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DiagnosticandInterventionalImaging(2013)94,1003—1016

CONTINUING

EDUCATION

PROGRAM:

FOCUS

.

.

.

No

more

fear

of

the

cavernous

sinuses!

F.

Charbonneau ,

M.

Williams ,

F.

Lafitte ,

F.

Héran

ImagingDepartment,A.deRothschildOphthalmologicalFoundation,25-29,rueManin,75940 Pariscedex19,France

KEYWORDS MRI;

Cavernoussinuses; Oculomotility

Abstract Afterareview oftheanatomyofthecavernoussinuses(CS),thisworkpresents

theclinicalpictureandimagingprotocoloflesionswhichoccurinthisarea.Itoutlines exten-sionandimagingfeaturesoftheselesions.ItemphasisesMRIappearance,suchasT1,T2and diffusionsignal,typeofcontrastmediumuptake.AcomplementaryCTscanisperformedif anassociated abnormalityofthebaseoftheskullissuspectedonMRI(lysis, condensation). Thispaperproposesastraightforwardclassificationsystemdependingonimagingandsetsout theprincipalsymptomsofthemainaetiologiesofCSlesionswhicharerepresentedbyvarious diseasessuchastumours,inflammations,vascularabnormalities.Complementarytoimaging, theirdiagnosisisbasedonclinicaldatai.e.knowncancer,signssuggestinginflammation.Its richiconographyallowsthisarticletobeusedasareferenceincurrentclinicalpractice. ©2013Éditionsfrançaisesderadiologie.PublishedbyElsevierMassonSAS.Allrightsreserved.

Thecavernoussinusesarelocatedonbothsideofthesellararea.Pathwaysof commu-nicationbetweenorbit,faceandbrain,theycontainmanyneurovascularelements.

The purposeof thisarticle istoshowhowanatomicalunderstanding andsystematic analysisof thecavernous sinusesarehelpful tomake thediagnosis ofthe main lesions foundinthisarea(vascular,inflammatory,neoplastic)andtoexplaintheirdiversitiesand functionaleffects.

Anatomical

review

and

correlation

between

anatomy

and

MRI

[1—3]

The cavernoussinusesareosteo-dural-meningealcompartmentslocatedonbothsideof thesellararea(Fig.1).Theycommunicateviathesuperiororbitalfissurewiththeorbit, viatheforamenrotundumandtheinferiororbitalfissurewiththepterygopalatinefossa andviatheovalforamenwiththeinfratemporalfossaandthemasticatorspace.

Correspondingauthor.

E-mailaddress:[email protected](F.Héran).

2211-5684/$—seefrontmatter©2013Éditionsfrançaisesderadiologie.PublishedbyElsevierMassonSAS.Allrightsreserved. http://dx.doi.org/10.1016/j.diii.2013.08.012

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1004 F.Charbonneauetal.

Figure1. Anatomo-MRIcorrelationofthecavernoussinuses(a).T1spinechocutswithinjection(b).T2spinechocoronalcuts(c).

Their inferior and lateral walls and their roof are extensionsoftheduramater.Themedialwalliseither non-existentorincompleteandconsiststhenofathinlayerof collagen.

Theycontainvascularstructures:thecarotidsiphon, sur-roundedbysympatheticfibresandvenousplexusesreceiving thesuperiorophthalmicvein,cerebralveins(median, infe-rior) and the spheno-parietal sinus. These veins drain backwardsviatheinferiorandsuperiorpetroussinusinthe transversesinusandthejugularbulb.

They also contain cranial nerves (CN) III (oculomotor nerve),IV(trochlearnerve),branchesoftheV(trigeminal nerve):V1(ophthalmic)andV2(maxillary),whichrunfrom toptobottominthelateralwallofthecavernoussinusand VI(abducensnerve)whichfollowsthelengthofthelower andlateralsidesoftheintracavernousportionofthecarotid siphon.

