J Neurol Surg B Skull Base 2017; 78(S 01): S1-S156
DOI: 10.1055/s-0037-1600702
Oral Presentations
Georg Thieme Verlag KG Stuttgart · New York

Surgical Biopsy of Indeterminate Lesions of the Cavernous Sinus and Meckel's Cave: Diagnosis and Therapeutic Impact

Joshua D. Hughes
1   Mayo Clinic, Rochester, Minnesota, United States
,
Joseph Kapurch
1   Mayo Clinic, Rochester, Minnesota, United States
,
Jamie Van Gompel
1   Mayo Clinic, Rochester, Minnesota, United States
,
Michael J. Link
1   Mayo Clinic, Rochester, Minnesota, United States
› Author Affiliations
Further Information

Publication History

Publication Date:
02 March 2017 (online)

 

Introduction: Lesions of the cavernous sinus(CS) and Meckel’s cave(MC) can be from a variety of etiologies including neoplastic, infectious, or inflammatory. In some cases, a definitive diagnosis cannot be made from imaging or laboratory studies, necessitating tissue. We review our institutional series of indeterminate CS and MC lesions necessitating biopsy to assess diagnostic accuracy, complications, and outcomes.

Methods: Electronic institutional records from 1994–June 2016 were searched for CS and MC lesions that underwent surgery or biopsy. Indeterminate lesions were defined as lesions with an atypical, enhancing appearance on imaging, a broad differential, and the need for tissue for definitive diagnosis to determine treatment. Collected data included patient clinical characteristics, location, symptomatology, clinical work-up, surgical approach, pathologic diagnosis, temporary and permanent deficits, and outcomes. Twenty-four different pathologies were found and broadly categorized as primary tumors (atypical appearing meningioma, schwannoma, etc), metastatic tumors, lymphomas, inflammatory lesions, and infectious lesions.

Results: 82 patients were found with a mean age of 57.1 ± 16.6(2–85) years. A history of cancer, infection, inflammatory disease or immunosuppression was present in 23(28%), 5(6%), 3(4%), and 2(2%) respectively. There were 50(61%) and 15(18%) patients with lesions primarily in the CS or MC respectively, and 17(21%) in both locations. Symptoms were present for a mean of 10.3 ± 16.5 (0.5–120) months and 55 (68%) were progressive. Thirty-one (38%) patients had retro-orbital pain. Cranial nerve involvement included optic [n = 15 (20%)], oculomotor [n = 28 (35%)], trochlear [n = 12 (15%)], trigeminal[n = 42(53%)], and abducens[n = 32(41%)]. A steroid course was tried in 23 (29%) patients and lumbar puncture was the most common test performed[n = 33(41%)] prior to surgery. Approaches included frontotemporal craniotomy [46 (56%)], endoscopic endonasal [20 (24%)], percutaneous transforamen ovale [11 (13%)], or retrosigmoid craniotomy [5(6%)]. An initial non-diagnostic biopsy occurred in 12 (15%) patients; 9 underwent a second procedure. Final diagnosis was metastatic in 28 (35%), primary in 17 (21%), inflammatory in 13 (16%), lymphoma in 12 (14%), infectious in 4(5%), and non-diagnostic in 8 (10%) patients. Of patients with a cancer history(n = 23), 11 (48%) had a diagnosis consistent with their prior diagnosis, while the remaining had a second cancer 9(39%) or non-diagnostic biopsy 3 (13%). Prior to surgery, the primary suspicion within a broad differential was stated in 24 (29%) patients and was correct in 8 (33%). Diagnostic results directed therapy in 61 (74%) patients. Postoperative complications were 8 temporary cranial nerve deficits, 3 remained permanent; 2 deaths secondary to withdrawal of care after surgical complications, 1 carotid artery injury and 1 postoperative coagulopathy leading to postoperative hematoma, 2 wound infections and 1 subdural hematoma secondary to CSF leak.

Conclusions: In this series of 82 patients with indeterminate lesions of the CS and MC, a tissue diagnosis was made in 90% of patients and directed further therapy in 74%. The most common diagnoses were metastatic or primary lesions. The instance of a second cancer in patients with a history of cancer was common and, when stated, the primary differential was often incorrect. While these findings endorse biopsy as an important diagnostic tool, it is not without risk, which in this series were permeant cranial nerve deficit(4%), wound complications(4%), and surgery-related mortality(2%). Open biopsy should be considered only when other measures have failed.