Background: Cavernous sinus meningioma (CSM) causes gradual ophthalmoplegia and may eventually cause compression of the chiasma. Throughout the years, she remained active and healthy until she died in 2018 at age 88, of ovarian cancer. 1: 1-0, 10. 1: 1-8, 3. It depends on your specifics. doi: 10.3171/foc.2003.14.6.3. Like patient 1, one may prefer to wait until retirement or other events, or like patients 1 and 3, one may prefer not to take any risk of life. Resection of the intracavernous carotid artery likely entails an extraintracranial bypass to reconstruct the ICA ( 32 ). The mild eyelid droop was corrected by a small attachment to his glasses and he was able to continue his work as a dentist. Radiation, including GKR, have long term complications that may not be seen for several decades. However, the individualized treatments and long follow-ups, together with detailed literature review, suggest that CSM requires individualized staged treatments based on each patient’s condition. J Comput Assist Tomog. 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. The treatment of cavernous sinus meningiomas: Evolution of a modern approach. [ 3 ] analyzed this outcome and disagreed with their conclusion, commenting that it was not clear to them that aggressive surgical resection substantially improved either the natural history of the tumor or the prognosis after less radical treatment. The location of a meningioma determines the complexity of surgery to remove it. In 65 patients, Sekhar's classification, modified Kobayashi grading, and the Karnofsky Performance Scalewere used to define tumor extension, tumor removal, and clinical outcomes, respectively. Radiation treatment is used as an alternative treatment for CSM. Required fields are marked *. J Neurooncol. Br J Psychiatry. The question remains as to what treatment approach is most conducive to longest survival with minimum disability. Operation can be associated with death and disability; radiation can be associated with long-term complications. The actual therapeutic effect of radiation is also difficult to measure, unless the ophthalmoplegia is eliminated or at least reduced. The functional outcome in 43 (46%) patients was improved, 40 (43%) remained stable, and 11 (12%) had worse preexisting or newly developed symptoms. At operation, partial removal of the tumor was done without entering deep in the cavernous sinus and was followed by conventional radiation therapy. The edema caused a bit more brain fog post treatment and as expected I felt very fatigued. 1995. Thus, in most patients, neither surgery nor radiation needs to be the starting treatment. For example, Ryan et al. J Neurosurg. If a radical operation is recommended, patients often accept this option, despite the potential postoperative ophthalmoplegia, believing that in order to avoid death they must undergo the operation. Therapy. Meningiomas of the midline skull base that arise near the pituitary gland include planum sphenoidale, tuberculum sella, clinoidal, optic canal, cavernous sinus, Meckel’s cave and petroclival meningiomas. Epub 2009 Apr 9. The tumor is commonly treated by operation, radiation, or both. Ophthalmoplegia, whether spontaneous or resulting from treatments of CSM, is a serious complication. The tumor is commonly treated by operation or radiation; while effective, both treatments have limited and partial therapeutic effects. At operation, the tumor was a part of the cavernous sinus, hard in consistency, and unlike pituitary tumors, it was very solid. The greatest improvement was seen for CN V deficits, whereas CN II and CN IV deficits showed the smallest degree of recovery. Privacy, Help Six years later, he had developed complete IIIrd nerve palsy together with closure of the left eye, and a computed tomography (CT) scan showed clear evidence for CSM [ Figure 1b ]. Tumors may be primary or arise as either local spread or metastases. A review of literature supports the above statements, as does a detailed review of literature by Klinger et al. Certainly, patients in this study showed that disturbing diplopia may not occur for a long time. Cavernous sinus meningiomas (CSMs) are challenging lesions for the skull base neurosurgeon to manage given their close association with cranial nerves II-VI and the internal carotid artery. Regardless of the cause, however, its occurrence is a major consideration for choice of a treatment. The tumor is commonly treated by operation, radiation, or both. Cavernous sinus meningiomas can cause double vision, dizziness and facial pain. Sometimes radiation can help reduce the size of a meningioma. A meningioma is a tumor that grows from the meninges — the protective membranes that cover the brain and spinal cord. Due to this history, multiple pathologists reviewed the histology and had mixed opinions. Thus, there seems to be no urgency in treating CSM with either operation or radiation treatment, especially if it is asymptomatic, or the symptoms are not disturbing to the patient and can be treated with noninvasive treatment. 