Clinical Imaging 40 (2016) 2332

Contents lists available at ScienceDirect

Clinical Imaging
journal homepage: http://www.clinicalimaging.org

The caverno-apical triangle: anatomic-pathological considerations and

pictorial review
Jared Narvid , Jason F. Talbott, Christine M. Glastonbury
Division of Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA

a r t i c l e

i n f o

Article history:
Received 9 March 2015
Received in revised form 4 August 2015
Accepted 12 August 2015
Keywords:
Cavernous sinus
Orbital apex
Skull base
Superior orbital ssure

a b s t r a c t
Background: The caverno-apical triangle (CAT) is dened from the components that dene its contours: the
cavernous sinus and the orbital apex. A wide range of pathologies arise from the space between the cavernous
sinus and the orbital apex.
Object: To better dene radiologically this critical anatomic landmark and establish an organized approach
for image analysis to help generate focused differential diagnoses and accurately characterize lesions found on imaging.
Conclusion: We have identied common imaging characteristics of frequently encountered lesions and divided them
into specic categories to facilitate creation of logical and focused differential diagnoses.

2015 Elsevier Inc. All rights reserved.

1. Introduction
The caverno-apical triangle (CAT) is dened from its shape and the
components that delineate its contours: the cavernous sinus and the
orbital apex. A wide range of pathologies may arise from the space
between the cavernous sinus and the orbital apex. Detection and
appropriate characterization of pathology at the CAT remains vital as
pathology can affect critically important structures often progressing
intracranially and within the orbit. Moreover, this region remains a
challenging location for operative biopsy and the procurement of tissue
diagnosis. Accordingly, the informed radiologist can guide clinical management by alerting clinicians to the involvement of local anatomic
structures and by generating an appropriate differential diagnosis. Despite this, the CAT has not been previously described in the literature
as a distinct anatomic landmark, and because of its small size, it can be
readily overlooked on imaging.
Clinical ndings of CAT lesions are variable including orbital apex and
cavernous sinus syndromes but these lesions can also be asymptomatic.
Moreover, the clinically important anatomic relations in this area may result
in high morbidity. Computed tomography (CT) and magnetic resonance
imaging (MRI) are complementary in formulating limited differential and
sometimes precise diagnoses and in dening the relationship with adjacent
neurovascular structures to guide the surgical approach. As a broad range of
lesions can occur here, our purpose is to better dene radiologically this critical anatomic landmark and establish an organized approach for image

Corresponding author. Division of Neuroradiology, University of California,

San Francisco, 505 Parnassus Avenue, L-352, San Francisco, CA 94143-0628, USA.
Tel.: +1-415-353-1863; fax: +1-415-353-8606.
E-mail address: Jared.narvid@ucsf.edu (J. Narvid).
http://dx.doi.org/10.1016/j.clinimag.2015.08.005
0899-7071/ 2015 Elsevier Inc. All rights reserved.

analysis to help generate focused differential diagnoses and accurately

characterize lesions found on imaging.

2. Normal anatomy and contents

The CAT forms part of the anteromedial aspect of the middle cranial
fossa. Its name is dened from the components that dene its contours:
the cavernous sinus and the orbital apex. This triangular-shaped region
is formed by the cavernous sinus anterior to Meckels cave and extends
to the superior orbital ssure (SOF) where the III, IV, Vi, and VI cranial
nerves enter the orbital apex superolateral to optic nerve (Fig. 1).
The bony connes of the CAT are formed by the greater and lesser
wings of the sphenoid bone that project transversely from the sphenoid
corpus, bending superiorly in their anterior portion, and contain foramina through which the cranial nerves exit. The lesser wings are two thin
triangular plates of bone arising from the anterior aspect of the sphenoid bone. The inferior surface constitutes a portion of the superior
wall of the orbit and overhangs the SOF, the elongated opening between
the wings. The posterior CAT is formed at the anterior cavernous sinus
in the plane of the caroticoclinoid foramen (Henle) [1]. The posterior
roof of the CAT is formed by the surgical carotico-oculomotor triangle
at the level of the anterior clinoid process [2].
More noteworthy is an understanding of the anatomic relationships
between the anterior cavernous sinus and its connecting foramina that
serve as neurovascular channels to the orbit and thus permit egress of
pathology along natural anatomic conduits. The SOF is situated between
the greater and lesser wings and body of the sphenoid bone. At the
ssure, the dura covering the middle fossa and cavernous sinus blends
into the periorbita of the orbital apex and the annular tendon of Zinn
from which the extraocular muscles arise [3]. The lateral margin of the

