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 ISBN 978-3-540-00818-7 e-ISBN 978-3-540-68889-1 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 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitations, broadcasting, reproduction on microfi lm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permit- ted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permis- sion for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law. The use of general descriptive names, trademarks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover-Design and Layout: PublishingServices Teichmann, 69256 Mauer, Germany Printed on acid-free paper – 21/3180xq 9 8 7 6 5 4 3 2 1 0 springer.com 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 cra- nial 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. Further- more, there is an abundance of dural arteries in the sellar region that are interconnected and derive from the carotid system. Due to its specifi c vascular anatomy, the cavernous sinus is a common site of various types of arteriovenous (AV) fi stulas, which are essentially benign lesions but which may endanger both vision and cranial nerve function. These fi stulas, 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 con- tinues by explaining the anatomic and hemodynamic classifi cations of AV fi stulas 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, diagnos- tic and therapeutic radiology of AV cavernous fi stulas, Benndorf devotes an entire chapter to clinical, largely neuro-ophthalmological symptoms and signs. The radiological chap- ters, all beautifully illustrated and containing a treatise on hemodynamics, will undoubt- edly 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 radiol- ogy of AV fi stulas 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. Heidelberg Klaus Sartor 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 treat- ment and clinical management of patients with various types of intracranial arteriovenous shunting lesions, in particular fi stulas of dural origin involving the cavernous sinus. It is intended as a practical guide and reference for those involved in the diagnosis and treat- ment of these lesions. Completing this book would have been impossible without the moti- vation, 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 fi rst CSF patients together. My most sincere gratitude goes to Jacques Moret (Foun- dation 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 dedi- cated 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 transophthal- mic SOV approaches became necessary. My colleague and friend, Andreas Bender (Charité until 1998), one of the most talented interventional neuroradiologists I had the good for- tune 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. X Preface The following colleagues and friends contributed additional interesting and valuable imaging material: Jacques Moret (Foundation Rothschild, Paris), Alessandra Biondi (Pitié-Salpêtrière University Hospital, Paris); Gyula Gal (Uni- versity Hospital Odense); Michel Mawad (BCM, Houston); Jacques Dion (Emory University Hospital, Atlanta); Richard Klucznik (TMH, Houston); Maria Angeles De Miquel (Hospital Universitari de Bellvitge, Barcelona); Michael Soederman (Karolinska University Hospital, Stockholm); Winston Lim (Singapore General Hospital); Adriana Campi (Ospedale San Raffaele, University of Milan); Rob De Keizer (University Hospital, Leiden); Charbel Mounayer (Foundation Rothschild, Paris); Raimund Parsche (Ruppiner Kliniken); Bernhard Sander (MRI Praxis, Berlin) and Ullrich Schweiger (Ullsteinhausklinik, Berlin). Special credit goes to Alessandra Biondi, Gyula Gal, Stefanie Schmidt, Diane Nino (BCM Houston), Phillip Randall (TMH Houston) and Mia Carlson (MDA, Houston) for review, suggestions and corrections of the text. The superb clinical photographs were taken by Franz Haffner and Peter Behrend (Charité, Berlin); David Gee (Houston) produced the high-quality dry skull pic- tures. Corinna Naujok (Charité, Berlin), Charlie Thran (TMH, Houston) and Scott Weldon (BCM, Houston) helped to create the nicely colored illustrations. Dirk Emmel (Charité, Berlin) provided invaluable support for the digital storage of the image material. Richard Klucznik (TMH, Houston) was very helpful in acquiring high-resolution 3D-data for the imaging studies of the