scholarly journals Robotic Radiosurgery for Persistent Postoperative Acromegaly in Patients with Cavernous Sinus-Invading Pituitary Adenomas—A Multicenter Experience

Cancers ◽  
2021 ◽  
Vol 13 (3) ◽  
pp. 537
Author(s):  
Felix Ehret ◽  
Markus Kufeld ◽  
Christoph Fürweger ◽  
Alfred Haidenberger ◽  
Paul Windisch ◽  
...  
Keyword(s):  
Disease Control ◽  
Effective Treatment ◽  
Cavernous Sinus ◽  
Treatment Options ◽  
Cavernous Sinus Invasion ◽  
Robotic Radiosurgery ◽  
Patient Morbidity ◽  
Biochemical Remission ◽  
Patients Experience

Background: The rates of incomplete surgical resection for pituitary macroadenomas with cavernous sinus invasion are high. In growth hormone-producing adenomas, there is a considerable risk for persistent acromegaly. Thus, effective treatment options are needed to limit patient morbidity and mortality. This multicenter study assesses the efficacy and safety of robotic radiosurgery (RRS) for patients with cavernous sinus-invading adenomas with persistent acromegaly. Methods: Patients who underwent RRS with CyberKnife for postoperative acromegaly were eligible. Results: Fifty patients were included. At a median follow-up of 57 months, the local control was 100%. The pretreatment insulin-like growth factor 1 (IGF-1) levels and indexes were 381 ng/mL and 1.49, respectively. The median dose and prescription isodose were 18 Gy and 70%, respectively. Six months after RRS, and at the last follow-up, the IGF-1 levels and indexes were 277 ng/mL and 1.14, as well as 196 ng/mL and 0.83, respectively (p = 0.0001 and p = 0.0002). The IGF-1 index was a predictor for biochemical remission (p = 0.04). Nine patients achieved biochemical remission and 24 patients showed biochemical disease control. Three patients developed a new hypopituitarism. Conclusions: RRS is an effective treatment for this challenging patient population. IGF-1 levels are decreasing after treatment and most patients experience biochemical disease control or remission.

scholarly journals Detachable balloon embolization as the preferred treatment option for traumatic carotid-cavernous sinus fistula?

2019 ◽  
Vol 26 (1) ◽  
pp. 90-98
Author(s):  
Yin Niu ◽  
Tunan Chen ◽  
Jun Tang ◽  
ZhouYang Jiang ◽  
Gang Zhu ◽  
...  
Keyword(s):  
Cavernous Sinus ◽  
Coil Embolization ◽  
Treatment Options ◽  
Detachable Balloon ◽  
Double Balloon ◽  
Carotid Cavernous Sinus Fistula ◽  
Balloon Technique ◽  
Glue Embolization ◽  
Balloon Embolization

Objective The purpose of the study was to investigate the treatments and outcomes of patients with traumatic carotid-cavernous sinus fistula (TCCF). Methods All patients diagnosed with TCCF at our institution from January 2013 to December 2018 and meeting the inclusion/exclusion criteria were included in the study. Results A total of 24 patients were included in this study. Of them, 21 (87.5%) were treated with detachable balloon embolization, 1 (4%) with coil embolization, 1 (4%) with balloon-assisted coil embolization, and 1 (4%) with balloon-assisted coil and glue embolization. Among the 21 patients treated with detachable balloon embolization, 10 underwent double-balloon technique embolization including double-detachable balloon embolization (n = 6) and balloon-assisted detachable balloon embolization (n = 4). The fistulas in 17 patients (17/21, 81%) were successfully occluded after the first attempt of detachable balloon embolization, while those in the remaining 4 patients were occluded after a second surgery due to TCCF recurrence or pseudoaneurysm development. Preservation of the internal carotid artery (ICA) was observed in 19 cases after the first treatment by detachable balloon embolization (19/21, 90.4%). ICA was occluded in the remaining two patients, as revealed by a complete angiographic evaluation of the circle of Willis. All patients achieved complete resolution of ocular and orbital manifestations as well as pulsatile bruit, except for three patients whose oculomotorius and/or abducens remained paralyzed during the follow-up period. Conclusion Although several endovascular treatment options are available for TCCF, the detachable balloon embolization is still the preferred method of TCCF, as evidenced in our study. Furthermore, double balloon technique, an improvement upon the conventional detachable balloon embolization, is extremely safe and can effectively treat patients with refractory TCCF.

Transcavernous surgery; an effective treatment for pituitary macroadenomas

1995 ◽  
Vol 133 (2) ◽  
pp. 156-165 ◽  
Author(s):  
Akira Matsuno ◽  
Tomio Sasaki ◽  
Nobuhito Saito ◽  
Toshihiro Mochizuki ◽  
Takamitsu Fujimaki ◽  
...  
Keyword(s):  
Effective Treatment ◽  
Cavernous Sinus ◽  
Transsphenoidal Surgery ◽  
Elevated Serum ◽  
Serum Levels ◽  
Pituitary Hormones ◽  
Cavernous Sinus Invasion ◽  
Stimulation Tests ◽  
Sufficient Degree ◽  
Pituitary Macroadenomas

Matsuno A, Sasaki T, Saito N, Mochizuki T, Fujimaki T, Kirino T, Takakura K. Transcavernous surgery; an effective treatment for pituitary macroadenomas. Eur J Endocrinol 1995:133:156–65. ISSN 0804–4643 The endocrinological outcome in four patients with pituitary macroadenomas laterally invading the cavernous sinus, who were treated surgically by the transcranial transcavernous approach, was compared with that in four patients with macroadenomas that had been removed transsphenoidally. The decrease in the elevated serum levels of anterior pituitary hormones after transcavernous surgery ranged from 58.4% to 90.1%, whereas after transsphenoidal surgery it ranged from 0% to 46.1%. The responsiveness of pituitary hormones to stimulation tests was restored and maintained after transcranial transcavernous surgery. Transsphenoidal surgery achieved neither sufficient tumor reduction nor produced a satisfactory endocrinological remission. When cavernous sinus invasion is suspected by magnetic resonance imaging, even if it cannot be confirmed with certainty, transcranial transcavernous surgery is recommended. It is a useful surgical procedure for obtaining a sufficient degree of tumor extirpation and satisfactory endocrinological improvement in patients with macro-adenomas laterally invading the cavernous sinus, particularly somatotroph or corticotroph macro-adenomas. Postoperatively, mild cranial nerve paresis may occur, but this may resolve in 1–4 months. Akira Matsuno, Department of Neurosurgery, Teikyo University Ichihara Hospital, 3426-3 Anegasaki, Ichihara City, Chiba 299-01, Japan

scholarly journals Reoperation for growth hormone–secreting pituitary adenomas: report on an endonasal endoscopic series with a systematic review and meta-analysis of the literature

2018 ◽  
Vol 129 (2) ◽  
pp. 404-416 ◽  
Author(s):  
João Paulo Almeida ◽  
Armando S. Ruiz-Treviño ◽  
Buqing Liang ◽  
Sacit B. Omay ◽  
Sathwik R. Shetty ◽  
...  
Keyword(s):  
Systematic Review ◽  
Growth Hormone ◽  
Disease Control ◽  
Cavernous Sinus ◽  
Tumor Size ◽  
Hormonal Control ◽  
Cavernous Sinus Invasion ◽  
Surgery Group ◽  
The Mean ◽  
First Time

OBJECTIVESurgery is generally the first-line therapy for acromegaly. For patients with residual or recurrent tumors, several treatment options exist, including repeat surgery, medical therapy, and radiation. Reoperation for recurrent acromegaly has been associated with poor results, with hormonal control usually achieved in fewer than 50% of cases. Extended endonasal endoscopic approaches (EEAs) may potentially improve the results of reoperation for acromegaly by providing increased visibility and maneuverability in parasellar areas.METHODSA database of all patients treated in the authors’ center between July 2004 and February 2016 was reviewed. Cases involving patients with acromegaly secondary to growth hormone (GH)–secreting adenomas who underwent EEA were selected for chart review and divided into 2 groups: first-time surgery and reoperation. Disease control was defined by 2010 guidelines. Clinical and radiological characteristics and outcome data were extracted. A systematic review was done through a MEDLINE database search (2000–2016) to identify studies on the surgical treatment of acromegaly. Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the included studies were reviewed for surgical approach, tumor size, cavernous sinus invasion, disease control, and complications. Cases were divided into reoperation or first-time surgery for comparative analysis.RESULTSA total of 44 patients from the authors’ institution were included in this study. Of these patients, 2 underwent both first-time surgery and reoperation during the study period and were therefore included in both groups. Thus data from 46 surgical cases were analyzed (35 first-time operations and 11 reoperations). The mean length of follow-up was 70 months (range 6–150 months). The mean size of the reoperated tumors was 14.8 ± 10.0 mm (5 micro- and 6 macroadenomas). The patients’ mean age at the time of surgery was younger in the reoperation group than in the first-time surgery group (34.3 ± 12.8 years vs 49.1 ± 15.7 years, p = 0.007) and the mean preoperative GH level was also lower (7.7 ± 13.1 μg/L vs 25.6 ± 36.8 μg/L, p = 0.04). There was no statistically significant difference in disease control rates between the reoperation (7 [63.6%] of 11) and first-time surgery (25 [71.4%] of 33) groups (p = 0.71). Univariate analysis showed that older age, smaller tumor size, lower preoperative GH level, lower preoperative IGF-I level, and absence of cavernous sinus invasion were associated with higher chances of disease control in the first-time surgery group, whereas only absence of cavernous sinus invasion was associated with disease control in the reoperation group (p = 0.01). There was 1 case (9%) of transient diabetes insipidus and hypogonadism and 1 (9%) postoperative nasal infection after reoperation. The systematic review retrieved 29 papers with 161 reoperation and 2189 first-time surgery cases. Overall disease control for reoperation was 46.8% (95% CI 20%–74%) versus 56.4% (95% CI 49%–63%) for first-time operation. Reoperation and first-time surgery had similar control rates for microadenomas (73.6% [95% CI 32%–98%] vs 77.6% [95% CI 68%–85%]); however, reoperation was associated with substantially lower control rates for macroadenomas (27.5% [95% CI 5%–57%] vs 54.3% [95% CI 45%–62%]) and tumors invading the cavernous sinus (14.7% [95% CI 4%–29%] vs 38.5% [95% CI 27%–50%]).CONCLUSIONSReoperative EEA for acromegaly had results similar to those for first-time surgery and rates of control for macroadenomas that were better than historical rates. Cavernous sinus invasion continues to be a negative prognostic indicator for disease control; however, results with EEA show improvement compared with results reported in the prior literature.

Incidentally detected acromegaly: single-center study of surgically treated patients over 22 years

2020 ◽  
pp. jim-2020-001605
Author(s):  
Erica Alexandra Giraldi ◽  
Emir Veledar ◽  
Nelson M Oyesiku ◽  
Adriana G Ioachimescu
Keyword(s):  
Multimodality Treatment ◽  
Mass Effect ◽  
Tumor Diameter ◽  
Cavernous Sinus Invasion ◽  
Improved Outcomes ◽  
Number Of Patients ◽  
Single Center Study ◽  
Remission Rates ◽  
Biochemical Remission

Acromegaly is a rare disease associated with comorbidities that are common in the general population. Most patients undergo screening for classic phenotypical (CP) or mass effect manifestations. By retrospective review of pituitary tumor surgeries performed between 1994 and 2016 (1836), we identified patients with acromegaly (112). Main presentations were: CP (43%), mass effect (26%), incidentally detected (ID) tumors (17%), and other (14%). We compared the ID and CP groups regarding prevalence, clinical, biochemical, radiological and histopathological characteristics, and postoperative outcomes. The prevalence of ID among all surgeries increased after 2011 from 0.6% to 1.9% (p=0.01), while prevalence of CP remained stable (2.8% and 2.33%, p=0.65). Almost half of ID (47.4%) presented with otolaryngological manifestations. The ID and CP groups were similar regarding age, gender, comorbidities (hypertension, diabetes, hypopituitarism), tumor diameter and cavernous sinus invasion. Median insulin-like growth factor (IGF-1) and growth hormone (GH) levels were lower in the ID than CP (p<0.05 and p=0.07). Patients younger than 40 had smaller tumors in the ID than CP, while the opposite was true for older patients. The 3-month biochemical remission rates were similar (68% ID and 58% CP). A similar number of patients had normal IGF-1 at last follow-up (89.5% ID and 81.25% CP) after surgery alone and multimodality treatment. In conclusion, an increased number of patients with GH-secreting adenomas were ID in recent years. Education of physicians other than endocrinologists regarding presentation and comorbidity clustering may lead to an earlier diagnosis of acromegaly and improved outcomes.

scholarly journals Actinomyces europaeus Isolated from a Breast Abscess in a Penicillin-Allergic Patient

2018 ◽  
Vol 2018 ◽  
pp. 1-4 ◽  
Author(s):  
Sarah E. White ◽  
Stephen D. Woolley
Keyword(s):  
Antimicrobial Agent ◽  
Antibiotic Therapy ◽  
Effective Treatment ◽  
Treatment Options ◽  
Allergic Patient ◽  
Penicillin Allergy ◽  
Breast Abscess ◽  
Incision And Drainage ◽  
Rigorous Treatment

This is a case of Actinomyces europaeus in the breast abscess of a penicillin-allergic woman. The mainstay of treatment for actinomycosis is penicillin, and there is a lack of literature describing nonpenicillin treatment options. A 69-year-old woman presented acutely with a breast abscess which was managed with incision and drainage and antibiotic therapy to good response. 21 days after presentation, Actinomyces were grown from the culture of pus, so the patient was recalled and more rigorous treatment and follow-up were initiated. The penicillin allergy led to difficulty in the identification of an appropriate antimicrobial agent that was also logistically feasible to be given on an outpatient IV basis. IV tigecycline followed by oral clarithromycin was found to be effective treatment.

scholarly journals Giant GH-secreting pituitary adenomas: management of rare and aggressive pituitary tumors

2015 ◽  
Vol 172 (6) ◽  
pp. 707-713 ◽  
Author(s):  
Ilan Shimon ◽  
Raquel S Jallad ◽  
Maria Fleseriu ◽  
Chris G Yedinak ◽  
Yona Greenman ◽  
...  
Keyword(s):  
Somatostatin Analogs ◽  
Pituitary Tumors ◽  
Pituitary Surgery ◽  
Response To Treatment ◽  
Visual Field Defects ◽  
Cavernous Sinus Invasion ◽  
Maximal Diameter ◽  
Biochemical Remission ◽  
Lost To Follow Up

ObjectivesPatients with acromegaly usually harbor macroadenomas measuring between 10 and 30 mm in maximal diameter. Giant (adenoma size ≥40 mm) GH-secreting pituitary tumors are rarely encountered and the aim of this study is to analyze different methods for managing them.Design and methodsWe have identified 34 patients (15 men and 19 females) with giant adenomas among 762 subjects (4.5%) with acromegaly in our records, and characterized their clinical characteristics and response to treatment.ResultsMean age at diagnosis was 34.9±12.5 years (range, 16–67 years). Mean adenoma size was 49.4±9.4 mm (range, 40–80 mm); 30 adenomas showed cavernous sinus invasion and 32 had suprasellar extension. Twenty-nine (85%) patients had visual field defects. Mean baseline IGF1 was 3.4±1.8×ULN. All patients except one underwent pituitary surgery (one to three procedures), but none achieved hormonal remission following first surgery. Among the 28 subjects with visual disturbances, 14 recovered post-operatively and 13 improved. Treatment with somatostatin analogs was given to all patients after surgical failure. Six achieved remission, nine others were partially controlled (IGF1<1.5×ULN; 3/9 when combined with cabergoline), and 17 did not respond (two were lost). Nine patients were treated with pegvisomant, alone (n=4) or in combination with somatostatin analogs (n=5); five are in remission and two are partially controlled. Pasireotide-LAR achieved hormonal remission in one of the six patients. Currently, after a mean follow-up period of 8.9 years, 17 patients are in biochemical remission, eight are partially controlled, and seven are uncontrolled (two were lost to follow-up).ConclusionsGiant GH-secreting adenomas are invasive, uncontrolled by surgery, and respond poorly to medical treatment. Aggressive multimodal therapy is critical for their management, enhancing control rate and biochemical remission.

scholarly journals MON-298 IGF-1 in the Early Post-operative Assessment of Acromegaly

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Diane Donegan ◽  
Alicia Algeciras-Schimnich ◽  
Dana Z Erickson
Keyword(s):  
Cavernous Sinus ◽  
Surgical Intervention ◽  
Patient Anxiety ◽  
Cavernous Sinus Invasion ◽  
Delayed Treatment ◽  
First Line Therapy ◽  
Significant Difference ◽  
Suppression Test ◽  
Operative Assessment

Abstract Introduction: Transsphenoidal surgery is recommended as first line therapy in the vast majority of patients with acromegaly. Successful surgical intervention is determined by normalization of insulin like-growth factor (IGF) - 1 and adequate suppression of growth hormone (GH) during glucose GH suppression test or random GH levels &lt;1.0 ng/mL. Given the long half-life of IGF-1, evolution of IGF-1 and GH assays and limitations of GH suppression test, clinicians remain reliant on IGF-1 results 3–6 months following surgery to assess disease remission following surgical intervention. This can lead to delayed treatment of patients with persistent disease and significantly increase patient anxiety. Aim: To determine if IGF-1 levels at 6 weeks were equally predictive of surgical outcomes when compared to IGF-1 levels at 3–6 months postoperative. Methods: Retrospective review of patients with newly diagnosed acromegaly who had surgery between 2010–2019 and had post-operative IGF-1 level measured at 6 weeks and 3–6 months. IGF-1 was measured using the Siemens Immulite assay until 2016 when it was replaced by a LC-MS/MS assay. IGF-1 measurements at 6 weeks are obtained based on clinician discretion. Results: 69 patients (mean age 49 ± 14.8, female 31/69, 44.9%) with acromegaly had surgery and IGF-1 follow-up measurements at 6 weeks and 3–6 months. Persistent acromegaly was noted in 45/69 at 3–6 months. The median IGF-1 pre-operative was 701 ng/ mL (289–1600), 6 weeks postoperative was 286 ng/ mL (109–1038) and at 3–6 months was 267 ng/ mL (77–996). The median pre-operative IGF-1 was significantly higher than the median IGF-1 level at 6 weeks and 3–6 months (P=&lt;0.001). Although a statistically significant difference was seen between IGF-1 levels at 6 weeks and 3–6 months, the mean difference between these time points was small (20 ng/mL, P=&lt;0.001). There was a greater percent reduction in IGF-1 at 6 weeks following surgery in those who had a normal IGF-1 at 3–6 months compared to those who did not (63% vs 35%, P=&lt;0.01). Among patients who were deemed in remission at 3–6 months (24/69, 35%), 3/24 patients (all male with macroadenoma and no cavernous sinus invasion) had mildly elevated IGF-1 levels at 6 weeks (≤1.12 upper limit of normal) which subsequently normalized. In all of these patients, GH was &lt;1 ng/mL post-op. In 1 male (macroadenoma and cavernous sinus invasion), IGF-1 levels increased from normal at 6 weeks to abnormal when measured at 3–6 months. Conclusion: In the vast majority of patients, 6 weeks post-operative IGF-1 can be used to assess response to surgery avoiding a delay in treatment. However, we would recommend repeating IGF-1 levels at 3–6 months in those who have marginally elevated IGF-1 above normal (≤ 1.12), without cavernous sinus invasion and a post-operative GH of &lt;1 ng/mL prior to intervening if the IGF-1 is elevated 6 weeks as the IGF-1 may normalize.

scholarly journals Early Results of Microsurgical Treatment of Acromegaly

2018 ◽  
Vol 2 (1) ◽  
pp. 22-29 ◽  
Author(s):  
Pablo Ajler ◽  
Alvaro Campero ◽  
Federico Landriel ◽  
Ezequiel Goldschmidt ◽  
Santiago Hem ◽  
...  
Keyword(s):  
Cavernous Sinus ◽  
Multivariate Logistic Regression Analysis ◽  
Transnasal Approach ◽  
Cavernous Sinus Invasion ◽  
Early Results ◽  
Contrast Enhanced ◽  
Major Predictor ◽  
Cure Rates ◽  
Disease Persistence

Abstract Purpose Acromegaly is an unusual disorder caused by abnormal oversecretion of growth hormone by pituitary adenomas. Transsphenoidal surgery is frequently the first management option. The objective of this article is to establish the effectiveness of a transnasal transsphenoidal approach in the treatment of GH-producing adenomas, and to identify risk factors for disease persistence. Methods We conducted a retrospective review of 81 patients treated for acromegaly with transsphenoidal microsurgery between 2006 and 2010. Results Macroadenomas accounted for 66.7% of the cases, contrast-enhanced MRI revealing cavernous sinus invasion in 28.4% of the patients (23 subjects). Cure was achieved in 72.8% (59 of 82). All microadenomas (27 cases) were managed effectively with surgery whereas cure rates stood at 66.7% for macroadenomas. Monovariate analysis showed that disease persistence was statistically associated with three variables. Odds ratio for remission stood at 1.68 for microadenomas and 0.033 for cavernous sinus invasion (p<0.001). Preoperative GH values were statistically associated with cure during follow up (p<0.05). Multivariate logistic regression analysis showed that only cavernous sinus invasion continued to be significantly associated with disease persistence (OR 3.52, p<0.05). Conclusion The transnasal approach proves effective in the treatment and cure of acromegaly. Cavernous sinus invasion is a major predictor of disease persistence.