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J. Narvid et al. / Clinical Imaging 40 (2016) 2332

Fig. 1. Anatomy of the CAT. Left, illustration of the right CAT (red triangle) that includes the anterior cavernous sinus (blue) and the orbital apex. Upper right, labeled ex vivo skull
base, superolateral view. (1) Anterior clinoid, (2) sphenoid ridge, (3) optic strut, (4) optic canal, (5) superior orbital ssure, (6) planum sphenoidale, (7) chiasmatic sulcus, (8) tuberculum sellae,
(9) pituitary fossa, (10) dorsum sellae, (11) posterior clinoid, (12) carotid sulcus, (13) foramen rotundum, (14) foramen ovale, and (15) middle clinoid. Lower right, axial postcontrast T1 MR;
lower left, axial noncontrast CT illustrating the CAT. The CAT forms part of the anteromedial aspect of the middle cranial fossa. Its name is dened from its shape and the components that
dene its contours: the cavernous sinus and the orbital apex. This triangular-shaped region is formed by the cavernous sinus anterior to Meckels cave and extends to the SOF where cranial
nerves 3, 4, 51, and 6 enter the orbital apex, superolateral to the optic nerve.

SOF and CAT, sometimes referred to as the horizontal meningeal limb,

is covered by the frontotemporal dural fold [4]. It is important to note,
however, that the foramen for the ophthalmomeningeal vein (Hyrtl) is
situated in the greater wing and may form the lateral CAT, usually
connecting the lateral half of the orbit with cerebral veins and cavernous
sinus. A meningolacrimal artery may also pass through this foramen and
supply lacrimal territory [5]. The anterior CAT is formed as an osseous tunnel for the numerous neurovascular structures entering the orbital apex
and associated with the annulus of Zinn and posterior muscle cone [6].
3. Clinical presentation of lesions
Symptoms associated with CAT lesions are myriad but can be absent
as well. Involvement of the anterior cavernous sinus can produce cranial
neuropathies equivalent to the cavernous sinus syndrome. Various
combinations of Horners syndromes, oculomotor palsy, and facial
sensory loss can be seen [7]. Similarly, the orbital apex syndrome has
been described wherein ophthalmoplegia is combined with optic
nerve dysfunction [8]. All such symptoms may be accompanied by
ophthalmologic red ags pointing to a retrobulbar lesion [9].

4. Materials and methods

A database of exemplary lesions is maintained by the University of
California, San Francisco (UCSF) Department of Radiology and Biomedical Imaging as a collaborative effort between Laboratory for Radiological Informatics and AGFA Medical Imaging, UCSF Digital Teaching File.
Subsequent to query of this database, electronic medical records of
patients presenting to the tertiary referral center, UCSF, and the San
Francisco General Hospital were reviewed. This study qualied for
exempt/waived requirement for informed consent under UCSF institutional review board guidelines.

5. Range of pathological lesions of the CAT

From our collection of cases from three hospitals and on review
of the available literature, we created an imaging guide to creating a
differential diagnosis of the common and unusual CAT lesion
(Table 1). The table may be of value for reminding radiologists of the
varied pathologies and specic features of each.

Table 1
Differentiating features of CAT lesions by CT and MR
Lesion

CN III, IV, V, VI involvement

Cavernous sinus involvement

Enhancement

Bony changes on CT

Extra-CAT abnormality

Lesional T2 signal intensity

Meningioma
Schwannoma
PNTS
IOIa
GPAb
Sarcoid
AVM

Uninvolved
Involved
Involved
Involved
Uninvolved
Variable
Uninvolved

Variable
Variable
Involved
Involved
Variable
Variable
Variable

Homogenous
Peripheral/Target
Homogenous
Homogenous
Homogeneous
Homogeneous
Serpentine

Hyperostotic
Smooth lytic
Absent
None
None
None
None

Dural tail
Extension to orbit
Primary site
EOM/Sclera
Face
Lacrimal/Uveal
Vascular pouch

Iso
Variable
Iso
Iso
Low
Low
Low

a
b

Idiopathic orbital inammation (formerly orbital pseudotumor).

