It has a higher rate of postoperative morbidity and mortality compared to acoustic neuroma. Cavernous sinus developments and future perspectives. Proper evaluation and patient counseling are required. I am in the beginning stages of being diagnosed with meningioma they are not 100% thats what it is yet. Description of a meningioma arising from the paranasal sinuses bilateral frontal and ethmoidal sinus origin. Demographic data, procedural data, symptomatic improvement, radiological regression, and progression free. Most publications are available for download in spanish. Cavernous sinus dissection and bleeding in meningiomas. Cureus staged gamma knife radiosurgery for large skull. And are a typical adult female tumors with peak incidence of 4060 y.
Abstractophthalmic vein thrombosis is an extremely rare entity. The tumor removal of cavernous sinus meningiomas usually results in severe neurological deficits. Treatment of cavernous sinus meningiomas 5 md anderson. These features are suggestive of a cavernous sinus meningioma. It is a network of veins that sit in a cavity, approximately 1 x 2 cm in size in an adult. Olfactory groove and tuberculum sella meningioma duration. This article is from middle east african journal of ophthalmology, volume 18. In the patients who had srs as the primary treatment, the fiveyear local control rate was 96. Thirtynine patients were managed surgically with 42 surgical procedures. Meningioma with sigmoid sinus venous thrombosis radiology. Cavernous sinus meningioma in radiological progress dr. All the chapters have been developed with high quality and including the most modern approaches for the different aspects they deal with.
Cavernous sinus meningiomas are rare tumors that affect the cavernous sinus, an area that controls eye movement and allows your face to feel sensations. Cavernous sinus meningioma csm gradually compresses the above nerves and artery causing varied degrees of unilateral ophthalmoplegia. A 33yearold female patient presented with diplopia and left eye ptosis 26 weeks into her first pregnancy. Its benign appearance and 4year disease free survival without clinical or radiological evidence of intracranial disease favors the.
They can range from simply keeping an eye on the tumor through imaging cat scan, mri, etc. Cavernous sinus dissection and bleeding in meningiomas full. In addition to cranial nerves iii, iv, vi, and the frontal branch of the v th nerve, it contains the carotid artery and receives venous drainage from the orbit and basilar plexus. The lesion was not detected on a nonenhanced brain ct. We encountered two cases of dumbbellshaped middle cranial fossa meningioma with interdural cavernous sinus extension, which were successfully removed by surgical means.
No investigation was conducted at the time and her symptoms subsided 4 weeks post partum. A meningioma exclusively located inside the superior sagittal. Except in situations of symptomatic mass effect, unusual clinical presentation, or atypical imaging features, surgery to confirm the histologic diagnosis is unlikely to provide clinical benefit. Stereotactic radiosurgery srs and fractionated stereotactic radiotherapy srt are advanced modalities of radiotherapy for treatment of patients with inoperable and symptomatic csms.
The authors have been treating skull base meningiomas using relatively lowdose gamma knife radiosurgery gks. Clival meningiomas are located on the underside of the cerebrum within the posterior cranial fossa. Apr 25, 2014 cavernous sinus meningioma in radiological progress dr. Cavernous sinus meningiomas csms are rare, representing approximately 1% of all meningiomas. Posterior fossa meningioma is the second most common tumor in the cerebellopontine angle. Unlimited viewing of the articlechapter pdf and any associated supplements and figures. In the present study, volumestaged, lowdose gks was performed for large skull base meningiomas with a maximum diameter 4 cm. Torcular, transverse, and sigmoid sinus meningiomas. The carotid siphon of the internal carotid artery, and cranial nerves iii, iv, v branches v 1 and v 2 and vi all pass through this blood filled space nearby structures.
Manuel delgado garcia doctor in medicine and surgery ph. Tumor was centimeters by centimeters in diameter on her initial mri. Superior and inferior ophthalmic veins thrombosis with. C the meningioma removed with the occluded superior sagittal sinus. The lateral dural wall of the cavernous sinus is composed of two layers, the outer dural layer dura propria and the inner membranous layer. Linac radiosurgery for cavernous sinus meningiomas. On the other hand, the improvement of the anatomical knowledge and the microsurgical techniques together with diffusion of radiosurgery are currently changing the treatment strategy, opening new perspectives. A large right paraselllar mass is noted measuring up to 18 mm thick, filling the cavernous sinus and moderately narrowing in the transverse portion of the cavernous carotid artery. Endonasal endoscopic approach for a giant cavernous sinus. I am afraid that if they open me up and realize its lymphoma then thats a whole different ball game.
