Transcavernous Approach for Cavernous Sinus Meningiomas: A Single-Institution Experience

Background: Lesions involving the cavernous sinus (CS) are among the most challenging to approach. The complexity of the surrounding anatomy, nerve disposition, and rich venous drainage system are examples of challenges that must be navigated to treat these lesions. The treatment strategy has become a subject of debate in light of the advancements in radiotherapy techniques. The object of this paper is to present a single institutional case series of transcavernous approach (TcA) for primary and secondary CS meningiomas, and to report the clinical outcome of this approach.

Methods: From January 2012 to June 2023, 24 patients who underwent microsurgical resection of primary CS meningiomas or meningiomas invading the CS (secondary CS meningiomas) by transcavernous approach were retrospectively reviewed. The study was performed under Institutional Review Board approval and did not require patient consent. Information about patient demographics, surgical reports, neurological deficits, and long-term outcomes was obtained from the medical records. The occurrence of postoperative complications and the necessity of adjuvant radiation were also reviewed.

Results: Of the 24 patients, 13 (62%) were female, with a median age of 56 years. Sixty-nine percent were smokers, and 56% were obese. The majority of the meningiomas were lesions that invaded the CS (62%). Twenty-one (87.5%) were WHO grade I, in which the meningothelial subtype was more commonly found (91%). Only 3 cases of WHO grade II (1 atypical and 2 clear cells) were detected, and no case of WHO grade III was recorded. The median follow-up was 36 months (range between 3 months and 7 years).

The mean length of stay was 4 days. In our cohort of patients, 16 patients presented with pre-operative cranial nerve deficits, of which 79% showed postoperative improvement. Gross total resection was achieved in 16 (67%) patients. Seven (29%) patients were referred to post-operative radiation therapy.

Conclusion: CS meningiomas are challenging lesions for neurosurgeons due to the complexity of local anatomy, their unpredictable growth pattern, and their potential to invade surrounding structures. The TcA is a well-established approach that offers surgeons the ability to operate both intra- and extra-durally in the vicinity of the CS. With an experienced neurosurgical team, the TcA provides an optimal approach to CS meningiomas with minimal morbidity and favorable outcomes. In select patients, achieving a complete resection is attainable, sparing them from the need for postoperative radiation and its associated side effects.

Table 1

Cranial nerves	Preoperative (n)	Postoperative (n)
II	7 (29.1%)	1 (4.16%)
III	6 (25%)	1 (4.16%)
IV	4 (16.66%)	2 (8.33%)
V	10 (41.6%)	3 (12.5%)
VI	7 (29.1%)	1 (4.16%)

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Artikel online veröffentlicht:
05. Februar 2024