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Phlebography of the cavernous and intercavernous sinuses
Phlebogmphy of the Cavernous and Intercavernous Sinuses Et+~P+~)de DMIii+, M+|)+ ++ Renat() SFt:iante+ M, D++* + Vitmri+) laccath+o, MAt+++ Lm+c+o~:celia+ M+D+++ at++ l+t~igi Gentwe++ b.LD++
The +tt+dy~+|pitui|ar}" di+ea-~+~ i+ de,~¢ri|+,.xt+with vi+uaikation of !t i>a|m++>t always prc~++nt; hmvev+r+ mmetimes+ instead of the ¢avernou~ a+~dinte~we~nou~ ~ime,e~ a¢¢~+mpli~h~dthrough bcmg a +ramie d m t m d , it i+ made up of a fine+ rich plexus D:+eulanem+s+ tr,m+i++mora|+athctcri:atio~+ ++i+g +~+iM meth+ ttmt +cove+ t+u+t of the &ira mater of t:he fltulr of the rim+ ~+ m et++u¢+|ix ¢diabilR++ The m~+,itharatte+i+li+ normal and itaty l~>+a {4+ 8j {Fig+ 3)+ The ~utmior i~temavemous path+kg4G+| findin~ a¢~+diverted+ The vaI~,: Of lhi~ m¢lhi~ a~3 +mus i the ++am+west md ti~e tin+st variably Rmnd | i4+ I6L +he iodication, f~+¢its + ~ c in di+tg,~++i+~are dbcu+~i++ The p.~++~i+ ~+~+ing~i~+a+cd along d+e ~+pl~+rcd~v of the &+r~mn ~2Ilae+ hilitg of ¢omhlning mo+holo+:ica| im++ti~,:adOn+ with n:~:kmal }++>r| + + ~ t h the D++vP+~+¢di+oids (Fig+ X+)+ Px+th the D+++ ~+netbnal ++udle. ~+fpituitary; |mcP+um¢+b+ ~+cl+ecli+¢ M~+~Y~+m+ retie| and interior ieteteavet+um+ +imue+~ have a +light an+ plin+ i.~ +ugg~.+t++d+Th+ Ieeh+~ica| dev¢l++m+nt open> +set pro,+ { e ~ r Concavity+ p~+¢+s+*wthe |ira+re a+d |urihe+ |+t++ade++++he i+dk+a~i+m+h+r ++e |chic to their I~ati~m their ch~:.e proximity t~+ the o|+thi+~pu+c+edu+;++ hVF~+ph+:.+++ and their mi+demt+ mtema| pr~:+tim+ +he+-+ three re+all +im++~+++~ w c i a | i y +he at~&+i++rand it:dcrkm are pa+rti¢+t+a+iy m++ceplib+e +++¢ap|y |no+am+ +ff +premium within +he pit{++lag (~+>+~a+Eve++ wheI~ tile p+++++t+tc ¢t+aagm's are CeltiC+ b+:ct+mv a h+Ht++++ i+W+,',t+~J++Otl +~+r p i t + t i t ; i t +~|++-c+t~+ minimal ;rod |+~a|i:~+d+ thg,~,veffect+ era+ |+++++,:vn wall ~41~+e i4L ++h|u,+~+ch ~rm++ il~t¢++:+t t+~at + e ~++ie+¢ it+d> +tvtho,| t|~e ~d|a ~u+¢~c~ ~4L Thi~ is the p+in¢ipa| team+a whx/ :.h~mt3 |... mud+ m o t +~ddy +t+d+ phtvh+~taphv ++~+!+~+h ~+vat i~ter~,,,,t+ A+~at~+mka| Aspe¢ts The hvD+ph~al +~+~.a+- +~+mwdchic+iv ~++the ++.vH~+urcica +t ++ do+.cd +~q+~++++~++tvh~ t|+ d+aphm~ma +llae~ whict+ ,,++¢h+ K+t+~ce|~ +he mterc+/a~.d Ii+m+¢++++++m,+tlw L++eml |+,+~++++ia++e.;+tr h++tlu++Jby the +avv+~o~|+ +++it+++,>+ Nart+m+ ++atl.verw ve++~t++>inlet+tip}+ with the chata++ +cr++tk> ,+t cerv|mt| vcn++t+ ~+rm~e++ rim wi+|+m die di+m/ m+l+er of the ~eiIat +~+r m d ptovh|¢ at~+tom++¢s b¢0xcvI+ the cavvmo,+ smut+e+ tFiV+ +L Wlwrc ate ti,tlally three of lhvse anas~,+m~,~e~ wh+ch are term~+d the +interior+ int~,rior~
M;m:+hl and Mvdu+d h~ ~l~• pa~+ tadi~r~ph+c visuah:amm ~+f ff~e cav,:mtm~ a pm~+tary adtmmm+ The two mel|u~t~ ¢+~:d wv¢¢ inje~:dtm ~a a ff+m+;d veto and c~¢m+et¢~+r+e~t injection via the ~mdar vcm 12 17L
The medical ~ . . s e i+~din+ interested by l'~'lver+ ;rod a,~.u~. cia~e~ 14[. in ~hich sck~;tiv¢ catheleti:atitm of the inferior F~.m~sal ~inus (~++m:+ll}the tight sin,s) is done b~,+the ~r+ c++fa+~eous+ tran;femoral to~+te+ This gives a go~.t picture of
+||~I++|tX+~t+fh+t II~teIi%tV~++rllOt|+ +i|~||+t'+
The interior mlercavcmoa~ ~m~+.~ flu + Liggett and the mint ++eq++cm|+|,+ew+n ++++he it+re ~4+ 8i ff+~:+ ~+)+ m.+ m tl~e ai+++t++u|~++i~+pat+ uf th~++tic+ t~++<
A 7 ~+r"8F cad~vler u+ith prcfom~cd three i~ inm~t~ed via d~e tight tbm~md veto ~km~ d~c i,~i~i~r vena cava i ~ o the +i~hl at+im+u I+~+mlhele it ++pushed along the s~+~rior ve~m c+va t~+ the ~+I'+:+k++b+db of +l~e ti~ht mtema| jt+++k:ir veim With the aid o+ t+~mtaI and lateral flmm>+opi¢ image++ one aIwmpb t~+ ente+ the mfedor +++etromd +inu+ i+ a~ an+ teromediaL +++D:rio+di+eeti+m+ The tip ~+fthe cad~eter mu+ ally eaters d+e +ira+++b++ti+ d++s not pt~Ke~'.+~+r mote tha~ a F++m+++.I+++i++++Net++..}a+++re+c,+a+++l+L+'+++m+d+ R+d~4 ++:+.+2+~ f.+.++++++ +bw mill|mete+, l++)~ceco+eel ~+itkming of the catheter bats +++.Me+|+~i+++++,e t h++'~+~+++o~ ++++++++++++|+N++I~+I{+Na+p+¢+++t++~++ N + n obtai~l+ the t~di0gm+phi¢ in-tin|ignition g carded +t+ +~+++++{'++¢p¢++++ +++|++~+~t~|t+ t++l ~e++*+~++~p+~+L+++I++%~ | ~ m a Ne~m~h++++++ Vatlo~+ pc+vice+it+n+(stlch + the h¢eml ~+thigh h{mm|} ea~ ~++.a+2++JL+,~4+ad+ M~+dm+m~e ++~+++++++V++ P+m*m+N+ ~+ ~++++ Pro+t++cd+ |:+t+tfi+r dream+silt g+++e+ Hitt=+s axia| prt+eetion NaSa++ bah K+.+ m++A+|4+b~++++h++ ++~+~+~ ++m+.+m+eP;a+~q++ ,+m++++,+w||+++ ++ bv far +he k-++ I4L ~+ial vie++++a w taken rapidly (one +cg+++++p++~++~+.+¢+++&+++++m+L .+vk+v++~¢+++'++++.~a~+p|+~G radial|am f+¢ mecond to+ 8 +o I0 moon&)+ and an auto+ ~
&+*©++~I++S I ; 0 4 0 ~ + 0 7 ~ I 2~ :~ +~0 b~¸ L+~tle+I~+wn +rod ~ +++m~my(In¢+)
de |)ivitiis c~ ~t|; |$~|el-~g¢~phy ~t IntetGtvernou~ Sinuse~
A
B