scholarly journals The outcomes of conservatively observed asymptomatic nonfunctioning pituitary adenomas with optic nerve compression

2020 ◽  
pp. 1-8
Author(s):  
Kihwan Hwang ◽  
Yong Hwy Kim ◽  
Jung Hee Kim ◽  
Jung Hyun Lee ◽  
Hee Kyung Yang ◽  
...  
Keyword(s):  
Optic Nerve ◽  
Natural History ◽  
Cavernous Sinus ◽  
Pituitary Adenomas ◽  
Nerve Compression ◽  
Cavernous Sinus Invasion ◽  
Nonfunctioning Pituitary Adenomas ◽  
History Of ◽  
Optic Nerve Compression

OBJECTIVEThe authors investigated the natural history of asymptomatic nonfunctioning pituitary adenomas (NFPAs) with optic nerve compression.METHODSThis study retrospectively analyzed the natural history of asymptomatic NFPAs with documented optic nerve compression on MRI diagnosed between 2000 and 2016 from 2 institutions. The patients were followed up with regular endocrinological, ophthalmological, and radiological evaluations, and the endpoint was new endocrinopathy or neurological deficits.RESULTSThe study comprised 81 patients. The median age at diagnosis was 58.0 years and the follow-up duration was 60.0 months. As the denominator of overall pituitary patients, 2604 patients were treated with surgery after diagnosis at the 2 institutions during the same period. The mean initial and last measured values for tumor diameter were 23.7 ± 8.9 mm and 26.2 ± 11.4 mm, respectively (mean ± SD). Tumor growth was observed in 51 (63.0%) patients; however, visual deterioration was observed in 14 (17.3%) patients. Ten (12.3%) patients experienced endocrine deterioration. Fourteen (17.3%) patients underwent surgery for either visual deterioration (in 12 patients) or endocrine dysfunction (in 2 patients). After surgery, all patients experienced improvements in visual or hormonal function. The actuarial rates of treatment-free survival at 2, 3, and 5 years were 96.1%, 93.2%, and 85.6%, respectively. In the multivariate analysis, initial cavernous sinus invasion (HR 4.985, 95% CI 1.597–15.56; p = 0.006) was the only independent risk factor for eventual treatment.CONCLUSIONSThe neuroendocrinological deteriorations were not frequent and could be recovered by surgery with early detection on regular follow-up in asymptomatic NFPAs with documented optic nerve compression on MRI. Therefore, conservative management could be an acceptable strategy for these tumors. Careful follow-up is required for tumors with cavernous sinus invasion.

Petroclival meningiomas: surgical experience in 109 cases

1996 ◽  
Vol 84 (1) ◽  
pp. 20-28 ◽  
Author(s):  
William T. Couldwell ◽  
Takanori Fukushima ◽  
Steven L. Giannotta ◽  
Martin H. Weiss
Keyword(s):  
Cavernous Sinus ◽  
Surgical Approaches ◽  
Surgical Removal ◽  
Total Removal ◽  
Content Type ◽  
Cavernous Sinus Invasion ◽  
Petroclival Meningiomas ◽  
High Incidence ◽  
Progression Of Disease

✓ The surgical removal of petroclival meningiomas has historically been associated with a high incidence of morbidity and mortality. The 109 consecutive patients included in the present retrospective study represent a combined series of tumors operated on by the four authors during a period from 1980 to 1992. The series is composed of 40 men and 69 women ranging in age from 25 to 75 years (mean 51 years). Surgical approaches to tumors in this series included simple retromastoid (60 cases), combined supra- and infratentorial petrosal (22), transtemporal (primary transsigmoid retrolabyrinthine, translabyrinthine, or transcochlear (12)), subtemporal (11), and frontotemporal transcavernous (eight). Gross-total removal was achieved in 75 patients (69%). Recurrence or progression of disease occurred in 14 patients (13%) over a 6.1-year mean follow-up period, and it was found within the cavernous sinus in 12 of these cases. Four recurrent cases demonstrated histological compatibility with malignant meningioma. Perioperative death occurred in four patients, and there were 56 significant complications in 35 other patients. Review of this series, with the attendant complications, has facilitated the authors' decision-making when considering the risk of gross-total removal in selected patients with asymptomatic cavernous sinus invasion or tumor adherent to the brainstem.

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