Cavernous sinus síndrome. Diferencial diagnosis.
Poster No.:
C-1766
Congress:
ECR 2014
Type:
Educational Exhibit
Authors:
V. M. Vilela , H. C. Marques , L. L. Macedo , R. V. Leite , L. C.
1
1
1
1 1
2
2
2
Campos , B. L. Dutra ; Juiz de Fora, MG/BR, Juiz De Fora/BR
Keywords:
Neoplasia, Infection, Aneurysms, Biopsy, Abscess delineation,
MR-Diffusion/Perfusion, MR, CT, Neuroradiology brain, Head and
neck
DOI:
10.1594/ecr2014/C-1766
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Page 1 of 51
Learning objectives
The cavernous sinus syndrome usually results in mass effect on the internal structures
due to primary lesions or direct extension of parasellar lesions.
We reviewed the literature on the subject and presented characteristic imaging findings
of the main pathologies that cause this syndrome illustrated by cases from 4 institutions.
Images for this section:
Fig. 1: Coronal plane schematic drawing of the cavernous sinus and parasellar regions
anatomy. Observe the cavernous sinus (blue), cranial nerves (yellow) and arteries (red).
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Fig. 2: Cavernous sinus and parasellar regions anatomy. 3D CISS after intravenous
administration of the contrast material. Coronal plane at the level of the optic chiasm.
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Fig. 3: Coronal plane schematic drawing of the venous compartments inside the
cavernous sinus. Three vertical intercarotid lines (1 - medial line / 2- median line /3- lateral
line) allow split each cavernous sinus in five venous compartments.
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Background
The cavernous sinuses are extradural venous sinus covered by dura mater and are
located along the lateral aspect of the sella. The location of the venous sinuses and their
connections make this structure a potential route of spread for inflammation and cancer.
The most common causes (neoplastic, inflammatory / infectious and vascular) will be
addressed in this essay.
NEOPLASMS
Schwannoma
Represent about 8% of all intracranial tumors. It is most common in middle-aged women.
It has a predilection for sensory roots, and the vestibular root of the eighth cranial nerve
being the most affected (about 80%-90% of cases).
In the middle cranial fossa, the schwannoma of the trigeminal nerve is the most common.
Typically arise in Meckel's cave or cisternal segment of the nerve. Generally involve
cavernous sinus, and in 50% of cases, has a typical dumbbell shape.
Associated with cavernous hemangioma and meningioma is the most common primary
tumor of cavernous sinuses.
At MRI, classically appear as iso or hypointense lesions in T1 and variable signal intensity
on T2.
Predominantly Antoni A schwannomas are hypercellular and may appear as hypointense
lesions on T2. Moreover, predominantly Antoni B schwannomas are hypocellular and
may appear as hyperintense lesions T2. Larger lesions usually exhibit heterogeneous
signal intensity with T2 hypointense areas probably related to intratumoral hemorrhage
and hyperintense areas due to cystic necrosis.
The administration of contrast material results in intense homogeneous impregnation of
the solid component.
Cavernous hemangioma
Cavernous hemangioma is a vascular malformation formed by sinusoidal spaces
with endothelial lining, containing stagnant or slow-flowing blood. It has an fibrous
pseudocapsule that determines the well defined appearance of the lesion on imaging
studies and is most commonly observed in young adult female.
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The MRI study shows a lesion usually hypo / isointense to muscle on T1. Occasionally
these lesions contain regions of high signal intensity on T1, corresponding to thrombosed
vascular spaces.
Characteristically, it has greatly increased signal on T2. After intravenous infusion of
contrast and analysis in the late stages, the uptake is intense and homogeneous.
In the early stages after the use of gadolinium the uptake can be heterogeneous. However
images obtained dynamically can demonstrate a fairly typical finding: progressive,
centripetal and intense enhancement.
The main role of MRI in the evaluation of cavernous hemangiomas is to provide a precise
anatomical definition of the lesion and its relationship with adjacent structures.
