Cavernous Sinus Meningiomas: Imaging and Surgical Strategy

Abstract

Cavernous sinus (CS) meningiomas which are by definition those meningiomas which originate from the parasellar region are difficult skull base tumors to deal with. For deciding the most appropriate surgical strategy, surgeons need detailed preoperative neuroimaging. The vicinity of the tumor with the vital and highly functional neurovascular structures, tumor extensions into the basal cisterns and skull base structures, and the arterial vascularization and venous drainage pathways, as they shape operative strategy, are important preoperative data to take into account. Thin section CT scan with bone windows, 3D spiral CT reconstruction, MRI, MR angiography, and DSA performed with selective arteriography including late venous phases give those required detailed informations about the tumor and its relation with neurovascular and bony structures. The type of craniotomy and complementary osteotomy and the usefulness of an extradural anterior clinoidectomy with unroofing the optic canal can be decided from preoperative neuroimaging. Data collected also help in determining whether extensive exposure of the middle cranial fossa is necessary to ensure substantial devascularization of the tumor and whether proximal control of the internal carotid artery (ICA) at its intrapetrosal portion might be useful. Study of the capacity of blood supply of the Willis circle is wise for deciding the need and way of performing an extra-intracranial bypass together with tumor removal. Currently the concept of operating only the tumors with extracavernous extensions and to limit resection to only their extracavernous portions is the most accepted way of treating these tumors. It was that strategy that was adopted in the senior author's 220-patient series.Radiosurgery or stereotactic fractionated radiotherapy may complement surgery or can be only reserved for growing remnants.

Surgical management of giant sphenoid wing meningiomas encasing major cerebral arteries

“…1,9,11,12,19,23,24 When resection is contemplated, it is most often limited to the lateral compartment of the CS, followed by observation, or radiation therapy for symptomatic patients in order to reduce the rate of morbidity. 1,14,17,19,23,27,28 Although theoretically certain physical characteristics of the tumors, such as their hard or soft texture, the extent of their calcification, and/or the degree to which they are vascularized, would not prevent gross-total removal, they are nonetheless factors in determining whether more than 1 surgical session would be required. Obviously, highly calcified lesions (such as in case 10) or highly vascularized ones require more time for resection, and sometimes may not be completed in 1 session.…”

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 ].…”

Early intervention using high-precision radiotherapy preserved visual function for five consecutive patients with optic nerve sheath meningioma

“…At this moment, there are three primary treatment options for patients with cavernous sinus meningiomas: observation, microsurgical resection, and stereotactic radiosurgery (SRS). SRS may complement surgery or can be only reserved for growing remnants [ 26 ]. SRS can be replaced with FSRT or IMRT fundamentally and safely.…”