Duetorapidflux,theinternalcarotidarteryappearsas ahypointense(flowvoid)structureonspinechoT1(withor withoutinjection)andT2sequencesandasahyperintense structureonMRA(TOFwithoutorwithinjection)sequences. Thevenousplexuseshaveasignalthatvariesasa func-tionoftheirflux(slowfluxshowsashyperintense,fastflux showsashypointense).Theyarehomogeneouslyenhanced afterinjection.

The cranial nerves (CN) appear as structures with an isosignalrelativetothewhitematterinT1andT2spinecho. Theyarenotenhancedafterinjection.CNIVandVIare moredifficulttovisualisewithMRIthanCNIIIduetotheir smallersizeandtheirlocationwithinthecavernoussinuses.

When

should

impairment

of

the

cavernous

sinuses

be

suspected?

[3]

Ophthalmological

impairment

Duetotheelementsthatgothroughthecavernoussinuses and surrounding structures, cavernous sinus pathology shouldbeconsideredwhenanophthalmological symptoma-tologyisdiscovered(Fig.2).Theclinicalsymptomscombine varioustypesofsigns:

• oculomotordisorders(binoculardiplopia)dueto impair-ment of one or more ocular nerves affecting, in descending order, III, VI and IV and reaching in severe casesa total ophthalmoplegia (in 30% of cases), some-times painful, especially if inflammatory [4]. Notice thatisolatedimpairment of III,appearingsuddenly and associated with headache, should systematically and in emergency lead to investigate a ruptured aneurysm

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Nomorefearofthecavernoussinuses! 1005

Figure2. PtosisasaresultofimpairmentoftheeyelidelevatormuscleinnervatedbyIIIandchemosisoftherighteye(a)withparalysis

inadductionbyimpairmentofthelateralrightmuscleinnervatedbyCNVI(b)anddiscreetlimitationinadductionbyimpairmentofthe rightmedialinnervatedbyCNVIII(c)showingaduralfistula.Otherpatient:clearexophthalmiaandleftptosisinapatientmonitoredfor sphenoorbitalmeningioma.

inducing III impairment(particularly ifthis aneurysmis developedontheposteriorsideofthecarotidsiphon,at theoriginoftheposteriorcommunicatingartery); • visual acuity loss, related to compression of the

ante-rior visual pathways (optic nerve or opticchiasm), due eithertothesuperiordevelopmentofthelesionortothe compression of the opticnerve withinthe orbital apex by the anteriorextensionof thelesion via thesuperior orbitalfissure,foundin40%ofcases.Recentalterationof visualacuityduetoacompressionrequiresinemergency aneurosurgicalconsultation;

• ClaudeBernard-HornerSyndromeduetoperi-carotid sym-pathetic plexus impairment and associating ptosis and myosis,muchmorerare(4%ofcases);

• exophthalmos painful or painless, pulsatile or non-pulsatile,dependingonitsetiology;

• chemosisduetovenousswellingorinflammation.

Other

clinical

symptoms

Other clinical symptoms suggestive of a lesion of the cavernous sinuses may develop: paraesthesia and neu-ralgia by impairment of CN V, retro-orbital pain and headache,disturbancesofthehypothalamic-pituitaryaxis, neurological deficiencies due to brainstem or acoustic-facialbundlecompression,seizures complicatingtemporal irritation caused by posterior or lateral extension of the lesion.

Cerebralischemiabycompressionoftheinternalcarotid arteryisexceptional.

How

to

investigate

a

lesion

of

the

cavernous

sinuses?

[5]

The

purpose

of

imaging

The purpose of imaging is to specify the nature of the lesion, to assess its extensions following various spatial planes(Fig.3)anditseffects(directorindirect)onorbital components[6].

Investigation

of

the

cavernous

sinuses

by

MRI

TheMRIprotocolassociatescoronalthinslices(2—3mm)on T2spinechoandT1spinechoaftercontrastmedium injec-tioncoveringthecavernoussinusesandorbits,andaxialthin slicesonT1spinechowithinjectionandfatsaturation,in somecasescompletedbyaxialthinslicesonT2spinecho.