The most common are neurogenic tumors and cavernoma. I was told its in a very tricky part and the biopsy has to be surgery. Tumors of the nasopharynx, skull base, and sphenoid sinus may extend to the cs as can perineural and hematogenous metastases. A 40yearold woman presented with rightsided ophthalmoplegia, ptosis, and retroorbital pain. Conclusion cavernous sinus meningioma is a tumor growing from the meninges that is located in the cavernous sinus. Meningiomas involving the cavernous sinus may start in the sinus or grow into it as part of a larger tumor involving the medial sphenoid wing, orbit. Imaging lesions of the cavernous sinus american journal. Meningiomas invading the sagittal or transverse sinuses. Should meningiomas involving the cavernous sinus be totally resected. The oculomotor and trochlear nerves are embedded in its lateral. The coronal projection provided imaging of cranial nerves within the cavernous sinus. Cavernous sinus surgery is considered neurosurgically feasible. The cavernous sinuses are osteoduralmeningeal compartments located on both side of the sellar area. Meningioma near the cavernous sinus brain tumors inspire.
Risks are rooted primarily in tumor location, particularly with respect to the proximity of important neurovascular structures. Outcome of aggressive removal of cavernous sinus meningiomas. The development of microsurgical and skull base techniques as well as advances in anesthesia and neuroradiology have allowed safe and systematic treatment of these lesions. On the other hand, the improvement of the anatomical knowledge and the microsurgical techniques together with diffusion of radiosurgery are currently changing the treatment strategy, opening new perspectives to the.
Median dose was 52 gy with standard fractionation and median follow up was 6. Meningiomas are the most common tumor arising from the lateral wall of the cavernous sinus. Surgery of meningiomas involving major dural sinuses leaves the surgeon confronted with a difficult dilemma. Dumbbellshaped middle cranial fossa meningioma with. Microsurgical ressection for parasagittal meningiomas with. It is located at the central base of the skull, on either side of the sella turcica.
Since 1989, 24 patients with cavernous sinus meningiomas have been treated at stanford university medical center with linear accelerator linac radiosurgery. In this article, a treatment strategy for volumestaged gks and results for. Management of cavernous sinus meningioma presenting with. Cavernous sinuses are paired dural venous sinuses located in the middle cranial fossa on the side of the body of sphenoid bone. Despite the advances in techniques and technologies, the management of cavernous sinus cs meningiomas still remains a challenge for both neurosurgeons and radiation oncologists. The reported incidences of permanently impaired extraocular muscle function developing after resection of cavernous sinus meningioma is 14% to 58%. There are a number of spinal meningioma treatments used to relieve the symptoms or remove the tumor altogether. The remaining 102 patients were prospectively followed up at 1 y intervals with clinical, neuroophthalmological and mri examinations. Cavernous sinus is constituted of paired venous structures located in the middle cranial fossa. The neurosurgical atlas is committed to promoting neurosurgical education free of charge. The inner layer of the lateral edge of the cavernous sinus contains the critical structures, it separates the lateral wall and its contents form the venous spaces. These types of meningiomas often grow as part of a larger lesion within the sphenoid bone. Meningioma extensions included meckels cave 5, prepontine cistern 4, sellarsuprasellar 7, and middle fossa 3.
Total removal grade i or ii resection of petroclival meningiomas is achievable in 76. Surgery is considered the mainstay of the treatment and a complete resection is considered curative in who grade i meningiomas. Aug 11, 2016 cavernous sinus dissection and bleeding in meningiomas ocs the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. This case report describes the epidemiology, the clinical presentation as well as the current treatment options for this condition. Meningiomas of the cavernous sinus cs are extremely difficult to treat surgically with acceptable morbidity and mortality.
