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
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
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);
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.
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.
1008 F.Charbonneauetal.
Figure5. Duralfistulaoftherightcavernous.HypertrophyanddiscreetT2signaloftherightmedial,inferiorandlateralmuscles(a,
greenarrows)anddilationofthesuperiorophthalmicvein(a,bluecircle).Abnormalvesselsintherightcavernoussinus(b).DynamicMRA (c):opacificationinthearterialphaseofthecavernoussinusesandsuperiorophthalmicvein(c,redarrows).
Figure6. Meningiomaoftherightcavernoussinus,shorteningthecalibreoftheinternalcarotidartery,whichappearstobemedially
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:
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
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
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).
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
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
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.
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.
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