The T2spinechocoronalstudycovering thecavernous sinusesandorbitsallowsdepiction,whethertheyexist,of: • effects of the lesion on the anterior visual pathways: compressionofopticchiasm,compression,signal abnor-mality and atrophy of the opticnerves, dilation of the opticnervesheath(Fig.4);

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1006 F.Charbonneauetal.

Figure3. Extensionoflesionsofthecavernoussinus:a:atthetopnearthechiasma(yellowarrows)andopticnerves;b:laterally(blue

arrows)towardsthetemporallobeoutwardly,thesellarregioninside;c:atthebottomtowardstheinfratemporalfossaviatheforamen ovale(redarrow);d:tothefrontviathesuperiororbitalfissure(greenarrow);e:atthebottomandtothefronttowardsthepterygopalatine fossaviatheforamenrotundumandtheinferiororbitalfissure;f:attheback(pinkarrows)towardsMeckel’scavumandthemeaningsof Pacchioni’sforamenovale.

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Nomorefearofthecavernoussinuses! 1007

Figure4. Rightsupracavernouscarotidaneurysmresponsibleforcompressionoftheopticnerveinitscisternalportion(a,redarrow).

AtrophyandT2hypersignaloftherightopticnerveinitsorbitalportion(b,bluearrow).MRATOF(c). • direct effects (compression, invasion) or indirect

compression (venous swelling,denervation)onthe ocu-lomotor muscles(hypertrophyoratrophy withabnormal highT2signalofmuscle);

• dilationofthesuperiorophthalmicvein,duetoimpaired drainage(Fig.5).

T1axialstudywithinjectionandfatsaturationsequence providesanexcellentassessmentoforbitalextensionofthe lesion.

Investigation of an inferiorextension intothe pterygo-platinefossaviatheforamenrotundum(andinferiororbital fissure)andexophthalmosisperformedintheaxialplane.

Thin T2 spin echo axial sequence may be very useful inidentifyingminorvascular impairmentofthecavernous sinuses.

VascularinvestigationbyMRATOFshouldbeperformed in case of asudden onsetof CNIII impairmentand acute headache (suspicion of ruptured aneurysm), if a carotid-cavernous, a dural fistula or compression of the internal carotid artery are evocated (Fig. 6). Complementary

dynamicMRAorarterialangioscanofferaprecisedepiction ofcarotid-cavernousorduralfistula(Fig.7).

Orbital

echo-Doppler

Thisexaminationprovestobeveryusefultoexplorevascular abnormalitiesofthecavernoussinusesasitdetectsindirect signsoffistulaconsistingofinversionandarterialisationof thefluxinadilatedsuperiorophthalmicvein(Fig.8)[7].

CT

scan

CTscanshouldbecarriedouttostudytheskullbase.It pro-videsargumentstodifferentiate identicaltissular lesions, due to their specific bone involvement i.e.; hyperostosis in case of meningioma, lysis caused by metastases and othermalignantlesions,Itdepictsmicrocalcifications (chon-drosarcoma),Itismandatorytoevaluatefacialbonesorbase oftheskullimpairmentduetothelesion,andinpresurgical phaseinordertobetteridentifyboneandlesion relation-ships.

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1008 F.Charbonneauetal.

Figure5. Duralfistulaoftherightcavernous.HypertrophyanddiscreetT2signaloftherightmedial,inferiorandlateralmuscles(a,

greenarrows)anddilationofthesuperiorophthalmicvein(a,bluecircle).Abnormalvesselsintherightcavernoussinus(b).DynamicMRA (c):opacificationinthearterialphaseofthecavernoussinusesandsuperiorophthalmicvein(c,redarrows).

