Cavernous Sinus Hemangiomas Research Articles

Haemangioma of Cavernous Sinus- A Case Series

Extra-axial cavernous sinus haemangioma are rare extra-axial parasellar lesions. These are non-neoplastic lesions, but can behave in a manner like that of neoplastic lesions as their slow growth with progressive enlargement of thin-walled vascular channels may result in extrinsic compression on adjacent retro-orbital neural structures. It is important to diagnose these lesions preoperatively as surgery in these lesions is often complicated by incomplete removal, severe intraoperative haemorrhage and significant operative morbidity and mortality. A parasellar lesion showing homogeneous markedly increased signal on T2 or proton density weighted images with progressive centripetal “filling-in” with contrast on dynamic Magnetic Resonance Imaging (MRI) should suggest the diagnosis. We are presenting three interesting cases of cavernous sinus haemangioma.

Evaluation of Skull Base Tumors with Dynamic TurboFLASH MRI during Gadolinium Injection.

Background and Purpose This study was aimed to investigate the role of dynamic TurboFLASH gadolinium (Gd) magnetic resonance (MR) imaging in improving the differential diagnosis of skull base tumors. Methods Eleven patients with skull base tumors underwent standard MR and ultrafast TurboFLASH sequence during gadolinium injection. Results The characterization of tumor vascularity was performed. Different patterns of gadolinium uptake for each tumor type were observed. This is particularly important to identify tumors at high risk of intraoperative bleeding. All glomus tumors, typically highly vascularized, showed an enhancement at the arterial phase, reflecting the arterialization of these tumors which is not detectable on conventional MR. No signal increase at the arterial phase was instead observed in other cases in which the ruling out of a glomus tumor was important because of the location of the lesion. Moreover TurboFLASH identified the pathognomonic "filling-in" profile of cavernous sinus cavernous hemangiomas (CSCH), that is, the progressive centripetal enhancement of the lesion at the beginning of the venous phase. Conclusion The dynamic analysis of tumor contrast enhancement with the TurboFLASH sequence provides useful additional information to that obtained with conventional MR, improving the differential diagnosis of skull base tumors, particularly in the distinction between glomus and nonglomus tumors and in diagnosing CSCH.

Clinical Features, Intradural Transcavernous Surgical Management, and Outcomes of Giant Cavernous Sinus Hemangiomas: A Single-Institution Experience

Cavernous sinus hemangiomas (CSHs) are rare vascular tumors. Stereotactic radiosurgery is an effective treatment for small CSHs. The optimal treatment for giant CSHs is controversial. This study reports advantages of a complete intradural transcavernous approach in total resection of CSHs. Between January 2012 and January 2017, 15 patients with giant CSHs were treated surgically. All cases were evaluated with a contrast-enhanced magnetic resonance imaging scan and confirmed histopathologically. A complete intradural approach was used for all patients. Clinical manifestations, radiographic characteristics, operative techniques, and outcomes of patients were analyzed. Headache was the most common initial symptom, followed by decreased visual acuity and diplopia. Postoperative magnetic resonance imaging showed that gross total resection was achieved in 13 patients. Two patients had experienced total ipsilateral visual loss for several years before surgery; vision improved in all remaining patients with preoperative visual diminution. The most common early neurologic deficit was cranial nerve VI dysfunction, which was observed in 9 patients (60%; 5 new deficits). Only 2 patients (13.3%) experienced permanent morbidity on long-term follow-up. The early postoperative morbidity rate for cranial nerve III dysfunction was 33.3% (5 patients), and only 1 patient (6.7%) experienced permanent morbidity. Four patients (26.7%) had slight postoperative facial numbness. Surgical total resection is the primary and reasonable choice for giant CSHs. Microsurgical resection of giant CSHs through a completely intradural transcavernous approach is an alternative treatment option for giant CSHs.

Treatment of Cavernous Sinus Hemangiomas with Gamma Knife Radiosurgery as a Primary and Sole Therapy.

