Efficacy of induced hypotension in the surgical treatment of large cavernous sinus cavernomas

Anesthetic Management and Considerations in a Rare Case of Parietal Bone Hemangioma

Parietal bone hemangiomas represent a minority of diagnosed brain tumors. These lesions require careful management under anesthesia due to their vascularity and cranial location. We discuss a 31-year-old female with chronic headaches who underwent surgery for the removal of a large parietal bone hemangioma, necessitating considerations for stable hemodynamics, intracranial pressure (ICP), and bleeding risks. There is no standard anesthetic for these cases, so a mixed anesthetic approach was used, combining intravenous anesthesia with sevoflurane, aimed at optimizing control during the procedure.

Spectrum of Surgically Resected Lesions of the Cavernous Sinus: A Neuropathologic Audit

Background  The cavernous sinus is a complex space composed of extradural venous plexus within dural folds. Several important structures like the carotid artery, cranial nerves, and sympathetic nerve fibers traverse through this space. Radiological diagnosis may not be definitive and in the context of discordance between clinical and neuroimaging diagnosis, histopathological evaluation becomes essential for diagnosis and management. Literature on the pathological spectrum of lesions is scarce as, with a shift in the treatment paradigm, most small lesions of cavernous sinus are treated with radiosurgery. However, surgical management still plays a role for larger lesions and in radiologically ambiguous cases for planning the definitive management.

Materials and Methods  We retrospectively reviewed all surgically resected lesions of the cavernous sinus over the last two decades (1998–2019). The clinical presentation, neuroimaging features, and histopathological findings were reviewed. Lesions extending from sella and other adjacent areas were excluded.

Results  Thirty-eight cases of isolated cavernous sinus mass lesions were diagnosed over the last two decades (1998–2019). Cavernous hemangiomas (19 cases, 50%) constituted the most frequent pathology, followed by aspergilloma, meningioma, schwannoma, metastatic adenocarcinoma, chondrosarcoma, and chordoma. Overall, 29.4% (10/34) could not be accurately diagnosed on neuroimaging. Of these, four cases of cavernous hemangiomas were mistaken for either meningioma (three cases) or schwannoma (one case). Neither chordoma nor chondrosarcoma was suspected.

Conclusion  This is the first study in literature, enumerating the pathological and imaging spectrum of surgically resected cavernous sinus lesions. Cavernous hemangiomas, metastases and chordomas, and chondrosarcoma posed the greatest difficulty in diagnosis on neuroimaging and the reasons for the same are analyzed. In the context of clinical and neuroimaging discordance in diagnosis, pathological characterization becomes essential for appropriate and timely management.

The dural angioleiomyoma harbors frequent GJA4 mutation and a distinct DNA methylation profile

The International Society for the Study of Vascular Anomalies (ISSVA) has defined four vascular lesions in the central nervous system (CNS): arteriovenous malformations, cavernous angiomas (also known as cerebral cavernous malformations), venous malformations, and telangiectasias. From a retrospective central radiological and histopathological review of 202 CNS vascular lesions, we identified three cases of unclassified vascular lesions. Interestingly, they shared the same radiological and histopathological features evoking the cavernous subtype of angioleiomyomas described in the soft tissue. We grouped them together with four additional similar cases from our clinicopathological network and performed combined molecular analyses. In addition, cases were compared with a cohort of 5 soft tissue angioleiomyomas. Three out 6 CNS lesions presented the same p.Gly41Cys GJA4 mutation recently reported in hepatic hemangiomas and cutaneous venous malformations and found in 4/5 soft tissue angioleiomyomas of our cohort with available data. Most DNA methylation profiles were not classifiable using the CNS brain tumor (version 12.5), and sarcoma (version 12.2) classifiers. However, using unsupervised t-SNE analysis and hierarchical clustering analysis, 5 of the 6 lesions grouped together and formed a distinct epigenetic group, separated from the clusters of soft tissue angioleiomyomas, other vascular tumors, inflammatory myofibroblastic tumors and meningiomas. Our extensive literature review identified several cases similar to these lesions, with a wide variety of denominations. Based on radiological and histomolecular findings, we suggest the new terminology of "dural angioleiomyomas" (DALM) to designate these lesions characterized by a distinct DNA methylation pattern and frequent GJA4 mutations.

Cavernous Sinus Vascular Venous Malformation

Vascular venous malformations of the cavernous sinus have multiple imaging features that can be used to distinguish them from other entities in the region. Accurate identification of these lesions is essential: Vascular venous malformation lesions carry considerable risk of intraoperative hemorrhage, so preoperative recognition of vascular venous malformations can greatly impact the treatment strategies used. Nevertheless, because of their scarcity, many radiologists are unfamiliar with the radiologic and clinical features of cavernous sinus vascular venous malformations. This article will describe a case of an asymptomatic vascular venous malformation; outline its imaging, clinical, and pathologic features; and review the relevant literature regarding this diagnosis.