Figure6. Meningiomaoftherightcavernoussinus,shorteningthecalibreoftheinternalcarotidartery,whichappearstobemedially

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Nomorefearofthecavernoussinuses! 1009

Figure7. Angioscaninthearterialphase.Post-traumaticrightcarotid-cavernousfistula:increaseoftherightcavernousvolume,dilation

ofthearterialisedsuperiorophthalmicvein,gradeIexophthalmia,hypertrophyoftheoculomotormuscles.

Figure8. Orbitalecho-Dopplerintheinvestigationofaduralfistula(followonfromthecaseinFig.4).Indirectsignsofaduralfistula

withtotherightadilatedsuperiorophthalmicvein,andwitharterialisedflux.Totheleft,physiologicaldirectionandnormalfluxofthe superiorophthalmicvein.

Cavernous

sinus

pathology:

how

to

get

clues?

Lesionsareoftendifficulttodistinguishfromeachother. Thereis nocorrelationbetweenlesion sizeandclinical symptoms.

The

first

step

is

given

by

the

clinical

data

In case of sudden andacuteonset of thesymptoms, rup-tureofananeurysmoftheposterioraspectofthecarotid artery or carotid-cavernous fistula have to be ruled out. Thecarotid-cavernousfistulacomplicatestheruptureofan intracavernousaneurysmoratraumaoftheskullbaseand isresponsibleforpulsatileexophthalmos.

Iftheonsetissubacuteandpainful,inflammatory condi-tioninyoungpatientsorlymphomainolderpatientsarethe maindiagnostichypothesis.

Aprogressivenon-painfulonsetindicatesslowly progres-sivedisease,suchasmeningioma.Iftheseclinicalfeatures areassociatedtochemosis,conjunctivalhyperhaemiaina womanovertheageof60,aCSduralfistulahastoberuled out.

The

second

step

depends

on

radiological

findings

Whenalesionisfoundwithinacavernoussinus,the follow-ingquestionsneedtobeanswered:

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1010 F.Charbonneauetal.

Figure9. Bi-temporalhemianopsiaandleftdiplopia.Masssyndromecentredonthesellarandsuprasellarregion(a,pinkcross)with

invasionoftheleftcavernoussinus(b,c,d:greenarrows)infavourofhypophysealadenomaresponsibleforcompressionoftheoptic chiasmapushedupwards(b,pinkarrows).

• Where is the initial location of the lesion? In the cav-ernoussinusornearby,asthislesioncanbeanextension of an extra cavernous lesion, especially hypophyseal (Fig. 9), of the skull base (Fig. 10) or the facial bones?

• WhichT2signal doesit show?intenseT2hyposignal or hypersignal?

• Howdoesitenhanceaftercontrastinjection? • Whatareitsextensionsinthethreespatialplanes? • Whatareitseffectsonthemainstructuresinvolved(optic

nerves,opticchiasm,etc.)?

NoticethatthinT2spinechosequences(coronal±axial) arethefirstsequencestoperform.

Practical

classification

as

a

function

of

imaging

results

[8,9]

Vascularorigin

This origin is suspectedif the cavernoussinus is enlarged andshowsastronghyposignalonT2,

Therefore,further vascular sequences need tobe car-riedout:MRA TOF,dynamicMRA, ratherthan ‘‘standard’’ sequenceswithinjection.Severalpathologiesmaybefound, such as aneurysm, carotid-cavernous fistula, dural fistula (Fig.11).

Comments: The size of the cavernous sinus can be normal in case of dural fistulas. The signal in

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Nomorefearofthecavernoussinuses! 1011

Figure10. Spheno-orbitalosteomeningioma:leftexophthalmosandophthalmoplegia,non-painful,progressiveforseveralyearsina

55-year-oldpatient.Tissuelesioncentredonthemainwingofthesphenoid(a,redcircle)invadingtheleftcavernoussinus(b)associatedwith hypertrophyandcondensationofthelargewingofthesphenoid(c,redstar),orbitalinfiltrationpushingintotherightlateralmuscleand rightsuperiorcomplex—eyelidelevator(c).

macro-aneurysms or thrombosed aneurisms is often het-erogeneous (global hyposignal with components in iso-hypersignal onT2 and hypersignal on T1). MRA TOF with injection may be used to differentiate circulating and thrombosedportions.