m~tic inj~.:tor delivers 20 ml of ~ r l ~ t m~ium (we prefer ~X~ megM~ine di~tri:oate |Ur~,¢~fi~L ~ince we ~he~,e it Dyes ~he ~ s t #|e~gra#~ic pict/~te) with a flow M 5 ~o 7 ml per ~:c~nd~ In ~xia| views d~e ~llar ~gion is ps~j¢~t¢~ onto the relatively t tent image of the sphen~-~M~d sinus and the three intercaverno~s sinuses can ~: ck-arl~ identified bec~lu~ethey are not obscured by other str~cr~res, sltch as the bnsihr venous plex~s (the rich|~" ana~tomotic #exus connecting the two inf,.riot ~:trosal sinuses~ which~ esp~:c:iai|~• in ~ n t a i "¢iews~ ~c~mes sl~F~dm~ed ot~ the inferior and ~sterior in~e~cavemo~s sin~s)~ The ~s~ltin~ #|ebt~g,~m is clear e to be interfere& ~ it i~ ~ s r ro ~d~rm im;~ges~btraction in order to ~void e~ors c~u~d b~. the si¢~rimrosition of vat(oils bony smtctiires (Figs. 3, 4L Adt~t~ate injection provides complete filling of the right caverno~S sin~s~ the d ~ incercavemous sinuses, the let~ cap.moils 8inus~ the orbital veins~ t|~e inferior ~:trosa| sin~ses~ the basi|ar venott4 plext~s~ :rod the intem;~l j@idar veins. Teehnica|iy the investigat~r~ is ~ceptable whcr~ ~here is g ~ d filling of ~he su~riot orbital vein on the side op~site to that i n j ~ t ~ i4]. |n:~llfficient q~ntity or t/ow of c~m~rast m~xiitm~ iml:~-r~%ctcatheteri:ation tff d~e inferior I-,etr~al sirtt~s~ or preferential| flow via the ~si|ar ve~t~s piex~s ma,i call fc,t either simadta~eous percute.,~e~us t~ns~ femoral catheteri:ation of the coati, lateral inferior l~tt~a| sin.s (Fig. 2) or compte~,km of the interns| jug~l;Ir vein in the neck.
~5260
Under norma| conditions (Fig, 2) the cavemo~s sinu~s f o ~ ~x~ br~ad ~ n & at ~he lateral a ~ c t s of the pit~itap~" f ~ . ~ e i r ¢eguk~rmedia| e~dge is straight l~r siightIy c~m- Fi~ 3 N , ~ L ~ h ~ ' ~ i ~ m ~', =~t~'~Bxs~ T&. iaJCn~ m ~ cave, The radiot~r'M~cent image of the internal car~tid c , ~ ~u~ t,. ,~t~. ~ ~.~fafi,¢. rich~xu~ ~a~o~ ck~t¢ ~ ~ e P i is seen within ~he cavernous slm~s. The~e is a|~aVs 8 . l ~ l ~,f |he d~¢.l ~. l¢¢~,4 ~ , ~b~,~"¢,i (go ¢~t~d~.,~~)¢;~s~a
307
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tee 5+ Ph¢:b-+m+m+++ax+atpr-~',++++m+T~+ ~O+d ++a++~,+++j'<~++Jq am+~++++ ,mu+ +++++m+ve~.Mi+~i+ ~m~+~ g+a++{|ar++~a+ow)+ ~ h ~+m+ i+ +~+++pum++~+t+hin am+we)+ The ++q~++ +n+~++++,+a++~++++~m + -+++,++q+,:.i++e. ++Pro +~+m~++++++no+>,++ +4~h+ p+~+++a+¢;,+m+
+:+v 4 3.++++,~dph+,+b++++mm++va++++++~+,+++.+O++,+u+&+c+~dp+gm++ The: +,h~+
++++ewd+~+~++~gh+++++ Oh+~v++++++~+~++~cgu+c.+Fhc +++~++,'++mt~+c+++mcm+ +++++mu+ + ++++++p:~m+++:+++++~¢++++, p~+~4++m++meh++L+,+~~ :he ++q++++mp~+dk++y +g++++:e++++'<++++ + +~+~+ mum+++p++b~++ ++++:++I +++~+~ 3+ ~++h+++
++~+~+
mr+k++++++, + + + l ~
+|tip of c~mtra,+ medium b~etween the in~ema| ca+otid a++e~+ a~d the media+ ma+a:+r++ff ~he +ira+s° T h e three i~+ercavemo~++ sim++4s +orm ha+row t m m v e ~ + ban&+ T h e a~te+ioP is stmigh++ a~d the ~++her two am +h~htlv c~mcave a+teHodv+ T h e infeti++~ i+te+cavemm,s smt++~ i ~+~+a~|vch++~ t~+ ~he D+~s~etio~i~tercave~m~u simms+ W h e ~ in+e@+tin~ phlebagmms+ ho~++ver+ it i+ imp~++tant to+ {u:+a+i~ mind that anattm~icM varkmt+ ~+f vent+u+ stout+ +m+~++£ale nm++~|~com+++{+~ Phk%+~pk+e A+'m+++mm+h+~,.+:+ Pm+ita~+ disea+,++ ¢at~+t.s ahemtitms +of +he ph| phic +indiag+ d+sctib~+d ahwe+ Eve~ minimal cha~ge+ o f pressure wi~hir+ the pit~+im~+ + ~ + can cause comp~e~ion o~ dis+ placement o f the+e delicate venous strocmte++ T h e m~+&a| ma+em o f the ¢avemo++ sire++ ~ c o m e + d e f o ~ e d and the ~ n d oleo+intrust medmm medml to the internal cau+t+d ½+
+mu+ +~++u++.+e,+e.1+n +~ &+to~+~i+bemv~m+he +u,, am+~+ T+e ge+i+m ++~u+m++mop+curacym++~g++~.m++,.~+upy+g~+ +¢[+~+,f+hegt++~+ The +n~5¢+h+mgcw++v+~+m,ainu+ t+,+ ~+m~emm+~.+~+<++++
comes p ivelv na~ower or even d i ~ a p ~ a ~ |4, 13] (Fig. 5L ~ h e amcr~or and inferior in~e~avemous +inure+ which a~v mo~+ c h ~ b + m ¢~mtac+ with the pitu~ta~++ ~ ¢ o m e fl~t+ ten+] ca+{+ o+ a + amputat+J {Fig. 6}. | may e a u ~ ~ h ~ v*o s i m ~ s m ~ a p ~ m wi~h a ma~ked inerea+e o f ~he concavity o f t h e inferior intetca
simms {Fig 5}+ A |esion deve|oping anterkMy ma}' o M i ~ m t e the anterior inte~averr~+us ~inus~ p ~ x J ~ i n g a cb~re+'is. ~ie O++ha~'~ image on the ph m [41 {Fig. 7 ) m
d~. |++~+++~+~'t M: Ph}c+~+++:+++++|+v++++h+lcr~:++++cm+m++~+++i++c+ 309
+++y++a++l+ ~++t++~+++p+++~+ti+O++n++~+d m t~ C~+t ++++if+h+++++
c++~:a+m# t~,+++++m+ i~ ~nammic~}B,sition, the B~t¢~}o~}me,cavernous~imL-, d c ~ not ,a~a|ly invo|ved ~nti| th~ te~on ~d~ p~.,+ duces ~|terat~orts of the ¢ntitc +¢iI~ t~tt¢~ca, mchMin~ the do.urn s¢ilae Enlarging lesions progressively cause the di~appe~wance of the infi2rior and nnterior intercavemous sinuses, while the pc~sterior one may b,:come hy~.rm~phic a~:fi~t ~tbrc +t to~+ disappear:s (Fig. 8L The cavernous sinu~:s beck+me stcgm#~" concave media|ly+ displi~:ed laterally I6L and of d e c r e e d thickness [ 13I* ~met/mcs VC~; targc Ies~ons bk~k the m+ ~ercavemous sirm~'s comp|eteiy ~md thus prevent tmih,teral injection from filling h~tt~ cavemou~ sim~ses a~ the a m e time (FIR. 9L lnfihmtion of ~he cavemot+s sitars by a ne,+plastic leskm ¢m,~e~. a filling: decec~ with i~e~ld;+r, jacked