Temporal Volume Change of Cavernous Sinus Cavernous Hemangiomas after Gamma Knife Surgery

Cavernous hemangiomas occur very rarely in the cavernous sinus. This study aimed to evaluate the efficacy of Gamma Knife surgery (GKS) on cavernous sinus cavernous hemangioma (CSCH) and to analyze the temporal volume change. We retrospectively reviewed the clinical data of 26 CSCH patients who were treated with GKS between 2001 and 2017. Before GKS, 11 patients (42.3%) had cranial neuropathies and 5 patients (19.2%) complained of headache, whereas 10 patients (38.5%) were initially asymptomatic. The mean pre-GKS mass volume was 9.3 mL (range, 0.5-31.6 mL), and the margin dose ranged from 13 to 15 Gy according to the mass volume and the proximity to the optic pathway. All cranial neuropathy patients and half of headache patients showed clinical improvement. All 26 patients achieved mass control; remarkable responses (less than 1/3 of the initial mass volume) were shown in 19 patients (73.1%) and moderate responses (more than 1/3 and less than 2/3) in 7 patients (26.9%). The mean final mass volume after GKS was 1.8 mL (range, 0-12.6 mL). The mean mass volume at 6 months after GKS was 45% (range, 5-80%) compared to the mass volume before GKS and 21% (range, 0-70%) at 12 months. The higher radiation dose tended to induce more rapid and greater volume reduction. No treatment-related complication was observed during the follow-up period. GKS could be an effective and safe therapeutic strategy for CSCH. GKS induced very rapid volume reduction compared to other benign brain tumors.

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.

Report of a case of cavernous haemangioma of the cavernous sinus

Cavernous haemangioma of the cavernous sinus is a rare vascular malformation. It's often confused with other parasellar masses. Here, we report a case of a female with a left parasellar mass which was misdiagnosed as schwannoma vs meningioma using CT and MRI. The patient was operated via the pterional approach but resection had been halted due to severe haemorrhage and only tumour biopsy could be obtained. The diagnosis of cavernous sinus haemangioma was established by histopathology and confirmed by subsequent digital subtraction angiography. The patient refused second surgery or adjuvant radiosurgery and the treatment strategy was observation and follow-up. Retrospectively, we included the key radiographic features of cavernous sinus haemangioma which would facilitate pre-operative diagnosis and avoid unforeseen operative complications. Diagnostic radiographic features include a well-defined mass in the cavernous sinus which shows isodense to slightly hyperdense attenuation on non-contrast CT scan with possible adjacent pressure bone remodelling. On MRI, it shows remarkable high T₂ signal; intense homogenous enhancement or characteristic progressive contrast enhancement on sequential enhanced images. On digital subtraction angiography, it may demonstrate a vascular blush.

Hypofractionated stereotactic radiosurgery: a new treatment strategy for giant cavernous sinus hemangiomas

OBJECTIVE Cavernous sinus hemangiomas (CSHs) are rare benign vascular tumors that arise from the dural venous sinuses lateral to the sella. Stereotactic radiosurgery (SRS) has emerged as a principal alternative to microresection for small- and medium-sized CSHs. Resection is a reasonable option for large (3-4 cm in diameter) and giant (> 4 cm in diameter) CSHs. However, management of giant CSHs remains a challenge for neurosurgeons because of the high rates of morbidity and even death that stem from uncontrollable and massive hemorrhage during surgery. The authors report here the results of their study on the use of hypofractionated SRS (H-SRS) to treat giant CSH. METHODS Between January 2008 and April 2014, 31 patients with a giant CSH (tumor volume > 40 cm³, > 4 cm in diameter) treated using CyberKnife radiosurgery were enrolled in a cohort study. Clinical status and targeted reduction of tumor volume were evaluated by means of serial MRI. The diagnosis for 27 patients was determined on the basis of typical imaging features. In 4 patients, the diagnosis of CSH was confirmed histopathologically. The median CSH volume was 64.4 cm³ (range 40.9-145.3 cm³). Three or 4 sessions of CyberKnife radiosurgery were used with a prescription dose based on the intent to cover the entire tumor with a higher dose while ensuring dose limitation to the visual pathways and brainstem. The median marginal dose to the tumor was 21 Gy (range 19.5-21 Gy) in 3 fractions for 11 patients and 22 Gy (range 18-22 Gy) in 4 fractions for 20 patients. RESULTS The median duration of follow-up was 30 months (range 6-78 months) for all patients. Follow-up MRI scans revealed a median tumor volume reduction of 88.1% (62.3%-99.4%) at last examination compared with the pretreatment volume. Ten patients developed new or aggravated temporary headache and 5 experienced vomiting during the treatment; these acute symptoms were relieved completely after steroid administration. Among the 30 patients with symptoms observed before treatment, 19 achieved complete symptomatic remission, and 11 had partial remission. One patient reported seizures, which were controlled after antiepileptic drug administration. No radiation-induced neurological deficits or delayed complications were reported during the follow-up period. CONCLUSIONS Hypofractionated SRS was an effective and safe modality for treating giant CSH. Considering the risks involved with microsurgery, it is possible that H-SRS might be able to serve as a definitive primary treatment option for giant CSH.