Characteristicsofcontrastenhancementafter injection

Added to cavernous sinus increased volume, and analysis of T2 and T1 signal of the lesion, the characteristic of enhancementafterinjectionbringsupplementary etiolog-icalarguments:

• if the contrast medium uptake is intense and extends alongthetentorialandtemporalmeninges,ameningioma isstronglysuspected(Fig.12)[10];

• amoderatecontrastmediumuptakeislessspecific.The lesion couldbe a metastasis (shouldalways bekept in mind)(Fig.13)or specificor non-specificinflammation, themostfrequentbeingsarcoidosis(Fig.14)[8].Itcanbe duetoinfiltrationofthecavernoussinusbyan haemopa-thysuchaslymphoma(Fig.15).Theclinicalcontextand

athoraco-abdomino-pelvicCTscanprovideargumentsfor themostlikelyaetiology.

Characteristicappearanceofcertainlesions[9]

Veryheterogeneouslesions,lesionsgloballyhyperintenseon T2withareasstronglyhypointense(CTscanshows calcifi-cation),demonstratingheterogeneousandintensecontrast mediumuptake,aregenerallyofcartilaginousorigin.Final diagnosisdisclosedarechondromaeitherchondroidor chon-dromyxoid (Fig. 16), chondrosarcoma (Fig. 17) and more rarelychordoma[11].

LesionswithacenteronhypersignalT2,anhypointense borderrim onT2sequence andwhich enhance after con-trastmedium injection ina speckled gradual manner, are suggestiveofcavernoushaemangioma(Fig.18)[12,13].

CNVintracavernousschwannomamaycausefacial neu-ralgia. The lesion is centred on Meckel’s cave, appears globally hyperintense on T2 sequence with cystic por-tionsandis intenselyenhancedafter injection.Itmaybe responsibleforerosionof theorbitalapexonthe CTscan

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1012 F.Charbonneauetal.

Figure11. Rightexophthalmosandchemosis,painless,progressiveforseveralyearsina70-year-oldpatient.Hypertrophiedright

cav-ernoussinus,clearT2hyposignal(a),dilationofthesuperiorophthalmicvein(bandd,redarrow),hypertrophyoftherightoculomotor musclesanddiscreetT2hypersignal(b,yellowarrows),arciformformationwithclearT2hyposignalbehindtheinternalcarotidartery(c, redarrow)correspondingtothedilatedveins.MRATOF:rapidfluxwithintherightcavernoussinus,peripheraltotheinternalcarotidartery (e,redcircle)(arciformimagevisibleonnativecuts),reflectingarterialisationofthecavernoussinus(e),dynamicMRA;opacificationfrom thearterialphaseoftherightcavernoussinusandthedilatedrightsuperiorophthalmicvein(f).

Figure12. Meningiomaoftheleftcavernoussinus:non-painfulprogressiveleftophthalmoplegiaina58-year-oldpatient.Tissuelesion

locatedontheleftcavernoussinus(a)whosevolumeisincreasedinT2isosignal(b)andstronglyenhancedafterinjection(c).Extension upwardstowardsthetentoriumcerebelli(a,redarrow)andsupero-internally,invadingthesellarregion,compressingtheleftportionof theopticchiasma(b,redarrows)andlaterallypushingbackthetemporallobe(withoutabnormalityoftheparenchymatoussignal).

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Nomorefearofthecavernoussinuses! 1013

Figure13. Painlessleftophthalmoplegia,rapidlyprogressive,ina75-year-oldpatientwithahistoryofmammaryneoplasm.Cerebraland

leftcavernoussinusmetastases.SeveralnodularformationswithT2hyposignal(a,bluearrow)withlittlecontrastuptake(bandc;blue arrows)oftheroofandlateralwalloftheleftcavernoussinus.Signsofdenervationoftheoculomotormuscles:atrophy,T2hypersignal(d). Presenceofotherlesions:pituitarystem(a,pinkarrow),rightexternaltemporalsubcorticalandlefttemporalinsular(e,yellowarrows).

