Improving Function in Cavernous Sinus Meningiomas: A Modern Treatment Algorithm

Abstract

Background: The efficacy and safety of radiosurgery led to paradigm shift in the management of cavernous sinus meningiomas. Nevertheless, patients are still significantly affected by cranial nerve deficits related to the mass effect of these tumors. Our management strategy involves the combination of a functional surgical decompression followed by radiation therapy. Methods: We reviewed a single institution's cohort of patients who underwent endoscopic endonasal decompression (EED) for symptomatic meningiomas primarily involving the cavernous sinus (CS) from 2010 to 2016. The preoperative neuro-ophthalmological exam was compared to the 1- and 6-month postoperative exams. The patient's length of hospital stay, complications, and radiological and clinical follow-up were noted. Results: A total of 17 patients underwent EED for CS meningiomas that fit our radiological criteria. The final outcome at the 6-month visit showed five patients (62.5%) with normalization of deficit and three patients (37.5%) with partial improvement of the CNII deficit. Out of the 12 patients who had cavernous sinus cranial nerves (CSCN) deficits, the final outcome at the 6-month visit showed four patients (33.33%) with normalization of deficit, seven patients (58.3%) with partial improvement, and one patient (8.33%) with no improvement. There were no intraoperative complications. Conclusion: The EED for CS meningiomas is a valuable technique when addressing acute/subacute CNII and CSCN deficits. This conservative surgical approach showed good functional outcomes, low morbidity, and low complication rates. However, it does not exempt the need for radiosurgery/radiation therapy for control of tumor growth.

Critical Appraisal of Minimally Invasive Keyhole Surgery for Intracranial Meningioma

“…Perhaps the most serious critique of keyhole meningioma surgery is that ultimately the patient is not well-served because overly conservative tumor removal leads to the eventual need for repeat surgery, radiosurgery, or possibly both. However, our overall meningioma resection rates for all locations except petroclival meningiomas are comparable to prior reports 10,13,[44][45][46]51 , and our progression/recurrence rate of 14% is similar to prior reports (almost all in patients who underwent NTR or STR), although this rate will undoubtedly increase with longer follow-up 9,10,54−57 . A growing collective experience places functional preservation as a higher priority than GTR resection, as highlighted by recent reports 2,10,13,35 .…”

Streamlining brain tumor surgery care during the COVID-19 pandemic: A case-control study

“…The endoscopic endonasal route is now a well-accepted approach for many midline skull base and parasellar non-pituitary tumors. In our experience and that of others, using smaller incisions with more focused craniotomies, or the natural endonasal corridor facilitate less brain exposure, rapid healing, reduced pain need for narcotics, and a greater willingness for patients to mobilize and leave the hospital soon after surgery [15,17,31,33,[39][40][41]. Similarly, strict complication avoidance protocols help facilitate short LOS, reduced ICU use, and lower overall complication rates [42,43].…”

Midline Skull Base Meningiomas: Transcranial and Endonasal Perspectives

“…The current treatment strategy relies on the tumor extracavernous resection and intracavernous debulking and decompression followed by adjuvant radiosurgery, as firstly suggested by Couldwell et al [ 110 , 150 , 183 , 184 , 185 , 186 , 187 , 188 , 189 , 190 , 191 , 192 , 193 , 194 , 195 , 196 , 197 , 198 , 199 , 200 , 201 , 202 , 203 , 204 , 205 , 206 , 207 , 208 , 209 , 210 , 211 , 212 ]. Surgical decompression determines the improvement of preexisting neurological symptoms against a negligible complication occurrence [ 188 , 190 , 206 , 213 , 214 , 215 ].…”

“…EEA provided some major advantages: (i) the direct visualization over the bony prominences of nerves and vessels contributes to obviating the risk for neurovascular injury; (ii) the medial wall of the cavernous sinus is made up of only a thin and inconstant dural layer, thus depicting a sliding door that allows the surgeon to follow and debulk the tumor within the cavernous sinus [ 248 , 249 ]; (iii) early relief of the pituitary gland with a concurrent improvement of its function [ 213 ]; (iv) a direct infero-medial decompression of the optic canal [ 187 ]; (v) the approaches to the cavernous sinus and to the sella do not expose subarachnoid spaces; therefore, the risk of CSF leak is extremely low ( Figure 8 ).…”

“…The current scenario for using the ventral route for cavernous sinus treatment foresees a conservative transsphenoidal decompression through the removal of the bone overlying sellar and cavernous sinus regions, dural opening, and debulking of the tumor. Furthermore, a 180° medial optic nerve decompression can be performed if needed [ 187 , 213 , 215 , 250 , 251 ].…”