Dear Editor,
We read the article entitled “Unusually Long Survival of an Adult Patient with Atypical
Teratoid/Rhabdoid Tumor of the Sellar Region: A Follow-Up Report” in a recent issue
of the journal with great interest. Almalki et al. reported the follow-up of an adult
female diagnosed with a sellar atypical teratoid/rhabdoid tumor treated with surgical
resection, radiotherapy, and chemotherapy. Almost 2 years postoperatively, she had
no radiological evidence of recurrence since the first management.[[1]]
Herein, we would like to provide a figure [[Figure 1]] and a table [[Table 1]] to better comprehend the sellar region that clinico-anatomically correlate with
the cavernous sinus. As we already stated previously, any process that affects the
intracranial region may lead to lesions in more than one cranial nerve (CN) or structure,
and when this occurs, the clinical presentation could be complex, causing a delay
in the diagnosis.[[2]] One example of this complexity is the isolated Horner's syndrome secondary to rhinosinusitis,
which can be explained by Raeder syndrome affecting the third neuron of the oculosympathetic
pathway.[[3]]
Figure 1: Schematic diagram of the cavernous sinus. 1: Optic chiasm, 2: Pituitary gland, 3a:
Diaphragm selli, 3b: Meningeal layer, 3c: Endosteal layer, 4: Cavernous sinus, 5:
Internal carotid artery, 6: VI Cranial nerve, 7: III Cranial nerve, 8: IV Cranial
nerve, 9: V1 Cranial nerve, 10: V2 Cranial nerve, 11: Sphenoid sinus, 12: Sphenoid
bone, 13: Brain, 14: Subarachnoid space
Table 1: Cavernous sinus contents and rule of 3 (CAVERN)
The sellar region includes the sella turcica and the pituitary gland (adenohypophysis
and neurohypophysis); on the other hand, the parasellar region comprizes the cavernous
sinuses, suprasellar cistern, hypothalamus, and ventral inferior third ventricle.
It is noteworthy that the anatomic localization of the lesions during the clinical
examination is essential for the differential diagnosis between sellar and parasellar
lesions. In this way, due to the small size of the pituitary gland and its proximity
to many important structures, the neuroimaging diagnosis is challenging.[[4]]
The cavernous sinus is a venous dural sinus located on either side of the pituitary
fossa and the body of the sphenoid bone between the endosteal and meningeal layers
of the dura. The dural venous sinuses are embryologically created by the separation
of these meningeal layers, and they are full of venous blood and lined by endothelium.
The cranial nerves III, IV, V1, and V2 enter by the lateral wall of the cavernous
sinus, but the internal carotid artery and the CN VI enter more centrally. It is worthy
of mentioning that the sympathetic trunk forms a plexus of nerves around the internal
carotid artery known as the carotid plexus. Furthermore, all the nerves that pass
in the cavernous sinus go after in the superior orbital fissure.[[5]]
In summary, the neuroanatomy of the sellar and parasellar regions is intricate and
needs a continuous review. In this context, the comprehension of these small structures
and its correlation with the neurological examination can improve the differential
diagnosis, prompt the diagnosis of rare pathologies, and avoid its complications.
Conflicts of interest
None.
Reviewers:
Not Applicable (Correspondence)
Editors:
Elmahdi Elkhammas, (Columbus OH, USA)
Salem A Beshyah (Abu Dhabi, UAE)