Meningioma
Meningioma is usually a benign slow growing tumor. Most cavernous sinus meningiomas
arise from the lateral wall, juxtaposed to the dura mater. May extend posteriorly to
Meckel's cave and cerebellopontine cistern. The dural tail sign is often observed. When
it involves the internal carotid artery, usually determines stenosis.
At MRI study meningiomas are most often isointensos the gray matter on T1 and less
commonly hypointense.
About 50% remain isointense on T2-weighted images, while 40% are hyperintense .
After intravenous infusion of contrast material, meningiomas have intense homogeneous
uptake.
Often a dural linear and peripheral uptake can be seen ( dural tail sign ).
Other secondary signs such as mass effect, thickening of the dura mater, adjacent white
matter edema and hyperostosis are often used for diagnosing meningiomas.
A clear separation between the tumor and the pituitary gland (which indicates that the
tumor is non-pituitary origin) helps in the differential diagnosis with pituitary adenomas.
Meningiomas characteristically determine constriction of the adjacent vessel lumen. This
is rare in pituitary adenoma.
En plaque meningioma originating in the sphenoid bone may affect the cavernous sinus .
Involvement of the carotid and the optic canal are important findings and must be
described on imaging studies.
Pituitary adenoma
Pituitary adenomas are benign pituitary neoplasms that generally affect middle-aged
adults (20-40 years). Are classified according to size in microadenomas (<10 mm) and
macroadenomas (> 10 mm).
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Giant macroadenomas (> 4 cm) account for 0.5% of cases and are more likely to grow
laterally to invade the cavernous sinus, and may take the characteristic number "8" or
"snowman" shape.
MRI typically demonstrates a hypo / isointense lesion in T1, iso / hyperintense on T2 and
intense homogeneous enhancement.
Intratumoral hemorrhage occurs in 20% to 30% of pituitary adenomas, mostly in
macroadenomas.
Cystic degeneration, with or without bleeding, can also occur. The cystic degeneration
in an adenoma is evident as an area of very low signal intensity on T1 and markedly
hyperintense on T2 weighted sequences.
One of the critical points in the evaluation of this tumor is to determine cavernous sinus
invasion. In this context, the cavernous sinus can be partitioned by three vertical lines.
The imaging method of choice is MR, but the diagnosis of invasion can only be concluded
surgically.
Chordoma
Chordomas are rare tumors that arise from remnant cells of the notochord along the
neuraxis. Thirty five percent arise in the skull base, 50% in sacroiliac region, and 15% in
the other levels of the spine. Generally are midline tumors and in the skull have the clivus
as primary site, involving the cavernous sinus by direct invasion. Intracranial chordoma
affect middle-aged adults (30-50 years), with no sex predilection. Exhibit locally invasive
behavior and generally determine destruction / erosion of adjacent bone.
MR imaging is more sensitive for detection of cavernous sinus involvement.
These tumors are characteristically isointense (75%) or hypointense (25%) on T1, may
contain small hyperintense foci related with hemorrhage and / or high protein content.
Typically have high signal intensity on T2, and may contain small hypointense foci related
calcifications and / or bone fragments.
At angiography, avascular pattern is often observed.
Metastasis are uncommon and recurrence after surgery is common.
Necrosis and tumor volume greater than 70ml are indicative worse prognosis.
Chondrosarcoma
It is a tumor of cartilaginous origin and potentially lethal. Local recurrence and metastasis
are common, being considered a tumor with poor prognosis. The petrooccipital fissure
is the primary site at the skull's base, but can also originate from lacerus foramen,
sphenoethmoidal complex, anterior cranial fossa and clivus. Chondrosarcomas can
locally invade the cavernous sinuses.
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The lesion shows low or intermediate signal intensity on T1 and high signal intensity on
T2.
As in chordoma, may contain hyperintense foci on T2 related calcifications and / or bone
fragments.
Generally shows intense contrast uptake.
Multiple chondrosarcomas can be found in Ollier (multiple enchondromatosis) and
Maffuci syndromes (multiple enchondromas with cutaneous hemangiomas).
Chondrosarcoma can occur in patients with Paget disease.