edges (F~g+ 10) ~he l~cet of the ph|cF~¢mm of gteate.q mter~'~ i-. d~at minor c h a n ~ , such as ~ a l l tmih~te~l cdte~ations ~+fthe mMia| ~ l i of ~ cavemc~s +im~ o~ d~,~hcemmt o, ilmtxm++ tion of an intetcavemous sinus+ can h+ seen F~,-6~tc ~mv ahemtions of the ~:|la t~r¢ica become app;ircnt or when thes~ alte~tions are minimal |41. Indications Pit~ita~ micm~denoma+ ptovid~ the mo~t interesting ;rod the most im~+~tant indi¢a~io~ for phlebugmphv of the in.
t
310 S~fgicalNeumkNy Vol ~5 No 4 Aptd P)+|
this di;~m'~is and justifies surgical action+ The ph|eN++ gr.ff~ic picture d ~ i m ~ {Miot~thic) empw ~lla either is almost completely normal or, in more advanced l~rms+ is characterized b)+an increasing of the distances ~tween the cavernous sinum+sand between the inrercavemot+s sim+~s {namely tile amerior and die infer|up ones)+ ~:cat+++at+the enlargement i~t+the ~A|a t~+Nica+ However+ ones &~s not .~eethn+: signs t+fasymmetrieN and circunua:ri~d pressure+ either on the cavernous or on the intemavemous sinuses+ that aw characteristic of an adenoma (as de~crii~d al:~ve). The pre~nce of such signs unmistakably evokes the exis+ tence of an expansive k.skm (adennma) Complications No majt~r ¢omNieations have ~ e n i;bserved either in ~ r ca~s or in tho~ rep~+rted in the literature {181. In expert hands the investigation is easy m ~ffonn+ rakes le~ than P~+~++~ +++~k'~+++++m a~+a+H,W,:~+++~+The ~+++P+++&+++m++fi+m +:+l ;,,b.++ one lu~ur &,es not requiie a general anesthetic or heavy tb~t++he~m++++++~+++#+:n~++i+++++<~ucm+m++tomes~,c am/m~l+++d+ ~ scdatMn+ is well m|emted+ and can t:~a~ffomled on an oute+'~"~m+++m++++in+v+ a + 1++++,+~++mare++T¢+cm+:&d .++g+. +4 +b: ~I+ +dI¢++IOa+P++++1|~+++ + + ~ % + J ~+~d +~'~,r~+~r+ +++++~+++teSt P+++++&~++++ ++++~++|+ patient basg. As a precaution the patient sh(mld be given ++++hec~m++d+++mrs:sam+:is++iv +,b+,c~t,d.The ~++w+a~+m+~+~+aG+a heparin+ We have not observed extmva~don d contrast ++a+++++lu++y,g++++mt ++ifihmm+gJw gel++++a+cm+ms+++++,~+ medium or pJptured ve~|s+ even in Ixltients with increased v ~ a l a r f~gi|it~" (Cushing*s disea~eL Even if tb~zse problems were m c~:ur+ we &a r~t ~|ieve that they wouM tercavemou+ s/hums { t81. Lesions only }mm in diameter represent ..~6ous complications+ cause marked phieb,~gmphic t+hanges lind; this is a great improvement over findings obtained from computeri:ed Future Prospects tomo~tmphlc (C~) scans, which can only detect lesions of 7 T~e method o f rcrcmaneous~ tmnsfemom} catheteri~dnn mm or larger [ l 51 12L Phle t h ~ provides the that ~'e use R~r phlebogmphy of the intercavemous sinuses earlWst diagram*isof an lntmeellar Ieskm ~+erefom+ we feel aim gives us the chance t o measure the level of the pitu~ that it i+ an e+~e~tia/investigation liar all patients susg~cvcd icag" harm|mrs in vadmls parts of the ~d}" Currendy we of having a pituitary adenoma+ even when no ~ellar ehange~ take bkx~d rumples from the common iliac vein. the left are present (~rade OL In this sitiiatio~ it is the investigation renal vein ( i n n which the le+~adrenal vein usually dminsL of choice. The concardance o+ phleN~gmphic and clinical the hepatic veins, the tight atrium. R~th in~ernal jugular findmgs alh+ws ~me m p¢,~eed with an ~ m t i ~ m withmlt veins, and the inferior ~ m ~ l sinus. Thus all the main pituitary bare, ones can be measured (F@+ l IL the nc*ed R+r further diagnostic pr~,ed++~es|4+ 18/+ Stmh >:lecdve sampling iS U~fu| ~eau~e it facilitates a With larger sdlar lesions that can ~ diagno~-d by other radio|ogicat methc,als. ph|eb~gmp|wy comp|ements these detailed stndy nfpituita~ activity (R~ example+ sampling at methods and p+ovides preoperative infi+rmation as to (I) the infi±tit~r~ t m m | sin~, which drains the pituit:ay arc~+ the hteral expansum o+ the ~llar minor {91 13|; (2) the measurt~ blc~d levels ~fore dilution c~cur~ with ble,~ sit~ of the carotid sip|runs and of the cavernous and inter+ from other p~=s of {he h~,dr): this methc-] also allmv~ the cavemnus sinuses; ++nd(3) the involvement of the cavern+ determination of any ~topicalty produced substances with ous stresses 119+ 201+ This is esN~cialty mefut when the hormonal activity, which can cause a clinical syndrome transsphenoidal muu~ is to be reed [ 161; for instance, when that resembles pituitary dimrder.~+ This problem ~mca~ e++ the ~sirion and the nature ~ff the +nfieriorintercavemous l,ecially in mine t y ~ s of Cushlng's syndrome {3+ 101+when sinus are knt~wm one can av~+id troublesome b|eeding at it may ~ difficult to i:e or exclude primary pituitae¢ o~mtion [4, ISL Similady~ preo~mtive evidence that a di~mJe~; such tesions may ~ extmpttuita~*+ in which case neop|asdc lesion is infiltrating the cavemnus sinus leads to a pituimD" o~vmtiun ~a~ould~ completely unsuccessful +rhg is on|y a preliminart reign=+ since we do not yet the Correct choice lff treatment I2+ I1 I+ In our opinion+ #le~+gmphy is al~+ t+seful in studying have +~fficiem data m show statistical significance. How+ the empty sella when one suspects that there is an a s c i i ever. we have already ~ e a a i n e d that prolactin levels ate ated l~ion such as an adenoma, ~ e pr~ence d phle~+ higher centml|y than peripherally+ | h a this ~ d i e n t ~-'.aphic si~.~azD~cal of"an adenoma is ~lid confi,natkm markedly incnaa~d in patients with h ~ m l a c t i n e m i a due
