Surgical Management of Large Cavernous Sinus Hemangiomas by Extradural Transcavernous Approach: A Surgeon’s Experience over Two Decades

Background: Cavernous sinus hemangioma (CSH) is a rare type of benign vascular tumor. Because of their location, propensity for profuse bleeding during surgery, and relationship to complex neurovascular structures, they are notoriously difficult to excise. The aim of this study was to evaluate the senior surgeon’s experience in dealing with large cavernous sinus hemangiomas over the last two decades.

Methods: A total of 24 patients with CSH were operated during the period ranging from January 2001 to July 2018. Mean follow-up was 32.6 years and ranged from 3 months to 8 years. Patient’s symptoms and clinical signs were assessed and analyzed. Follow-up imaging was assessed for presence of residual tumor. One patient received secondary GKRS while one patient received post-op radiotherapy.

Results: Most common symptom was headache seen in 20/24 (83.33%) patients followed by visual deterioration in 14/24 (58.3%) and sixth nerve paresis in 8/24(33.3%) patients. Tumor volume ranged from 20.7 to 109.3 cm³. All patients underwent an extradural transcavernous approach for microsurgical resection of the tumor. The extent of resection achieved were gross total excision in 18/24 patients (75%), near-total excision and subtotal excision in 3/24 patients (12.5%) each. One patient was reoperated following subtotal excision and gross total excision was performed in the second surgery. Perioperative mortality was seen in two patients: One died following intra-op ICA injury and progressive thalamic infarcts. The second patient had a sudden cardiac event prior to discharge.

Conclusion: Following microsurgical resection of large CSH, transient cranial nerve paresis is common. Excellent EOR can be achieved by extradural transcavernous approach. Intra op ICA injury is a devastating complication, cross compression films may not be adequate and balloon occlusion test should be routinely done. Excessive blood loss is a concern and may necessitate subtotal removal in some instances.