Nasopharyngeal carcinoma
Nasopharyngeal carcinoma usually affects middle-aged adults (before 50 years) with a
man / woman ratio of 2.5 / 1. Often originates in the pharynx lateral recess (Rosenmuller's
fossa) with 90% of cases showing lymph node metastasis at diagnosis.
It is considered the most common primary malignant tumor invading the cavernous
sinus. Intracranial spread can occur directly through the erosion of the skull base or via
perineural spread along branches of the trigeminal nerve. The tumor may also extend
to the petrooccipital synchondrosis and lacerus foramen to the inferior aspect of the
cavernous sinus or the carotid channel, reaching the cavernous sinus without determining
bone destruction.
At MR imaging, appears as a hypointense lesion on T1 and moderately hyperintense on
T2-weighted images.
The most aggressive tumors, including undifferentiated types, may appear hypointense
on T2.
Generally they have moderate and homogeneous enhancement by the contrast medium.
Carcinoma of the sphenoid sinus
Uncommon tumor that usually affects 50 to 70-year old people, with male predilection.
They are aggressive tumors that often determine bone destruction and may directly
invade the cavernous sinuses.
The sphenoid sinus carcinomas are lesions with soft tissue attenuation at CT, with
heterogeneous moderate / intense enhancement by the contrast medium.
They are aggressive tumors that usually determine erosion / destruction of adjacent bone
structures.
Normally the area of bone destruction is extensive compared with the volume of the soft
tissue component. Bone remodeling is uncommon.
Present as iso / hypointense lesion on T1 and variable signal intensity on T2-weighted
imagnes.
Moderate / intense heterogeneous enhancement by gadolinium.
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Signs of dural and perineural involvement are frequent.
Sequences with fat saturation are important for the characterization of the lesions. Orbital
invasion can also occur.
Rhabdomyosarcoma
Rhabdomyosarcoma is a malignant mesenchymal tumor that usually affects children (1st
and 2nd decades), but rarely found in adults. It is the most common sarcoma in head and
neck, compromising, in order of frequency, orbit, nasopharynx, temporal bone, sinonasal
cavity and cervical neck. It is an aggressive tumor that determines bone destruction and
that can directly invade the cavernous sinus, which is one sign of poor prognosis.
MR imaging shows a isointense lesion on T1 with variable signal on T2 and moderate
diffuse enhancement the by contrast medium.
Larger lesions may have heterogeneous signal intensity in different sequences due to
intratumoral bleeding.
Lymphoma
CNS lymphomas are uncommon neoplasms and represent about 2% of tumors at this
location. However CNS tumors are more frequent in immunosuppressed patients. The
preferred sites are cerebral hemispheres, but may compromise the cavernous sinus by
direct extension of a primary lesion or hematogenous spread.
They are generally isointense the muscle on T1 and iso / hypointense on T2.
The low signal intensity on T2 is characteristic, but not very sensitive.
They show diffuse homogeneous gadolinium enhancement.
Metastasis
Metastasis to the cavernous sinus can occur via hematogenous or perineural spread.
Generally the tumors that determine hematogenous spread to the cavernous sinuses are
from renal, gastric, thyroid, lung and mammary primary sites.
Perineural spread is commonly seen over the trigeminal nerve branches and generally
originates from squamous cell carcinoma, neurogenic tumors and lymphoma. Other
tumors that potentially can reach the cavernous sinuses are juvenile angiofibroma, cystic
adenoid carcinoma, melanoma and basal cell carcinoma.
The metastases usually present as lesions with soft tissue attenuation at CT, expanding
the cavernous sinus and variable enhancement after contrast medium administration.
Bone destruction and foraminal enlargement can also be observed.
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INFLAMMATORY AND INJURIES INFECTIOUS
Tolosa-Hunt syndrome
Also known as painful external ophthalmoplegia, Tolosa-Hunt syndrome is a term applied
to an idiopathic inflammatory process involving the cavernous sinus and / or the upper
orbital fissure similar to orbital pseudotumor.
MR imaging has greater sensitivity (around 85%) and can show an isointense tissue to
muscle on T1, iso / hyperintense on T2 and diffuse homogeneous enhancement by the
contrast medium.
