by ROBERT G. OJEMANN, M.D.
© Congress of Neurological Surgeons Honored Guest Presentation
Originally Published Clinical Neurosurgery, Volume 40, Chapter 17, Pages 321-383, 1992
Used with permission of the Congress of Neurological Surgeons.
HTML Editor: Stephen B. Tatter, M.D., Ph.D.

FIG. 17.10. Cavernous sinus meningioma. This 62-year-old woman presented with intermittent trigeminal neuralgia that was easily controlled with Tegretol when symptoms recurred. No treatment has been given and the tumor has remained stable by MRI for 3 years. (A and B) MRI axial (A) and Corona] (B) images after gadolinium show the tumor involving the left cavemous sinus, with the bulk of the tumor growing posteriorly and supeiorly.

Contents

• Introduction to the therapy of Meningiomas (File 1)
• General Considerations in Management of Meningiomas (File 1)
  • Surgery of Meningiomas (File 1)
  • Radiation Therapy of Meningiomas (File 1)
  • Observation of Meningiomas (File 1)
• Summary of Dr. Ojemann's Meningioma Series (File 1)
  • CAVERNOUS SINUS MENINGIOMAS (This File)
    • Management (This File)
    • Results (This File)
• References (File 22)

CAVERNOUS SINUS MENINGIOMAS

(Meningioma Management, File 10)

Management

Meningiomas involving the cavernous sinus may start in the sinus or grow into it as part of a larger tumor involving the medial sphenoid wing, orbit, other areas of the middle fossa, clivus, or petrous bone. The extent of the tumor is defined by MRI. If a major surgical procedure is planned angiography is needed to define the position and involvement of the internal carotid artery and its branches and to evaluate the possibility of occluding the internal carotid artery if the need arises.

FIG. 17.11. Cavernous sinus meningioma. This 47-year-old woman presented with increasing numbness in the right side of her face. At operation the tumor was completely removed from the fifth nerve. (A and B) MRI axial (A) and coronal (B) images after gadolinium, showing growth into Meckel's cave.

The decision regarding treatment is often difficult because the symptoms may be mild or nonprogressive, the natural history in some patients may be one of minimal or no growth for long periods of time, there is risk of significant cranial nerve morbidity with surgical treatment, and the long-term results of new surgical treatments and radiation therapy modalities are unknown (FIG. 17.10).

At the present time, surgery is indicated in younger patients with worsening symptoms (Fig. 17.11). Radiation therapy is used when there is regrowth following subtotal removal and in older patients with worsening symptoms. Patients of any age with nonprogressive or mild symptoms are observed.

The application of microsurgical techniques to the treatment of lesions in the cavernous sinus has been reviewed (4, 15, 63, 76). The anatomy of the cavernous sinus must be understood in order to treat these tumors. The approach is a frontal-temporal craniotomy. VanLoveren et al. (76) have clearly outlined the steps in the operative procedure which may be utilized depending on the extent of the tumor growth. When the tumor involves Meckel's cave the tentorium is opened posterior to the entrance of the fourth nerve, and the fifth nerve is followed anteriorly to aid dissection of the tumor from the nerve.

Results

In this series there were six patients, five women and one man, ranging in age from 35 to 51 years (Table 17.8). In no patient could I be sure of a total removal. All have had a good functional result. One patient had a tumor growing into Meckel's cave from the posterior cavernous sinus (Fig. 17.11). Postoperative complications included three temporary and one persistent third nerve palsy, a wound infection, and a pulmonary embolus. Three have been given radiation therapy. There has been no evidence of further growth in any of the patients.

Sekhar and Altschulen (63) reported complete removal of a meningioma in the cavernous sinus in 40 of 45 patients, with no mortality, fairly low morbidity, and low recurrence rate to date.

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