinus has been used as a sign of pituitary tumors (SHIU et coll., WAGA et coll.), although no normal values for the transverse diameter of the pituitary fossa, as defined by the medial borders of the cavernous sinuses, are given in the literature. As several problems remain regarding phlebography by injection of contrast medium into a frontal vein for examination of disorders in and close to the base of the skull the present investigation was undertaken to: (1) evaluate the value of the method to demonstrate the basal veins of the skull; (2) arrive at a deeper knowledge of the normal phlebographic anatomy of the cavernous sinus and adjacent basal venous sinuses; and (3) determine the normal transverse diameter of the pituitary fossa, as assessed from the medial borders of the cavernous sinuses.
Anatomy While the detailed anatomy of the cavernous sinus is still a matter of dispute, especially with respect to the positions of the cranial nerves and the carotid artery in relation to the 'cavernous tissue', the general arrangement of the basal venous sinuses is not a matter of controversy among anatomists (HAFFERL 1969). The nomenclature used in the present report appears in Fig. 1. The cavernous sinuses (CS) are located on each side of the sella turcica, extending from the superior orbital fissure to the apex of the pyramid. The upper and lateral walls of the sinus are formed by the dura, the upper part of the medial wall consists of a septum towards the pituitary fossa while the infero-medial part borders on the lateral surface of the body of the sphenoidal bone. Anteriorly, each cavernous sinus
Downloaded from acr.sagepub.com at Harvard Libraries on July 7, 2015
ORBITAL PHLEBOGRAPHY
3
~"""",,----',"""""---VDS -r-~CI,---
SPHS
,......,M~~~rt--AICS ill'~'---~'""""''i-'-'t--
CS
~-------"~-PICS
i!-----\:"'""\-- PP PDF ~~~~---+.'-I~ BP ~~~---\-t~---~I--
IPS ~.....----f':+-- I J V -......,/-J-f--SPS '---f:-f--- SS
""","+---TS
Fig. 1. Basal venous sinuses. AICS ~ anterior intercavernous sinus, BP ~ basilar plexus, CS ~ cavernous sinus, IJV ~ internal jugular vein, IPS ~ inferior petrosal sinus, PICS ~ posterior intercavernous sinus, POF = plexus of the foramen ovale, PP = pterygoid plexus, SPHS = sphenoparietal sinus, SPS = superior petrosal sinus, SS ~ sigmoid sinus, TS = transverse sinus, VOS = superior ophthalmic vein.
is connected to the superior ophthalmic vein (VOS) which leaves the orbit through the superior orbital fissure and often also to the sphenoparietal sinus (SPHS) that follows the free edge of the smaller sphenoidal wing. The sphenoparietal sinus is often joined by the middle cerebral veins, which, however, may also enter the cavernous sinus separately. The venous plexus of the foramen ovale.. . and adjacent foramina (POF) connects the lateral part of the cavernous sinus with the pterygoid plexus (PP). From the superior posterior part of the cavernous sinus, the superior petrosal sinus (SPS) runs in its sulcus to the sigmoidsinus, while the larger inferior petrosal sinus (IPS) leaves the inferior posterior part of the cavernous sinus, and passes in the sulcus with its name to the anterior part of the jugular foramen, where it empties in the internal jugular vein (IJV). The two cavernous sinuses are interconnected through the anterior (AICS) and posterior intercavernous sinuses (PICS) located in the sellar diaphragm at the anterior and posterior edge of the sella turcica, and through the basilar plexus (BP), which is a venous network on the clivus. This plexus i(also connected with the inferior petrosal sinuses and the deep cervical veins.
Material In order to obtain a 'normal material', patients with a disorder possibly affecting the veins at the base of the skull, or with an intraorbital disorder causing an occlusion of the intraorbital veins, were not included. Examinations without satisfactory technical quality permitting a detailed evaluation of the anatomy of the cavernous sinuses and the adjacent basal sinuses were also excluded. Thus out of the initial
Downloaded from acr.sagepub.com at Harvard Libraries on July 7, 2015
4
JAN BRISMAR
20 examinations
Fig. 2. Distribution of unisatisfactory examinations (hatched) in the total series of 101 examinations 1971-1973.
1971
1972
1973
material of 101 examinations in 94 patients there remained 26 patients, 10 females and 16 males, constituting the 'normal material'. The relevant veins and sinuses were included in the projections used with the following exceptions: in the axial view in one patient the petrosal sinuses and the jugular veins were not included, and in another patient not the jugular veins. The number of examinations remaining for an analysis of the anatomy of these veins thus amounted to 25 and 24, respectively. Four children were included in the 'normal material' (age: one day, four months, two years and four years). The oldest patient was 71 years of age. Method and technical results A complete examination of the cavernous sinuses is included in the technique for orbital phlebography used by the present author. It has been described in detail previously (BRISMAR 1974 a), to which report the reader is referred. Measurements of the transverse diameter of the pituitary fossa, were performed on the axial films without correction for magnification. The film-focus distance was about 100 em, and the head of the patient rested on the automatic film changer. During the latter part of this series, linear angio-tomography has also been performed in the a.p. projection in several cases. The examinations have been classified as adequate or incomplete. Those with only fragmentary or unilateral demonstration of the cavernous sinus and its drainage and those without an axial view have been assigned to the incomplete ones. As the examination technique was gradually worked out during the series, incomplete examinations were more common at the beginning and due to too slow injection of contrast medium, defective external compression, or absence of adequate views. Among the last 70 examinations, only four were classified as incomplete. In one of these, the injection of contrast medium was partly perivascular; in another the collaterals over the midline in the forehead were underdeveloped; in the third case
Downloaded from acr.sagepub.com at Harvard Libraries on July 7, 2015
ORBITAL PHLEBOGRAPHY
5
Table Incidence of filling of basal venous sinuses in the 'normal material'. SPHS~sphenoparietal sinus, CS ~ cavernous sinus, AICS = anterior and PICS =posterior intercavernous sinuses, BP = basilar plexus, POF~plexus of the foramen ovale, H'S'
