Large sphenoid wing meningiomas involving the cavernous sinus: conservative surgical strategies for better functional outcomes.
OBJECTIVE
The ability to resect meningiomas that involve the medial and anterior compartments of the cavernous sinus has been refuted. In this retrospective study, we determined the efficacy of total resection of meningiomas that invade the cavernous sinus but are restricted to the lateral compartment.


METHODS
We reviewed the charts of 38 consecutive patients with sphenocavernous, clinoidocavernous, and sphenoclinoidocavernous meningiomas who underwent surgical treatment. We assessed early and late cranial nerve morbidity, extent of resection, and long-term outcome (mean, 96 mo).


RESULTS
In all patients, tumors exceeded 3 cm diameter. In 22 of 24 patients, total microscopic excision was achieved in tumors that involved only the lateral compartment of the cavernous sinus and touched or partially encased the cavernous internal carotid artery (i.e., modified Hirsch Grades 0 and 1, respectively). In 2 of 24 patients, remaining tumor infiltrated the superior orbital fissure. All 14 patients who had tumors that encased (with or without narrowing) the cavernous segment of the internal carotid artery (Hirsch Grades 2-4) underwent incomplete resection. Among 38 patients, mortality was 0%, late cranial nerve deficits remained in 6 (16%), and late Karnofsky Performance Scale scores exceeded 90 in 34 patients (90%). Four patients (10.5%) developed a recurrence or regrowth. Of 20 patients who were treated with either linear accelerator-based stereotactic radiosurgery or fractionated conformal radiotherapy, 11 had residual tumor and a moderate to high proliferative index, 4 had atypical tumors and 1 had angioblastic meningioma after total excision, 2 had regrowth, and 2 had recurrent tumors. In 18 (90%) of the 20 patients who underwent radiation, tumor size was reduced or controlled.


CONCLUSIONS
On the basis of this study and a review of the literature, we demonstrate that sphenocavernous, clinoidocavernous, and sphenoclinoidocavernous meningiomas of Hirsch Grades 0 and 1 can be excised from the lateral compartment of the cavernous sinus without postoperative mortality and with acceptable rates of morbidity. Residual tumor in the medial compartment (Hirsch Grades 2-4) may be treated with some form of radiation therapy or observation.
Abdel-Aziz
Khaled M
KM
Department of Neurosurgery, The Neuroscience Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267, USA.
Froelich
Sebastien C
SC
Dagnew
Elias
E
Jean
Walter
W
Breneman
John C
JC
Zuccarello
Mario
M
van Loveren
Harry R
HR
Tew
John M
JM
D000328:Adult; D000368:Aged; D002343:Carotid Artery, Internal / Q000473:pathology; D002426:Cavernous Sinus / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008577:Meningeal Neoplasms / Q000473:pathology* / Q000601:surgery*; D008579:Meningioma / Q000473:pathology* / Q000601:surgery*; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D020127:Recovery of Function; D012189:Retrospective Studies; D013100:Sphenoid Bone / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome