Microsurgical Resection of a Parasellar Meningioma Invading the Cavernous Sinus, Bone, and Optic Canal: 2-Dimensional Operative Video

Abstract Parasellar meningiomas, regardless of the initial origin, frequently involve the optic canal and cavernous sinus, leading to visual loss and ocular movement dysfunction.1 Hyperostotic bony invasion to the surrounding skull base is common.2 Visual acuity prognosis can be improved by surgical resection through different technical maneuvers, including opening the optic canal and the preservation of the visual apparatus vascular supply by developing the intra-arachnoidal dissection planes.1,3,4 To achieve radical dissection and reduce recurrences, the extradural invaded bone is thoroughly resected. Likewise, the soft and nonadherent invasive tumor around the cavernous carotid can be extensively removed.1,3,4 New or worsening of the ophthalmoplegia is frequent after cavernous sinus exploration and tumor resection. However, it is usually temporary and improves progressively in 80% of patients.1,3,4 Safely approaching these lesions requires extensive anatomic knowledge through cadaveric dissection and training, allowing us to achieve tumor control, preserve or improve visual function, and avoid or delay irradiation therapy.1,3,4 Pituitary function preservation is also possible in many patients through surgery, which is at higher risk with irradiation. We demonstrate the technical maneuvers through a case of a 49-yr-old woman who presented with a parasellar meningioma involving the cavernous sinus, both optic canals, and extensive bony invasion. The patient consented to the surgery and publication of her images. Image at 1:14 and middle and right image at 1:31 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas. Vol 1, ©LWW, 1998. Left image at 1:31 reprinted from Arnautovic et al,5 by permission from JNSPG.

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Extradural anterior clinoidectomy in surgical management of clinoidal meningiomas

The Egyptian Journal of Neurology Psychiatry and Neurosurgery ◽

10.1186/s41983-021-00336-x ◽

2021 ◽

Vol 57 (1) ◽

Author(s):

K. El-Bahy ◽

Ashraf M. Ibrahim ◽

Ibrahim Abdelmohsen ◽

Hatem A. Sabry

Keyword(s):

Cavernous Sinus ◽

Tumor Resection ◽

Visual Outcome ◽

Extent Of Resection ◽

Optic Canal ◽

Falciform Ligament ◽

Cavernous Sinus Invasion ◽

Anterior Clinoidectomy ◽

Microsurgical Techniques

Abstract Background Despite the recent advances in skull base surgery, microsurgical techniques, and neuroimaging, yet surgical resection of clinoidal meningiomas is still a major challenge. In this study, we present our institution experience in the surgical treatment of anterior clinoidal meningiomas highlighting the role of extradural anterior clinoidectomy in improving the visual outcome and the extent of tumor resection. This is a prospective observational study conducted on 33 consecutive patients with clinoidal meningiomas. The surgical approach utilized consisted of extradural anterior clinoidectomy, optic canal deroofing with falciform ligament opening in all patients. The primary outcome assessment was visual improvement and secondary outcomes were extent of tumor resection, recurrence, and postoperative complications. Results The study included 5 males and 28 females with mean age 49.48 ± 11.41 years. Preoperative visual deficit was present in 30 (90.9%) patients. Optic canal involvement was present in 24 (72.7%) patients, ICA encasement was in 16 (48.5%), and cavernous sinus invasion in 8 (24.2%). Vision improved in 21 patients (70%), while 6 patients (20%) had stationary course and 1 patient (3%) suffered postoperative new visual deterioration. Gross total resection was achieved in 24 patients (72.7%). The main factors precluding total removal were cavernous sinus involvement and ICA encasement. Mortality rate was 6.1%; mean follow-up period was 27 ± 13 months. Conclusions In this series, the use of extradural anterior clinoidectomy provided a favorable visual outcome and improved the extent of resection in clinoidal meningioma patients.

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Endoscopic endonasal management of non-functioning pituitary adenomas with cavernous sinus invasion: a 10- year experience

Rhinology Journal ◽

10.4193/rhino14.309 ◽

2015 ◽

Vol 53 (4) ◽

pp. 308-316

Author(s):

F. Ferreli ◽

M. Turri-Zanoni ◽

F.R. Canevari ◽

P. Battaglia ◽

M. Bignami ◽

...

Keyword(s):

Cavernous Sinus ◽

Tumor Resection ◽

Mass Effect ◽

Extent Of Resection ◽

Tumor Control ◽

Endoscopic Endonasal ◽

Cavernous Sinus Invasion ◽

Visual Outcomes ◽

Contrast Enhanced ◽

Wait And See

Background: The management of Non-Functioning Pituitary Adenoma (NFPA) invading the cavernous sinus (CS) is currently a balancing act between the surgical decompression of neural structures, radiotherapy and a wait-and-see policy. Methods: We undertook a retrospective review of 56 cases of NFPA with CS invasion treated through an endoscopic endonasal approach (EEA) between 2000 and 2010. The Knosp classification was adopted to describe CS involvement using information from preoperative MRI and intraoperative findings. Extent of resection and surgical outcomes were evaluated on the basis of postoperative contrast-enhanced MRI. Endocrinological improvement and visual outcomes were assessed according to the most recent consensus criteria. Results: EEA was performed using direct para-septal, trans-ethmoidal-sphenoidal or trans-ethmoidal-pterygoidal-sphenoidal approach. Visual outcomes improved in 30 (81%) patients. Normalization or at least improvement of previous hypopituitarism was obtained in 55% of cases. A gross total resection was achieved in 30.3% of cases. The recurrence-free survival was 87.5%, with a mean follow-up of 61 months (range, 36-166 months). No major intraoperative or postoperative complications occurred. Discussion: EEA is a minimally-invasive, safe and effective procedure for the management of NFPA invading the CS. The extent of CS involvement was the main factor limiting the degree of tumor resection. The EEA was able to resolve the mass effect, preserving or restoring visual function, and obtaining adequate long-term tumor control.

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Endoscopic Endonasal Transmaxillary Transsphenoidal Approach for Excision of a Superior Orbital Fissure-Cavernous Sinus Meningioma: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy093 ◽

2018 ◽

Vol 15 (5) ◽

pp. E61-E62

Author(s):

Ehab El Refaee ◽

Steffen Fleck ◽

Marc Matthes ◽

Henry W S Schroeder

Keyword(s):

Mr Imaging ◽

Cavernous Sinus ◽

Tumor Resection ◽

Middle Turbinate ◽

Lateral Wall ◽

Optic Canal ◽

Superior Orbital Fissure ◽

Endoscopic Endonasal ◽

Cavernous Sinus Meningioma ◽

Left Middle

Abstract We present a 43-old-male who suffered from a slowly progressive loss of vision in the left eye. Magnetic resonance (MR) imaging revealed a well-circumscribed contrast-enhancing lesion in the region of the anterior cavernous sinus and superior orbital fissure that extended into the optic canal. A schwannoma or meningioma was suspected. A transcranial surgery performed at another institution was not successful in removing the tumor and further deterioration of vision occurred. After resection of the left middle turbinate, the sphenoid and maxillary sinus were opened. The bulging of the tumor was seen at the lateral wall of the sphenoid sinus. After bony decompression of the optic canal, the dura was opened. A meningioma was exposed that arose in between the dural layers of the cavernous sinus. A nice dissection plane was found and the tumor was circumferentially dissected and finally totally removed. There were no complications such as double vision or visual field deficit. MR imaging confirmed a total tumor resection. The visual acuity normalized within a few days. MR imaging obtained 3 yr after surgery shows no recurrence.

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Microsurgical Resection of Recurrent Cavernous Sinus Hemangioma by Superior and Lateral Approach: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz313 ◽

2019 ◽

Vol 19 (2) ◽

pp. E165-E166

Author(s):

Qazi Zeeshan ◽

Juan P Carrasco Hernandez ◽

Michael K Moore ◽

Laligam N Sekhar

Keyword(s):

Optic Nerve ◽

Carotid Artery ◽

Cavernous Sinus ◽

Tumor Resection ◽

Cranial Nerves ◽

Brain Magnetic Resonance Imaging ◽

Mass Effect ◽

Lateral Approach ◽

Microsurgical Resection ◽

The Right

Abstract This video shows the technical nuances of microsurgical resection of recurrent cavernous sinus (CS) hemangioma by superior and lateral approach. A 77-yr-old woman presented with headache and difficulty in vision in right eye for 6 mo. She had previously undergone attempted resection of a right CS tumor in another hospital with partial removal, and the tumor had grown significantly. Neurological examination revealed proptosis, cranial nerve 3 palsy, and loss of vision in right eye (20/200). Left side visual acuity was 20/20. Brain magnetic resonance imaging (MRI) demonstrated a large CS mass with homogeneous enhancement, measuring 3.3 × 3.3 × 2.6 cm, extending into the suprasellar cistern with mass effect on the right optic nerve. It extended anteriorly to the region of the right orbital apex and abuted the basilar artery posteriorly. She underwent right frontotemporal craniotomy, posterolateral orbitotomy and anterior clinoidectomy as well as optic nerve decompression, and the CS tumor was removed by superior and lateral approach. An incision was made into the superior wall of the CS medial to the third nerve. On lateral aspect the tumor had extended outside the CS through the Parkinson's triangle. Posteriorly it extended through the clival dura. Anteriorly tumor encased the carotid artery and it was gradually dissected away. At the end of the operation, all of the cranial nerves were intact. Postoperative MRI showed near complete tumor resection with preservation of the internal carotid artery. At 6 mo follow-up her modified Rankin Scale was 1 and vision in left eye was normal. Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

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Does Prior Microsurgery Improve or Worsen the Outcomes of Stereotactic Radiosurgery for Cavernous Sinus Meningiomas?

Neurosurgery ◽

10.1227/01.neu.0000431471.64289.3d ◽

2013 ◽

Vol 73 (3) ◽

pp. 401-410 ◽

Cited By ~ 28

Author(s):

Hideyuki Kano ◽

Kyun-Jae Park ◽

Douglas Kondziolka ◽

Aditya Iyer ◽

Xiaomin Liu ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Cavernous Sinus ◽

Cranial Nerve ◽

Progression Free Survival ◽

Tumor Control ◽

Improvement Rate ◽

Cranial Nerve Function ◽

Cranial Neuropathies ◽

Microsurgical Resection

Abstract BACKGROUND: Stereotactic radiosurgery (SRS) is an important option for patients with cavernous sinus meningiomas. OBJECTIVE: To evaluate cranial nerve outcomes in patients who underwent SRS for cavernous sinus meningiomas with or without prior microsurgery. METHODS: During a 23-year interval, 272 patients underwent Gamma Knife SRS for cavernous sinus meningiomas (70 men, 202 women; median age, 54 years). In this series, 99 patients underwent prior microsurgical resection. The median tumor volume was 7.9 cm3 and median marginal dose was 13 Gy. The median follow-up period was 62 months (range, 6-209 months). RESULTS: The progression-free survival after SRS was 96% at 3 years, 94% at 5 years, and 86% at 10 years. After SRS, 13 of 91 patients (14%) who underwent prior microsurgery had improvement of preexisting cranial nerve symptoms or signs. In comparison, 54 of 145 patients (37%) without prior microsurgery had improvement of preexisting cranial nerve symptoms or signs. The improvement rate of cranial nerve deficits after SRS in patients without prior microsurgery was 20% at 1 year, 34% at 2 years, 36% at 3 years, and 39% at 5 years. Patients who had not undergone prior microsurgery had significantly higher improvement rates of preexisting cranial nerve symptoms and signs (P = .001). After SRS, 29 patients (11%) developed new or worsened cranial nerve function. CONCLUSION: SRS provided long-term effective tumor control and a low risk of new cranial nerve deficits. Improvement in preexisting cranial neuropathies was detected in significantly more patients who had not undergone prior microsurgical procedures.