The lesion determines enlargement of the cavernous sinus and, in most cases, extends
to the orbital apex or superior orbital fissure, reinforcing the possibility of this syndrome
to be part of the same disease with orbital pseudotumor.
Involvement of the contralateral cavernous sinus (alternate form) is rare but may occur.
Reduced caliber of the internal carotid artery can be demonstrated up to 50% of cases.
An important finding that supports the clinical hypothesis and imaging findings is complete
resolution of the lesions with corticoid therapy, especially during the course of six months
of treatment.
Cavernous Sinus Thrombosis
Venous thrombosis can be classified into two forms, primary or aseptic found in
cases of cachexia, dehydration, congestive heart failure, postoperative and postpartum
contraceptive use, and secondary, or septic thrombophlebitis, which is more rare and
potentially fatal. It is the result of complications of infections involving paranasal sinuses,
cheek or periauricular region. Can occur also as a complication of orbital cellulitis,
bacterial meningitis and subdural empyema.
MR imaging is more sensitive and can more clearly demonstrate the peripheral
enhancement of cavernous sinus associated with small central thrombi.
Secondary signs should always be valued as: dilation / thrombosis of the
superior ophthalmic vein, exophthalmos, prominence of the extraocular muscles and
enhancement of the dura ipsilateral to the affected side.
DWI may demonstrate restricted diffusion of water due to the purulent material within the
cavernous sinus.
Tuberculosis
In Brazil, tuberculosis (TB) remains a relatively common cause of CNS lesions. Between
5% and 10% of TB patients will present CNS involvement that increase to about 20%
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in patients with AIDS. Leptomeningitis is the most common presentation, in most cases,
is secondary to hematogenous spread of a pulmonary focus. Skull base involvement is
characteristic and focal or diffuse lesions may affect the cavernous sinus. Alone or in
association with leptomeningitis, tuberculosis can involve the brain parenchyma, either
in the form of cerebritis or tuberculoma.
The most common imaging findings associated with tuberculous involvement
include impregnation of the basal cisterns, tuberculomas, hydrocephalus, meningeal
enhancement and infarcts, generally in the basal ganglia.
The tuberculomas may calcify in up to 25% of cases. Coexistence with pulmonary
tuberculosis is common and occurs in most cases.
On CT, the most common finding of tuberculous meningitis is exudate, isoatenuating or
slightly hyperattenuating, involving basal cisterns and presenting marked homogeneous
or nodular enhancement.
MR imaging shows more precisely the enhancement which may extend over the surface
of the cerebral hemispheres.
The sequence fluid attenuated inversion recovery (FLAIR) can be acquired after
gadolinium and in this situation, is the most sensitive for the detection of leptomeningeal
involvement. Tuberculomas are usually present as isointense lesions on T1 and
characteristically hypointense on T2 and present nodular or rim enhancement by the
contrast material.
Sarcoidosis
Sarcoidosis is a systemic granulomatous disease of unknown etiology and characterized
by an inflammatory process involving multiple systems. The lung and hilar lymph nodes
are the organs most frequently affected. CNS involvement occurs in 5% of patients.
The most characteristic MR imaging findings are thickening or distortion of cranial nerves
or meningeal surfaces, multiple small parenchymal lesions or large solitary masses and
the finding of small hyperintense on T2 periventricular white matter lesions.
At MR imaging, the lesions are most often isointense on T1, iso / hypointense on T2 and
have homogeneous enhancement.
VASCULAR INJURIES
Aneurysm
Aneurysms of the cavernous portion of the internal carotid artery have a relatively benign
course with risk of subarachnoid hemorrhage estimated at 0.4%. Approximately 5% of
giant aneurysms (> 2.5 cm) are found in the cavernous portion of the internal carotid
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artery. The majority of the aneurysms is idiopathic, but can occasionally be traumatic or
mycotic.
Aneurysms of the cavernous sinus usually present as round or oval lesions, well defined
limits and regular contours . May be patents or partially thrombosed . Calcifications can
be found in aneurysm walls.
