Extradural transcavernous approach to cavernous sinus cavernous hemangiomas

The Treatment Outcomes of Radiotherapy and Surgical Treatment for Patients with Cavernous Sinus Hemangioma: A Meta-Analysis

OBJECTIVE

Cavernous sinus hemangiomas (CSHs) are infrequent benign neoplasms. This meta-analysis was conducted with the objective of examining the prognostic outcomes of surgical interventions and radiotherapy (RT) in patients diagnosed with CSHs.

METHODS

A comprehensive literature search was performed across PubMed, Embase, and Web of Science databases, with traceability up to June 22, 2021. The evaluation of continuous variables was conducted by applying the weighted mean difference (WMD) and 95% confidence interval. A one-arm meta-analysis was used to scrutinize the tumor control rate, clinical improvement rate, recovery rates of abducens nerve palsy and visual disturbance, total resection rate, and the incidence rate of permanent nerve palsy post-treatment.

RESULTS

In total, 29 articles were incorporated into the meta-analysis. Post-RT for CSHs, a significant reduction in tumor volume was observed (WMD [95% confidence interval] = -17.16 [-21.52, -12.80] cm3). The tumor control rate, clinical improvement rate, recovery rate of abducens nerve palsy, and the recovery rate of visual disturbance were 97.1% (92.9, 99.7), 91.9% (82.3, 98.5), 95.6% (83.2, 100.0), and 86.3% (65.0, 99.5), respectively. Following surgical treatment, the total resection rate, mean intraoperative blood loss, recovery rate of visual disturbance, incidence rate of permanent nerve palsy, and recovery rate of abducens nerve palsy were 73.2% (57.1, 86.9), 971.17 mL (584.07, 1358.27), 66.4% (32.4, 0.942), 16.0% (4.6, 31.1), and 70.6% (51.0, 87.7), respectively. Notably, the recovery rate of abducens nerve palsy post-RT was markedly higher than postsurgical treatment.

CONCLUSIONS

The results of this meta-analysis underscore that RT is an effective and safe treatment modality for CSHs. Furthermore, the prognostic outcomes of RT demonstrated superiority over surgical intervention.

Cavernous sinus haemangioma masquerading as a pituitary macroadenoma: how the unexpected lurks in neurosurgery

Cavernous sinus haemangiomas are neoplastic lesions notoriously difficult to diagnose and excise. We present a case of a lesion that was clinically, biochemically, and radiologically consistent to a giant pituitary macroadenoma and discuss the unexpected near intra-operative exsanguination which enabled a pathognomonic diagnosis of a much rarer lesion to be made. This highlights the sinister nature of such a lesion, and its potential impact on patient care if partially excised, and that despite our advances in neurosurgical diagnostics the unexpected is to be expected.

Endoscopic endonasal transsphenoidal surgery for the cavernous sinus hemangioma: Surgical application and review of the literature

Aim

Cavernous sinus hemangiomas (CSHs) are hypervascular malformations and the surgical treatment is technically demanding. Although some articles have reported resection of CSHs using endoscopic endonasal transsphenoidal surgery (EETS), most of them were encountered for a lack of preoperative strategy guidance. Herein, we reported gross total resection (GTR) of intrasellar CSHs in two patients undergoing strategical EETS and compared EETS with frontotemporal craniotomy (FC) and stereotactic radiosurgery by literature review.

Material and methods

Two patients with CSHs who underwent EETS were reported. The literature review was conducted to exhaust studies that reported surgical treatment for CSHs. The tumor resection rate, and the postoperative short-term and long-term newly-developed or deteriorative cranial-nerve function rates were extracted.

Results

GTR was achieved with no postoperative complications in the two cases. Nine articles reported 14 cases undergoing EETS for CSHs and twenty-three articles reported 195 cases undergoing FC for CSHs. The GTR rates of EETS and FC were 57.14% (8/14) and 78.97% (154/195) respectively. The postoperative short-term and long-term newly-developed or deteriorative cranial-nerve function rates were 0% (0/7) and 0% (0/6) for the EETS group, and 57% (57/100) and 18.18% (18/99) for the FC group. According to the previous meta-analysis, stereotactic radiosurgery resulted in remarkable tumor shrinkage in 67.80% (40/59) of patients and partial shrinkage in 25.42% of patients.