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Outcomes of decompressive surgery for cavernous sinus meningiomas: long-term follow-up in 50 patients

Journal of Neurosurgery ◽

10.3171/2018.10.jns181480 ◽

2020 ◽

Vol 132 (2) ◽

pp. 380-387 ◽

Cited By ~ 7

Author(s):

Yair M. Gozal ◽

Gmaan Alzhrani ◽

Hussam Abou-Al-Shaar ◽

Mohammed A. Azab ◽

Michael T. Walsh ◽

...

Keyword(s):

Optic Nerve ◽

Cavernous Sinus ◽

Cranial Nerve ◽

Tumor Resection ◽

Lateral Wall ◽

Senior Author ◽

Tumor Control ◽

Subtotal Resection ◽

Adjuvant Radiation ◽

Neurological Morbidity

OBJECTIVECavernous sinus meningiomas are complex tumors that offer a perpetual challenge to skull base surgeons. The senior author has employed a management strategy for these lesions aimed at maximizing tumor control while minimizing neurological morbidity. This approach emphasizes combining “safe” tumor resection and direct decompression of the roof and lateral wall of the cavernous sinus as well as the optic nerve. Here, the authors review their experience with the application of this technique for the management of cavernous sinus meningiomas over the past 15 years.METHODSA retrospective analysis was performed for patients with cavernous sinus meningiomas treated over a 15-year period (2002–2017) with this approach. Patient outcomes, including cranial nerve function, tumor control, and surgical complications were recorded.RESULTSThe authors identified 50 patients who underwent subtotal resection via frontotemporal craniotomy concurrently with decompression of the cavernous sinus and ipsilateral optic nerve. Of these, 25 (50%) underwent adjuvant radiation to the remaining tumor within the cavernous sinus. Patients most commonly presented with a cranial nerve (CN) palsy involving CN III–VI (70%), a visual deficit (62%), headaches (52%), or proptosis (44%). Thirty-five patients had cranial nerve deficits preoperatively. In 52% of these cases, the neuropathy improved postoperatively; it remained stable in 46%; and it worsened in only 2%. Similarly, 97% of preoperative visual deficits either improved or were stable postoperatively. Notably, 12 new cranial nerve deficits occurred postoperatively in 10 patients. Of these, half were transient and ultimately resolved. Finally, radiographic recurrence was noted in 5 patients (10%), with a median time to recurrence of 4.6 years.CONCLUSIONSThe treatment of cavernous sinus meningiomas using surgical decompression with or without adjuvant radiation is an effective oncological strategy, achieving excellent tumor control rates with low risk of neurological morbidity.

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Microsurgical resectability, outcomes, and tumor control in meningiomas occupying the cavernous sinus

Journal of Neurosurgery ◽

10.3171/2015.3.jns142494 ◽

2016 ◽

Vol 125 (2) ◽

pp. 378-392 ◽

Cited By ~ 18

Author(s):

Anil Nanda ◽

Jai Deep Thakur ◽

Ashish Sonig ◽

Symeon Missios

Keyword(s):

