The cavernous sinus (CS) is one of the cranial dural venous sinuses. It differs from other dural sinuses due to its many afferent and efferent venous connections with adjacent structures. It is important to know well about its complex venous anatomy to conduct safe and effective endovascular interventions for the CS. Thus, we reviewed previous literatures concerning the morphological and functional venous anatomy and the embryology of the CS. The CS is a complex of venous channels from embryologically different origins. These venous channels have more or less retained their distinct original roles of venous drainage, even after alterations through the embryological developmental process, and can be categorized into three longitudinal venous axes based on their topological and functional features. Venous channels medial to the internal carotid artery “medial venous axis” carry venous drainage from the skull base, chondrocranium and the hypophysis, with no direct participation in cerebral drainage. Venous channels lateral to the cranial nerves “lateral venous axis” are exclusively for cerebral venous drainage. Venous channels between the internal carotid artery and cranial nerves “intermediate venous axis” contribute to all the venous drainage from adjacent structures, directly from the orbit and membranous skull, indirectly through medial and lateral venous axes from the chondrocranium, the hypophysis, and the brain. This concept of longitudinal venous axes in the CS may be useful during endovascular interventions for the CS considering our better understandings of its functions in venous drainage.
Background:The standard neurosurgical procedure for chronic subdural hematoma is a burr-hole surgery. Postoperative hemorrhage is one of the complications after burr-hole surgery. The hemorrhage generally occurs at the surgical site; however, remote hemorrhage is rare. Here, we report two cases of remote hemorrhage after burr-hole surgery for chronic subdural hematoma and discuss the possible mechanism underlying this rare complication.Case Description:Two patients presented remote hemorrhages after burrhole surgery for chronic subdural hematoma. In the first case, hemorrhage occurred in the interhemispheric fissure and contralateral subdural space. In the second case, hemorrhage occurred in the subdural space of the posterior fossa.Conclusion:Postoperative remote hemorrhage is a rare complication, and it can occur after both craniotomy surgery and burr-hole surgery. Neurosurgeons should consider the possibility of this rare complication, and sufficient care should be taken to select the most appropriate surgical procedure to prevent remote hemorrhage.
Background:Cranioplasty is a standard neurosurgical procedure which is performed after decompressive craniotomy. Fatal complications associated with this procedure are not well documented. Here, we report a case of fatal cerebral swelling after cranioplasty and discuss the possible mechanism of this complication.Case Description:A 64-year-old man was admitted with the diagnosis of cerebral hemorrhage, and emergency surgery for hemorrhage removal and decompressive craniotomy were performed. One month after surgery, cranioplasty was performed using a titanium mesh plate. Sixteen hours after the surgery, the patient became comatose with bilateral dilated pupils followed by blood pressure lowering. Computed tomography of the brain showed bilateral massive cerebral edema. The titanium mesh plate was immediately removed, however, the patient’s neurological condition did not recover and he died 7 days after the surgery. We speculated that the negative pressure difference and increase in cerebral blood flow after cranioplasty may have attributed to the fatal cerebral swelling.Conclusion:Fatal cerebral swelling after cranioplasty is a rare but devastating complication. Although it is rare, neurosurgeons should keep in mind that this fatal complication can follow cranioplasty.
Brainstem cavernous malformations account for 9 35 of all intracranial cavernous malformations and most brainstem cavernous malformations arise from the pons. Pontine cavernous malformations remain surgically challenging because of their deep seated and eloquent locations. Although several approaches have been reported to remove pontine cavernous malformations, there are only a few reports available regarding the transpetrosal approach in pontine cavernous malformation surgery. Here, we report our experience in treating patients with pontine cavernous malformations by the transpetrosal approach. Furthermore, alternate surgical approaches to pontine cavernous malformations will be discussed. A total of six cases were included in this study. There were four men and two women with an average age of 46.2 years. All cases presented neurological deficits caused by hemorrhage before surgery. The anterior transpetrosal approach was used in four and a combined transpetrosal approach was used in two cases. Gross total removal was achieved in all cases with an acceptable surgical outcome. We consider that a small cortical incision which allows multi direction dissection is the most important factor to avoid additional neurological deficits in cavernous malformation surgeries. Therefore, the transpetrosal approach can be used to minimize neurological deficits after removal of pontine lesions.
To report on unusual veins traversing the petromastoid part of the temporal bone (petrosal bone) and to discuss their embryological origins. Methods: Unusual veins traversing the petrosal bone were incidentally found on CTA, MRI, or conventional angiography in four cases. We have evaluated the course of these veins in detail and have reviewed the previous descriptions in the literatures about similar venous variations as well as the osseous and venous embryology around the petrosal bone. Results: In all cases, the vein was anteriorly connected to the dural venous sinus around the foramen ovale and entered the petrosal bone through the facial hiatus. With regard to the subsequent running course and its exit from the petrosal bone, the vein crossed the petrous internal carotid artery, exited the petrosal bone into the petroclival fissure, and entered the inferior petrosal sinus in two cases. In one case, the vein exited the petrosal bone through the stylomastoid foramen after running the entire length of the facial canal. In the remaining case, the vein ascended in the petrosal bone along its anterior aspect and emptied into the superior petrosal sinus. The running course of these veins may correspond to the course of the embryonic primary head sinus and its tributaries. Conclusion: Here we report on rare venous channels in the petrosal bone. We also believe that these veins may be remnants of the embryonic primary head sinus, based on their course in the petrosal bone and the embryological development of the veins in the region.
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