To evaluate the effectiveness of Gamma Knife radiosurgery (GKRS) as the primary and only therapy for the treatment of cavernous sinus hemangiomas (CSH) and to report the tumor volume dynamics, course of symptoms, and complications after stereotactic radiosurgery. A total of 10 CSH patients were treated with GKRS using a median margin dose of 14.2Gy (range 13-16Gy). The median follow-up period was 42 months (range 12-85 months). Tumor volumes were calculated from magnetic resonance images before treatment and compared with those after treatment. Prior to the treatment, all patients complained of headache and retro-orbital pain, and six patients complained of diplopia due to abducens nerve paralysis. Within six months of treatment, all patients declared some improvement in headache and retro-orbital pain, and abducens nerve paralysis recovered fully in all six patients. At the first-year follow-up, at least 74% decrease in tumor volume was noted with average tumor volume reduction of 90.2% in all treated patients. Tumors less than 6 cm3 in volume nearly disappeared at 24 months. No tumor progression, re-growth, or radiation-induced adverse effects were noted in our patients. Characteristic radiological features that enable identification of CSH avert the need for an open biopsy for diagnosis. Under suitable circumstances, GKRS may be considered as the primary and only therapy for CSH. GKRS has favorable outcomes in the treatment of CSH, demonstrating good tumor shrinkage, symptom recovery, and low incidence of side effects.

Unilateral congenital glaucoma may be the earliest presenting sign of orbitofacial neurofibromatosis and intracranial lesions: a case series

Purpose The aim was to report a number of cases initially presenting with unilateral congenital glaucoma within the first year of life that subsequently were found to be associated with the orbitofacial variant of neurofibromatosis-1 (NF1) as well as with variable intracranial lesions. Patients and methods The records of 340 patients presenting with unilateral congenital glaucoma were retrospectively reviewed to identify patients who subsequently developed orbitofacial NF ipsilateral to the glaucoma or other manifestations of NF1. All clinical, radiological, or histopathological data for enucleated globes, if available, were reviewed. Results Seven patients were identified with a mean age at presentation of 4.3±5.4 months. They presented with unilateral buphthalmos and high intraocular pressure with subtle proptosis and/or lid swelling. The mean age at NF1 diagnosis was 23.14±18.5 months. Initial imaging reports were either read as ‘normal’ or described a lesion near the cavernous sinus (CS): CS thrombosis, clival meningioma, histiocytosis, carotid cavernous fistula, or CS hemangioma. Once the diagnosis of NF1 was made, subsequent imaging studies (computed tomography and/or MRI) showed a defect at the greater wing of sphenoid bone (all patients); neurofibroma involving the CS, orbit, and nearby intracranial and subcutaneous structures to varying degrees (all patients); and hamartomas at the level of the basal ganglia (six patients). Associated intracranial lesions were sphenoid wing meningioma, optic nerve glioma, and trigeminal schwannoma. Histopathology of two enucleated eyes showed glaucomatous changes with prominent ciliochoroidal hyperplasia in one case and a ciliary body schwannoma in another. Conclusion In newborns with unilateral congenital glaucoma, the differential diagnosis should include NF1. Targeted radiologic examinations may reveal diagnostic signs and decrease disease morbidity. The glaucoma surgeon may opt for earlier aggressive intervention in this potentially blinding disease.

Therapeutic Effect of Hypofractionated Stereotactic Radiotherapy Using CyberKnife for High Volume Cavernous Sinus Cavernous Hemangiomas.