GPA (formerly Wegeners granulomatosis).

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25

Fig. 2. CAT meningioma. A 36-year-old female who initially presented to the emergency department with nonspecic visual changes and headache. Initial MRI performed in 2003 demonstrates early subtle T2 asymmetry (A) on axial T2-weighted image and contrast enhancement (B) on axial T1-weighted postcontrast image within the CAT on the left (yellow arrows).
This MRI exam was interpreted as normal at an outside institution. Follow-up MRI including axial FIESTA (C) and sagittal postcontrast T1 (D) sequences performed 10 years later reveals
conspicuous progression of tumor involving the anterior CAT where the cavernous dura blends into the apical periorbita and annulus of Zinn (yellow arrow) yet equally shows the orbital
apex as a conduit to the inferior orbital ssure (red arrow).

6. Meningiomas
Parasellar meningiomas account for 510% of meningiomas, and
these are also the most frequent tumor in the cavernous sinus [10].
At CT and MRI examination, they usually show a broad dural basis
and strong enhancement (Fig. 2). They are isohyperintense on T2weighted imaging and markedly hyperintense on arterial spin labeling

(ASL) [11]. However, psammomatous meningiomas can be heavily

calcied and lack contrast enhancement and ASL hyperintensity.
These meningiomas characteristically are dense on CT images. FLAIR images may also demonstrate expansion of the anterior cavernous sinus
and loss of hyperintense clinoidal and apical fat (Fig. 3). They may demonstrate mass effect by constricting the lumen of the ICA, a relatively
specic sign [12]. Adjacent hyperostosis is characteristic. Meningiomas

Fig. 3. CAT meningioma. Axial FLAIR images (A and B) demonstrate loss of clinoidal and apical (yellow arrows in A and B, respectively) fat as a clue to a CAT lesion on FLAIR in this 57-year-old
female who presented with left ptosis.

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Fig. 4. CAT schwannoma. A 14-year-old male with left oculomotor palsy underwent MRI that revealed a spindle-shaped lesion with intermediate T2 signal intensity on axial T2-weighted
image (A yellow arrow) and homogenous enhancement (B, yellow arrow) on axial T1-weighted postcontrast image centered at the SOF suggestive of, although not diagnostic for,
schwannoma. Arc susceptibility artifact projecting over the orbits and skull base related to dental hardware (braces).

Fig. 5. CAT schwannoma. A 43-year-old male with known vestibular schwannoma presents for routine surveillance imaging. (A) Subtle T2 hyperintense oval mass at the left CAT is centered along the SOF on axial T2-weighted image. (B) Characteristic enhancement on axial T1-weighted postcontrast image in areas that lack T2 hyperintensity is noted, a characteristic
feature of schwannoma, asymptomatic and incidentally noted in this case.

that involve the CAT are more difcult to excise given their concomitant
involvement of both cavernous sinus and orbital apex [13,14].
Those meningiomas within the CAT that present operative risk
are increasingly treated with stereotactic or conformal fractionated
radiation therapy. When tumor is within close proximity to the optic
nerve, high-dose single fraction radiosurgery is contraindicated secondary to the high risk of radiation-induced optic neuropathy [15]. Thus,
the anatomic location within the CAT may inform treatment options.
7. Peripheral nerve sheath tumors (schwannomas)
Schwannomas comprise 1% of all neoplasms of the orbital apex [16].
They are typically slow growing masses that are sharply circumscribed
and extend along the axis of the involved nerve (Fig. 4). Schwannomas
are typically hyperintense on T2-weighted images with heterogeneous
contrast enhancement (Fig. 5). A particularly useful differentiating feature is that the enhancement occurs in regions of low T2 and isointense
T1 signal [17]. Within the CAT, these lesions tend to enlarge the vertical
neural limb of the SOF with smooth bony erosion that distorts their
normal spindle appearance into that of an hourglass (Fig. 6).
8. Perineural tumor spread
Perineural tumor spread (PNTS) is a well-recognized pathological behavior of many head and neck (HN) cancers and represents the dissemination of tumor from the primary site via the nerve and neural sheath as a
mode of metastasis. The common HN culprits include cutaneous squamous