Meningioma originating from the lateral wall of the cavernous sinus is rare with only two reported cases. Anteriorly, the tumor extends for 1 centimeter into the apex of the right orbit, medially into the upper right sphenoid sinus. Cavernous sinus meningiomas can cause double vision, dizziness and facial pain. She underwent a partial resection of the cavernous sinus meningioma, and the remnant was subsequently treated by gamma knife radiosurgery see figure. The first technique will involve pealing of the outer layer of the lateral wall of the cavernous sinus before the dura is opened and the tumour attacked, and the second group of cases will be operated by a standard technique, where the tumour will be directly attacked with out pealing of the outer layer. Interdural cavernous sinus is called the lateral dural wall in the cavernous sinus, which is composed of two layers, the outer dural layer and the inner membranous layer. They communicate via the superior orbital fissure with the orbit, via the foramen rotundum and the inferior orbital fissure with the pterygopalatine fossa and via the oval foramen with the infratemporal fossa and the masticator space. The paired cavernous sinuses are thinwalled venous pockets below and behind the orbits or eye sockets that collect blood draining from the face, eye, and anterior brain. Over the past 10 years, 41 patients with histologically benign meningiomas involving the cavernous sinus underwent aggressive surgery. We report a case of a 57yearold patient with a history of intracranial hypertension visual impairment, headaches, and papillary edema due to a meningioma exclusively located inside the superior sagittal sinus sss. Radiosurgery was an effective primary management strategy for patients with an imaging defined cavernous sinus meningioma. Mar 07, 2017 what options are available for spinal meningioma treatment. As note below, radiosurgery is particularly well suited for treating cavernous sinus meningioma, but if the tumor is too close to the optic tract it may be better to use fractionated radiation go here and here.
Some meningiomas are found along the dural lining in the venous sinuses of the brain and skull base locations where arachnoid cap cells are most abundant. In those patients with typical meningioma, the control rate was 93. Meningiomas are the most common primary intracranial tumors in the adult population 1. Medially, the cavernous sinus is related to the pituitary gland and the sphenoid sinus. Cavernous sinus meningioma with the involvement of the. Gamma knife radiosurgery for cavernous sinus meningiomas. Cavernous sinus meningiomas cavernous sinus meningiomas wilson, charles b. Meningiomas are the most common brain tumor in the adult population. Patients age ranged between 31 and 86 years mean 57.
Meningiomas located in the torcular, transverse, and sigmoid sinus ss regions are dangerous tumors to deal with. The authors evaluated the long term symptomatology, the image findings, and the toxicity of patients with csms. The cs is a parasellar anatomic compartment that contains bilateral internal carotid arteries, the iiird, ivth, first two divisions of the vth and vith cranial nerves, the pericarotid sympathetic plexus, and a network of interconnected venous spaces. Cavernous sinus meningioma with the involvement of the medial sphenoidal wing mimicking hypertrophic pachymeningitis. This book is aimed at neurosurgeons with an interest in updating their knowledge on the latest state of meningiomas surgery and management. Evaluation of over 255 patients with sellar and parasellar lesions allowed study of the computed tomographic ct appearance of the cavernous sinus. Cavernous sinus meningiomas arise from the dura of the cavernous sinus more specifically, the lateral wall dura or arise from the adjacent dura in the petroclival region, the sphenoid ridge, or the clinoid process with extension to the cavernous sinus. They are generally considered benign lesions but after the 2007 who classification, the proportion of atypical meningiomas has steeply increased. Mean relapse free survival for atypical meningiomas was 11. Now, he has edited a new volume with articles by specialists in this topic presenting the. The rationale for aggressive surgical removal of cavernous sinus meningiomas is based on the presumption that the extent of removal is inversely related to the rate of recurrence. Cavernous sinus meningioma in radiological progress youtube. The cavernous sinus within the human head is a true dural venous sinus not a venous plexus creating a cavity called the lateral sellar compartment bordered by the temporal bone of the. On native and contrastenhanced t1weighted images, there was no clear signal difference between them.
The authors present a case of a 72yearold woman suffering from headache. Foremost authorities present the milestone text on meningioma management, now in a fully updated second edition almeftys meningiomas, second edition is the definitive guide to meningioma diagnosis, treatment, and surgery, and reflects over a decade of major advances in the diagnosis and management of both intracranial and spinal meningiomas. Intraosseous cavernous hemangiomas of the skull are rare. A case of meningioma originating from the lateral wall of. Elsevier surgery for menlnglomas cavernous sinus re. A minority of these tumours present with clinical and histological features suggesting aggressive potential atypical and malignant meningiomas. Venous reconstruction in surgery of meningiomas invading the. Cavernous sinus meningioma operative video cases the. The cavernous sinus cs is a venous plexus that lies between the periosteal and dural layers of the dura mater. Types of meningiomas meningioma types mount sinai new york. Cavernous sinus meningioma nancy huynh ophthalmic medical. Case report successful management of refractory headache.