Objective:To evaluate the efficacy and safety of hypofractionated stereotactic radiotherapy using CyberKnife for high volume cavernous sinus cavernous hemangiomas.Materials and Methods:We collected data from 12 patients with high volume cavernous sinus cavernous hemangiomas treated with hypofractionated stereotactic radiotherapy using CyberKnife in our institute, including 2 men and 10 women/female child, aged 4 to 60 years. Initial tumor volumes ranged from 11.8 to 96.6 cm3 with a median of 24.3 cm3. Irradiation doses were 19.5 Gy with 3 fractions in 2 patients, 21 Gy with 3 fractions in 8 patients, 25 Gy with 5 fractions in 1 patient, and 30 Gy with 3 fractions in 1 patient. We used 109 to 155 beams during treatment, and target volumes reached over 95% of the prescribed dose. Follow-up ranged from 3 to 54 months. We evaluated the efficacy and safety of the CyberKnife system based on changes in the diagnostic images and involved cranial nerves or symptoms.Results:Of the 12 patients, 11 were followed for 3 to 54 months with a mean follow-up of 16.3 months; 1 patient was lost to in-person follow-up. Lesion volumes in the followed 11 patients were calculated after fractionated radiotherapy. All tumor volumes decreased (28.6%-94.1%) and symptoms improved (including blurred vision, visual field defects, diplopia, headaches, and facial numbness) after therapy. Postoperative magnetic resonance images revealed a tumor volume range of 2.8 to 41.0 cm3 (median, 6.5 cm3), significantly lower compared with the pretreatment range of 11.8 to 70.1 cm3 (median, 24.3 cm3; T = 0.00, P = .003 < .05). A single patient experienced radiotherapy-related cerebral edema, which resolved after 5 days of mannitol and dexamethasone.Conclusions:Based on the current results, though preliminary, hypofractionated stereotactic radiotherapy using CyberKnife is an effective and safe alternative for high volume cavernous sinus cavernous hemangiomas and is the recommended primary treatment in high-risk patients with this condition.

Surgical Management and Outcomes of Cavernous Sinus Hemangiomas: A Single-Institution Series of 47 Patients

The purpose of this study was to analyze the outcomes of cavernous sinus hemangiomas (CSHs) treated surgically, and to investigate factors that affect the gross total resection (GTR), newly developed or deteriorated cranial nerve injury (NDDCNI), and follow-up neurologic performance, and to further discuss the optimal treatment for CSHs. Clinical data of 47 patients with CSHs treated surgically at our institution between 2012-2018 were retrospectively reviewed. GTR was achieved in 26 (55.3%) patients. Significant relations were identified between the invasion of the sella turcica (odds ratio [OR]= 0.012; 95% confidence interval [CI], 0.001-0.213; P= 0.002), skull base ward (OR= 27.838; 95% CI, 2.995-258.748; P= 0.003), and GTR. The preoperative Karnofsky Performance Scale (KPS) score (OR= 2.966, per 10 score increase; 95% CI, 1.136-7.743; P= 0.026) and the invasion of the sella turcica (OR=7.137; 95% CI, 1.282-39.726; P= 0.025) were factors that significantly affected the incidence of NDDCNI. The average follow-up KPS score, which increased significantly compared with the pre (P < 0.001) and postoperative KPS scores (P < 0.001), was 89.1. Increased tumor size (OR= 0.044, per 1cm increase; 95% CI, 0.004-0.477; P= 0.010) was a risk factor for unfavorable follow-up KPS score. Being treated by an experienced skull base surgeon favors the total removal of CSHs, whereas the invasion of the sella turcica does just the opposite. Increased tumor size is a risk factor for unfavorable follow-up KPS score. The invasion of the sella turcica was related to NDDCNI and unfavorable follow-up KPS score.

Stereotactic radiosurgery for hypervascular intracranial tumors.

