Cavernous sinus meningiomas

Introduction

A relatively uncommon location for meningiomas is within the cavernous sinus. ^, Surgery within the cavernous sinus has undergone constant change from observation to aggressive surgical resection to stereotactic radiosurgery. Surgery within this region has been tempered by the risk of uncontrollable bleeding and damage to the cranial nerves. Meningiomas can involve just the cavernous sinus but can also grow into the cavernous sinus from elsewhere, including the tuberculum sellae, medial sphenoid wing, and petroclival regions, among others. In this chapter, we present a case of a left cavernous sinus meningioma.

Example case

Chief complaint: headaches and left eye vision loss

History of present illness

A 57-year-old, right-handed woman with rheumatoid arthritis presented with progressive headaches and left eye vision loss. For the past 5 to 6 months, she had increasing frequency and severity of headaches, and also complained of left eye vision loss. She saw an ophthalmologist who found left optic nerve atrophy and decreased visual fields in the left eye in all quadrants ( Fig. 50.1 ).

Medications : Prednisone.
Allergies : No known drug allergies.
Past medical and surgical history : Rheumatoid arthritis, appendectomy, hysterectomy.
Family history : No history of intracranial malignancies.
Social history : Lawyer, no smoking, occasional alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Cranial nerves II to XII intact except decreased visual acuity in the left eye; No drift, moves all extremities with full strength.