de D+vm+,, e+ a|+ Phic}~+e++aphv+~++I|r++,+:g+,:av,ct++++++++Stow,c+ $I I
m~{s am/+0r d~e pa.~pc~a~h'c sin&+:++of~+thc~ +ypes oI ~,cllar Whc~l o~c tries tO dote(* d~c smaHcsi iIllta~,|hr ~g evcl~ iIl{r~piluRaPf lc:,~m as car|if as ~+,s,b~e+ a+~d whe~ dia}m~+~, ~i¢ exploralioi~ of d~e pitmtaW {os,,a at limes ~ccm~ h~ bc jus{ihcd | ?l+ we mamhd+] that p|~Db,}~traphy ~cpw,ct]t~ m+c pr{~.~,+ The mdka+um., ~+~ i+s ~++,amplc.~ ++h}m whd+ h+ mcas+++c +c~i+m;d l+vel+ ++fhor+m,r+c<
Rdm,.~es
Fig '+1%~+s++us ++++:,,l++++h+,+u+k'+:+hvm~++Ve++<+qH++++++.+,,+++++~+++y+
{a+C+sm'mm+k+~c,+++g.+{~} L+:{~:+,c+,+,a~re+i,++++{c+ H + + + +~v++ ~d) R+Kht,~++:+++am{<) h~t++++'+++++++&+ ~++'++++({} I++~+q+++++lm1+md ++++I++
h+ a micmadeaoma+ amd ~ha~ ia d~e~: padems ~hcw are dis~inc{ dfffi:~c~cc,~ ~t~+,'*+:'e~ the levels ~r+ ti~e Iwo imemal B=gular vei~+ gikewi+~e, m pa~{ent, with C~4~in~'sdisease, ad~cm,¢or~ic~m~pic h~m~onc {ACTIt) concc~{¢ad{m m d~c iaferiot p~m~al +im+~+c~}mpated with A C g H coacen+ ~mtu,m +r~ a p+a~ipi+,,+++~alvein. is hi+.d~cr hy a / ~ c a ~ ~g +wo o~r mr:,,++ A larger m+mk++ ~+fcam:+ is n~vx,.+a+ l~+rthese r,:s.hs +~}Pro"|~+liy eva|uated+ b+++them a + a+~.ad+ similar +er~}+fs i++ d'+c Ihcmmrc {++ lO+ 18I+
Phle~<~gva~w of 1he ime~cave~u+ ,m*a:~+ is a~ m~stiga+ don that is ea,++ym l+'+g++~+m+++is well ill+Dinted+ and has n,++ mr++ ¢omplica+kms+ Ti+e a~awmieal aad f.~c+hmaI characteristics of the delicate vcn~+> sin+crates ar~umd +he pimimef f{~+~ allow eady r e c ~ i t i o a o{ even mimma| at+ tem¢ioa+ of its ¢(mtcnr+ Fo~ lemon+ +mall,+++.+thaa 7 mm i+ ,Jkm*¢I¢~, ~,~'hichate m~,t ~++.atly ++It d ¢ + n ~ with C + mam~i+, we ~+~lmv+ +hat phD ph+¢ i+ the iavcstigation of ch{+ke la cx~n+t
M2 Sl~rga'alNt.~m4ogv',A4 ~5 N++4 Apri| i981
+5 Rh+m+'qAL+ 'i }lardyIKL CharoN+i++SM M~¢+o+,,+++gt++d +m+++~m+ ,+++++r,+~i l& ~4m~ J [N,gea~li¢ dte~adcm~m~ mme.elk,re~ p~r phleb*~taphie de~ ~im~ mlereav~meux+ in P~gmhng.~ of the ~4¢.o~,d gur~.a~, +(h+e+t++m,,if+i+e.rhm.d hm¢+¢awm,m:+.~+++++aM +dis++e~+~*++ S++~Nvuvr,+12:0,+-lO4+Io7,+ W.~Gh ,r o~ tStmtary Aden.ms++, I3ns+ .%:~emN¢ 20-22. PaN It, Rh,,+++,+~AL+ Ham~+'S Rem~WH M+¢m~utgicidatom+myof die pa Walkc+JR+ffat~12D:P+t~m~+~'a+J,:mt+mapt++:v.*ntinga~n:i'+,tmngpait,. +++I+++phthah+r, ple¢++++St+inNetm48:+1%~2+. 1+77 .,'++:ila+¢+v~++ma;~d+:+~em+.m,+>m~+++C[+nNeu+,++v~+e24:+4+8++++77 ! 7+ T.,veta~JM. W~+~El+:['m+m+t++mm+~.++~li,+4~m+,ed 2+B++hmu+r+:++ 20+ W+!mm(g+ I\+mp,,e+~C: Tr;m+phcn+,'++L+[+met.inimical+em<+al+if gdham>& \'++qik{+~+1+~6+12GIpp 2++0rm+++;+tv;+¢.,+.++x. ] +'+~e.l+++mme 4s:l }-22, I978
Book Review E~ot Cnm~unds and Brain Function: Ncun~:ndocrine bromncdp0ne; the medical management of acmmegaty with bmm~)criptine and the treatment of the amenorrhea+ and Neuropsychiatric Aspects (in Advance~ in Biochemical Psycho#armacokNy, VoL 23) ~dacu~hea syndrome in women with suspected pituitary edited b:, +',£,.& G,,N:,tein, D.mdd B+ Cab,c+ micmaden.mas are Ix+th addrc~+d as well Atm&~m Lieb~'r~mm. and Mi&a¢t ()+ TMmcr+ N,ew Y+uk+ Phammcothempy of parkinmmism is covered in a brief * t P+¢~. 1980 Rca¢, review+ A R4k+w.upof ,p m five yea~ is giv~enin >Ain~onism patient.~ treate~ with bmmocdptine+ A compari~m 43I Ira+ R~.aewed ~b Gc.+VeJ+/),k-reran, M,D. Ph.D. ,od Hden L M.m+~m, M+D++ Chic,<.+ I~in+m This hardRmnd nob+me contains a .~enes ~f pape~ pre+ s~med ~ a ~vmposium+ Er~:ot A&ak~id. m Neumkgic+ Nei+mp.+~°chiamc and Ne~m~vn&vrine DiumJe~+ hem it} New Y~+rkin ~9D. It is publi+.hcda> the twenty.third nob rune of A&~mce~ m Bi~chcrmc,d [email protected]~c.b~ag*The 39 papers are divid+xt into the lb~lowing ections: bic~hem+ i~t~"and pharm~mdoey+neuroe~&~dnology+ parkinumim~+ gcrmmc dim)triers+:rod dvskin,:sia. O~ interest ~o rh~se in the dingaI a~d basic netm,~+v ences is a review of tt~¢ c~rrent kn~+wledee~g ere~.~+corn+ p.mnds+ Ergut actions at catechoiamine receptor.., erranteL k.cts {m co~eicaland striata] doF<+minendicand serot.net~ic ~eceptt~rs, and tl~e interactions ~tween ergot derNat~ves and rbe cvchc nuc|eotide system are di~guss~+ Some e m phasis is given m the neurophatmacd~+;~¢of synthetic ergot detivaives in man aM the pharmacokinetica of bmmo+ criptine m man. The section dinting with neur