To evaluate the safety and efficacy of SRS treatment of central neurocytomas (CNCs), cavernous sinus hemangiomas (CSHs), and glomus tumors (GTs); and to compare upfront stereotactic radiosurgery (SRS) and adjuvant SRS in the treatment of these hypervascular tumors. This was a retrospective review of consecutive CNCs, CSHs, and GTs treated with SRS between 1993 and 2017. Tumor response was categorized based on volumetric analysis on magnetic resonance imaging: (1) tumor regression [> 10% decrease in tumor volume (TV)]; (2) stable tumor (≤ 10% change in TV); or (3) tumor progression (> 10% increase in TV). Sixty hypervascular tumors (CNC: 28; CSH: 16; GT: 16) underwent SRS between 1993 and 2017. Margin doses were 13Gy, 12Gy, and 14Gy for CNCs, CSHs, and GTs, respectively. Tumor regression was observed in 54 tumors (90%) with initial SRS after a median follow-up of 82months. Relative reductions in TVs for CNCs were 38%, 52%, and 73% at 12, 24, and 48months, respectively. Relative reductions in TVs for CSHs were 51%, 68%, and 88% at 12, 24, and 48months, respectively. Relative reductions in TVs for GTs were 22%, 31%, and 47% at 12, 24, and 48months, respectively. Upfront SRS was performed in 26 patients (43%). No difference in relative TV reductions were found between upfront and adjuvant SRS. Adverse radiation effects were observed in five patients. No mortality was encountered. SRS for hypervascular tumors is associated with high rates of tumor regression with low risk of complications. No significant difference in rates of relative TV reduction were found between upfront and adjuvant SRS. Hence, upfront SRS may be considered in select patients.

Review of Surgical Anatomy of the Tumors Involving Cavernous Sinus.

The lesions involving cavernous sinus (CS) and lateral sellar region includes tumors, vascular lesions, infection, inflammation, and trauma. Tumors associated with CS cause significant distortion of the microanatomy posing an additional surgical challenge to the neurosurgeons. The surgical approach and microsurgical anatomy with respect to the origin and growth of the tumor within the CS region have not been comprehensively described in recent years. We conducted a review of literature concerning CS and associated tumors, complied through MEDLINE/OVID and using cross-references of articles on PubMed with the keywords cavernous sinus, CS tumors, pituitary adenoma, meningioma, schwannoma, chordoma, CS hemangiomas, extradural, interdural, intradural, skull base, gamma knife radiosurgery, endoscopic endonasal approach. Based on the tumor origin and growth pattern, the tumors associated with CS can be classified into three categories: Type-I: tumor originating from CS, Type-II: originating from lateral wall of CS, and Type-III: extraneous origin and occupying CS. The review focuses on approach to a tumor within each type of tumor in the CS region. The emphasis is that the tumor growth pattern and significant distortion of the CS anatomy caused by the tumor growth should be considered while planning the optimal surgical approach for tumors in this region to ensure complete tumor resection with minimal neurovascular morbidity.

Cavernous Sinus Hemangioma: Case Report and Review

Cavernous Sinus Hemangioma: Case Report and Review

A patient with cavernous sinus cavernoma who was difficult to diagnose by imaging modalities

Cavernous Sinus Cavernous Hemangioma (CSCH) is a relatively rare vascular lesion, accounting for 0.4-2.0% of tumors of the cavernous sinus. Due to multiple differential diagnoses, a diagnosis based on pre-operative imaging is very important. This case report describes a patient with CSCH in whom it was difficult to determine a pre-operative diagnosis based on imaging modalities.

The evaluation of effect of gamma knife on cavernous sinus hemangioma through computed tomography

Objective: Using Computed Tomography (CT) to evaluate the treatment effect of gamma knife surgery in the treatment of Cavernous Sinus Hemangioma (CSHs). Method: This article retrospectively analysed 31 patients with CSHs who were confirmed clinically and pathologically from Oct 2013 to Apr 2015 in Imaging Center of Xian Central Hospital. Using CT scan images to observe the changes of patient’s clinical symptoms and tumour size before and after gamma knife treatment. The various data were statistically analysed. Further analysis of the influence of tumour lesion size, location and therapeutic dose on the therapeutic effect. Results: With CT scan, the location of tumour lesion and calcification for CHSs patients can be clearly be seen. After treatment with gamma knife, the diameter of tumour reduced from 3.57 ± 0.46 cm to 2.93 ± 0.56 cm, with significant reduction (P<0.05). From the change of Gross Tumour Volume (GTV) of these patients, 0 cases is complete remission, 22 cases are partial remission, 8 cases are stable and 1 case is progressive. The effective rate of gamma knife is 10.97%, and the stable rate is 96.77%. Furthermore, after treatment with gamma knife, 20 patient’s headache symptoms have been improved, 13 patient’s diplopia symptom have been improved, 5 patient’s tinnitus symptom have been alleviated, 18 patient’s eyelid ptosis symptom have been improved, 21 patient’s facial numbness symptom have been improved. Additionally, the location of tumour lesion is one factor that influences the treatment effect (P<0.05). Conclusions: Gamma knife treatment could improve nerve function and other symptoms in patients with CHSs, and has a good therapeutic effects and important value.

