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Management of Meningiomas
File 10: CAVERNOUS SINUS MENINGIOMAS

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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.


Disclaimer: The information and reference materials contained herein are intended solely to provide background information. They were written for an audience of physicians. They are in no way intended to constitute medical advise. For medical advise a physician must, of course, be consulted.
MRI of Meningioma
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


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.

MRI of Meningioma
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

TABLE 17.8 Cavernous Sinus Meningiomas
aRemoval bOutcome Complications Recurrence
T 0 Good 6 Temporary 3rd
nerve palsy
3 Given radiation
therapy; no
growth (1-9
years)
RST 1 Fair 0
ST 5 Poor 0 Permanent 3rd
nerve palsy
aT, total removal
RST, radical subtotal removal
ST, subtotal removal
bGood, free of major neurological deficit
and able to return to previous activity level
Fair, independent but not able to return to full activity
because of new neurological deficit or significant
preoperative deficit that did not fully recover
Poor, dependent.

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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