Discussion

The results showed that the intrasellar type of CSHs could be removed safely by EETS without crossing the nerves in the CS.

Personalized Gamma Knife radiosurgery for cavernous sinus hemangiomas: A Chinese single-center retrospective study for 10 years of 187 patients

Background

The aim of this study is to retrospectively review the effectiveness and safety of personalized Gamma Knife radiosurgery (GKRS) for cavernous sinus hemangiomas (CSHs) and to summarize experience of personalized GKRS treatment for different volume of CSHs.

Methods

187 CSHs patients who received personalized GKRS treatment in our center from January 1, 2011 to December 31, 2020 were enrolled in this study and classified into small and medium CSHs (<20 ml), large CSHs (20–40 ml) and giant CSHs (≥40 ml) according to tumor volume. The personalized GKRS treatment strategy included single GKRS and staged GKRS. Tumor shrinkage rate, clinical symptoms response, and complications after GKRS were recorded during the follow-up period. Multivariate factors influencing clinical symptoms response were analyzed after personalized GKRS treatment.

Results

After a mean follow-up duration of 28 months (range 12–124 months), the tumor control rate was 100%, and the mean shrinkage rate of CSHs was 93.2% (61.3%–100%) in the last follow-up. Of the 115 patients with preexisting symptoms, 43 (37.5%) patients showed symptom disappearance, 17 (14.7%) patients demonstrated improvement, and 55 (47.8%) patients remained with no change. Previous surgical resection of CSHs (OR = 0.025, 95% CI 0.007–0.084, P = .000) was identified to be an independent risk factor for no symptom improvement after GKRS treatment.

Conclusions

Personalized GKRS is an effective and safe treatment for different volume of CSHs, which is capable of shrinking the tumor and improving symptoms with extremely low incidence of adverse effects and might be considered as the primary treatment strategy for CSHs.

Convexity Dura-Based Cerebral Cavernous Malformation Mimicking Meningioma: A Case Report and Literature Review

Cavernous angioma, cavernoma, cavernous hemangioma, also called cerebral cavernous malformation (when present in the brain), are benign vascular malformations, usually intraparenchymal; however, a few reported cases are in the extra-axial location—as middle cranial fossa, near the cavernous sinuses, and in the cerebellopontine angle—and are rarely reported as dura-based convexity lesion resembling meningioma. We report a giant dura-based, convexity, a cerebral cavernous malformation. We wish to notify the case as occurring at a rare location and a large-sized cerebral cavernous malformation. A case of young female presented with a long-standing history of headache. Computed tomography scan and magnetic resonance imagings (MRIs) suggested right occipital dura-based large mass lesion of approximately 5 cm in diameter. The lesion was excised and pathology studies confirmed the diagnosis of a cerebral cavernous malformation. A follow-up MRI confirmed total resection of the lesion and the patient had a smooth postoperative recovery.

Comparative Anatomical Assessment of Full vs Limited Transcavernous Exposure of the Carotid-Oculomotor Window

BACKGROUND

Although the full transcavernous approach affords extensive mobilization of the oculomotor nerve (OMN) for exposure of the basilar apex and interpeduncular cistern region, this time-consuming procedure requires substantial dural dissection along the anterior middle cranial fossa.

OBJECTIVE

To quantify the extent to which limited middle fossa dural elevation affects the carotid-oculomotor window (C-OMW) surgical area during transcavernous exposure after OMN mobilization.

METHODS

Four cadaveric specimens were dissected bilaterally to study the C-OMW area afforded by the transcavernous exposure. Each specimen underwent full and limited transcavernous exposure and anterior clinoidectomy (1 procedure per side; 8 procedures). Limited exposure was defined as a dural elevation confined to the cavernous sinus. Full exposure included dural elevation over the gasserian ganglion, extending to the middle meningeal artery and lateral middle cranial fossa.