Cavernous Sinus Hemangioma: Diagnosis and Treatment

Cavernous Sinus Hemangioma: Diagnosis and Treatment

Moyamoya Disease Associated with Tuberculum Sellae Meningioma and Cavernous Sinus Hemangioma

Primary moyamoya disease associated with skull base tumors has been reported only rarely in the literature. Surgical treatment can be complicated due to the compensatory collateral circulation through meningeal and leptomeningeal anastomosis. A standard frontotemporal craniotomy may interrupt critical transdural anastomoses. We report a case of primary moyamoya disease coexisting with tuberculum sellae meningioma and left cavernous sinus hemangioma. Simultaneous management of tuberculum sellae meningioma and moyamoya disease was performed using a left modified pterional incision. Two separate bone windows were opened to protect the transdural anastomosis via the middle meningeal artery. The tuberculum sellae meningioma was successfully removed through a small frontal craniotomy, and encephaloduromyosynangiosis was used to treat moyamoya disease through a temporoparietal craniotomy. Finally, CyberKnife radiotherapy was used to treat the left cavernous sinus hemangioma at 6 weeks after the initial operation. The patient recovered well without complications. This is the first report of moyamoya disease associated with tuberculum sellae meningioma and cavernous sinus hemangioma. With careful bone flap design, moyamoya disease and skull base tumors can be treated simultaneously. Care should be taken to avoid interruption of critical dural-pial collaterals and injury to fragile moyamoya vessels.

Gamma Knife surgery for a hemangioma of the cavernous sinus in an adult: Case report and short review of the literature

Cavernous sinus hemangiomas (CSH) are rare benign extra-axial vascular lesions. Both radiological and clinical aspects are important, for deciding a therapeutic modality, including medical treatment, radiation therapy or microsurgery. In the particular case of CSH, a radical removal of the tumor often cannot be achieved and is associated with a considerable risk for intraoperative uncontrollable bleeding. An alternative treatment modality is radiosurgery. Here we report the case of a 45-year-old patient, who presented with diplopia due to left abducens nerve palsy. A left-sided cavernous sinus lesion was found, initially considered to be a meningioma. However, after serial MR acquisitions, a progressive and heterogeneous enhancement was observed. In order to clarify the diagnosis between meningioma and hemangioma, a diagnostic Tc-99m labeled red blood cells (RBC) scintigraphy (Tc-99m RBC scintigraphy) was performed and showed a typical perfusion blood pool mismatch, with accumulation of the RBC at the level of the left CS, which is typical for a hemangioma. The patient underwent Gamma Knife surgery. The CSH showed a significant reduction in size starting 6 months after treatment and a full regression of the left abducens nerve palsy was observed within 1 year. These clinical and radiological results persisted over the next 3 years.