Endoscopic transorbital route to the cavernous sinus through the meningo-orbital band: a descriptive anatomical study

OBJECTIVE Exposure of the cavernous sinus is technically challenging. The most common surgical approaches use well-known variations of the standard frontotemporal craniotomy. In this paper the authors describe a novel ventral route that enters the lateral wall of the cavernous sinus through an interdural corridor that includes the removal of the greater sphenoid wing via a purely endoscopic transorbital pathway. METHODS Five human cadaveric heads (10 sides) were dissected at the Laboratory of Surgical NeuroAnatomy of the University of Barcelona. To expose the lateral wall of the cavernous sinus, a superior eyelid endoscopic transorbital approach was performed and the anterior portion of the greater sphenoid wing was removed. The meningo-orbital band was exposed as the key starting point for revealing the cavernous sinus and its contents in a minimally invasive interdural fashion. RESULTS This endoscopic transorbital approach, with partial removal of the greater sphenoid wing followed by a "natural" ventral interdural dissection of the meningo-orbital band, allowed exposure of the entire lateral wall of the cavernous sinus up to the plexiform portion of the trigeminal root and the petrous bone posteriorly and the foramen spinosum, with the middle meningeal artery, laterally. CONCLUSIONS The purely endoscopic transorbital approach through the meningo-orbital band provides a direct view of the cavernous sinus through a simple and rapid means of access. Indeed, this interdural pathway lies in the same sagittal plane as the lateral wall of the cavernous sinus. Advantages include a favorable angle of attack, minimal brain retraction, and the possibility for dissection through the interdural space without entering the neurovascular compartment of the cavernous sinus. Surgical series are needed to demonstrate any clinical advantages and disadvantages of this novel route.

Gamma Knife Surgery for Cavernous Sinus Hemanginoma: A Report of 32 Cases

BACKGROUND

Cavernous sinus hemangioma (CSH) is a rare type of benign vascular tumor. Microsurgery for CSH treatment usually results in profuse bleeding and cranial nerve injury. Radiosurgery is an alternative treatment for CSH. The objective of this study was to elucidate the efficacy and safety of gamma knife surgery (GKS) for the treatment of CSH.

METHODS

A total of 32 patients with CSH underwent 34 times of GKS as a primary and exclusive treatment from 2009 to 2015 at West China Hospital. The diagnosis was mainly based on findings of magnetic resonance imaging. The treatment was performed with the Leksell Gamma Knife model C. The follow-up period was from 12-67 months. Changes in imaging results and signs or symptoms were analyzed. Studies of patients who had undergone radiosurgery and microsurgery were compared.

RESULTS

Clinical improvement was observed after GKS in 26 of 27 patients who presented with signs or symptoms of CSH. Tumor shrinkage was detected in all cases. A reduction in tumor volume of 0-25%, 26%-50%, 51%-75%, and 76%-100% was observed in 3, 2, 8, and 19 cases, respectively. Remarkable tumor shrinkage occurred within 6-12 months after GKS. According to a retrospective analysis of 151 patients diagnosed with CSH, 77 patients underwent GKS without any complications, 17 of 74 patients were treated with microsurgery and exhibited persistent complications, and 1 patient died.

CONCLUSIONS

GKS is a safe and effective treatment for most cases of CSH. The concept of GKS as an adjuvant treatment for CSH requires reconsideration.

Extradural transcavernous approach to cavernous sinus cavernous hemangiomas

OBJECTIVE

Cavernous sinus cavernous hemangioma (CSCH) is a rare extra-axial vascular lesion and is difficult to be removed due to their location, propensity for profuse bleeding during surgery, and relationship to complex neurovascular structures. The purpose of this study is to report our experience of the removal of CSCHs through a completely extradural transcavernous approach.

METHODS

Twelve patients with CSCH, who were operated through a purely extradural approach, were retrospectively studied. Clinical symptoms and signs, radiographic characteristics, operative techniques and outcomes of these patients were analyzed.

RESULTS

Headache and visual impairment were the most common clinical symptoms, followed by facial hypesthesia and ptosis. Radiographically, CSCHs have a characteristic pattern. On computed tomography (CT) scans, CSCHs are isodense or minimally hyperdense, with an intense homogenous contrast administration. Magnetic resonance image (MRI) scans revealed well-demarcated and hypo- to isointense lesions on T1-weighted images and characteristically, markedly hyperintense lesions on T2-weighted images. The T2-weighted images showed a marked homogeneous and an intense enhancement after contrast administration. All CSCHs were treated by a completely extradural transcavernous approach. Gross total excision was achieved in all 12 patients. Post-operative complication included transient cranial nerve dysfunction for 2-3 months in eight patients, and three patients developed a permanent VI nerve palsy. The follow-up period ranged from 4 to 117 months (mean 62 months), and no patient had experienced tumor recurrence.

CONCLUSION

CSCHs are rare and challenging skull base tumors. The microsurgical resection, using an extradural transcavernous approach which allows complete tumor resection with an acceptable intraoperative and postoperative complications, should be considered as a favorable choice among all treatments.

A new classification and clinical results of Gamma Knife radiosurgery for cavernous sinus hemangiomas: a report of 53 cases

BACKGROUND

Cavernous sinus hemangiomas (CaSHs) are rare vascular lesions in the cavernous sinus(CS). Gamma Knife radiosurgery (GKS) provides a treatment modality alternative to microsurgery. This study was conducted to describe a new classification of CaSHs based on their magnetic resonance (MR) imaging findings and determine the efficacy and safety of GKS in a large series of CaSH patients.