RESULTS

The C-OMW area achieved with the limited transcavernous exposure, compared with full transcavernous exposure, provided significantly less total area with OMN mobilization (22 ± 6 mm2 vs 52 ± 26 mm2, P = .03) and a smaller relative increase in area after OMN mobilization (11 ± 5 mm2 vs 36 ± 13 mm2, P = .03). The increase after OMN mobilization in the C-OMW area after OMN mobilization was 136% ± 119% with a limited exposure vs 334% ± 216% with a full exposure.

CONCLUSION

In this anatomical study, the full transcavernous exposure significantly improved OMN mobilization and C-OMW area compared with a limited transcavernous exposure. If a transcavernous exposure is pursued, the difference in the carotid-oculomotor operative corridor area achieved with a limited vs full exposure should be considered.

Long-term outcomes of staged Gamma Knife radiosurgery for giant cavernous sinus hemangiomas: a single-center retrospective study

OBJECTIVE

Cavernous sinus hemangiomas (CSHs) are rare benign tumors originating from the cavernous sinus. Gamma Knife radiosurgery (GKRS) has been recommended as a primary treatment for small- to medium-sized CSHs. The optimal treatment for giant CSHs is still controversial. In this study, the authors retrospectively reviewed the effectiveness and safety of staged GKRS treatment for giant CSHs.

METHODS

Twenty-two patients with giant CSH who received staged GKRS treatment in the Gamma Knife Treatment Center of Henan Province during the period from January 1, 2011, to December 31, 2018, were enrolled in this study. Six patients had received microsurgery before GKRS, the other 16 patients were diagnosed according to clinical symptoms and MR images. All of the enrolled patients received 2-stage GKRS, and the mean interval between the two GKRS treatments was 6.5 months (range 6-12 months). For the first GKRS, the median isodose line was 48% (range 45%-50%), the median marginal dose was 13 Gy (range 11.5-14 Gy), and the median coverage of CSHs was 80% (range 70%-88%). For the second GKRS treatment, the median isodose line was 50% (range 45%-55%), the median marginal dose to the CSHs was 10.5 Gy (range 9-12.5 Gy), and the median coverage of the CSHs was 88% (range 80%-94%).

RESULTS

All of the patients received an outpatient review of an enhanced MR image of the head and a clinical physical check every 6 months after the first GKRS treatment. The mean follow-up duration was 52 months (range 24-84 months). The tumor control rate was 100% 24 months after staged GKRS, and at the last follow-up the mean tumor shrinkage rate was 96.7% (range 90.6%-100%) and the mean residual CSH volume was 2.1 ml (range 0-8.5 ml). Twenty patients suffered central nervous system (CNS) injury symptoms to varying degrees before staged GKRS treatment. Complete symptom recovery was found in 11 (55%) patients, improved symptoms in 5 (25%) patients, and no change in 4 (20%) patients after treatment. Only 1 patient suffered temporary preexisting headache aggravation and 1 patient suffered temporary preexisting diplopia aggravation 1 week after receiving the first GKRS treatment. Subacute or chronic complications were not detected after staged GKRS.

CONCLUSIONS

Staged GKRS is an effective treatment for giant CSHs. Because of the impressively low incidence of adverse effects, staged GKRS may be considered as a primary treatment for giant CSHs.

Surgical Treatment of Cavernous Sinus Cavernomas: Evidence from Vietnam

Cavernous sinus cavernomas, a rare vascular malformation, represents 3% of all benign cavernous sinus tumors. Both clinical and radiological signs are important for differentiating this condition from other cavernous sinus diseases. The best treatment is radical removal tumor surgery; however, due to the tumor being located in the cavernous sinus, there are many difficulties in the surgery. We report a case of a 35-year-old female who only presented sporadical headache. After serial magnetic resonance imaging acquisitions, a tumor measuring 30 mm in the left cavernous sinus and heterogenous enhencement was observed. Then, the patient underwent an operation with an extradural basal temporal approach. Postoperatively, the tumor was safely gross total removed. The patient developed left oculomotor nerve palsy but fully recovered after 3 months of acupunture treatment, and developed persistent left maxillofacial paresthesia. The surgical treatment for cavernous sinus cavernomas may be considered a best choice regarding safety and efficiency.