	Pablo Augusto Rubino, MD, Román Pablo Arévalo, MD, Hospital El Cruce, Buenos Aires, Argentina	Chae-Yong Kim, MD, PhD, Seoul National University Bundang Hospital, Seoul, South Korea	Laligam N. Sekhar, MD, Harborview Medical Center, University of Washington, Seattle, WA, United States	Harry Van Loveren, MD, University of South Florida, Tampa, FL, United States
Preoperative
Additional tests requested	Pituitary hormone panel Neuropsychological assessment MR angiography OCT	Cerebral angiogram Neuroophthalmology evaluation	Cerebral angiogram with carotid compression to assess collaterals CT bone	MRA Neuroophthalmology
Surgical approach selected	Left pretemporal approach with anterior clinoidectomy and anterior petrosectomy	Left frontotemporal craniotomy	Left frontotemporal craniotomy, orbital osteotomy, optic nerve decompression, anterior clinoidectomy	Left frontotemporal orbitozygomatic, posterior orbitotomy, anterior clinoidectomy, anterior petrosectomy
Anatomic corridor	Left pretemporal	Left subfrontal	Left trans-Sylvian	Left trans-Sylvian
Goal of surgery	Extensive resection and visual preservation (Simpson grade II–IV)	Optic nerve decompression, expected subtotal resection	Optic nerve decompression, extensive resection without cranial nerve injury, Simpson grade II–III	Decompression of left optic nerve and brainstem in preparation for radiation, Simpson grade IV resection
Perioperative
Positioning	Left supine	Left supine	Left supine with 45 degree right rotation, neck preparation	Supine with 45 degree right rotation
Surgical equipment	Doppler Ultrasonic aspirator Lumbar drain	Surgical navigation IOM Ultrasonic aspirator	Surgical navigation IOM (SSEP, MEP) Surgical microscope	Surgical navigation Surgical microscope Ultrasonic aspirator
Medications	Mannitol Antiepileptics	Steroids	Mannitol Steroids Antiepileptics	Mannitol Steroids Antiepileptics
Anatomic considerations	Left ICA, optic nerve, trigeminal nerve and its branches, lateral wall and roof of cavernous sinus, subarcuate eminence, Kawase triangle	Optic nerve, ICA, ACA, MCA	Left ICA, optic nerve, cavernous sinus cranial nerves	Optic nerve and chiasm, ICA, basilar artery, PCA, anterior choroidal, brainstem, cranial nerves III/IV/VI, SOF
Complications feared with approach chosen	ICA, optic nerve, oculomotor, cavernous sinus injuries	Left temporal lobe injury, arterial injury	Optic and cranial nerve, ICA injury	Brain retraction injury, optic nerve injury
Intraoperative
Anesthesia	General	General	General	General
Skin incision	Left pterional	Left pterional	Left pterional	Left pterional
Bone opening	Left pretemporal	Left frontotemporal with limited posterolateral orbitotomy and extradural clinoidectomy	Left frontotemporal, orbital osteotomy	Left frontotemporal, orbital osteotomy, orbital roof, anterior clinoidectomy
Brain exposure	Left pretemporal	Left frontotemporal	Left frontotemporal	Left frontotemporal
Method of resection	Lumbar drain placed, left pretemporal craniotomy, drilling of lesser sphenoid wing, drainage from lumbar drain, middle fossa peeling to separate dural sheaths from middle fossa dura, separation of the extra from intracavernous tumor portions, extradural portion removed, secure petrosal and intracavernous portions of the ICA, dura is opened to access the superior and external walls of the cavernous sinus, anterior clinoidectomy, removal of intracavernous portion of tumor, anterior petrosectomy by identifying limits of Kawase triangle (GSPN laterally, arcuate eminence posteriorly, posterior edge of Gasserian ganglion, petrous ridge medially), identify meatal plane (bisection of 120 degree angle between GSPN and arcuate eminence) and drilling of petrous ridge, removal of the bone (between V3 anteriorly, ICA/cochlea laterally, superior semicircular canal/IAC posteriorly until dura of posterior fossa reached, T-shaped posterior fossa dura opening with ligation and sectioning of superior petrosal sinus with care of trochlear and trigeminal nerves, removal of remaining posterior fossa tumor component, small sheets of tumor may be left if they are adherent to ICA or cranial nerves, lumbar drain for 48–72 hours	Left frontotemporal craniotomy, posterolateral orbitotomy, drill down sphenoid wing and extradural clinoidectomy and optic canal unroofing, open dura, subfrontal approach with early identification of optic nerve and ICA, unroof optic canal, opening of the falciform ligament and optic nerve sheath, follow these structures through tumor, internal debulking of tumor, extracapsular devascularization and dissection, removal of involved dura and bone	Left frontotemporal craniotomy with full orbitotomy, extradural optic nerve decompression under microscopic visualization consisting of anterior clinoidectomy and decompression of orbital roof, open dura, Sylvian fissure dissection, complete optic nerve decompression with opening of the falciform ligament and optic canal, remove tumor from optic nerve then subdural space, open cavernous sinus superiorly and laterally and remove tumor if soft, dura closure with graft	Left frontotemporal incision, subfascial dissection, MacCarty burr hole, one piece orbitozygomatic with orbital cuts done with mallet and osteotome, pterion is further reduced, complete posterior orbitotomy, optic canal unroofed, anterior clinoidectomy, dura opened in Dolenc fashion along Sylvian fissure, dura cut circumferentially around tumor, dissection around cavernous sinus by mobilizing temporal dura, opening of lateral wall of cavernous sinus, anterior petrosectomy using Kawase approach at the petrous apex on plane overlying predicted location of IAC and anterior to it, posterior fossa dura exposed, drill posteriorly to reveal dura of IAC, continue drilling posteriorly toward superior semicircular canal and laterally toward the cochlea, temporal lobe dura is cut perpendicular to superior petrosal sinus, posterior fossa dura opened, superior petrosal sinus ligated, dura retracted with sutures, posterior fossa component excavated with ultrasonic aspirator, capsule mobilized from brainstem and cranial nerves, removal of cavernous sinus component last, if tumor is soft can be removed but if hard leave attached to cranial nerves, reconstruction with dural substitute, fill dead space in clinoidal and subtemporal areas with fat
Complication avoidance	Extradural removal of tumor first, securing of ICA for intracavernous tumor removal, leaving residual adherent to critical structures, anterior petrosectomy for wide posterior fossa exposure from middle fossa, lumbar drain for 48–72 hours	Extradural clinoidectomy and optic canal unroofing, early identification of optic nerve and ICA, opening falciform ligament, removal of involved dura and bone	Full orbitotomy, anterior clinoidectomy and optic nerve decompression, trans-Sylvian opening, remove tumor from optic nerve first and cavernous sinus portion last	Orbitozygomatic craniotomy, optic nerve decompression, anterior petrosectomy, leaving cavernous sinus portion for last
Postoperative
Admission	ICU	ICU	ICU	ICU
Postoperative complications feared	Cranial nerve III palsy, visual decline	Left temporal lobe injury, arterial injury	ICA injury, seizures, cerebral edema, cranial nerve injuries, loss of work	Left optic nerve, cranial nerve III/IV/VI palsy, CSF leak
Follow-up testing	MRI within 48 hours after surgery	MRI within 48 hours after surgery Neuroophthalmology evaluation	CT or MRI immediately after surgery	CT day of surgery MRI within 24 hours after surgery
Follow-up visits	1 month after surgery	1 month after surgery	10 days after surgery	10 days after surgery 6 weeks after surgery
Adjuvant therapies recommended for WHO grade	Grade I–observation Grade II–observation Grade III–radiation	Grade I–observation Grade II–SRS Grade III–conventional radiotherapy	Grade I–radiation Grade II–radiation Grade III–radiation	Grade I–observation Grade II–radiation with residual Grade III–radiation