cell and basal cell carcinoma and melanoma (particularly desmoplastic melanoma), mucosal primary tumors such as squamous cell carcinoma and nasopharyngeal carcinoma, salivary gland malignancies (especially adenoid
cystic carcinoma), and lymphoma. Among patients with PNTS, 40% may
be asymptomatic, which puts the onus on the radiologists to be vigilant
to its presence [18]. Detection of PNTS has important therapeutic implications either directing the surgeon to additionally involved areas or permitting recognition of unresectable disease. Perineural spread (PNS) most
often occurs along the branches of the trigeminal nerves (CNV) and facial
nerve (CNVII).
Within the context of the CAT, two anatomically and pathologically
distinct subtypes of PNTS can be distinguished. First, CNV1 divides into
the nasociliary, frontal, and lacrimal nerves just before it enters the orbit
via the SOF. Forehead skin tumors such as basal cell carcinoma thus can
spread via the frontal nerve toward the CAT (Fig. 7). These can extend intracranially through the SOF. Following orbital exenteration, careful evaluation of the CAT is critical for identifying potential recurrence on
surveillance imaging (Fig. 8). Second, PNTS can involve branches of
CNV2 extending intracranially along foramen rotundum. Typical malignancies that involve CNV2 are cutaneous malignancies, mucosal squamous cell malignancies, and minor salivary gland tumors. Knowledge of
the site of primary tumor allows for careful examination of the appropriate local nerves for enhancement, nerve thickening, and foraminal enlargement. On the other hand, involvement of the CAT can alert the
radiologists to look for cutaneous malignancies of the eye, nose, and
cheek; tumors of the maxillary or ethmoid sinuses; tumors of the palate
and nasopharynx; and involvement of pterygopalatine fossa.

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Fig. 6. CAT neurobroma in patient with neurobromatosis 1 (NF-1). A 20-year-old female with NF-1 presents with progressively enlarging CAT and orbital mass. This neurobroma
shows heterogenous T2 (A) on axial T2-weighted image and contrast-enhancement (B) with waisting (yellow arrows) at the CAT on a axial T1-weighted postcontrast image.

9. Inammatory processes

enhancement of the lacrimal glands. A CAT lesion with lacrimal changes

should raise suspicion for these diagnoses.

9.1. Neurosarcoid
9.2. Granulomatosis with polyangiitis
Sarcoidosis is an idiopathic inammatory disorder characterized histopathologically by noncaseating granulomas and epithelioid proliferation [19]. Up to 80% of patients affected by systemic sarcoid will have
involvement of the orbit, often involving the orbital apex and CAT
[20]. Thickening of the optic nerve can be seen with characteristic low
T2 inammatory changes (Fig. 9). Optic nerve involvement, uveal involvement, and nodular pachymeningeal thickening are ndings that
are most specic for sarcoid. In addition, orbital sarcoid and idiopathic
orbital inammatory (IOI) disease often present as enlargement and

Granulomatosis with polyangiitis (GPA) (previously known as

Wegener granulomatosis) has a predilection for the upper and lower respiratory tracts and kidneys, although patients frequently exhibit HN
manifestations (7299% of cases) and less commonly central nervous
system disease (2254%) [21,22]. Although the diagnosis of patients
with systemic disease is supported by the often elevated ANCA/antiPR3, patients with chronic isolated HN manifestations lack autoantibodies, thereby raising the stakes for radiologic diagnosis [21].

Fig. 7. Basal cell carcinoma (BCC) with PNS into the CAT. A 55-year-old female patient with newly diagnosed BCC undergoes MRI to evaluate for deep extension of tumor. Asymmetrical
enhancement at the left CAT (A, red triangle) along with medial canthal enhancement suggests a primary cutaneous lesion (yellow arrow in B) and perineural tumor within the inferior
orbital ssure (red arrow in B), both images are axial T1-weighted postcontrast. The lesion at the CAT is the tip of the iceberg as the tumor extends to the pterygopalatine fossa
(C) and along vidian (yellow arrow in D) and maxillary nerves (red arrow in D). Orbital involvement of the infraorbital nerve is seen on coronal T1 postcontrast image (yellow arrow in
E) as a route of spread toward the CAT; coronal T1-weighted postcontrast images.