Cavernous Sinus ◽

Tumor Resection ◽

Tumor Control ◽

Karnofsky Performance Scale ◽

Tumor Removal ◽

Recurrence Rates ◽

Neurological Outcomes ◽

Initial Surgery

OBJECTIVE Cavernous sinus meningiomas (CSMs) represent a cohort of challenging skull base tumors. Proper management requires achieving a balance between optimal resection, restoration of cranial nerve (CN) function, and maintaining or improving quality of life. The objective of this study was to assess the pre-, intra-, and postoperative factors related to clinical and neurological outcomes, morbidity, mortality, and tumor control in patients with CSM. METHODS A retrospective review of a single surgeon's experience with microsurgical removal of CSM in 65 patients between January 1996 and August 2013 was done. Sekhar's classification, modified Kobayashi grading, and the Karnofsky Performance Scale were used to define tumor extension, tumor removal, and clinical outcomes, respectively. RESULTS Preoperative CN dysfunction was evident in 64.6% of patients. CN II deficits were most common. The greatest improvement was seen for CN V deficits, whereas CN II and CN IV deficits showed the smallest degree of recovery. Complete resection was achieved in 41.5% of cases and was not significantly associated with functional CN recovery. Internal carotid artery encasement significantly limited the complete microscopic resection of CSM (p < 0.0001). Overall, 18.5% of patients showed symptomatic recurrence after their initial surgery (mean follow-up 60.8 months [range 3–199 months]). The use of adjuvant stereotactic radiosurgery (SRS) after microsurgery independently decreased the recurrence rate (p = 0.009; OR 0.036; 95% CI 0.003–0.430). CONCLUSIONS Modified Kobayashi tumor resection (Grades I–IIIB) was possible in 41.5% of patients. CN recovery and tumor control were independent of extent of tumor removal. The combination of resection and adjuvant SRS can achieve excellent tumor control. Furthermore, the use of adjuvant SRS independently decreases the recurrence rates of CSM.

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Neuroophthalmological evaluation after Gamma Knife surgery for cavernous sinus meningiomas

Neurosurgical FOCUS ◽

10.3171/foc-07/12/e10 ◽

2007 ◽

Vol 23 (6) ◽

pp. E9 ◽

Cited By ~ 7

Author(s):

Alberto Franzin ◽

Alberto Vimercati ◽

Marzia Medone ◽

Carlo Serra ◽

Stefania Bianchi Marzoli ◽

...

Keyword(s):

Gamma Knife ◽

Cavernous Sinus ◽

Tumor Volume ◽

Tumor Resection ◽

Cranial Nerves ◽

Gamma Knife Surgery ◽

Tumor Control ◽

Tumor Control Rate ◽

Line Therapy ◽

The Mean

Object Treatment options for patients with cavernous sinus meningiomas (CSMs) include microsurgical tumor resection, radiotherapy, and radiosurgery. Gamma Knife surgery (GKS) is increasingly being used because it is associated with lower mortality and morbidity rates than microsurgery. The purpose of this study was to assess the role of GKS in the treatment of CSM and to thoroughly analyze the clinical response to GKS. Methods Between January 2001 and December 2005, 123 patients (25 men and 98 women; mean age 62.6 ± 11 years, range 31–86 years) who underwent treatment for CSMs were included in this study. Of these, 41 patients underwent microsurgery before GKS, whereas the remaining 82 had GKS as a first-line therapy after a diagnosis was made based on magnetic resonance imaging findings. Dysfunction in cranial nerves (CNs) II, III, IV, V, and VI was noted in 74 patients at the time of GKS. The mean tumor volume was 7.99 cm3 (0.7–30.5 cm3). The mean prescription dose to the tumor margin was 13.8 ± 1.1 Gy (range 10–20 Gy). Results The overall tumor control rate was 98.4% with a median follow-up of 36 months. The actuarial tumor control rate at 5 years was 90.5%. A reduction in tumor volume was observed in 53 patients (43.1%), whereas in 68 patients (55.3%) no volumetric variation was recorded. Of the 74 patients who presented with CN deficits, improvement was noted in 23 (31.1%). Conclusions Gamma Knife surgery is a useful treatment for CSM both as a first- or second-line therapy. It is a safe and effective treatment for tumors located close to the optic pathways.