Mri showed a large, lobulated, hyperintense lesion in the right cavernous sinus on t2weighted image. Singlefraction radiosurgery of benign cavernous sinus. Radiosurgery is increasingly used to treat unresectable cavernous sinus tumors. The mass is t1 isotense and t2 hyperintense with vivid contrast enhancement. A 54yearold patient with meningioma originating in bilateral frontal and ethmoidal sinus and invading the right orbit. Meningiomas are quite frequently encountered in a neurosurgical practice. The mri showed a parietal meningioma with adjacent thick bone. The association between these two entities is nevertheless very uncommon. The imaging differentials are cavernoma, meningioma, and schwannoma. In the presence of a totally occluded sinus, the question whether to restore the venous circulation by performing a bypass when a completely occluded sinus is resected, rather than just remove the tumor and the obstructed segment. I have enclosed an account of the physician strike in canada in 1987, and i suggest that many of the issues involved in the strike are also involved in malpractice. A cavernous sinus meningioma is a benign tumor arising from the cells that form the internal lining membrane of the brain, called the pia mater, which expands to fill the cavernous sinus. Evidencebased treatment of cavernous sinus meningioma.
Cavernous sinus cs meningiomas which are by definition those meningiomas which originate from the parasellar region are difficult skull base tumors to deal with. Listing a study does not mean it has been evaluated by the u. The mass also compresses the left temporal lobe and left pons. For deciding the most appropriate surgical strategy, surgeons need detailed preoperative neuroimaging. Gkrs for cavernous sinus meningioma csm are presented, and factors possibly affecting outcome are investigated. There was a permanent neurological deficit in seven 8. The tumor removal of cavernous sinus meningiomas usually results in. Cavernous sinus meningiomas, surgical neurology 10. Original article gamma knife radiosurgery of cavernous sinus. Cases with middle fossa meningiomas will be randomised to one of two surgical techniques.
T1 treatment of cavernous sinus meningiomas 5 au blake, p. Anatomic research on cadaver specimens, together with the advances made in cranial base and microvascular surgery over the past 2 decades, have made it possible to completely resect lesions within the cavernous sinus. One hundred and seventeen patients with cavernous sinus meningiomas had linac radiosurgery at our institution in the period 19932007. Thus, the use of eea has spread, except for tumors larger than 4 cm and edematous tumors 1. This same phenomenon occurred during second pregnancy at 20 weeks of gestation, with patient becoming symptom free again 6 weeks after giving birth. However, recently, delicate procedures for neural and vascular structures can be performed via eea. One case with subtotal removal of a medial sphenoid wing meningioma which had invaded the sinus. Meningiomas also differ in the extent of their cavernous sinus involvement. Treatment strategy in the stereotactic irradiation era. However, on t2weighted images, the intra sinus material signal was less intense than the dural mass, so it might have represented an organized thrombus, that extended into the jugular foramen. The cavernous sinus is one of the dural venous sinuses of the head.
Optimal visualization of the cavernous sinus was obtained with continuous contrast enhancement of both axial and coronal tomograms. Stereotactic radiosurgery srs is an important treatment option for patients with cavernous sinus meningiomas csm. Cavernous sinus meningiomas were once considered unresectable. A 67yearold man presented with recent memory disturbance and partial seizure. Atypical grade ii and malignant grade iii meningiomas constitute approximately 57% and % of meningiomas, respectively 10, 19, 38. A case of meningioma of the petroclival portion extending into the cavernous sinus developed right hemiparesis and aphasia due to postoperative intracerebral hemorrhage. Today, meningiomas with primary or, more commonly, secondary involvement of the cavernous sinus remain a surgical challenge. Meningiomas involving the cavernous sinus may start in the sinus or grow into it as an extension from a larger tumour involving the medial sphenoid wing, orbit, clivus, or petrous bones. The cavernous sinus has many vital structures passing through it, including the carotid artery and the third, fourth, fifth, and sixth cranial nerves.
The lesion was hypointense on t1weighted image, with intense enhancement. Surgery for cavernous sinus cs tumors continues to be one of the most significant challenges in neurosurgery, despite major technical advancements, accumulating knowledge, surgical expertise, and improvements in anatomic understanding in the last decades. The authors evaluated the long term symptomatology, the image findings, and the toxicity of. Dissecting the tumor by progressive reduction of the tumor size, the tumor capsule can be gently folded into the central portion of the wound and traction always being applied to the tumor rather than the surrounding brain.
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