Extradural Transcavernous Approach to Cavernous Sinus Hemangiomas: Series of 12 Cases

Objective and Importance: Cavernous sinus hemangiomas (CSHs) are uncommon lesions and comprise less than 1% of all parasellar masses. Because of their location, propensity for profuse bleeding during surgery, and relationship to complex neurovascular structures, they are notoriously difficult to excise.

Clinical Presentation: The author describes his experience with 12 cases of CSHs. Headache and visual impairment were the most common presenting complaints, followed by facial hypesthesia and diplopia. CT revealed isodense to hyperdense expansile lesions in the region of the cavernous sinus and middle cranial fossa. MRI examinations revealed hypo- and isointense lesions on T1-weighted images (WI) and markedly hyperintense on T2-WI, with marked homogeneous enhancement after contrast administration.

Intervention: All CSHs were treated by a purely extradural transcavernous approach. This involved reduction of sphenoid ridge, exposure of superior orbital fissure, drilling of anterior clinoid process, coagulation and division of the middle meningeal artery, and peeling of the meningeal layer of the lateral wall of the cavernous sinus off the inner membranous layer. The cranial nerves in the lateral wall of the cavernous sinus were exposed (III, IV, V1, V2, and V3 cranial nerves). The tumor was accessed through its maximum bulge either through the lateral or the anterolateral triangle. The tumor was removed, using rapid decompression, coagulation of feeder from the meningohypophyseal trunk, and dissected along the cranial nerves. All but one patient had complete tumor excision. Transient ophthalmoparesis (complete resolution in 6–8 weeks) was the most common surgical complication.

Conclusion: We describe one of the largest series of pure extradural transcavernous approach to the CSHs.