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the lacrimal glands, the myositis form (the most common) affects the
muscles, the neuritis form affects the optic nerve sheath, the apical
form affects the posterior orbit, the episcleral form affects the anterior
orbit, and the diffuse form affects the entire orbit. When occurring
at the orbital apex and CAT, this entity has been termed TolosaHunt
syndrome [25].
TolosaHunt syndrome is a painful ophthalmoplegia caused by
inammation of the cavernous sinus or SOF. It has been proposed to
be the result of exaggerated immunological process triggered by
viral or bacterial infection [26]. Accordingly, these inammatory
processes can involve the CAT beginning either within the orbital
apex or anterior cavernous sinus (Fig. 11) and extending into the
pterygopalatine fossa (Fig. 12).

9.4. Infection

Fig. 8. Basal cell carcinoma (BCC) recurrence in the CAT following orbital exenteration.
After orbital exenteration, the rst clue to recurrence can be asymmetrical soft tissue in
the CAT (red triangle); axial T1-weighted postcontrast image.

Like sarcoid, chronic inammation can give rise to T2 hypointense inammatory/brous tissue (Fig. 10). Unlike sarcoid, GPA often produces
sinonasal bony destructive changes not typical of other lesions centered
in the CAT [23].
9.3. IOI disease
IOI disease, also previously known as pseudotumor, is an autoimmune phenomenon of unclear etiology consisting of orbit inammation
with inltration of myobroblasts and spindle cells [24]. There are six
different distributions of inammation in orbital pseudotumor, dened
by the anatomic structures that are involved: the dacritis form affects

Invasive fungal sinusitis most commonly occurs in the setting of uncontrolled diabetes (6080%) or in patients otherwise immunocompromised by neutropenia or HIV [27]. Aspergillus and mucormycosis
constitute the overwhelming majority of responsible fungal organisms.
Clinically, headache and facial pain are typically out of proportion to the
clinical evaluation and the often subtle imaging ndings. Ulceration of
the nasal cavity or eschar is a specic clinical and radiologic sign [28].
Prompt treatment is necessary to avoid vision loss and death and includes intravenous amphotericin B, surgical debridement, and sometimes hyperbaric oxygen therapy and/or orbital exenteration. On MRI,
signal intensity is variable on T1- and T2-weighted sequences due to
varying degrees of edema and fungal elements. Invasive disease appears
as hypointense masses on T1- and T2-weighted sequences that lack
enhancement on postcontrast sequences (Fig. 13) [2931]. Hypointense
signal often reects necrotic, devitalized tissues associated the
angioinvasive nature of invasive fungal disease [32]. In addition, invasion into the cavernous sinus can compromise the cavernous carotid

Fig. 9. Neurosarcoid involving the CAT. A 49-year-old female presents with double vision and known lung disease. Left CAT asymmetry (A, red triangle) extends into the orbital apex (B) on
postcontrast T1 axial images. Coronal T2-weighted (C) and T1-weighted postcontrast images (D) show T2 hypointense enhancing tissue within the SOF and orbital apex (red arrows in
C and D). These ndings should prompt search for optic nerve involvement, uveal involvement, and nodular pachymeningeal thickening, relatively specic signs of sarcoid.

J. Narvid et al. / Clinical Imaging 40 (2016) 2332

29

Fig. 10. GPA involving the CAT. Nonspecic loss of T1 fat signal (A, yellow arrow) within the left CAT on axial precontrast T1-weighted image, a subtle clue to inammatory changes and
enhancement on postcontrast T1-weighted image (B) associated with biopsy-proven GPA in this 55-year-old male who presented with left vision loss.

Fig. 11. IOI disease involving the CAT. Postcontrast CT (A) for this 19-year-old female with right retroorbital pain and diplopia shows subtle asymmetry (yellow arrow) without bony
changes as seen to better advantage within the right CAT on T1-weighted axial postcontrast MR (B). The patients severe right retroorbital pain and response to steroids corroborated
the diagnosis of pseudotumor.

Fig. 12. IOI disease involving the CAT. A 27-year-old female presented with left orbital pain. Asymmetrical enhancement in the left CAT on axial T1-weighted postcontrast MR images
(A, red triangle) reveals more extensive inammation into the PPF, orbital apex and pterygomaxillary ssure (B, yellow arrow).