The patent aneurysm presents as isoatenuanting lesion or slightly hyperattenuating and
intense enhancement by the contrast medium .
The thrombosed or partially thrombosed aneurysm usually features high density and
peripheral enhancement. The lumen of the partially thrombosed aneurysm may show
intense enhancement.
At MR imaging, the patent aneurysm is presented primarily as a round / oval lesion with
absence of signal (flow void).
The trombosed or partially thrombosed aneurysm shows variable signal intensity due to
the various stages of hemoglobin degradation. Typically, they are hyperintense on T2 or
have a laminated appearance with hypointense halo.
Magnetic resonance angiography (MRA) and CT angiography (angio - CT) have greater
sensitivity to detect aneurysms . Furthermore, they are useful to characterize aneurysms
and direct a more appropriate treatment.
Fistula Carotidocavernosa
Carotidcavernous fistula is an abnormal connection between the arterial carotid system
and the cavernous sinus. It is classified into direct or indirect.
Direct fistula is due to a high flow communication between the internal carotid artery
and the cavernous sinus, which can occur after trauma or be secondary to rupture of an
intracavernous aneurysm. Indirect or dural fistula is a low flow fistula that occurs between
meningeal branches of the carotid artery (external and / or internal) and the cavernous
sinus.
CT may demonstrate a widening of the cavernous sinus (high flow fistulas due to the
presence of intercavernous communications, can result in expansion of both cavernous
sinuses).
At MR imaging, dilation of venous structures, in particular the superior ophthalmic vein
and the cavernous sinus, is usually much more visible.
Asymmetrical increasing of the cavernous sinus and of the arterial caliber, prominent
intraosseous vessels and dilated cortical veins can be identified.
Cavernous sinus thrombosis is less common.
Secondary signs should always be searched, such as: proptosis, orbital edema and
thickening of the extraocular muscles.
In an attempt to directly visualize the fistula, angio-MR imaging and / or CT angiography
is necessary. These studies may also demonstrate early cavernous sinus, orbital veins
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and ipsilateral petrosal sinus filling, since there is communication with the arterial system.
Digital arteriography however remains the gold standard for characterizing the fistula.
Images for this section:
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Fig. 12: Chordoma. Axial post-gadolinium T1-weighted MR imaging demonstrates a
slight enhancing expansive lesion with its epicenter in the clivus and extension to the left
cavernous sinus.
Fig. 16: Nasopharyngeal carcinoma. Axial post-gadolinium T1-weighted MR images.
There is a lesion obliterating the pharyngeal left lateral recess and extending to the
ipsilateral pterygopalatine fossa (A, B). From the pterygopalatine fossa it extends
posteriorly and superiorly to reach the cavernous sinus (arrowhead in C). It also extends
superiorly through the inferior orbital fissure and then through the superior orbital fissure
to reach the cavernous sinus (black arrows in D).
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Fig. 25: Tolosa-Hunt syndrome. 19-year-old adolescent female, presenting retroorbital
pain and diplopia. The MR imaging study shows a lesion involving the right cavernous
sinus. The lesion is isointense on T1 (arrowhead in A), hypointense on T2 (arrow in
B) and demonstrates diffuse enhancement by gadolinium (C). The patient was treated
with corticosteroids, improved clinically and control examination performed after 47
days demonstrated almost complete resolution of the lesion.(Axial post-gadolinium T1weighed MR imaging)(arrowhead in D).
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Fig. 30: Sarcoidosis. 52-year-old woman, with pulmonary sarcoidosis treated for three
years, presenting right diplopia. There is a lesion with enhancement involving the right
cavernous sinus (arrow in A). It is noticed enhancement of dura mater anteriorly to the
cavernous sinuses, as well as in the frontoparietal high convexity, more evident on the
right (arrowheads in B). Hyperintense lesions affecting the periventricular white matter,
more evident on the left were also noticed on axial FLAIR MR imaging (C).
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Fig. 34: Partially thrombosed aneurysm. Coronal post-contrast T1-weighted MR imaging
demonstrates that patent lumen intensely enhances.
