The Role of Endoscopic Endonasal Approach in the Treatment of Cavernous Sinus Meningioma

Objective: Treatment of cavernous sinus (CS) meningioma remains controversial. Radical resection of these lesions through the transcranial route is associated with significant morbidity. Studies have suggested surgical decompression followed by radiotherapy to treat these lesions. This approach is further favored with the development of endoscopic skull base surgery. Prior studies described the use of transsphenoidal decompression of CS meningiomas. Here we outline a role for an endoscopic endonasal approach in treating CS meningioma by decompression or radical resection. We provide four case illustrations of this approach.

Method: We illustrate our philosophy with four symptomatic patients with CS meningiomas. Three of these patients presented with newly diagnosed symptomatic CS meningioma. Two patients presented with unilateral CN 6 palsy. One patient had unilateral CN 3 and 6 palsies. The fourth patient had a recurrent tumor and complete right CN 3, 4, and 6 palsies as well as partial cranial nerve 7 palsy and complete hearing loss on that side. As part of her prior surgeries, her right ICA was sacrificed. She presented with radiologic tumor progression causing brainstem compression.

Results: The three patients with new diagnoses underwent endoscopic endonasal cavernous sinus decompression with postoperative cranial nerve improvement, while the patient with recurrence had a radical endoscopic endonasal resection of the tumor followed by gamma-knife focused on the minimal residual on the seventh cranial nerve. None of the patients experienced endocrine dysfunction. None of the patients had new neurological deficits.

Conclusion: CS meningiomas can be successfully managed via a purely endoscopic endonasal approach. Our experience shows that both decompression and radical resection can be safely performed with this approach. The choice of resection vs. decompression is guided by patient factors, medical history, and symptoms. We recommend EEA decompression for new symptomatic CS meningioma with incomplete loss of CN functions. In patients with total loss of CN functions, a radical resection of the CS meningioma can be achieved with EEA.