MEDICAL RADIOLOGY

Diagnostic Imaging

Editors:

A. L. Baert, Leuven

M.Knauth, Göttingen K. Sartor, Heidelberg

Goetz Benndorf

Dural Cavernous

Sinus Fistulas

Diagnostic and

Endovascular Therapy

Foreword by

K. Sartor

With 178 Figures in 755 Separate Illustrations, 540 in Color and 19 Tables

1 3

Goetz Benndorf, MD, PhD

Associate Professor, Department of Radiology

Baylor College of Medicine

Director of Interventional Neuroradiology

Ben Taub General Hospital

One Baylor Plaza, MS 360

Houston, TX 77030

USA

Medical Radiology · Diagnostic Imaging and Radiation Oncology Series Editors:

A. L. Baert · L. W. Brady · H.-P. Heilmann · M. Knauth · M. Molls · C. Nieder · K. Sartor

Continuation of Handbuch der medizinischen Radiologie

Encyclopedia of Medical Radiology

DOI 10.0007 / 978-3-540-68889-1

Medical Radiology · Diagnostic Imaging and Radiation Oncology ISSN 0942-5373

Library of Congress Control Number: 2004116221

♥ 2010, Springer-Verlag Berlin Heidelberg

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Dedicated to my parents,

Dorothea

and Eberhard Benndorf

Foreword

Of the dural venous sinuses, the cavernous sinus is anatomically the most complex. It has an intimate topographical relationship with the internal carotid artery and the sixth cranial nerve (both of which pass through its meshwork) and houses the cranial nerves III, IV and V1-2 in its lateral wall. Medially it abuts the pituitary gland, while laterally it nears the temporal lobe; Meckel’s cave with the trigeminal ganglion lies immediately posterior to it. Located essentially at the center of the skull base, the cavernous sinus connects with numerous dural sinuses and veins of all three cranial fossae, as well as the orbit. Furthermore, there is an abundance of dural arteries in the sellar region that are interconnected and derive from the carotid system.

Due to its specific vascular anatomy, the cavernous sinus is a common site of various types of arteriovenous (AV) fistulas, which are essentially benign lesions but which may endanger both vision and cranial nerve function. These fistulas, including their largely endovascular interventional treatment, are the topic of Götz Benndorf’s monograph. After describing the relevant anatomy of the cavernous sinus in great detail, the author continues by explaining the anatomic and hemodynamic classifications of AV fistulas of the cavernous sinus. This is followed by important information on etiology, pathogenesis and prevalence of the various lesions. Before embarking on the main part of his book, diagnostic and therapeutic radiology of AV cavernous fistulas, Benndorf devotes an entire chapter to clinical, largely neuro-ophthalmological symptoms and signs. The radiological chapters, all beautifully illustrated and containing a treatise on hemodynamics, will undoubtedly convince readers of the immense diagnostic and therapeutic experience of the author in his chosen topic. The treatment focuses on transvenous embolization rather than the transarterial approaches.

I am unaware of any publication that covers the diagnostic and interventional radiology of AV fistulas of the cavernous sinus in such a clear, systematic and complete way as Benndorf’s book. Any interventional neuroradiologist dealing with skull base lesions needs a copy, as does any skull base surgeon. In addition, the book would not look out of place on a neurologist’s bookshelf.

Preface

This volume of Medical Radiology is based to a large degree on my Ph.D. Thesis at Charité, Humboldt University (Berlin, 2002) and contains most of the original text and imaging material. During my subsequent years (2003 to 2009) at the departments of radiology, Baylor College of Medicine (BCM) and The Methodist Hospital (TMH) in Houston, this work grew substantially, and thus required more time to complete than anticipated. Nevertheless, I hope, the result represents a happy ending that was worth waiting for. The monograph stands for more than 13 years of personal experience in performing endovascular treatment and clinical management of patients with various types of intracranial arteriovenous shunting lesions, in particular fistulas of dural origin involving the cavernous sinus. It is intended as a practical guide and reference for those involved in the diagnosis and treatment of these lesions. Completing this book would have been impossible without the motivation, help and support from my teachers, colleagues and friends.

Acknowledgements:

I am very thankful to Christiane Kagel (University Greifswald) and Christiane Poehls (Helios Klinikum Berlin-Buch), who between 1989 and 1991, taught me the basic principles of diagnostic cerebral angiography and vascular interventional radiology. Horst Peter Molsen (Charité, Berlin), my INR fellowship director from 1991 to 1993, introduced the techniques of transvenous catheterization and embolization to me while we were treating the first CSF patients together. My most sincere gratitude goes to Jacques Moret (Foundation Rothschild, Paris) for his generous permission to use some of his material for my thesis. During his numerous visits and lectures at the Benjamin Franklin Hospital, Free University Berlin from 1992 to 1997, Pierre Lasjaunias (†, Kremlin Bicetre, Paris) was not only a brilliant teacher, but also a great inspirer in the studies of the vascular anatomy of the cavernous sinus region. I am very much indebted to Wolfgang Lanksch (Charité, Berlin), chair of the department of neurosurgery, who was my clinical mentor and a steady supporter of my work from 1991 to 2003.

I owe many special thanks to the entire INR team at Rudolf-Virchow-Hospital, Charité, but mostly to two nurses, Angelika Wehner and Petra Schlecht, whose loyal devotion and outstanding assistance over many years played a key role in the successful performance of complex endovascular procedures. Christof Barner, immensely experienced and dedicated neuroanesthesiologist at Charité, became an indispensable colleague for achieving good clinical outcomes. I also wish to thank Horst Menneking (maxillo-facial surgeon, Charité) for his exceptionally skillful surgical work in those cases, where transophthalmic SOV approaches became necessary. My colleague and friend, Andreas Bender (Charité until 1998), one of the most talented interventional neuroradiologists I had the good fortune to meet, helped me to master the treatment challenges of several of my early patients. Stephanie Schmidt, ophthalmologist at Charité until 2003, was an outstanding clinician and a most pleasant colleague to work with.

The majority of presented case reports are of patients, for whom staff members from the departments of neurosurgery, neurology and ophthalmology at Charité provided excellent care.

Contents

1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2.1 Arteriovenous Fistula and Pulsating Exophthalmos . . . . . . . . . . . . . . . . 3 2.2 Angiography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2.3 Therapeutic Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.4 Embolization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

3 Anatomy of the Cavernous Sinus and Related Structures . . . . . . . . . . . . . . 15

3.1 Osseous Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 3.2 Anatomy of the Dura Mater and the Cranial Nerves . . . . . . . . . . . . . . . . 20 3.3 Vascular Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

4 Classification of Cavernous Sinus Fistulas (CSFs) and

Dural Arteriovenous Fistulas (DAVFs) . . . . . . . . . . . . . . . . . . . . . . . . . . 51

4.1 Anatomic Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 4.2 Etiologic Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 4.3 Hemodynamic Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

5 Etiology, Prevalence and Natural History of

Dural Cavernous Sinus Fistulas (DCSFs) . . . . . . . . . . . . . . . . . . . . . . . . . 65

5.1 Etiology and Pathogenesis of Type A Fistulas . . . . . . . . . . . . . . . . . . . . 66 5.2 Etiology and Pathogenesis Type B–D Fistulas . . . . . . . . . . . . . . . . . . . . 67 5.3 Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

6 Neuro-Ophthalmology in Dural Cavernous Sinus Fistulas (DCSFs) . . . . . . . . 85

6.1 Extraorbital Ocular Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 6.2 Orbital Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 6.3 Other and Neurological Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . 91 6.4 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94