Figure14. Painfulophthalmoplegiaina35-year-oldwoman:sarcoidosisofrecentappearancewithincreasedvolumeoftheleftcavernous

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1014 F.Charbonneauetal.

Figure15. PainfulophthalmoplegiaofrecentonsetwithincreasedvolumeoftheleftcavernoussinusbynodularformationswithaT2

isosignal(yellowarrows)moderatelyenhancedafterinjection.Ina70-year-oldman:lymphoma.

Figure16. Rightcavernoussinus syndrome.MRIshowsmultilobulatedmass, T2hypersignal (a),T2 hyposignal(b), heterogeneously

enhanced(c).Chondromyxoidchordoma.

Figure17. ProgressiverightVI.HeterogeneouslesionpresentingmanyzoneofT2hyposignal(b).Interventionstoppedduetohaemorrhagic

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Nomorefearofthecavernoussinuses! 1015

Figure18. Hypoesthesiaoftherightcheek.Lesionoftherightcavernoussinus,spillingoverintothesellarcavity,T2hypersignal(a),

peripherallyenhancedafterinjection(bandc).Cavernoushaemangioma.

Lesions hyperintense on T1 and T2, vanishing on fat suppression sequences are fatty tumours (dermoid cyst, lipoma).

Conclusion

Therearenumerouscavernoussinuspathologies.MRI anal-ysisneedsspecificprotocols.Correlationsbetweenimaging findingsandclinicaldataaremandatorytoreachthe nar-rowestdiagnosticrangeandinalargeamountofcasesthe correctdiagnosis.

TAKE-HOMEMESSAGES

• Ifacavernoussinuslesionissuspected,wepropose thefollowingprotocolBrainexamination:

◦ sagittalT1;

◦ axialFLAIRorT2±diffusion;

◦ coronalT1withinjectionofgadolinium;

◦ cavernoussinusesandorbitexaminationusingthin slices(2—3mm);

◦ coronalT2±T1;

◦ axialT1withinjectionandfatsaturation. • Furthersequences(MRATOF,dynamicMRA)willbe

carriedoutdependingontheclinicalcontextandthe signalofthelesion.

• Thereisnocorrelationbetweenthesizeofthelesion and the severity of clinical symptoms, cavernous sinusthereforeexplorationneedsbothasystematic analysisandtheuseofthinfocusedslices.

• AnalysisofMRIisspeciallyfocusedontheepicentre ofthelesion,itssignalonT2sequences,thetypeof enhancementitshows.

• Complementary CT scan of the base of the skull, in order to study bone changes and thoraco-abdomino-pelvic CT scan investigating a general pathology: neoplastic, inflammatory, infectious... maybehelpful.

Clinical

case

MrA.B., 52 years old,monitored in ENT, consults for the gradualonsetofdiplopia.Onexamination,impaired eleva-tionandadductionofthelefteyeandmildleftmyosisare foundassociatedtoaleftcheekhypoesthesia.Thereisno exophthalmia,novisualdisturbance.Neurological examina-tionisotherwisenormal.Thepatientdidnotbringbackhis previousimagesbuthadprobablyunderwentabrainMRIand CTscan.AnewMRIisproposed(Figs.19—21).

Questions

1. Whichprobablelocationfitstheseclinicalsigns? 2. Look at the MR images and describe the lesion

(Figs.19—21)

3. Wouldyouaskforanotherimagingexamination?(Fig.22) 4. Whatisthemostlikelyaetiologicaldiagnosis?

Answers

1. Theassociationofisolatedoculomotorcranialnerve,of Horner syndrome(myosis)andtrigeminalcranialnerve impairmentwithoutanyotherneurologicalsignsisvery suggestiveofacavernoussinuslesion.