of bmmcrare that their review is of*+mughly comparable ..urines" and recommend furfl~er re,,~arch+ ~ e difficulty with the review is clarified in the ch;kpter comparing rating scales mea>uringmlt~mm of tm~tmen~ in the geriaric >> tient Gmfounding ratit~oas, lack of meaurement of emotional £tctors, and the limitation of single ~ales applied m th& complex +x~pulationdo not permit adequate assessment of outcome+ The Iack of impm~ment of dyskinetic padems or of the mntor and c¢Nnkive dist,~tmncm in schimphreni¢ patients t+ea{ed w~th etgo~ dop~dne a~mgts is well presented althtm+ah the mdng ~
The +tt+dy~+|pitui|ar}" di+ea-~+~ i+ de,~¢ri|+,.xt+with vi+uaikation of !t i>a|m++>t always prc~++nt; hmvev+r+ mmetimes+ instead of the ¢avernou~ a+~dinte~we~nou~ ~ime,e~ a¢¢~+mpli~h~dthrough bcmg a +ramie d m t m d , it i+ made up of a fine+ rich plexus D:+eulanem+s+ tr,m+i++mora|+athctcri:atio~+ ++i+g +~+iM meth+ ttmt +cove+ t+u+t of the &ira mater of t:he fltulr of the rim+ ~+ m et++u¢+|ix ¢diabilR++ The m~+,itharatte+i+li+ normal and itaty l~>+a {4+ 8j {Fig+ 3)+ The ~utmior i~temavemous path+kg4G+| findin~ a¢~+diverted+ The vaI~,: Of lhi~ m¢lhi~ a~3 +mus i the ++am+west md ti~e tin+st variably Rmnd | i4+ I6L +he iodication, f~+¢its + ~ c in di+tg,~++i+~are dbcu+~i++ The p.~++~i+ ~+~+ing~i~+a+cd along d+e ~+pl~+rcd~v of the &+r~mn ~2Ilae+ hilitg of ¢omhlning mo+holo+:ica| im++ti~,:adOn+ with n:~:kmal }++>r| + + ~ t h the D++vP+~+¢di+oids (Fig+ X+)+ Px+th the D+++ ~+netbnal ++udle. ~+fpituitary; |mcP+um¢+b+ ~+cl+ecli+¢ M~+~Y~+m+ retie| and interior ieteteavet+um+ +imue+~ have a +light an+ plin+ i.~ +ugg~.+t++d+Th+ Ieeh+~ica| dev¢l++m+nt open> +set pro,+ { e ~ r Concavity+ p~+¢+s+*wthe |ira+re a+d |urihe+ |+t++ade++++he i+dk+a~i+m+h+r ++e |chic to their I~ati~m their ch~:.e proximity t~+ the o|+thi+~pu+c+edu+;++ hVF~+ph+:.+++ and their mi+demt+ mtema| pr~:+tim+ +he+-+ three re+all +im++~+++~ w c i a | i y +he at~&+i++rand it:dcrkm are pa+rti¢+t+a+iy m++ceplib+e +++¢ap|y |no+am+ +ff +premium within +he pit{++lag (~+>+~a+Eve++ wheI~ tile p+++++t+tc ¢t+aagm's are CeltiC+ b+:ct+mv a h+Ht++++ i+W+,',t+~J++Otl +~+r p i t + t i t ; i t +~|++-c+t~+ minimal ;rod |+~a|i:~+d+ thg,~,veffect+ era+ |+++++,:vn wall ~41~+e i4L ++h|u,+
M;m:+hl and Mvdu+d h~ ~l~• pa~+ tadi~r~ph+c visuah:amm ~+f ff~e cav,:mtm~ a pm~+tary adtmmm+ The two mel|u~t~ ¢+~:d wv¢¢ inje~:dtm ~a a ff+m+;d veto and c~¢m+et¢~+r+e~t injection via the ~mdar vcm 12 17L
The medical ~ . . s e i+~din+ interested by l'~'lver+ ;rod a,~.u~. cia~e~ 14[. in ~hich sck~;tiv¢ catheleti:atitm of the inferior F~.m~sal ~inus (~++m:+ll}the tight sin,s) is done b~,+the ~r+ c++fa+~eous+ tran;femoral to~+te+ This gives a go~.t picture of
+||~I++|tX+~t+fh+t II~teIi%tV~++rllOt|+ +i|~||+t'+
The interior mlercavcmoa~ ~m~+.~ flu + Liggett and the mint ++eq++cm|+|,+ew+n ++++he it+re ~4+ 8i ff+~:+ ~+)+ m.+ m tl~e ai+++t++u|~++i~+pat+ uf th~++tic+ t~++<
A 7 ~+r"8F cad~vler u+ith prcfom~cd three i~ inm~t~ed via d~e tight tbm~md veto ~km~ d~c i,~i~i~r vena cava i ~ o the +i~hl at+im+u I+~+mlhele it ++pushed along the s~+~rior ve~m c+va t~+ the ~+I'+:+k++b+db of +l~e ti~ht mtema| jt+++k:ir veim With the aid o+ t+~mtaI and lateral flmm>+opi¢ image++ one aIwmpb t~+ ente+ the mfedor +++etromd +inu+ i+ a~ an+ teromediaL +++D:rio+di+eeti+m+ The tip ~+fthe cad~eter mu+ ally eaters d+e +ira+++b++ti+ d++s not pt~Ke~'.+~+r mote tha~ a F++m+++.I+++i++++Net++..}a+++re+c,+a+++l+L+'+++m+d+ R+d~4 ++:+.+2+~ f.+.++++++ +bw mill|mete+, l++)~ceco+eel ~+itkming of the catheter bats +++.Me+|+~i+++++,e t h++'~+~+++o~ ++++++++++++|+N++I~+I{+Na+p+¢+++t++~++ N + n obtai~l+ the t~di0gm+phi¢ in-tin|ignition g carded +t+ +~+++++{'++¢p¢++++ +++|++~+~t~|t+ t++l ~e++*+~++~p+~+L+++I++%~ | ~ m a Ne~m~h++++++ Vatlo~+ pc+vice+it+n+(stlch + the h¢eml ~+thigh h{mm|} ea~ ~++.a+2++JL+,~4+ad+ M~+dm+m~e ++~+++++++V++ P+m*m+N+ ~+ ~++++ Pro+t++cd+ |:+t+tfi+r dream+silt g+++e+ Hitt=+s axia| prt+eetion NaSa++ bah K+.+ m++A+|4+b~++++h++ ++~+~+~ ++m+.+m+eP;a+~q++ ,+m++++,+w||+++ ++ bv far +he k-++ I4L ~+ial vie++++a w taken rapidly (one +cg+++++p++~++~+.+¢+++&+++++m+L .+vk+v++~¢+++'++++.~a~+p|+~G radial|am f+¢ mecond to+ 8 +o I0 moon&)+ and an auto+ ~
&+*©++~I++S I ; 0 4 0 ~ + 0 7 ~ I 2~ :~ +~0 b~¸ L+~tle+I~+wn +rod ~ +++m~my(In¢+)
de |)ivitiis c~ ~t|; |$~|el-~g¢~phy ~t IntetGtvernou~ Sinuse~
A
B
m~tic inj~.:tor delivers 20 ml of ~ r l ~ t m~ium (we prefer ~X~ megM~ine di~tri:oate |Ur~,¢~fi~L ~ince we ~he~,e it Dyes ~he ~ s t #|e~gra#~ic pict/~te) with a flow M 5 ~o 7 ml per ~:c~nd~ In ~xia| views d~e ~llar ~gion is ps~j¢~t¢~ onto the relatively t tent image of the sphen~-~M~d sinus and the three intercaverno~s sinuses can ~: ck-arl~ identified bec~lu~ethey are not obscured by other str~cr~res, sltch as the bnsihr venous plex~s (the rich|~" ana~tomotic #exus connecting the two inf,.riot ~:trosal sinuses~ which~ esp~:c:iai|~• in ~ n t a i "¢iews~ ~c~mes sl~F~dm~ed ot~ the inferior and ~sterior in~e~cavemo~s sin~s)~ The ~s~ltin~ #|ebt~g,~m is clear e to be interfere& ~ it i~ ~ s r ro ~d~rm im;~ges~btraction in order to ~void e~ors c~u~d b~. the