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Fig. 4: Trigeminal schwannoma. Dumbbell shaped lesion occupies the cerebellopontine
cistern and extending to the Meckel´s cave and left cavernous sinus, with small areas of
cystic / hemorrhagic degeneration. The lesion is hyperintense on T2.
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Fig. 5: Trigeminal schwannoma. Axial post-gadolinium T1-weighted MR imaging shows
a intense enhancing dumbbell shaped lesion occupying the cerebellopontine cistern and
extending to the Meckel´s cave and left cavernous sinus.
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Fig. 6: Cavernous hemangioma. Axial T2-weighted MR imaging shows a markedly
hyperintense lesion involving the right cavernous sinus.
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Fig. 7: Cavernous hemangioma. Axial T1-post-gadolinium - intermediate phase
demonstrates intense, progressive and centripetal enhancement.
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Fig. 8: Meningioma. Axial T1-weighted contrast-enhanced MR imaging demonstrates a
lesion involving the left cavernous sinus and determining ICA stenosis. It is also observed
intraorbital lesion extension through the superior orbital fissure and the dural tail sign.
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Fig. 9: Typical macroadenoma. Coronal T2-weighted MR imaging shows a isointense
to the gray matter lesion with a "snowman" shape, completely surrounding the right ICA
without determining stenosis.
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Fig. 10: Typical macroadenoma. Coronal post-gadolinium T1-weighted MR imaging
shows a lesion with intense homogeneous enhancement with a "snowman" shape,
completely surrounding the right ICA without determining stenosis.
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Fig. 11: Chordoma. Axial T2-weighted MR imaging demonstrates a heterogeneous and
predominantly hyperintense expansive lesion with its epicenter in the clivus and extension
to the left cavernous sinus.
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Fig. 13: Chordoma. CT shows bone erosion / destruction with calcifications and bony
fragments within the lesion.
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Fig. 14: Chondrosarcoma. Axial T2-weighted MR imaging shows a hyperintense lesion
with hypointense foci related with calcifications and epicenter in the left cavernous sinus.
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Fig. 15: Chondrosarcoma. Axial post-gadolinium T1-weighted MR imaging shows a
intense enhancing lesion with epicenter in the left cavernous sinus.
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Fig. 17: Rhabdomyosarcoma. 16-year old adolescent male. Bulky expansive lesion
involving the nasopharynx, sphenoid sinus, mid cranial fossa and the left cavernous
sinus. The lesion is isointense on T1.
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Fig. 18: Rhabdomyosarcoma. 16-year old adolescent male. Bulky expansive lesion
involving the nasopharynx, sphenoid sinus, mid cranial fossa and the left cavernous
sinus. The lesion is slightly hypointense on T2. There is opacification of the left mastoid
cells resulting from obstruction of the ipsilateral Eustachian tube.
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Fig. 19: Rhabdomyosarcoma. 16-year old adolescent male. Bulky expansive lesion
involving the nasopharynx, sphenoid sinus, mid cranial fossa and the left cavernous
sinus. The lesion shows diffuse moderate enhancement.
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Fig. 20: Non-Hodgkin lymphoma. Axial T2-weighed MR imaging shows a hypointense
lesion involving the left cavernous sinus.
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Fig. 21: Non-Hodgkin lymphoma. Axial post-gadolinium T1-weighed MR imaging shows
a diffuse homogeneous enhancing lesion involving the left cavernous sinus.
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Fig. 22: Non-Hodgkin lymphoma. Other findings: gadolinium-enhancing dural lesion and
diffuse bone infiltration characterized low signal on T1 (not shown).
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Fig. 23: 56-year-old woman, complaining of diplopia and without pathological
antecedents. Axial post-contrast T1-weighted MR imaging shows two nodular lesions in
the brain parenchyma. The hypothesis of secondary lesions has been suggested and the
diagnosis of inflammatory breast carcinoma was confirmed later.
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Fig. 24: 56-year-old woman, complaining of diplopia and without pathological
antecedents. Coronal post-contrast T1-weighted MR imaging shows a sellar lesion
with extension to the suprasellar lateral aspect of the right cavernous sinus with
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heterogeneous enhancement. The hypothesis of secondary lesion has been suggested
and the diagnosis of inflammatory breast carcinoma was confirmed later.