Radiographic analysis for infarcted angiomatous polyps in maxillary sinus

Objective:To explore the CT, MRI manifestations of the polyp of maxillary sinus cavernous hemangioma. To summarize the imaging characteristics and it may assist doctors to diagnose infarcted angiomatous polyps in maxillary sinus with further developing.Method:A retrospective analysis of the CT, MRI manifestations and clinical analysis about 27 cases confirmed by surgery pathology who are maxillary sinus cavernous hemangioma.Result:Twenty-seven cases were unilateral diseases, and clinical manifestations were nasal congestion. Twenty-seven cases were proceeded CT scan, of which 9 cases of double-phase dynamic enhanced CT examination, 11 cases with MRI examination, of which 6 cases with MRI enhanced examination. CT scan showed unilateral maxillary sinus full of mixed density and involving the nasal cavity, maxillary sinus abnormal expansion of deformation, with local bone resorption damage in 27 cases, but without violation the adjacent tissue. CT enhanced scan of lesions shows that the spotted blood vessels were significantly enhanced and progressive enhancement. MRI can clearly identifylesions and obstructive sinusitis and morbid shape was irregular with mixed signal. T2WI showed high and low mixed ring signals, and the edge of the irregular low signal ring, with enhanced nodules and patchy unevenly enhanced.Conclusion:Most polypof maxillary sinus cavernous hemangioma clinical manifestations are unilateral nasal obstruction. CT shows the maxillary sinus irregular expands and compression bone absorption with a prompt action to this disease.Vascular-like enhancement and progressive enhancement are characteristic enhanced CT manifestations of this disease. MRI can better show the lesion range. T2WI with high and low ring mixed signals, low ring signals, and mostly enhanced nodules, uneven enhancement of plaqueare characteristic imaging manifestations.

Multimodality Management of Cavernous Sinus Hemangiomas-An Institutional Experience.

Objective Cavernous sinus hemangiomas (CSHs) are benign lesions accounting for less than 2% of the cavernous sinus tumors. They provide a formidable surgical challenge because of their vascularity and their being surrounded by critical neurovascular structures. In this study, one of the largest in available literature, we analyze our experience in the management of these unusual tumors and review the available literature. Materials This is a retrospective analysis of patients who were managed surgically (both microsurgical and Gamma knife radiosurgery [GKRS]) for CSH at our Institution from 2007 to 2015. Complete demographic, clinical-radiologic surgical records were analyzed. Follow-up data were collected from the hospital records. Results Total 23 patients were managed. Among these, 15 patients underwent microsurgery (group 1) whereas 8 underwent GKRS (group 2). Predominant clinical presentation in both the groups included headache and involvement of multiple cranial nerves. Five patients in group 1 had deteriorating vision. The volume of tumors ranged from 29 to 115 cm 3 (mean = 64.57 cm 3 ) in group 1 and from 2.1 to 11.6 cm 3 in group 2. GKRS was performed with a mean dose of 13 Gy, an average isodose line of 50% with an average coverage of 96%. In group 1, the follow-up period ranged from 6 to 62 months (mean = 29.4 months). The extraocular movement (EOM) preservation rate in our series was not favorable, as most patients presented late with large tumors and established deficits. Recurrence/residual tumor was seen in two cases. In group 2, the follow-up was 5 to 48 months. All of them showed significant reduction in size. Conclusion Both surgery and radiosurgery are highly effective in the management of CSHs. They are complementary to each other, with individual characteristics-the size and volume of the lesion-being the main factors in deciding the choice of treatment.

Dynamic Contrast-Enhanced Magnetic Resonance Imaging in Diagnosis of Cavernous Hemangioma of Cavernous Sinus.

Dynamic Contrast-Enhanced Magnetic Resonance Imaging in Diagnosis of Cavernous Hemangioma of Cavernous Sinus.

P17.04 Gamma knife surgery for Cavernous sinus cavernous hemangioma - comparative results to surgery and radiation therapy