METHODS

From April 2007 to November 2012, 53 patients harboring CaSHs were treated using Leksell Gamma Knife model C (before April 2012) or Perfexion (from May 2012 ) at the Gamma Knife Center of Huashan Hospital. Of the 53 patients, 15 with definitive histopathologic diagnoses after surgery, 38 were diagnosed based on their MR imaging findings. There were 15 male and 38 female patients with a mean age of 52 (range, 25-76) years old. The characteristics of MR images of CaSHs were their extremely high homogeneous intensity on T2-weighted and FLAIR images: as bright as cerebrospinal fluid signal. According to the relationship between the carotid line and their location, CaSHs were classified into three types: the intrasellar, parasellar and mixed type. The mean volume of the tumors was 13.2 ± 8.2 cm(3) (range, 1-41 cm(3)). A mean marginal dose of 13.3 Gy (range, 8-15 Gy) was directed to the 49%-64% isodose line (mean 53%).

RESULTS

Of the 53 tumors, 6 (11%) were classified as intrasellar type. Eight (15%) were parasellar type and the other 39 cases(74%) mixed type. The mean radiological and clinical follow-up time of this study was 24 (range, 2-67 months) and 34 months (range, 2-73 months), respectively. The tumor control rate was 100%. The mean tumor volume reduction was 79.5% (range, 16.5%-100%) compared with the pre-GKS volume. Six months after GKS, MR imaging revealed an average of 60.2% tumor volume reduction (range, 16.5%-89.2%). Twenty-nine cases (55%) showed a >80% tumor volume decrease. Neurologically, only two of these patients showed clinical deterioration, and 33 patients demonstrated an obvious improvement in ocular or endocrine disorders. At last follow-up, there were no more complications related to GKS, and none of the tumors progressed.

CONCLUSIONS

Our study showed that GKS is a useful and safe therapeutic method for CaSHs as both a primary and adjuvant treatment. The new classification of CaSHs may help predict their clinical course during tumor development and treatment response after GKS. Further studies with long-term follow-up and larger numbers of cases are necessary to optimize the treatment conditions and verify the benefit of this treatment.

Conservative management of cavernous sinus cavernous hemangioma in pregnancy

Cavernous sinus cavernous hemangiomas in pregnancy are extremely rare lesions. The precise management of these lesions remains unknown. The authors present a case of a cavernous hemangioma in pregnancy, centered within the cavernous sinus that underwent postpartum involution without surgical intervention. A 34-year-old pregnant patient (gravida 1, para 0) presented to an otolaryngologist with persistent headache and left-sided facial pain and numbness in the V1 distribution. While being treated for sinusitis, her symptoms progressed to include a left-sided oculomotor palsy and abducens palsy. Magnetic resonance imaging without contrast revealed an expansile mass within the left cavernous sinus consistent with a cavernous hemangioma. The patient was evaluated by a neurosurgeon who recommended close follow-up and postpartum imaging without surgical intervention. Although the lesion enlarged during pregnancy, the patient was able to undergo an uncomplicated cesarean section at 37 weeks. All facial and ocular symptoms resolved by 9 months postpartum, and MRI showed a decrease in lesion size and reduced mass effect. The authors conclude that nonsurgical management may be a viable approach in patients who have an onset or exacerbation of symptoms associated with cavernous sinus cavernous hemangiomas during pregnancy because postpartum involution may negate the need for surgical intervention.

Cavernous sinus hemangioma: a fourteen year single institution experience

Cavernous sinus hemangioma (CSH) is a rare extra-axial vascular neoplasm that accounts for 2% to 3% of all cavernous sinus tumors. Their location, propensity for profuse bleeding during surgery, and relationship to complex neurovascular structures are factors which present difficulty in excising these lesions. The authors describe their experience of 22 patients with CSH over 14 years at a tertiary care center. Patients were managed with microsurgical resection using a purely extradural transcavernous approach (13 patients) and with Gamma Knife radiosurgery (GKRS; Elekta AB, Stockholm, Sweden) (nine patients). Retrospective data analysis found headache and visual impairment were the most common presenting complaints, followed by facial hypesthesia and diplopia. All but one patient had complete tumor excision in the surgical series. Transient ophthalmoparesis (complete resolution in 6-8 weeks) was the most common surgical complication. In the GKRS group, marked tumor shrinkage (>50% tumor volume reduction) was achieved in two patients, slight shrinkage in five and no change in two patients, with symptom improvement in the majority of patients. To our knowledge, we describe one of the largest series of CSH managed at a single center. Although microsurgical resection using an extradural transcavernous approach is considered the treatment of choice in CSH and allows complete excision with minimal mortality and long-term morbidity, GKRS is an additional tool for treating residual symptomatic lesions or in patients with associated comorbidities making surgical resection unsuitable.

Controlled hypotension and blood loss during frontoorbital advancement

OBJECT

Controlled hypotension is routinely used during open repair of craniosynostosis to decrease blood loss, although this benefit is unproven. In this study the authors analyzed the longitudinal relationships between intraoperative mean arterial pressure (MAP) and calculated blood loss (CBL) during frontoorbital advancement (FOA) for craniosynostosis.

