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

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.

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.

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.

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.

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.

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.