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Fig. 26: Thrombosis of the cavernous sinuses. Axial T2-weighted MR imaging. 15-yearold teenager male, with fever and headache for 10 days with significant worsening in
the last 12 hours. Intravenous antibiotic treatment was initiated, but the evolution was
not favorable and the patient developed thrombosis of the internal carotid arteries and
consequent cerebral infarcts.
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Fig. 27: Thrombosis of the cavernous sinuses. 15-year-old teenager male, with fever and
headache for 10 days with significant worsening in the last 12 hours. Sagittal T1-weighed
MR imaging (not shown) demonstrates secretions accumulation in the sphenoid sinus.
Coronal T1-weighed (also not shown) and axial post-contrast T1-weighed MR imaging
show enlargement of the cavernous sinuses with peripheral enhancement and central
filling defects. It is also noticed enhancement of the adjacent dura and the mucosa of
the sphenoid sinuses.
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Fig. 28: Tuberculosis. 34-year-old HIV + male patient presented the bilateral cavernous
sinus syndrome. Axial post-contrast T1-weighed MR imaging demonstrates diffuse and
nodular leptomeningeal enhancement at the skull base. It is also noticed expansion of
the fourth ventricle.
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Fig. 29: Tuberculosis. 34-year-old HIV + male patient presented the bilateral cavernous
sinus syndrome. Axial post-contrast T1-weighed MR imaging demonstrates diffuse and
nodular leptomeningeal enhancement at the skull base. It is also noticed expansion of
the fourth ventricle.
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Fig. 31: Patent aneurysm. Axial T2-weighet MR imaging shows a rounded lesion in the
left cavernous sinus with absence of signal (flow void).
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Fig. 32: Patent aneurysm. Axial post-contrast T1-weighet MR imaging shows intense
homogeneous enhancement of the entire lesion.
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Fig. 33: Partially thrombosed aneurysm. Axial T2-weighted MR imaging demonstrates
isointense areas (thrombus) and areas of flow void (patent lumen).
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Fig. 35: Partially thrombosed aneurysm. MR angiography confirms the aneurysmal
dilatation of the cavernous segment of the left internal carotid artery.
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Fig. 36: Direct carotidcavernous fistula. 45-year-old man, presenting acute right diplopia,
chemosis and pulsatile exophthalmos. Arterial phase MR angiography demonstrates
opacification and enlargement of the right cavernous sinus and significant dilation of the
superior ophthalmic vein.
Fig. 37: Direct carotidcavernous fistula. 45-year-old man, presenting acute right diplopia,
chemosis and pulsatile exophthalmos. Arterial phase MR angiography demonstrates
opacification and enlargement of the right cavernous sinus and significant dilation of the
superior ophthalmic vein.
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Fig. 38: Indirect carotidcavernous fistula. 62-year-old woman, presenting edema,
conjunctival hyperemia and diplopia for 45 days. Axial T2-weighed MR imaging shows
bilateral proptosis, more evident on the left and dilatation of the superior ophthalmic veins.
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Fig. 39: Indirect carotidcavernous fistula. 62-year-old woman, presenting edema,
conjunctival hyperemia and diplopia for 45 days. Arterial phase MR angiography shows
early opacification of cavernous sinuses.
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Findings and procedure details
A 1.5 Tesla MR is used to perfor the exams.
Protocol included systematically sagittal T1 pre contrast, axial T1 and T2 fast spin echo,
axial FLAIR, axial gradient echo, diffusion wheighted with ADC map, and axial T1 post
gadolinium injection.
Conclusion
Lesions of the cavernous sinus and parasellar regions encompass a wide variety of
neoplastic lesions, inflammatory / infectious diseases and vascular diseases. Some show
typical imaging characteristics, others are suspected by their topography and finally there
are lesions with unspecific imaging characteristics but with secondary findings and clinical
presentations that are key in the differential diagnosis.
Personal information
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