Cavernous Sinus Venography and Stereotaxic Cryohypophysectomy*

ROBERT W. RAND, M.D., AND WILLIAM N. HANAFEE, M.D. Department oJ Surgery and Department of Radiology, U.C.L.A. School of Medicine, Los Angeles, California

HE dimensions of a normal pituitary vision. 6-s Certain intrasellar pituitary gland can be approximated by roent- tumors, especially those causing hyper- T genographic studies of the sella tur- pituitary syndromes (acromegaly, Cushing's cica. Tumors in this region, however, fre- syndrome, and Nelson's syndrome),4 have quently grow in a lobulated asymmetrical also been successfully removed with this fashion so that the osseous walls of the sella cryosurgical procedure. do not give a true representation of the tumor size. Pneumoencephalograms will Anatomy show suprasellar tumor extensions, and The paired cavernous sinuses are irregu- bilateral carotid angiography will, in some larly quadrangular structures, lying extra- cases, demonstrate lateral and (less well) dural and adjacent to the body of the suprasellar growth patterns. X-ray studies sphenoid bone. In the lateral walls are the are most useful to rule out internal carotid oculomotor nerves, trochlear nerves, and aneurysms simulating nonsecretory pituitary first divisions of the trigeminal nerves. The tumors. abducens nerves lie lateral to the carotid Lateral extensions of pituitary tumors arteries. They are connected to each other present diagnostic and therapeutic problems. by two venous sinuses lying both anterior Opacification of the cavernous sinuses by and posterior to the pituitary gland that are percutaneous retrograde injection, however, called the anterior and posterior intercom- has allowed accurate delineation of the municating sinuses. The portions of the in- lateral extensions of pituitary adenomas and tercommunicating sinuses lying beneath the their relationships to the carotid siphon and diaphragma sellae are sometimes spoken of the cranial nerves of the cavernous sinus. as circular sinuses. Thus, the pituitary gland These anatomicopathological findings have is surrounded by venous channels. The made possible accurate placement of cryo- cavernous sinuses extend from the superior probes during stereotaxic cryohypophysec- orbital fissure anteriorly where they receive tomy. the ophthalmic veins and tributaries of the History pterygoid plexus to the dorsum sellae Retrograde jugular venography has been posteriorly. An excellent surgical description used for study of glomus jugular tumors by of the cavernous sinuses has been made by Gejrot and Lindbom2 In their technique, Parkinson. 5 a small vascular catheter was passed per- The inferior petrosal sinuses drain from cutaneously into the internal jugular vein, the posterior inferior quadrant of the cavern- and the injected contrast solution was re- ous sinus toward the region of the jugular fluxed into the transverse sinus. Satis- foramen. Most anatomy texts show the in- factory opacification of the cavernous sinuses ferior petrosal sinuses draining into the did not occur. jugular bulb at the level of the jugular fora- Stereotaxic cryohypophysectomy was de- men. Our radiographic investigations (Fig. 1) veloped in 1963 to replace yttrium-90 sphere have shown that the inferior petrosal sinus hypophysectomy in the palliative treatment drains in four patterns: of metastatic mammary cancer and progres- 1. The inferior petrosal sinus drains di- sive diabetic retinopathy causing loss of rectly into the internal jugular vein. ~. The inferior petrosal sinus ends in a Received for publication May 19, 1966. communicating vein which joins the Revision received August ~5, 1966. * Supported in part by U.S. Public Health Service deep cervical plexus with the internal Grant CA 04423, jugular vein. 5~1 5~ Robert W. Rand and William N. Hanafee 3. Occasionally the inferior petrosal sinus pared and then anesthetized with 1% xylo- is not a single channel, but a slight caine infiltrated 3 cm above the sternal end of exaggeration of tile plexus of veins the clavicle along the medial border of the which lies on the dorsum sellae and sternocleidomastoid muscle. A ~ to 3 mm clivus. These channels drain both into stab-wound incision is made to allow easier the internal jugular vein and deep passage of the polyethylene catheter (Becton, cervical plexus. Dickinson XRP 0.045tt radiopaque) since 4. The inferior petrosal sinus may drain the outside diameter of the catheter is directly into the deep cervical veins. slightly larger than the puncture needle. A 3
89inch 18-gauge thin-walled needle without Technique a styler is attached to a 10ec syringe con- The initial technique and results of cavern- taining 5 cc of 1% xylocaine. This needle is ous sinography, which consists of passing a inserted and directed about 5 mm lateral to catheter percutaneously via the internal the internal carotid artery. The tip of the jugular vein cephalad into the inferior mastoid process may be used as an osseous petrosal sinus under fluoroscopic control, landmark to direct the angle of puncture. have been reported previously. ~ We are now The attached syringe is used to aspirate reporting the method in more detail because frequently since the pressure of the internal of technical changes and improvement in tile jugular vein is insufficient to cause blood to procedure. flow spontaneously from the needle. If the The patient's head and neck are slightly patient experiences pain, small amounts of hyperextended. The skin of tile neck is pre- xylocaine are injected as needed.

Fro. 1. Patterns of drainage of inferior petrosal sinuses observed during performance of cavernous sinus venography.