METHODS

The authors reviewed the records of infants with craniosynostosis who had undergone primary FOA between 1997 and 2009. Anesthesia records provided preoperative and serial intraoperative MAP. Interval measures of CBL had been determined during the course of the operation. The longitudinal relationships between MAP(mean), MAP(change), and CBL(change) were assessed over the same time interval and compared between adjacent time intervals to determine the directionality of associations.

RESULTS

Ninety infants (44 males and 46 females) underwent FOA at a mean age and weight of 10.7 ± 12.9 months and 9.0 ± 7.0 kg, respectively. The average intraoperative MAP was 56.1 ± 4.8 mm Hg, 22.6 ± 12.1% lower than preoperative baseline. A negative correlation was found between CBL(change) and MAP(mean) over the same interval (r = -0.31, p < 0.05), and an inverse relationship was noted between CBL(change) of the previous interval and MAP(change) of the next interval (r = -0.07, p < 0.05). Finally, there was no significant association between MAP(change) of the previous interval and CBL(change) of the next interval.

CONCLUSIONS

Calculated blood loss demonstrated a negative correlation with MAP during FOA. Directionality testing indicated that MAP did not affect intraoperative blood loss; instead, blood loss drove changes in MAP. Overall, these findings challenge the benefit of controlled hypotension during open craniofacial repair.

Gamma Knife radiosurgery for hemangiomas of the cavernous sinus: a seven-institute study in Japan

Object

Gamma Knife radiosurgery (GKS) is currently used for primary or postoperative management of cavernous sinus (CS) hemangiomas. The authors describe their experience with 30 cases of CS hemangioma successfully managed with GKS.

Methods

Thirty patients with CS hemangiomas, including 19 female and 11 male patients with a mean age of 53 years (range 19–78 years) underwent GKS at 7 facilities in Japan. Pathological entity was confirmed using surgical specimens in 17 patients, and neuroimaging diagnosis only in 13. Eight patients were asymptomatic before GKS, while 22 had ocular movement disturbances and/or optic nerve impairments. The mean tumor volume was 11.5 cm3 (range 1.5–51.4 cm3). The mean dose to the tumor periphery was 13.8 Gy (range 10.0–17.0 Gy).

Results

The mean follow-up period was 53 months (range 12–138 months). Among the 22 patients with symptoms prior to GKS, complete remission was achieved in 2, improvement in 13, and no change in 7. Hemifacial sensory disturbance developed following GKS in 1 patient. The most recent MR images showed remarkable shrinkage in 18, shrinkage in 11, and no change in 1 patient.

Conclusions

Gamma Knife radiosurgery proved to be an effective treatment strategy for managing CS hemangiomas. Given the diagnostic accuracy of recently developed neuroimaging techniques and the potentially serious bleeding associated with biopsy sampling or attempted surgical removal, the authors recommend that GKS be the primary treatment in most patients who have a clear neuroimaging diagnosis of this condition.

STEREOTACTIC RADIOSURGERY FOR CAVERNOUS SINUS OR ORBITAL HEMANGIOMAS

OBJECTIVE

Hemangiomas are rare but highly vascular tumors that may develop in the cavernous sinus or orbit. These tumors pose diagnostic as well as therapeutic challenges to neurosurgeons during attempted removal. We analyzed our increasing experience using stereotactic radiosurgery (SRS).

METHODS

Eight symptomatic patients with hemangiomas underwent SRS between 1988 and 2007. The presenting symptoms included headache, orbital pain, diplopia, ptosis, proptosis and impaired visual acuity. The hemangiomas were located in either the cavernous sinus (7 patients) or the orbit (1 patient). Four patients underwent SRS as primary treatment modality based on clinical and imaging criteria. Four patients had previous microsurgical partial excision or biopsy. The median target volume was 6.8 mL (range, 2.5–18 mL). The median prescription dose delivered to the margin was 14.5 Gy (range, 12.5–19 Gy). The dose to the optic nerve in all patients was less than 9 Gy (range, 4.5–9 Gy).

RESULTS

The median follow-up period after SRS was 80 months (range, 40–127 months). Six patients had symptomatic improvement; 2 patients reported persistent diplopia. Follow-up imaging revealed tumor regression in 7 patients and no change in tumor volume in 1 patient. All the patients improved after SRS.

CONCLUSION

Our extended experience confirms that SRS is an effective management strategy for symptomatic intracavernous and intraorbital hemangiomas. Our study is the first long-term report on the safety and efficacy of SRS.

Risks and benefits of deliberate hypotension in anaesthesia: a systematic review

This systematic review was performed to investigate and review the evidence on the risks and benefits of hypotensive anaesthesia in order to answer the following question: 'Should deliberate hypotension be used routinely during orthognathic surgery?' An electronic search on MEDLINE and the Cochrane Library database was carried out for all relevant articles using specific search keywords. All articles were classified by their levels of evidence. Studies with highest level of evidence and rated to have the lowest risk of bias were reviewed. Regarding the benefits of hypotensive anaesthesia, three studies reported significant decrease of blood loss in patients receiving hypotensive anaesthesia. Two studies reported a significant decrease in transfusion rate. Two studies demonstrated improved surgical field and significant reduction in operation time. In terms of risk, no significant changes in cerebral, cardiovascular, renal and hepatic functions in patients receiving hypotensive anaesthesia compared to control were reported. In conclusion, hypotensive anaesthesia appears to be effective in reducing blood loss. Serious consequences due to organ hypoperfusion are uncommon. Hypotensive anaesthesia can be justified as a routine procedure for orthognathic surgery especially bimaxillary osteotomy. Patient selection and appropriate monitoring are mandatory for this technique to be carried out safely.