si¢~rimrosition of vat(oils bony smtctiires (Figs. 3, 4L Adt~t~ate injection provides complete filling of the right caverno~S sin~s~ the d ~ incercavemous sinuses, the let~ cap.moils 8inus~ the orbital veins~ t|~e inferior ~:trosa| sin~ses~ the basi|ar venott4 plext~s~ :rod the intem;~l j@idar veins. Teehnica|iy the investigat~r~ is ~ceptable whcr~ ~here is g ~ d filling of ~he su~riot orbital vein on the side op~site to that i n j ~ t ~ i4]. |n:~llfficient q~ntity or t/ow of c~m~rast m~xiitm~ iml:~-r~%ctcatheteri:ation tff d~e inferior I-,etr~al sirtt~s~ or preferential| flow via the ~si|ar ve~t~s piex~s ma,i call fc,t either simadta~eous percute.,~e~us t~ns~ femoral catheteri:ation of the coati, lateral inferior l~tt~a| sin.s (Fig. 2) or compte~,km of the interns| jug~l;Ir vein in the neck.
~5260
Under norma| conditions (Fig, 2) the cavemo~s sinu~s f o ~ ~x~ br~ad ~ n & at ~he lateral a ~ c t s of the pit~itap~" f ~ . ~ e i r ¢eguk~rmedia| e~dge is straight l~r siightIy c~m- Fi~ 3 N , ~ L ~ h ~ ' ~ i ~ m ~', =~t~'~Bxs~ T&. iaJCn~ m ~ cave, The radiot~r'M~cent image of the internal car~tid c , ~ ~u~ t,. ,~t~. ~ ~.~fafi,¢. rich~xu~ ~a~o~ ck~t¢ ~ ~ e P i is seen within ~he cavernous slm~s. The~e is a|~aVs 8 . l ~ l ~,f |he d~¢.l ~. l¢¢~,4 ~ , ~b~,~"¢,i (go ¢~t~d~.,~~)¢;~s~a
307
+ + +>
+ ,
+ {
G: • , + + +
+
? +
++ + ? +
+
+ +
+
+
+, |
+
....+ +;
. . . . . . +?
tee 5+ Ph¢:b-+m+m+++ax+atpr-~',++++m+T~+ ~O+d ++a++~,+++j'<~++Jq am+~++++ ,mu+ +++++m+ve~.Mi+~i+ ~m~+~ g+a++{|ar++~a+ow)+ ~ h ~+m+ i+ +~+++pum++~+t+hin am+we)+ The ++q~++ +n+~++++,+a++~++++~m + -+++,++q+,:.i++e. ++Pro +~+m~++++++no+>,++ +4~h+ p+~+++a+¢;,+m+
+:+v 4 3.++++,~dph+,+b++++mm++va++++++~+,+++.+O++,+u+&+c+~dp+gm++ The: +,h~+
++++ewd+~+~++~gh+++++ Oh+~v++++++~+~++~cgu+c.+Fhc +++~++,'++mt~+c+++mcm+ +++++mu+ + ++++++p:~m+++:+++++~¢++++, p~+~4++m++meh++L+,+~~ :he ++q++++mp~+dk++y +g++++:e++++'<++++ + +~+~+ mum+++p++b~++ ++++:++I +++~+~ 3+ ~++h+++
++~+~+
mr+k++++++, + + + l ~
+|tip of c~mtra,+ medium b~etween the in~ema| ca+otid a++e~+ a~d the media+ ma+a:+r++ff ~he +ira+s° T h e three i~+ercavemo~++ sim++4s +orm ha+row t m m v e ~ + ban&+ T h e a~te+ioP is stmigh++ a~d the ~++her two am +h~htlv c~mcave a+teHodv+ T h e infeti++~ i+te+cavemm,s smt++~ i ~+~+a~|vch++~ t~+ ~he D+~s~etio~i~tercave~m~u simms+ W h e ~ in+e@+tin~ phlebagmms+ ho~++ver+ it i+ imp~++tant to+ {u:+a+i~ mind that anattm~icM varkmt+ ~+f vent+u+ stout+ +m+~++£ale nm++~|~com+++{+~ Phk%+~pk+e A+'m+++mm+h+~,.+:+ Pm+ita~+ disea+,++ ¢at~+t.s ahemtitms +of +he ph| phic +indiag+ d+sctib~+d ahwe+ Eve~ minimal cha~ge+ o f pressure wi~hir+ the pit~+im~+ + ~ + can cause comp~e~ion o~ dis+ placement o f the+e delicate venous strocmte++ T h e m~+&a| ma+em o f the ¢avemo++ sire++ ~ c o m e + d e f o ~ e d and the ~ n d oleo+intrust medmm medml to the internal cau+t+d ½+
+mu+ +~++u++.+e,+e.1+n +~ &+to~+~i+bemv~m+he +u,, am+~+ T+e ge+i+m ++~u+m++mop+curacym++~g++~.m++,.~+upy+g~+ +¢[+~+,f+hegt++~+ The +n~5¢+h+mgcw++v+~+m,ainu+ t+,+ ~+m~emm+~.+~+<++++
comes p ivelv na~ower or even d i ~ a p ~ a ~ |4, 13] (Fig. 5L ~ h e amcr~or and inferior in~e~avemous +inure+ which a~v mo~+ c h ~ b + m ¢~mtac+ with the pitu~ta~++ ~ ¢ o m e fl~t+ ten+] ca+{+ o+ a + amputat+J {Fig. 6}. | may e a u ~ ~ h ~ v*o s i m ~ s m ~ a p ~ m wi~h a ma~ked inerea+e o f ~he concavity o f t h e inferior intetca
simms {Fig 5}+ A |esion deve|oping anterkMy ma}' o M i ~ m t e the anterior inte~averr~+us ~inus~ p ~ x J ~ i n g a cb~re+'is. ~ie O++ha~'~ image on the ph m [41 {Fig. 7 ) m
d~. |++~+++~+~'t M: Ph}c+~+++:+++++|+v++++h+lcr~:++++cm+m++~+++i++c+ 309
+++y++a++l+ ~++t++~+++p+++~+ti+O++n++~+d m t~ C~+t ++++if+h+++++
c++~:a+m# t~,+++++m+ i~ ~nammic~}B,sition, the B~t¢~}o~}me,cavernous~imL-, d c ~ not ,a~a|ly invo|ved ~nti| th~ te~on ~d~ p~.,+ duces ~|terat~orts of the ¢ntitc +¢iI~ t~tt¢~ca, mchMin~ the do.urn s¢ilae Enlarging lesions progressively cause the di~appe~wance of the infi2rior and nnterior intercavemous sinuses, while the pc~sterior one may b,:come hy~.rm~phic a~:fi~t ~tbrc +t to~+ disappear:s (Fig. 8L The cavernous sinu~:s beck+me stcgm#~" concave media|ly+ displi~:ed laterally I6L and of d e c r e e d thickness [ 13I* ~met/mcs VC~; targc Ies~ons bk~k the m+ ~ercavemous sirm~'s comp|eteiy ~md thus prevent tmih,teral injection from filling h~tt~ cavemou~ sim~ses a~ the a m e time (FIR. 9L lnfihmtion of ~he cavemot+s sitars by a ne,+plastic leskm ¢m,~e~. a filling: decec~ with i~e~ld;+r, jacked
edges (F~g+ 10) ~he l~cet of the ph|cF~¢mm of gteate.q mter~'~ i-. d~at minor c h a n ~ , such as ~ a l l tmih~te~l cdte~ations ~+fthe mMia| ~ l i of ~ cavemc~s +im~ o~ d~,~hcemmt o, ilmtxm++ tion of an intetcavemous sinus+ can h+ seen F~,-6~tc ~mv ahemtions of the ~:|la t~r¢ica become app;ircnt or when thes~ alte~tions are minimal |41. Indications Pit~ita~ micm~denoma+ ptovid~ the mo~t interesting ;rod the most im~+~tant indi¢a~io~ for phlebugmphv of the in.