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Surgical Strategies and Clinical Outcome of Large to Giant Sphenoid Wing Meningiomas: A Case Series Study

Brain Sciences ◽

10.3390/brainsci10120957 ◽

2020 ◽

Vol 10 (12) ◽

pp. 957

Author(s):

Adrian Balasa ◽

Corina Hurghis ◽

Flaviu Tamas ◽

Rares Chinezu

Keyword(s):

Tumor Progression ◽

Cavernous Sinus ◽

Tumor Resection ◽

Case Series ◽

Optic Canal ◽

Common Symptom ◽

Initial Surgery ◽

Case Series Study ◽

Long Term Follow Up ◽

Tumor Association

Large to giant sphenoid wing meningiomas (SWMs) remain surgically challenging due to frequent vascular encasement and a tendency for tumoral invasion of the cavernous sinus and optic canal. We aimed to study the quality of resection, postoperative clinical evolution, and recurrence rate of large SWMs. This retrospective study enrolled 21 patients who underwent surgery between January 2014 and December 2019 for SWMs > 5 cm in diameter (average 6.3 cm). Tumor association with cerebral edema, extension into the cavernous sinus or optic canal, degree of encasement of the major intracranial arteries, and tumor resection grade were recorded. Cognitive decline was the most common symptom (65% of patients), followed by visual decline (52%). Infiltration of the cavernous sinus and optical canal were identified in five and six patients, respectively. Varying degrees of arterial encasement were seen. Gross total resection was achieved in 67% of patients. Long-term follow-up revealed improvement in 17 patients (81%), deterioration in two patients (9.5%), and one death (4.7%) directly related to the surgical procedure. Seven patients displayed postoperative tumor progression and two required reintervention 3 years post initial surgery. Tumor size, vascular encasement, and skull base invasion mean that, despite technological advancements, surgical results are dependent on surgical strategy and skill. Appropriate microsurgical techniques can adequately solve arterial encasement but tumor progression remains an issue.

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Stereotactic Radiosurgery of Cavernous Sinus Meningiomas

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1683430 ◽

2019 ◽

Vol 81 (02) ◽

pp. 158-164

Author(s):

Daniel Rueß ◽

Fenja Fritsche ◽

Stefan Grau ◽

Harald Treuer ◽

Mauritius Hoevels ◽

...

Keyword(s):

Side Effects ◽

Stereotactic Radiosurgery ◽

Cavernous Sinus ◽

Symptom Control ◽

High Rate ◽

Tumor Control ◽

Incomplete Resection ◽

Kaplan Meier ◽

Microsurgical Resection

Abstract Objective Microsurgical resection of cavernous sinus meningiomas (CSM) is associated with a high rate of incomplete resection, recurrence, and the risk for permanent, severe cranial nerve deficits. Stereotactic radiosurgery (SRS) has evolved as alternative treatment for primary and recurrent CSM. Here, we report about the long-term clinical and radiological follow-up (FU) of a unique cohort of patients with CSM treated with LINAC or Cyberknife based SRS. Methods In this single-center retrospective analysis, we include all patients with CSM who underwent single fraction SRS between 1993 and 2016. Clinical and radiological tumor control were evaluated by the Kaplan–Meier method. Additionally, patient data were analyzed in terms of symptom control and incidence of side effects rated by the common terminology criteria for adverse events (CTCAE; v4.03). Results 116 patients (female/male = 91/25; median age, 54 years; range, 33–82 years) were included. Mean tumor volume was 5.7 ± 3.3 cm3 (range, 0.6–16.2 cm3), the median marginal dose was 12.6 Gy applied to isodose levels of 75%. Median clinical FU was 55 months (range, 3–226 months). Tumor control was 98% after 2 and 5 years and 90% after 10 years. Twelve patients (10.3%) had permanent or transient radiation related toxicity (CTCAE I–III). An improvement of symptoms was observed in 26.7% of the symptomatic patients (n = 20 of 75). Conclusion SRS for CSM provides excellent long-term tumor and symptom control without considerable permanent side effects. Thus, SRS should be considered when counseling patients suffering from CSM.

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