Objectives: Cavernous hemangiomas occur very rarely in the cavernous sinus. These lesions share the same histologic features as intracerebral lesions, but their clinical picture is quite different. The objectives of this study are to evaluate the efficacy of Gamma Knife Surgery (GKS) on cavernous sinus cavernous hemangiomas (CSCHs) and to compare the results of GKS to those of surgical treatment and fractionated radiation therapy (FRT). Methods: Before 2000, we operated 7 cases of CSCHs. We have performed GKS for 26 cases and FRT for 4 cases since 2000. Among 26 cases that were treated by GKS, two patients were performed other treatment before GKS (surgery and FRT). Thirteen patients were diagnosed incidentally during the work up of other reason such as headache or head trauma. Most common symptom was cranial nerve palsy (ptosis, diplopia and facial sense change) in 12 cases. Results: Of 7 surgically treated cases, 4 patients had already had extraocular muscle palsy preoperatively. Gross total resection (GTR) was achieved using extradural approach in all 7 cases and there has been no tumor recurrence during follow up. However, 2 new trigeminal nerve deficits developed after operation. FRT was performed for 4 cases, usually large ones. All 4 tumors were well controlled, however, symptomatic radiation necrosis was developed at brainstem in 1 case. Twenty-six patients were treated by GKS. The mean tumor volume was 9.7 cm3 (range 0.5-31.6). The prescription dose to the tumor margin varied from 13 to 15 Gy by the proximity to the optic pathway. The mean follow up period was 46.1 months (range 11.1-131.1). Eleven patients showed marked clinical improvement within 3 months. All the cases showed significant shrinkage of the tumors was noted within 6 months and 11 patients had complete remission at the last follow up (34%). Mean residual volume comparing to pre-GKS initial volume was 20.8% (range 0-70%). There was no complication related to GKS during their follow up. Conclusion: Even though surgical resection for CSCHs is curative treatment, it is not always easy and safe. Because of the radiosensitive nature of CSCHs, FRT could be another treatment option in case of large CSCHs, but it has potential radiation-related risk. GKS is an effective and safe treatment modality and could be a treatment of choice for CSCHs.

Hypofractionated stereotactic radiosurgery: a new treatment strategy for giant cavernous sinus hemangiomas.

OBJECTIVE Cavernous sinus hemangiomas (CSHs) are rare benign vascular tumors that arise from the dural venous sinuses lateral to the sella. Stereotactic radiosurgery (SRS) has emerged as a principal alternative to microresection for small- and medium-sized CSHs. Resection is a reasonable option for large (3-4 cm in diameter) and giant (> 4 cm in diameter) CSHs. However, management of giant CSHs remains a challenge for neurosurgeons because of the high rates of morbidity and even death that stem from uncontrollable and massive hemorrhage during surgery. The authors report here the results of their study on the use of hypofractionated SRS (H-SRS) to treat giant CSH. METHODS Between January 2008 and April 2014, 31 patients with a giant CSH (tumor volume > 40 cm3, > 4 cm in diameter) treated using CyberKnife radiosurgery were enrolled in a cohort study. Clinical status and targeted reduction of tumor volume were evaluated by means of serial MRI. The diagnosis for 27 patients was determined on the basis of typical imaging features. In 4 patients, the diagnosis of CSH was confirmed histopathologically. The median CSH volume was 64.4 cm3 (range 40.9-145.3 cm3). Three or 4 sessions of CyberKnife radiosurgery were used with a prescription dose based on the intent to cover the entire tumor with a higher dose while ensuring dose limitation to the visual pathways and brainstem. The median marginal dose to the tumor was 21 Gy (range 19.5-21 Gy) in 3 fractions for 11 patients and 22 Gy (range 18-22 Gy) in 4 fractions for 20 patients. RESULTS The median duration of follow-up was 30 months (range 6-78 months) for all patients. Follow-up MRI scans revealed a median tumor volume reduction of 88.1% (62.3%-99.4%) at last examination compared with the pretreatment volume. Ten patients developed new or aggravated temporary headache and 5 experienced vomiting during the treatment; these acute symptoms were relieved completely after steroid administration. Among the 30 patients with symptoms observed before treatment, 19 achieved complete symptomatic remission, and 11 had partial remission. One patient reported seizures, which were controlled after antiepileptic drug administration. No radiation-induced neurological deficits or delayed complications were reported during the follow-up period. CONCLUSIONS Hypofractionated SRS was an effective and safe modality for treating giant CSH. Considering the risks involved with microsurgery, it is possible that H-SRS might be able to serve as a definitive primary treatment option for giant CSH.