Lateral transmaxillosphenoidal approach to the lateral compartment of the cavernous sinus: technical case report

This article outlines the surgical technique and the indications for the lateral transmaxillosphenoidal approach, which is illustrated by an index case. A 27-year-old woman presented with a trigeminal sensory deficit caused by a dermoid tumor occupying the lateral compartment of her right cavernous sinus. A lateral transmaxillosphenoidal approach was performed, and the tumor was removed lateral to the intracavernous carotid artery (ICA) and medial to intracavernous cranial nerves. The lateral transmaxillosphenoidal approach is similar to the transmaxillosphenoidal approach used for the removal of pituitary adenomas invading the medial compartment of the cavernous sinus. By opening the lateral wall of the sphenoid sinus just above and laterally to the carotid artery, tumor can be removed medial to the intracavernous cranial nerves and lateral to the ICA.

Dynamic enhancement features of cavernous sinus cavernous hemangiomas on conventional contrast-enhanced MR imaging

BACKGROUND AND PURPOSE

The reported MR imaging characteristics of cavernous sinus cavernous hemangiomas (CSCHs) in the literature are nonspecific. The purpose of our study was to explore dynamic enhancement features of CSCHs on conventional contrast-enhanced MR imaging and to correlate these features with histopathologic subtypes.

MATERIALS AND METHODS

Twenty-one patients (8 male and 13 female; age range, 13-63 years; average age, 42.6 years) with surgically confirmed CSCHs were retrospectively investigated. Preoperative MR study was performed in all cases, consisting of T1-weighted axial imaging, T2-weighted axial imaging, T1-weighted sagittal imaging, and contrast-enhanced T1-weighted axial, sagittal, and coronal images.

RESULTS

There were 4.8% (1/21) that showed homogeneous enhancement on all 3 contrast-enhanced sequences, whereas 95.2% (20/21) demonstrated heterogeneous enhancement on the first contrast-enhanced sequence. Among the 20 lesions, on subsequent contrast-enhanced sequences, 55.0% (11/20) showed homogeneous enhancement, whereas 35.0% (7/20) of lesions showed progressive contrast "filling in." The remaining 10% (2/20) exhibited no apparent enhancement changes. The 95.2% (20/21) of lesions with heterogeneous enhancement on the first contrast-enhanced sequence correlated with type B or type C pathologic findings, whereas 4.8% (1/21) with homogeneous enhancement correlated with type A pathologic findings. Among the 20 type B or type C lesions, 80% (16/20) achieved total or near-total resection.

CONCLUSION

Progressive contrast "filling in" in the tumors on conventional contrast-enhanced MR images can aid in differentiating between cavernous sinus lesions and suggest the diagnosis of cavernous hemangiomas.

Cavernous Hemangioma of the Cavernous Sinus, Skin, and Retina: Hemodynamic Changes after Treatment: Case Report

OBJECTIVE

There are several reports concerning cavernous hemangiomas of the skin and central nervous system. Additional retinal involvement has also been reported.

CLINICAL PRESENTATION

The authors report a 69-year-old woman with a giant extra-axial cavernous hemangioma of the right cavernous sinus involving the supra- and parasellar region, retina, and skin.

INTERVENTION

Shrinkage of its cutaneous part lead to subsequent increase of the volume of the intracranial part. Owing to compression of the optic and the oculomotor nerves, oculomotor disturbances, ptosis, and visual impairment to 0.2 occurred. Via a pterional approach microsurgical removal of the tumor except for a remnant of the intracavernous part was performed.

CONCLUSION

Hemodynamic connection between cutaneous, retinal, and intracranial hemangiomas should be considered.

Non-meningeal tumours of the cavernous sinus: a surgical analysis

The popularisation of cavernous sinus approaches and subsequent experience has shaped our treatment paradigms for cavernous sinus meningiomas. However, pathologies in this region are diverse and each one requires individual consideration. The purpose of this study was first to analyse, define and summarise the individual characteristics of different non-meningeal tumours of the cavernous sinus and, secondly, to stress that their surgery can be accomplished with acceptable morbidity and rewarding results when those characteristics are considered. A retrospective analysis of 42 cases of benign non-meningeal tumours of the cavernous sinus operated on at Marmara University between April 1992 and April 2003 is presented. The patients were 15 males and 27 females aged 24-72 years. The study cohort consisted of 13 pituitary adenomas, 11 trigeminal schwannomas, seven chordomas, three chondrosarcomas, two juvenile angiofibromas, two epidermoid tumours, one plasmacytoma, one cavernous haemangioma and one internal carotid plexus schwannoma. The 42 patients underwent 46 operations aimed at radical surgical excision. Total resection was achieved in 50% and subtotal resection in 50% of cases. The majority of incompletely resected tumours were pituitary adenomas and chordomas, and 95% required further treatment. Twenty-nine percent of patients developed complications, namely cerebrospinal fluid fistula, haematoma, hydrocephalus, diabetes insipidus, cerebral infarction and cranial nerve palsies. Recurrence was seen in 7.1% of patients. At final follow up at an average of 48.2 months after surgery, the mean Karnofsky performance scale had risen from 83.4 to 87.4. Non-meningeal tumours of the cavernous sinus can be surgically resected with acceptable morbidity and mortality. In selected tumours the results are better than those for cavernous sinus meningiomas. The best surgical results are achieved with interdural tumours of the lateral sinus wall and the worst surgical results are seen in invasive tumours such as chordomas and pituitary adenomas. Individual tumour characteristics are presented in the text.