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1016 F.Charbonneauetal.

Figure20. T2.

Figure21. T1GdFATSAT.

Figure22. Basescan.

2. The lesion is a tissular mass involving both the face andthemiddlefossa,invadingtheleftcavernoussinus, the infratemporal fossa andthe lowerpart of the left parapharyngealspace,thepituitaryareaandextending towardstheuppertemporallobe.ItishypointenseonT2 sequenceandenhancedafterinjection.Itisaggressive, asitdestroysthebaseoftheskull(sphenoid,clivus)and isresponsibleforatemporallobeoedema.

3. Asinallcasesoflesionsthatcandamagetheskullbase, a plainhigh resolution CTscanis necessary toprecise boneabnormalities.

4. Theepicentreofthisdestructivelesionislocatednotin thecavernoussinusbutintheleftparapharyngealspace. This is verysuggestive of an ENTlesion.The diagnosis hypothesis tosuggestfor thisCSlesion isan extension of the neoplasm and, in particular, a tumour of the cavum.

Diagnosis

This is a case of intracranial extension of UCNT of the nasopharynx,complicatingatreatmentfailure.

Disclosure

of

interest

Theauthorsdeclarethattheyhavenoconflictsofinterest concerningthisarticle.

References

[1]OsbornA.Imaginganatomy.SaltLakeCity:AmirsysPublishing; 2006.p.I176—223.

[2]KorchiAM,CuvinciucV,CaetanoJ,BeckerM,LovbladKO, Var-gasMI. Imaging ofthecavernoussinuslesions. DiagnInterv Imaging2013[PII:S2211-5684(13)00146-0].

[3]TangY,BoothT,StewardM,SolbachT,WilhelmT.The imag-ing ofconditions affecting the cavernous sinus.Clin Radiol 2010;65(11):937—45.

[4]Curone M, Tullo V, Proietti-Cecchini A, Peccarisi C, Leone M, Bussone G. Painful ophthalmoplegia: a retrospective study of 23 cases. Neurol Sci 2009;30(Suppl. 1):S133—5, http://dx.doi.org/10.1007/s10072-009-0067-1.

[5]DietmannJL.Neuro-imageriediagnostique.2eed.Paris:

Else-vierMasson;2012.p.493—510.

[6]BoulinA.Adviceandhintsonimagingthelateralsellar com-partments.DiagnIntervImaging2012;93(12):949—61.

[7]MillerNR.Duralcarotid-cavernousfistulas:epidemiology, clin-ical presentation, and management. Neurosurg Clin N Am 2012;23(1):179—92.

[8]RazekAA,CastilloM.Imaginglesionsofthecavernoussinus. AJNRAmJNeuroradiol2009;30(3):444—52.

[9]HéranF,LafitteF.IRMpratiqueenneuroradiologie.Paris: Else-vierMasson;2007.p.142—5.

[10]NebbalM,SindouM.Imagingforthemanagementofcavernous sinusmeningiomas.Neurochirurgie2008;54(6):739—49.

[11]LanzinoG, SekharLN, Hirsch WL,Sen CN, PomonisS, Sny-derman CH. Chordomas and chondrosarcomas involving the cavernoussinus:reviewofsurgicaltreatmentandoutcomein 31patients.SurgNeurol1993;40(5):359—71.

[12]SohnCH,KimSP,KimIM,LeeJH,LeeHK,CharacteristicMR. imagingfindingsofcavernoushemangiomasinthecavernous sinus.AJNRAmJNeuroradiol2003;24(6):1148—51.

[13]Tannouri F, Divano L, Caucheteur V, Hacourt A, Pirotte B, Salmon I, et al. Cavernous haemangioma in the cavernous sinus:casereportandreviewoftheliterature.Neuroradiology 2001;43(4):317—20.

[14]Bathla G, Hegde AN. The trigeminal nerve: an illustrated review of its imaging anatomy and pathology. Clin Radiol 2013;68(2):203—13.

References

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