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Fig. 13. Chronic invasive fungal infection in the CAT. A 63-year-old female with multiple medical problems was hospitalized for septic shock, altered mental status, and left-sided vision
loss. Axial T2-weighted image (A) shows subtle fullness and low signal in the left CAT (yellow arrow) with sinus mucosal thickening on axial CT images (B) and frank osteolysis at the
sphenoid sinus and SOF (C, yellow arrows). This T2-hypointense soft tissue is associated with low ADC values on axial MR (D, yellow arrow) diffusion imaging. The constellation of clinical
history, mucosal disease, bone erosion, and T2 hypointensity is highly suggestive of invasive fungal infection.

artery giving rise to infective pseudoaneurysms [33]. CT may also show

osteolysis at the sphenoid wall, optic strut, and SOF.
9.5. Vascular
Complex orbitofacial arteriovenous malformations can be seen as a
part of the cerebrofacial metameric syndromes as originally described
and common to cases involving arteriovenous malformations of the
brain and orbit (Bonnet-Dechaume-Blanc or Wyburn-Mason syndrome) [34]. These often involve abnormal high-ow vascularity extending through the CAT to involve both orbit and brain. However,
this appearance can also been found in dural arteriovenous stula
(DAVF) of the orbital apex often supplied by the meningolacrimal artery
and draining to the superior ophthalmic vein (Fig. 14) [35].
Cavernous sinus stulas, like all arteriovenous stulas, represent abnormal communications between arterial and venous blood circulations, either directly between the ICA lumen and the cavernous sinus
or indirectly between branches of the ICA and/or ECA and the cavernous
sinus. The former direct connection between ICA and cavernous sinus is
termed carotid cavernous stulas (CCFs), whereas communications
linking the cavernous sinus and dural arterial supply are more aptly
termed DAVFs of the cavernous sinus. Although both direct CCFs and
DAVFs may cause similar symptoms, namely pulsating exophthalmos,
they represent in terms of etiology and pathogenesis entirely different
lesions [36]. Direct CCFs arise either traumatically or via rupture of a

spontaneous cavernous carotid aneurysm, while numerous etiologies

have been suggested for DAVFs including hormonal, coagulopathic/
thrombotic, and traumatic possibilities [37]. Nevertheless, both types
may produce expansion and contrast enhancement on both CT and
MRI of the CAT.
Intracranial extracerebral hemangiomas arising from the cavernous
sinus are rare lesions. They are well demarcated, expansive, T2 hyperintense, and can be prone to severe intraoperative bleeding that raised
interest in Gamma Knife radiosurgery as a treatment [38]. As such, preoperative diagnosis is critical [39] although differentiation from meningioma can be challenging [40]. A profoundly and homogenous T2 CAT
lesion with heterogenous enhancement should raise the possibility of
a cavernous sinus cavernous hemangioma (CSCH) [41] (Fig. 15).
10. Conclusion
Accurate characterization and categorization of pathology at the CAT
is clinically relevant, as CAT lesions may cause both intraorbital and intracranial morbidity. We have identied common imaging characteristics of the most frequently encountered lesions at our institution and
divided them into specic categories to facilitate creation of logical
and focused differential diagnoses. The clinically important anatomical
relations in this area mean that pathology may result in high morbidity,
and surgical access is also difcult for pathological diagnosis. The
CAT should be carefully evaluated on CT/magnetic resonance (MR),

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31

Fig. 14. DAVF of the CAT. A 33-year-old man presented loss of visual acuity. Axial precontrast T1-weighted images (A and B) show loss of left CAT fat signal and a ovoid low-intensity lateral
apical lesion (yellow arrows) with avid enhancement on the axial T1-weighted postcontrast image (C, yellow arrow). Digital subtraction angiography with left external carotid injection
shows the middle meningeal artery lling a venous pouch that drains forward to the SOV, diagnostic of a DAVF.

Fig. 15. CSCH of the CAT. A 45-year-old female who presented with dizziness and headache. Axial FLAIR (A) and T2 (B) images show homogenous hyperintense circumscribed lesion at the
right CAT that avidly enhances (C) on coronal T1-weighted postcontrast image. The lesion was biopsied and found to be a cavernous hemangioma.

particularly when patients have symptoms of CN III, IV, or VI neuropathy;

orbital pain; or altered visual acuity.
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