Endoscopic Endonasal Surgery for Nonadenomatous Lesions of the Cavernous Sinus: Experience with 59 Cases

Objective: Cavernous sinus (CS) tumors are often considered inoperable given the high density of neurovascular structures within the CS and associated morbidity despite sophisticated microsurgical approaches. Study Design: Retrospective case review. Methods: Retrospective outcome review of 59 patients who underwent EES for nonadenomatous CS tumors. Results: The group included 28 meningiomas, 14 chordomas, and 17 other lesions. Clinical presentation included intracavernous CN palsies in 34 patients (57.6%). The goal of EES was decompression/biopsy in 17 cases; in the remaining cases, total or near-total (>90%) tumor resection from the CS was achieved in 23 (55%). Following EES, 31 patients (52.5%) received adjuvant treatment. Preexisting CN palsies improved/resolved in 14 patients (42.4%) and remained unchanged in 19 (55.9%); the rate of improvement was >44% after decompression. New CN palsies occurred in seven patients (11.9%) affecting mainly the abducens nerve. The CSF leak rate was 11.9%. Two patients (3.4%) suffered a carotid artery injury resulting in death in one case (mortality 1.7%) and no sequelae in the other. Conclusion: CS tumors are difficult to access without new neurological deficits. Given its medial corridor, EES provides equivalent or superior results to open approaches for CS tumors with fewer complications. The risk of intracavernous carotid artery injury remains high but the perioperative mortality due to vascular injury is less than 2%.