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Para-Cavernous Sinus Venous Structures: Anatomic Variations and Pathologic Conditions Evaluated on Fat-Suppressed 3D Fast Gradient-Echo MR Images

S. Tanouea, H. Kiyosuea, M. Okaharac, Y. Sagaraa, Y. Horib, J. Kashiwagib and H. Moria

a Department of Radiology, Oita University Faculty of Medicine, Oita, Japan
b Department of Radiology, Nagatomi Neurosurgical Hospital, Oita, Japan
c Department of Radiology, Shinbeppu Hospital, Tsurumi, Oita, Japan


Figure 1
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  		Fig 1. Schematic drawings of variations of the SMCV. Type A, SMCV connects with the proximal SPS and flows into the frontal aspect of the cavernous sinus. Type B, The SMCV connects with the lateral aspect of the cavernous sinus independently. Type C, The SMCV turns downward and connects with the pterygoid plexus through the middle cranial fossa. Type D, The SMCV runs across the pyramidal ridge and connects with the superior petrosal sinus or transverse sinus via the tentorial sinus. SOV indicates the superior orbital vein; PP, pterygoid plexus; SuPS, superior petrosal sinus; SS, sigmoid sinus; and TS, transverse sinus.


Figure 2
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  		Fig 2. Type A, A 69-year-old man with left maxillary cancer. The SMCV runs along the lesser sphenoid ridge (white arrows) to connect with the proximal segment of the SPS (black arrows) and connects with the anterior potion of cavernous sinus (arrowhead).


Figure 3
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  		Fig 3. Type C, A 60-year-old woman with right acoustic neurinoma. The SMCV runs along the sphenoid ridge, turns downward, and connects with the pterygoid plexus via the foramen ovale (white arrow). Note the hypoplastic SPS connects with the cavernous sinus (black arrow). This pattern is categorized as type C.


Figure 4
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  		Fig 4. Type D, A 58-year-old man with metastatic brain tumor from lung cancer. Under the temporal lobe, the SMCV runs across the pyramidal ridge posteriorly and connects with the transverse sinus via the tentorial sinus (white arrows).


Figure 5
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  		Fig 5. Schematic drawings of variations of the SPS. Type a, The SPS runs along the lesser sphenoid wing and connects to the anterior aspect of the cavernous sinus. Type b, The SPS runs along the lesser sphenoid wing and connects with the foramen ovale plexus or the pterygoid plexus. Type c, the hypoplastic SPS connects with the cavernous sinus. CS indicates the cavernous sinus


Figure 6
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  		Fig 6. Mixed type with type A and B. A 57-year-old woman with left cavernous dural arteriovenous fistula.

A, Lateral view; B, frontal view. Right carotid arteriogram demonstrates a left cavernous dural arteriovenous fistula draining into the cerebellar cortical veins via the superior petrosal sinus (arrows). Retrograde opacification of the SMCV is not shown.

C, On the contrast-enhanced gradient-echo MR image, a small venous structure connecting to lateral wall of the cavernous sinus, thought to be the SMCV, is observed (white arrow). The findings indicate the potential risk of cortical venous reflux to the medial temporal lobe. Another prominent SMCV flowed into the pterygoid plexus with no connection to the cavernous sinus (black arrow). Note the dilated inferior hypophyseal arteries joining the posteroinferior aspect of the cavernous sinus (arrowheads) and cortical venous reflux to the cerebellar veins (open arrows).

D, This patient was treated by transvenous embolization, and the shunt disappeared completely.


Figure 7
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  		Fig 7. Type C, A 43-year-old woman with a right direct carotid cavernous fistula.

A, Frontal view of a right carotid arteriogram demonstrates a right carotid cavernous fistula. Retrograde opacification of the SMCV is not shown.

B, On the contrast-enhanced gradient-echo MR image, 2 SMCVs are conjoined beside the cavernous sinus and flow through the middle carnial fossa (arrows). This patient was treated by transarterial and transvenous coil-packing of the right cavernous sinus.

C, The carotid angiogram immediately after embolization demonstrates no visualization of the shunt. Note the right SMCV flowing beside the coil mass (arrows).


Figure 8
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  		Fig 8. Schematic drawings of the developmental anatomy of cavernous and para-cavernous venous structures in the embryonic stage. SSS indicates superior sagittal sinus; PTS, primitive tentorial sinus; PS, prootic sinus; PMS, primitive maxillary sinus; and IPS, inferior petrosal sinus.

A, Lateral view; B, axial view. In an 8-week embryo, cerebral venous structures develop from primitive dural plexuses surrounding primitive cerebral vesicles. The plexuses fuse to form venous sinuses and cortical veins. Two major primitive sinuses, the primitive tentorial sinus and the prootic sinus, contribute to the development of cavernous sinus and para-cavernous sinus veins. The primitive SMCV is connected with the transverse sinus via the primitive tentorial sinus.

C, In a 12-week embryo, after several weeks, the primitive SMCV is elongated and develops anteromedially to form the SMCV as a development of the cerebral hemisphere. The prootic sinus contributes to form the superior ophthalmic vein, the cavernous sinus, and the foramen ovale venous plexus.

D, Axial view; E, lateral view. In a developed embryo, the SMCV makes further anteromedial development in the prenatal stage; however, in many patients, there is no direct connection between the SMCV and the cavernous sinus. Secondary anastomosis after birth may form a connection between the SMCV and the cavernous sinus, and the connection to the primitive tentorial sinus subsequently degenerates.





Copyright © 2009 by the American Society of Neuroradiology. Print ISSN: 0195-6108 Online ISSN: 1936-959X