Treatment Strategy and Clinical Outcome for Cavernous Sinus Lesion

Objective: The surgery for the lesions around the cavernous sinus is still challenging, especially for the lesion invading cavernous sinus, optic sheath, and oculomotor cave. The exposure of these region is sometimes necessary but have a risk of cranial nerve injury. In this presentation, we show the surgical strategies and techniques with video and also clinical outcome for these lesions.

Materials and Methods: Surgical resection is indicated for benign cases with neurological symptoms or tumor growth. For malignant cases, considering resection according to individual circumstances. Surgical strategy: the benign tumors invading cavernous sinus are removed as much as possible while preserving cranial nerves. For malignant tumors, preoperative symptoms and prognosis assessment are taken into account, and when necessary, the tumor is removed with sacrifice of cranial nerves followed by adjuvant therapy. Preoperative symptom and their postoperative course, adjuvant therapy, postoperative complication, degree of removal, recurrence were investigated in 22 surgical cases with cavernous sinus invasion (16 meningiomas [13 grade I and 3 grade II], 3 schwannomas, 1 squamous cell carcinoma, 1 chondrosarcoma, and 1 angiofibroma) between January 2013 and August 2019.

Results: Major preoperative symptoms were external ophthalmoplegia, visual disturbance, facial dysesthesia, brain swelling in 10, 8, 5, and 4 cases, respectively. And these symptoms recovered in 7 (70%), 7 (88%), 2 (40%), and 4 (100%) cases, respectively. Facial dysesthesia deteriorated in two schwannoma cases. Postoperative complications were temporary oculomotor paresis in three cases, facial dysesthesia in three cases, contralateral visual deterioration in one case, and brief transient hemiparesis by IC dissection or vasospasm in one case. Gross total removal was achieved in 12 lesions but 10 meningioma cases were partially removed (mainly remnant in cavernous sinus). One squamous cell carcinoma underwent chemoradiotherapy after total resection of tumor and cranial nerves in cavernous sinus. Two residual atypical meningioma in cavernous sinus underwent IMRT. One atypical meningioma recurred and underwent γ-knife radiosurgery.

Conclusion: In surgical resection of cavernous sinus lesion, sacrifice of cranial nerves is acceptable for malignant tumor, but that is not acceptable for benign tumor. Except for intentional sacrifice of V2 in trigeminal schwannoma and angiofibroma cases, almost all of the tumors can be well controlled with only acceptable transient insult by careful and delicate procedure, and accurate judgment of possibility of resection.