Venous cavernoma at 8 Tesla MRI

Cavernous angiomas or cavernomas are vascular malformations, which may be associated with risk of bleeding episodes. We present a case report comparing high resolution 8 Tesla gradient echo (GE) imaging with routine fast spin echo (FSE) at 1.5 Tesla in a patient with venous cavernoma. A 55-year-old male with a history of hemorrhagic stroke was studied using high-resolution 8 Tesla magnetic resonance imaging (MRI) system, which revealed venous cavernoma (9 x 8.6 mm) in the left parietal region and visualized adjacent microvascular supply. Signal loss was prominent in the cavernoma region compared to surrounding brain tissue, and signal intensity declined by factor 7.3 +/- 2.4 (679 +/- 62%) on GE images at 8 Tesla. Cavernoma was not apparent on routine T(2)-weighted FSE images at 1.5 Tesla MRI. This case report indicates that GE images at 8 Tesla can be useful for evaluation of vascular pathologies and microvasculature.

Diagnosis and surgical treatment of cavernous sinus hemangiomas: an experience of 20 cases

OBJECTIVE

To elucidate the advances of diagnosis and surgical treatment of the cavernous sinus hemangiomas (CSHs).

METHODS

The data from 20 patients with the CSHs surgically treated by authors from 1996 through 2000 was analyzed retrospectively, and a review of relevant literature was conducted.

RESULTS

These 20 cases accounted for 16.3% of all intracranial cavernous hemangiomas surgically treated in the same period at Huashan Hospital. The patients were aged from 32 approximately 69 years with an average age of 47 years. There were 17 females and 3 males. The common clinical manifestations were visual loss, diplopia, headache, facial numbness and extraocular muscle palsy. Computed tomography (CT) and magnetic resonance imaging (MRI) were major preoperative diagnostic modalities, but demonstrated nonspecific features. The preoperative misdiagnostic rate was 38.9%. Of the 20 patients undergoing craniotomy via modified pterional approach with or without orbitozygomatic osteotomy, tumors were removed through epidural approach (EDA) in 13 cases, intradural approach (IDA) in 7 cases. Hypotension was induced during the operation in 2 cases. Total tumor removal was achieved in 12 cases (92.3%) in the EDA group and nil in the IDA group. Incomplete tumor removal was 1 case (7.7%) in the EDA group and 7 cases (100%) in the IDA group. One patient in the IDA group died of intracranial hemorrhage postoperatively. Compared with preoperative manifestations, cranial neuropathies at discharge were worsened in 76.9% of patients in the EDA group and 83.3% of patients in the IDA group, improved in 15.4% of patients in the EDA group and 16.7% of patients in the IDA group, unchanged in 7.7% of patients in the EDA group. Follow-up study (range, 1 approximately 6 years; mean, 3 years) was available in 17 patients (89%). All patients in the EDA group improved without tumor recurrence. Nonimprovement (2 cases) and continued worsening (3 cases) occurred in the IDA group. In patients with tumor incompletely removed, the tumor enlarged in 2 cases, and unchanged or decreased in size in 3 cases, in which 2 cases underwent postoperative radiosurgery or radiotherapy. According to pathologic and MRI characteristics, the CSHs can be divided into two types, sponge-like type and mulberry-like type.

CONCLUSION

Cavernous hemangioma should be included in differential diagnosis for middle aged females with cavernous sinus tumors. Two types of the CSHs, sponge-like type and mulberry-like type, can be identified. The best microsurgical approach for the removal of the CSHs is epidural approach via the skull-base craniotomy. Radiosurgery should be considered for patients with incomplete tumor removal.

Extradural approach for cavernous hemangioma of the cavernous sinus: experience with 13 cases

The clinical, radiological, and surgical issues concerning cavernous hemangiomas located within the dural confines of the cavernous sinus were analyzed on the basis of experience with 13 cases. The feasibility of radical resection by an entirely extradural approach using a basal temporal surgical route to this relatively rare and formidable surgical problem was investigated. Thirteen patients, four males and nine females, with cavernous hemangioma involving the cavernous sinus were treated from 1992 to 2001. The patients were aged from 15 to 55 years. Headaches and deficits of the cranial nerves coursing through the cavernous sinus were the principal symptoms at presentation. Vision was affected in four patients. The radiological features in all patients were similar with a characteristic pattern of extension and encasement of internal carotid artery. The maximum size of the tumor was 28 to 73 mm (mean 44 mm). An entirely extradural route using the basal temporal approach was used successfully in seven cases. Total resection was achieved in 12 patients and partial resection was achieved in one patient. The follow up ranged from 8 months to 9 years (mean 45 months). The outcome of extraocular movements was poor in our series, possibly due to the massive sizes of the tumors encountered. There was no recurrence or growth of the residual tumor and all patients were leading active lives.

