Cavernous sinus invasion by pituitary macroadenomas: neuroradiological, clinical and surgical correlation

Abstract

-The classical imaging gold-standard for this diagnosis is the presence of tumor lateral to the carotid artery. Seventeen patients with pituitary macroadenomas with intraoperative confirmation of cavernous sinus invasion were studied with MRI. Only 8 patients had tumor lateral to the carotid artery; 13 had tumor within the carotid syphon and all lacked the ring enhancement of the medial wall of the cavernous sinus. In 10 patients, widening of the posterior double leaflets of the cavernous sinus could be. All patients were operated by the transesphenoidal route. Only one patient was cured by surgery alone. Only 3 patients disclosing the above mentioned MRI features were identified in a series of 250 patients and did not have cavernous sinus invasion. The present criteria proved to be useful in the pre-operative diagnosis of cavenous sinus invasion and patients' counselling. Pre-operative diagnosis of cavernous sinus invasion of pituitary tumors has a great impact in the management of such patients.KEY WORDS: pituitary tumors, magnetic resonance image, cavernous sinus invasion. Invasão de seio cavernoso por tumores pituitários: correlação neurorradiológica e clínico-cirúrgicaRESUMO -O critério imagenológico clássico para diagnóstico de invasão de seio cavernoso é a presença de tumor lateralmente à carótida em cortes coronais. Estudamos 17 pacientes com macroadenomas hipofisários com ressonância compátivel a invasão de seio cavernoso e que tiveram esta invasão confirmada cirurgicamente. Somente 8 destes pacientes possuíam tumor lateralmente à carótida (critério clássico). Treze pacientes possuíam tumor localizado entre as porções intracavernosas da carótida e em todos havia ruptura da captação anelar de contraste no seio cavernoso. Dez pacientes possuíam abertura dos folhetos posteriores do seio cavernoso. Todos os pacientes foram tratados por via transesfenoidal. Somente um caso obteve cura endocrinológica. Somente 3 pacientes portadores de algum destes sinais imagenológicos foram identificados em uma série de cerca de 250 casos e não possuíam invasão de seio cavernoso. Os critérios acima parecem adequadamente permitir prever a invasão do seio. Este diagnóstico é relevante já que a maioria dos pacientes com invasão de seio cavernoso acaba realizando terapia complementar. PALAVRAS-CHAVE: tumor hipofisário, ressonância magnética, seio cavernoso invasão.Cavernous sinus invasion by pituitary adenomas has been noted since the early days of pituitary surgery 1 . On the other hand, the pre-operative diagnosis of cavernous sinus invasion was rarely done before the introduction of CT scanning in the clinical practice and correctly performed only in the more obvious cases by means of CT 2 . The availability of high resolution MR imaging 3 has made it possible to study the sellar region in a detail not possible using CT scans 4 . Different criteria have

Gender differences in presentation and outcome of patients with Cushing's disease in Han Chinese

“…Caputo [9] and Nabarro [10] reported that premenopausal women may have smaller adenomas caused by menstrual abnormalities, while others showed that the rate of invasiveness and apoplexy were higher in men than in women. Further, in accordance with Cukiert [11], macroadenomas may be also related to cavernous sinus invasion. In the pituitary fossa, the absence of a bony interface could explain the invasion.…”

Magnetic resonance imaging of cavernous sinus invasion by pituitary adenoma diagnostic criteria and surgical findings

“…We observed a significantly increased prevalence of invasion in macroadenomas (83.5% of the patients with invasive tumors).This higher prevalence of invasive tumors has also been observed by others [1][2][3]5 , although Scotti et al 4 have not noticed such difference. Knosp et al 1 have also noted that the grade of parasellar extension was directly related to the tumor's size.…”

“…Experienced neurosurgeons can easily distinguish between normal and abnormal dural walls. Some authors [1][2][3][4][5][6] have tried to define imaging criteria for CSI using anatomical parameters, such as the intracavernous ICA and the CS venous compartments; they have also compared imaging and surgical findings.…”

Pituitary Adenomas and Invasiveness from Anatomo-Surgical, Radiological, and Histological Perspectives: A Systematic Literature Review

“…The initial radiological criteria of CS invasion, which underlined the importance of cavernous sinus ICA (Figure 3) [71,93,94], have been further refined and include analysis of the pituitary gland (its interposition between the tumor and CS is a sign of no invasion), of the CS venous compartments, CS size, ICA, and CS lateral wall (CSLW) displacement [68,71,[95][96][97][98][99][100][101]. All these criteria underline the difficulty of radiological diagnosis of CS invasion, which is considered certain only when total encasement of the ICA is present [11,67,71,87,94,95,97,[101][102][103][104][105]. [93] suggested three grades to define encasement of the parasellar ICA for tumors invading the CS: in grade 1, the tumor partially touches the ICA; in grade 2, the ICA is encircled without luminal narrowing, and in grade 3 the ICA diameter reduction is evident.…”