t
310 S~fgicalNeumkNy Vol ~5 No 4 Aptd P)+|
this di;~m'~is and justifies surgical action+ The ph|eN++ gr.ff~ic picture d ~ i m ~ {Miot~thic) empw ~lla either is almost completely normal or, in more advanced l~rms+ is characterized b)+an increasing of the distances ~tween the cavernous sinum+sand between the inrercavemot+s sim+~s {namely tile amerior and die infer|up ones)+ ~:cat+++at+the enlargement i~t+the ~A|a t~+Nica+ However+ ones &~s not .~eethn+: signs t+fasymmetrieN and circunua:ri~d pressure+ either on the cavernous or on the intemavemous sinuses+ that aw characteristic of an adenoma (as de~crii~d al:~ve). The pre~nce of such signs unmistakably evokes the exis+ tence of an expansive k.skm (adennma) Complications No majt~r ¢omNieations have ~ e n i;bserved either in ~ r ca~s or in tho~ rep~+rted in the literature {181. In expert hands the investigation is easy m ~ffonn+ rakes le~ than P~+~++~ +++~k'~+++++m a~+a+H,W,:~+++~+The ~+++P+++&+++m++fi+m +:+l ;,,b.++ one lu~ur &,es not requiie a general anesthetic or heavy tb~t++he~m++++++~+++#+:n~++i+++++<~ucm+m++tomes~,c am/m~l+++d+ ~ scdatMn+ is well m|emted+ and can t:~a~ffomled on an oute+'~"~m+++m++++in+v+ a + 1++++,+~++mare++T¢+cm+:&d .++g+. +4 +b: ~I+ +dI¢++IOa+P++++1|~+++ + + ~ % + J ~+~d +~'~,r~+~r+ +++++~+++teSt P+++++&~++++ ++++~++|+ patient basg. As a precaution the patient sh(mld be given ++++hec~m++d+++mrs:sam+:is++iv +,b+,c~t,d.The ~++w+a~+m+~+~+aG+a heparin+ We have not observed extmva~don d contrast ++a+++++lu++y,g++++mt ++ifihmm+gJw gel++++a+cm+ms+++++,~+ medium or pJptured ve~|s+ even in Ixltients with increased v ~ a l a r f~gi|it~" (Cushing*s disea~eL Even if tb~zse problems were m c~:ur+ we &a r~t ~|ieve that they wouM tercavemou+ s/hums { t81. Lesions only }mm in diameter represent ..~6ous complications+ cause marked phieb,~gmphic t+hanges lind; this is a great improvement over findings obtained from computeri:ed Future Prospects tomo~tmphlc (C~) scans, which can only detect lesions of 7 T~e method o f rcrcmaneous~ tmnsfemom} catheteri~dnn mm or larger [ l 51 12L Phle t h ~ provides the that ~'e use R~r phlebogmphy of the intercavemous sinuses earlWst diagram*isof an lntmeellar Ieskm ~+erefom+ we feel aim gives us the chance t o measure the level of the pitu~ that it i+ an e+~e~tia/investigation liar all patients susg~cvcd icag" harm|mrs in vadmls parts of the ~d}" Currendy we of having a pituitary adenoma+ even when no ~ellar ehange~ take bkx~d rumples from the common iliac vein. the left are present (~rade OL In this sitiiatio~ it is the investigation renal vein ( i n n which the le+~adrenal vein usually dminsL of choice. The concardance o+ phleN~gmphic and clinical the hepatic veins, the tight atrium. R~th in~ernal jugular findmgs alh+ws ~me m p¢,~eed with an ~ m t i ~ m withmlt veins, and the inferior ~ m ~ l sinus. Thus all the main pituitary bare, ones can be measured (F@+ l IL the nc*ed R+r further diagnostic pr~,ed++~es|4+ 18/+ Stmh >:lecdve sampling iS U~fu| ~eau~e it facilitates a With larger sdlar lesions that can ~ diagno~-d by other radio|ogicat methc,als. ph|eb~gmp|wy comp|ements these detailed stndy nfpituita~ activity (R~ example+ sampling at methods and p+ovides preoperative infi+rmation as to (I) the infi±tit~r~ t m m | sin~, which drains the pituit:ay arc~+ the hteral expansum o+ the ~llar minor {91 13|; (2) the measurt~ blc~d levels ~fore dilution c~cur~ with ble,~ sit~ of the carotid sip|runs and of the cavernous and inter+ from other p~=s of {he h~,dr): this methc-] also allmv~ the cavemnus sinuses; ++nd(3) the involvement of the cavern+ determination of any ~topicalty produced substances with ous stresses 119+ 201+ This is esN~cialty mefut when the hormonal activity, which can cause a clinical syndrome transsphenoidal muu~ is to be reed [ 161; for instance, when that resembles pituitary dimrder.~+ This problem ~mca~ e++ the ~sirion and the nature ~ff the +nfieriorintercavemous l,ecially in mine t y ~ s of Cushlng's syndrome {3+ 101+when sinus are knt~wm one can av~+id troublesome b|eeding at it may ~ difficult to i:e or exclude primary pituitae¢ o~mtion [4, ISL Similady~ preo~mtive evidence that a di~mJe~; such tesions may ~ extmpttuita~*+ in which case neop|asdc lesion is infiltrating the cavemnus sinus leads to a pituimD" o~vmtiun ~a~ould~ completely unsuccessful +rhg is on|y a preliminart reign=+ since we do not yet the Correct choice lff treatment I2+ I1 I+ In our opinion+ #le~+gmphy is al~+ t+seful in studying have +~fficiem data m show statistical significance. How+ the empty sella when one suspects that there is an a s c i i ever. we have already ~ e a a i n e d that prolactin levels ate ated l~ion such as an adenoma, ~ e pr~ence d phle~+ higher centml|y than peripherally+ | h a this ~ d i e n t ~-'.aphic si~.~azD~cal of"an adenoma is ~lid confi,natkm markedly incnaa~d in patients with h ~ m l a c t i n e m i a due