Merits of intralesional fibrin glue injection in surgery for the cavernous sinus cavernous hemangiomas

✓ In planning surgical treatment for extraaxial cavernous hemangiomas, care should be taken to control severe tumor bleeding. The authors present a case of a large cavernous hemangioma of the cavernous sinus, which was completely removed with the aid of multiple intratumoral injections of fibrin glue. This novel method is very effective for preventing excessive blood loss during surgery for this type of lesion.

Radiosurgery of cavernous hemangiomas in the cavernous sinus

BACKGROUND

Cavernous hemangiomas in the cavernous sinus are rare and demonstrate unique clinical courses. Although they rarely cause spontaneous bleeding, serious bleeding is not uncommon during operations. Total eradication of such tumors is very difficult because of the location and intraoperative bleeding. Consequently, alternatives to operative resection have been examined.

METHODS

Three cases of cavernous hemangiomas in the cavernous sinus, presenting chiefly with ocular signs and facial pain, were treated by radiosurgery using a gamma knife. Two of the patients had been operated on before radiosurgery, while the third patient was diagnosed on the basis of neurological signs as well as radiological findings.

RESULTS

MRI scans at the time of radiosurgery showed tumors in the cavernous sinus with low or iso-intensity on T1-weighted images and high signal intensity on T2-weighted images. All of the tumors intensely enhanced with gadolinium-DTPA. The tumors had diameters of 14 to 28 mm and were treated with a marginal dose of 14 to 17 Gy (mean 15.7 Gy). In the mean follow-up period of 27 months after radiosurgery, all of the tumors decreased in size (PR). Neurologically, none of the patients showed any deterioration, and one demonstrated an obvious improvement in ocular movement.

CONCLUSIONS

Radiosurgery for cavernous hemangioma in the cavernous sinus is apparently safe and effective with consistent tumor shrinkage. Therefore, radiosurgery is an excellent alternative to operative intervention and may even replace operative procedures if the tumors are small in diameter or when they recur.

Intratumoral injection of plastic adhesive material for removal of cavernous sinus hemangioma. Technical note

The authors present a case in which a cavernous sinus (CS) hemangioma was totally removed following intratumoral injection of a plastic fixation material. This unique method is extremely useful for the removal of CS hemangiomas, which often feature massive intraoperative bleeding as an unsolved problem.

Cavernous sinus hemangioma treated with gamma knife radiosurgery: usefulness of SPECT for diagnosis--case report

A 79-year-old female presented with cavernous sinus hemangioma manifesting as double vision due to right oculomotor and trochlear nerve pareses. Computed tomography and magnetic resonance imaging revealed bony erosion and a right cavernous sinus tumor with "tail sign" after contrast medium administration. Thallium-201 (201Tl) single photon emission computed tomography (SPECT) showed low uptake within the tumor, and technetium-99m-human serum albumin-diethylenetriaminepenta-acetic acid SPECT disclosed high uptake within the tumor. 201Tl SPECT usually shows very high uptake in meningiomas and malignant tumors, so the tumor was considered to be an unrelated benign tumor. The patient underwent partial resection of the tumor. Histological examination of the specimen confirmed cavernous hemangioma. The oculomotor nerve paresis partially improved. Gamma knife radiosurgery was carried out 4 months after the operation. The tumor markedly shrank with full recovery of extraocular movement 6 months after radiosurgery. SPECT is useful for distinguishing cavernous sinus hemangiomas from other cavernous tumors. Radiosurgery should be performed after partial resection or biopsy for cavernous sinus hemangiomas and may be the initial treatment for patients with small cavernous sinus hemangioma if the diagnosis can be established based on neuroimaging.

Radiosurgery for hemangiomas of the cavernous sinus and orbit: technical case report

OBJECTIVE AND IMPORTANCE

Hemangiomas of neurosurgical interest are histologically benign vascular tumors that most often occur in the orbit or cavernous sinus. Hemangiomas can be diagnosed by their characteristic radiographic and angiographic appearance and their tendency to bleed excessively during attempted removal. Intracranial or intraorbital hemangiomas require treatment when they become symptomatic.

CLINICAL PRESENTATION

We report four hemangioma patients who presented with ocular symptoms or signs, such as orbital pain, ophthalmoplegia, proptosis, or impaired visual acuity. Before our evaluation, two patients had each had incomplete resections aborted because of excessive blood loss, one patient had undergone a nondiagnostic transsphenoidal biopsy, and one patient had had an unsuccessful embolization.

INTERVENTION

All four patients were treated with gamma knife radiosurgery. Tumors received a minimal tumor dose that ranged from 14 to 19 Gy. Follow-up evaluations were performed 6 to 24 months after radiosurgery and revealed a reduction in tumor volume in three patients and no tumor progression in the fourth. All patients had symptomatic improvement, but one had persistent diplopia.

CONCLUSION

In this early experience, stereotactic radiosurgery proved to be an effective management strategy that avoided the potentially serious complications associated with surgery or embolization of cavernous sinus hemangiomas.