Venography of the Cavernous Sinus, Orbital Veins, and Basal Venous Plexus

Abstract

The dural sinuses about the base of the skull have received little attention in radiological literature. When opacified, the cavernous sinus together with the intercavernous sinuses offer intimate information about the configuration of the pituitary gland. In addition, free communication with the ophthalmic veins allows investigation for orbital mass lesions. The purpose of this report is to outline a technic for passing a catheter percutaneously via the internal jugular vein into the inferior petrosal sinus to visualize the cavernous sinus and orbital veins. Anatomy Free communication exists between the many rich venous plexuses about the base of the skull. Relatively large channels, the superior and inferior petrosal sinuses, unite the sigmoid sinus with the cavernous sinus. The superior ophthalmic vein drains directly into the cavernous sinus through the superior orbital fissure. The inferior ophthalmic vein may drain posteriorly directly into the cavernous sinus or to the pterygoid plexus. The pterygoid plexus communicates with the cavernous sinus through the foramina ovale, spinosum, and rotundum. Blood also leaves the superior and inferior ophthalmic veins to enter first the anterior facial vein, then goes to a separate channel that connects the internal and external jugular veins. The internal jugular vein begins as the superior jugular bulb at the jugular foramen in the suture between the petrous bone and the basal portion of the occipital bone. The jugular bulb is formed by the sigmoid sinus entering laterally to unite with the inferior petrosal sinus originating anteromedially. The glossopharyngeal, vagus, and accessory nerves lie between fibrous septa at the junction of the two sinuses. Technic Materials: We use a Wickbom needle (approximately 17-gauge 7 em thin-walled needle) for the jugular vein puncture. A Se1dinger type guide wire (O.D. 0.0315 in.) is passed through the needle to allow percutaneous insertion of a white polyethylene catheter! that has a preformed curve-tapered tip. An image intensifier that can be readily changed from the vertical to horizontal x-ray beam is essential for fluoroscopic maneuvering and control of the catheter. Procedure: The neck of the patient is prepared and draped for sterile puncture in a manner similar to that for carotid angiography. The skin and subcutaneous tissues are infiltrated with 1 per cent Xylocaine. Approximately 3 to 4 em above the clavicle and along the medial border of the sternocleidomastoid muscle a 2 to 3 mm stab wound of the skin is made to prevent hang-up of the catheter. Since the catheter is larger in diameter than the needle, this would invariably occur. A plain-tip syringe containing 5 cc of 1 per cent Xylocaine is attached to the Wickbom needle.