Management of Cavernous Sinus Meningioma via Endoscopic Skull Base Surgery and Adjunctive Stereotactic Radiotherapy

Background: Management of cavernous sinus meningiomas (CSM) poses a surgical challenge due to the neurovascular intricacies of their location. When surgery is indicated, combined minimally invasive surgery and radiotherapy has been may allow adequate tumor control while minimizing the morbidity and mortality associated with maximal resection as stand-alone therapy. Endoscopic decompression coupled with stereotactic radiotherapy (SRT) has recently gained recognition as a valuable therapeutic strategy for CSM in selected cases.

Objective: Assess the efficacy of CSM management with upfront endoscopic decompression, through either endonasal, transorbital or combined surgical techniques, succeeded by adjunctive SRT, and conduct a review of their outcomes.

Methods: We conducted a retrospective analysis of patient data with CSM who underwent a surgical and SRT treatment at our institution from January 2017 to March 2021. Surgical strategies encompassed the endoscopic endonasal approach (EEA), for exclusively intracavernous meningiomas or CSMs with medial extension, and the endoscopic transorbital approach (ETOA) for CSMs with lateral extension. A combined endonasal and transorbital strategy (EEA + ETOA) was used for larger CSMs. For each case, we report clinical and radiographic findings, and include the history of prior treatments.

Results: We included a total of 30 patients with CSM who underwent endoscopic decompression; 21 EEA, 8 ETOA, and 1 EEA + ETOA (mean age 50.8 years, ±SD 13, 80% female, 20% male). Mean tumor volume was 9.6 mL (range: 0.9–37.2 mL) ±SD 11.3. In the cohort, 53.3% exhibited cranial nerve deficits, and 46.7% had visual disturbances. CSM with medial extension into the sphenoid sinus and sella were identified in 33.3% of cases, while CSM with lateral extension in 53.3%. Orbital involvement was found in 66.7%, superior extension in 30%, and petroclival area involvement in 16.7%. Following decompression, all of the patients received adjuvant SRT, and one patient underwent subsequent craniotomy in a staged resection. 80% of tumors were World Health Organization grade I meningiomas, with the remainder (20%) classified as grade II. Median follow-up duration was 18 months (range: 12–66 months) Posttreatment improvement in cranial nerve function occurred in 20% of patients and visual recovery in 20%. Conversely, 20% experienced transient cranial neuropathy, and 6.7% presented deterioration of vision. Postoperative imaging revealed tumor control was achieved in 90% of patients, while 10% showed progression.

Conclusions: Surgical decompression through EEA and/or ETOA in conjunction with adjuvant SRT yields favorable results when addressing CSM. Results of this treatment strategy are promising in selected cases of unresectable CSM.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
05 February 2024