Cavernous Sinus Meningiomas: Surgical Strategies and Outcome in 111 Cases Treated over a Period of 14 Years

Abstract

Purpose: Cavernous sinus (CS) meningiomas represent particularly challenging lesions for neurosurgeons because of their deep location and strong adhesion to the sinus thus requiring surgical expertise and skills. Despite that, it's usually difficult to achieve a complete removal of these lesions without significant morbidity and/or mortality. We present our experience in the management of this kind of lesion with particular emphasis to surgical and nonsurgical strategies. Method: Meningiomas may arise primarily in the CS or secondarily invade it from the contiguous regions. In a period of 14 years (1992 to 2006) 111 meningiomas of the CS have been surgically treated. Based on the region of main development, meningiomas of our series were classified as purely intracavernous (8), sphenoethmoidal (23), clinoidal (45), sphenopetrous (21), and sphenopetroclival (14). In 17 cases the lesion was a recurrence. Seventy-one lesions were extensive (diameter > 3 cm) and most of the lesions involved more than one area of the CS. Clinical or radiological evidence of disease progression represented the main indication for surgery. All patients underwent complete neuroradiological investigation; in 54 cases an ICA balloon occlusion test was performed. In the early years we took an aggressive approach, accepting the risk of cranial nerves dysfunction or carotid occlusion to achieve gross total removal. After 1997 we adopted a less aggressive approach leaving a minimal intracavernous residual that was later treated by stereotactic radiosurgery. Result: In those patients treated earlier than 1997 a poorer outcome could be observed: grafting was used in 5 cases of damaged oculomotor nerves; short high-flow ICA bypass was performed in 2 cases and prophylactic long high-flow bypass in 1 case. Surgical outcome was better in the second period (1997 to 2006) as a result of a less aggressive technique. Conclusion: Surgical management of CS meningiomas remains difficult and these patients are usually referred to specialized centers. Auxiliary techniques (ultrasonic aspirator, coblation, intraoperative monitoring, etc.) make surgery safer. In our experience the most important way to achieve better results is represented by the choice of the most adequate surgical approach and by the assumption that in some cases a less invasive approach is preferable in order to spare the intracavernous cranial nerves and/or carotid.