Clinical Features, Intradural Transcavernous Surgical Management, and Outcomes of Giant Cavernous Sinus Hemangiomas: A Single-Institution Experience

BACKGROUND

Cavernous sinus hemangiomas (CSHs) are rare vascular tumors. Stereotactic radiosurgery is an effective treatment for small CSHs. The optimal treatment for giant CSHs is controversial. This study reports advantages of a complete intradural transcavernous approach in total resection of CSHs.

METHODS

Between January 2012 and January 2017, 15 patients with giant CSHs were treated surgically. All cases were evaluated with a contrast-enhanced magnetic resonance imaging scan and confirmed histopathologically. A complete intradural approach was used for all patients. Clinical manifestations, radiographic characteristics, operative techniques, and outcomes of patients were analyzed.

RESULTS

Headache was the most common initial symptom, followed by decreased visual acuity and diplopia. Postoperative magnetic resonance imaging showed that gross total resection was achieved in 13 patients. Two patients had experienced total ipsilateral visual loss for several years before surgery; vision improved in all remaining patients with preoperative visual diminution. The most common early neurologic deficit was cranial nerve VI dysfunction, which was observed in 9 patients (60%; 5 new deficits). Only 2 patients (13.3%) experienced permanent morbidity on long-term follow-up. The early postoperative morbidity rate for cranial nerve III dysfunction was 33.3% (5 patients), and only 1 patient (6.7%) experienced permanent morbidity. Four patients (26.7%) had slight postoperative facial numbness.

CONCLUSIONS

Surgical total resection is the primary and reasonable choice for giant CSHs. Microsurgical resection of giant CSHs through a completely intradural transcavernous approach is an alternative treatment option for giant CSHs.

Surgical Management and Outcomes of Cavernous Sinus Hemangiomas: A Single-Institution Series of 47 Patients

OBJECTIVE

The purpose of this study was to analyze the outcomes of cavernous sinus hemangiomas (CSHs) treated surgically, and to investigate factors that affect the gross total resection (GTR), newly developed or deteriorated cranial nerve injury (NDDCNI), and follow-up neurologic performance, and to further discuss the optimal treatment for CSHs.

METHODS

Clinical data of 47 patients with CSHs treated surgically at our institution between 2012-2018 were retrospectively reviewed.

RESULTS

GTR was achieved in 26 (55.3%) patients. Significant relations were identified between the invasion of the sella turcica (odds ratio [OR] = 0.012; 95% confidence interval [CI], 0.001-0.213; P = 0.002), skull base ward (OR = 27.838; 95% CI, 2.995-258.748; P = 0.003), and GTR. The preoperative Karnofsky Performance Scale (KPS) score (OR = 2.966, per 10 score increase; 95% CI, 1.136-7.743; P = 0.026) and the invasion of the sella turcica (OR = 7.137; 95% CI, 1.282-39.726; P = 0.025) were factors that significantly affected the incidence of NDDCNI. The average follow-up KPS score, which increased significantly compared with the pre (P < 0.001) and postoperative KPS scores (P < 0.001), was 89.1. Increased tumor size (OR = 0.044, per 1cm increase; 95% CI, 0.004-0.477; P = 0.010) was a risk factor for unfavorable follow-up KPS score.

CONCLUSIONS

Being treated by an experienced skull base surgeon favors the total removal of CSHs, whereas the invasion of the sella turcica does just the opposite. Increased tumor size is a risk factor for unfavorable follow-up KPS score. The invasion of the sella turcica was related to NDDCNI and unfavorable follow-up KPS score.