Abstract
Cavernous sinus (CS) meningiomas represent a formidable neurosurgical pathology. The desired treatment depends on tumor size and extensions apart from the presenting clinical symptoms of the patient. The last few decades have shown a paradigm shift in the management towards a multimodal treatment. For patients with tumors presenting with a medial extension or when the meningioma occupies the antero-inferior portion of the CS, an endoscopic biopsy can be safely performed through the endonasal route. The boundaries of endoscopic endonasal approaches have been pushed during the last decade, and a direct access to the CS may now be performed. At the same time, an extensive bony decompression to decompress the optic canal and the pituitary gland may be performed. Autologous fat may be interposed between the residual tumor and radiosensitive structures to safely perform adjuvant radiation therapy. The aim of this manuscript is to describe the role of endoscopic surgery in the management of cavernous sinus meningiomas along with the complementary role of radiotherapy. We describe the endoscopic anatomy and the surgical technique to safely perform the procedure and we review the surgical series reported in the literature dealing with the endoscopic approach for CS meningiomas with or without complementary radiation therapy. Endoscopic endonasal approaches have shown promising results in terms of improvement or stabilization of cranial neuropathy and hypopituitarism. Furthermore, the endoscopic approach may enhance the efficacy and safety of stereotactic radiosurgery through the performance of an hypophysopexy and/or chiasmopexy.
Highlights
Meningiomas account for one third of primary intracranial tumors with an incidence of 3-8 per 100,000 persons[1]
From a radiobiological point of view, meningiomas are considered as late responding tumors and they can be better controlled with a higher dose/fraction rather than conventional fractionation, as explained in the meta-analysis performed by Leroy et al.[37], where radiosurgery (RS) achieved a twice-higher rate of tumor volume regression than fractionated radiotherapy
The management of cavernous sinus (CS) meningiomas depends on the size and extension of the tumor and on the clinical manifestations of the patient
Summary
Meningiomas account for one third of primary intracranial tumors with an incidence of 3-8 per 100,000 persons[1]. This permits the performance of a precise bony decompression around the sella, the medial cavernous sinus, the optic canal, and, if necessary, of the clivus and Meckel’s cave[17] This approach allows the positioning of autograft fat between the tumor and radiosensitive structures for further treatments[28]. The interposition of abdominal fat (hypophysopexy) between the meningioma and the pituitary gland may limit the risk of post-radiation endocrinopathies From these studies, we can conclude that a biopsy or planned partial tumor removal may be safely performed, coupled with bony decompression, to improve the visual symptoms and obtain a decompression of the cavernous sinus. Endoscopy may improve or stabilize pre-existent cranial neuropathy and endocrinopathy (67% of patients in Lobo’s series improved their endocrinopathy and 42% of patient improved or resolved their cranial neuropathy)[32]
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