de D+vm+,, e+ a|+ Phic}~+e++aphv+~++I|r++,+:g+,:av,ct++++++++Stow,c+ $I I
m~{s am/+0r d~e pa.~pc~a~h'c sin&+:++of~+thc~ +ypes oI ~,cllar Whc~l o~c tries tO dote(* d~c smaHcsi iIllta~,|hr ~g evcl~ iIl{r~piluRaPf lc:,~m as car|if as ~+,s,b~e+ a+~d whe~ dia}m~+~, ~i¢ exploralioi~ of d~e pitmtaW {os,,a at limes ~ccm~ h~ bc jus{ihcd | ?l+ we mamhd+] that p|~Db,}~traphy ~cpw,ct]t~ m+c pr{~.~,+ The mdka+um., ~+~ i+s ~++,
Rdm,.~es
Fig '+1%~+s++us ++++:,,l++++h+,+u+k'+:+hvm~++Ve++<+qH++++++.+,,+++++~+++y+
{a+C+sm'mm+k+~c,+++g.+{~} L+:{~:+,c+,+,a~re+i,++++{c+ H + + + +~v++ ~d) R+Kht,~++:+++am{<) h~t++++'+++++++&+ ~++'++++({} I++~+q+++++lm1+md ++++I++
h+ a micmadeaoma+ amd ~ha~ ia d~e~: padems ~hcw are dis~inc{ dfffi:~c~cc,~ ~t~+,'*+:'e~ the levels ~r+ ti~e Iwo imemal B=gular vei~+ gikewi+~e, m pa~{ent, with C~4~in~'sdisease, ad~cm,¢or~ic~m~pic h~m~onc {ACTIt) concc~{¢ad{m m d~c iaferiot p~m~al +im+~+c~}mpated with A C g H coacen+ ~mtu,m +r~ a p+a~ipi+,,+++~alvein. is hi+.d~cr hy a / ~ c a ~ ~g +wo o~r mr:,,++ A larger m+mk++ ~+fcam:+ is n~vx,.+a+ l~+rthese r,:s.hs +~}Pro"|~+liy eva|uated+ b+++them a + a+~.ad+ similar +er~}+fs i++ d'+c Ihcmmrc {++ lO+ 18I+
Phle~<~gva~w of 1he ime~cave~u+ ,m*a:~+ is a~ m~stiga+ don that is ea,++ym l+'+g++~+m+++is well ill+Dinted+ and has n,++ mr++ ¢omplica+kms+ Ti+e a~awmieal aad f.~c+hmaI characteristics of the delicate vcn~+> sin+crates ar~umd +he pimimef f{~+~ allow eady r e c ~ i t i o a o{ even mimma| at+ tem¢ioa+ of its ¢(mtcnr+ Fo~ lemon+ +mall,+++.+thaa 7 mm i+ ,Jkm*¢I¢~, ~,~'hichate m~,t ~++.atly ++It d ¢ + n ~ with C + mam~i+, we ~+~lmv+ +hat phD ph+¢ i+ the iavcstigation of ch{+ke la cx~n+t
M2 Sl~rga'alNt.~m4ogv',A4 ~5 N++4 Apri| i981
+5 Rh+m+'qAL+ 'i }lardyIKL CharoN+i++SM M~¢+o+,,+++gt++d +m+++~m+ ,+++++r,+~i l& ~4m~ J [N,gea~li¢ dte~adcm~m~ mme.elk,re~ p~r phleb*~taphie de~ ~im~ mlereav~meux+ in P~gmhng.~ of the ~4¢.o~,d gur~.a~, +(h+e+t++m,,if+i+e.rhm.d hm¢+¢awm,m:+.~+++++aM +dis++e~+~*++ S++~Nvuvr,+12:0,+-lO4+Io7,+ W.~Gh ,r o~ tStmtary Aden.ms++, I3ns+ .%:~emN¢ 20-22. PaN It, Rh,,+++,+~AL+ Ham~+'S Rem~WH M+¢m~utgicidatom+myof die pa Walkc+JR+ffat~12D:P+t~m~+~'a+J,:mt+mapt++:v.*ntinga~n:i'+,tmngpait,. +++I+++phthah+r, ple¢++++St+inNetm48:+1%~2+. 1+77 .,'++:ila+¢+v~++ma;~d+:+~em+.m,+>m~+++C[+nNeu+,++v~+e24:+4+8++++77 ! 7+ T.,veta~JM. W~+~El+:['m+m+t++mm+~.++~li,+4~m+,ed 2+B++hmu+r+:++ 20+ W+!mm(g+ I\+mp,,e+~C: Tr;m+phcn+,'++L+[+met.inimical+em<+al+if gdham>& \'++qik{+~+1+~6+12GIpp 2++0rm+++;+tv;+¢.,+.++x. ] +'+~e.l+++mme 4s:l }-22, I978
Book Review E~ot Cnm~unds and Brain Function: Ncun~:ndocrine bromncdp0ne; the medical management of acmmegaty with bmm~)criptine and the treatment of the amenorrhea+ and Neuropsychiatric Aspects (in Advance~ in Biochemical Psycho#armacokNy, VoL 23) ~dacu~hea syndrome in women with suspected pituitary edited b:, +',£,.& G,,N:,tein, D.mdd B+ Cab,c+ micmaden.mas are Ix+th addrc~+d as well Atm&~m Lieb~'r~mm. and Mi&a¢t ()+ TMmcr+ N,ew Y+uk+ Phammcothempy of parkinmmism is covered in a brief * t P+¢~. 1980 Rca¢, review+ A R4k+w.upof ,p m five yea~ is giv~enin >Ain~onism patient.~ treate~ with bmmocdptine+ A compari~m 43I Ira+ R~.aewed ~b Gc.+VeJ+/),k-reran, M,D. Ph.D. ,od Hden L M.m+~m, M+D++ Chic,<.+ I~in+m This hardRmnd nob+me contains a .~enes ~f pape~ pre+ s~med ~ a ~vmposium+ Er~:ot A&ak~id. m Neumkgic+ Nei+mp.+~°chiamc and Ne~m~vn&vrine DiumJe~+ hem it} New Y~+rkin ~9D. It is publi+.hcda> the twenty.third nob rune of A&~mce~ m Bi~chcrmc,d [email protected]~c.b~ag*The 39 papers are divid+xt into the lb~lowing ections: bic~hem+ i~t~"and pharm~mdoey+neuroe~&~dnology+ parkinumim~+ gcrmmc dim)triers+:rod dvskin,:sia. O~ interest ~o rh~se in the dingaI a~d basic netm,~+v ences is a review of tt~¢ c~rrent kn~+wledee~g ere~.~+corn+ p.mnds+ Ergut actions at catechoiamine receptor.., erranteL k.cts {m co~eicaland striata] doF<+minendicand serot.net~ic ~eceptt~rs, and tl~e interactions ~tween ergot derNat~ves and rbe cvchc nuc|eotide system are di~guss~+ Some e m phasis is given m the neurophatmacd~+;~¢of synthetic ergot detivaives in man aM the pharmacokinetica of bmmo+ criptine m man. The section dinting with neur
of bmmc