2018 Apr;44(4):E11. Talacchi A, Hasanbelliu A, D'Amico A, Regge Gianas N, Locatelli F, Pasqualin A, Longhi M, Nicolato A. Neurosurg Rev. This paper represents 2 to almost 5 decades of follow-up of five patients in whom operation, radiotherapy, and/ or conservative management were done based on the evidence of presenting symptoms and a doctor–patient decision as to the best option to offer a longer life with less disability. COVID-19 is an emerging, rapidly evolving situation. Sughrue ME, Rutkowski MJ, Aranda D, Barani IJ, McDermott MW, Parsa AT. A thorough understanding of the anatomy and surgical approaches are crucial to success, as is knowledge of the … The long-term side effects of radiation therapy for benign brain tumors in adults. 1994. Evidence of meningioma infiltration into cranial nerves: clinical implications for cavernous sinus meningiomas. To maintain his vision, radiation therapy was done. Even after immunohistochemical and electron microscopic findings the neuropathologists remained in doubt. 2018. Beer-Furlan A, Priddy BH, Jamshidi AO, Shaikhouni A, Prevedello LM, Ditzel Filho L, Otto BA, Carrau RL, Prevedello DM. Nevertheless, in some patients, as in patients 4 and 5, diplopia can cause considerable limitation in their function to work; in such cases, a limited operation to relieve symptoms, followed by radiation, seems reasonable. In response, DeMonte et al. Thus, in most patients, neither surgery nor radiation needs to be the starting treatment. J Neurosurg. Management options for cavernous sinus meningiomas. Please enable it to take advantage of the complete set of features! National Library of Medicine The histology of the tumor was never determined, but upon presentation of her scans on numerous occasions, no one doubted meningioma as the diagnosis. Despite technical advances regarding microsurgical resections of cavernous sinus meningiomas, they are rarely completely resected and are often accompanied by a high rate of neurological disturbances. 2000. Thus, before recommending any treatment, an in-depth assessment of the patient’s goals, desires, and physical condition is an essential part of the doctor–patient relationship. Facial disfigurement can cause adverse effects in the patient’s self-image, social status, ability to find employment, and personal relationships. She also had galactorrhea and due to that a pituitary tumor located in the cavernous sinus was considered. Figures 5a and b show her 6- and 7-year follow-up, respectively. 1. al-Mefty O, Kersh JE, Routh A, Smith RR. Brainstem structures dramatically benefit from surgical decompression as do the cranial nerves. Yu E, Forghani R. Sellar, parasellar and clival region: Skull base cancer imaging. Besides visual limitation, ophthalmoplegia causes emotional stress and disability. [ 2 ] treated 90 CSM patients symptomatically for 2–5 years. In CSM the risks of surgery are high not only surgically but also personally as Javad describes so well. doi: 10.3171/2018.1.FOCUS17703. The morbidity rate was 16% in this study, with ocular nerve dysfunction improved in 40% of patients postoperatively. 73: 502-12, 2. A year or two after the operation, she became pregnant with twins. [ 3 ] emphasized that most of the patients in their study had shown signs of recent tumor growth, and all of the tumors extended outside of the cavernous sinus. Neurosurg Focus. Cavernous sinus meningioma (CSM) is the most common primary cavernous sinus (CS) lesion. One was followed for 36 years after craniotomy. Treatment of cavernous sinus meningiomas. Park KJ, Kano H, Iyer A, Liu X, Tonetti DA, Lehocky C. Gamma knife stereotactic radiosurgery for cavernous sinus meningioma: Long-term follow-up in 200 patients. Operations, especially radical or aggressive ones, are associated with high mortality and morbidity. For while the appearance of the tumor at operation and radiologic evaluations left no doubt for meningioma, several neuropathologists remained doubtful and could not make up their mind if the tumor was meningioma or pituitary adenoma. Natural history of cavernous sinus meningiomas. I have known Dr. Javad Hekmatpanah for over 50 years. The tumor is often histologically benign, slow growing, and seldom life threatening. 81: 245-51, 5. anatomy of the cavernous sinus along with modern MRI of the cavernous sinus and CSMs can facilitate a multi-modality treatment strategy that minimizes treatment mor - bidity while attempting to maximize tumor control. Klinger DR (1), Flores BC, Lewis JJ, Barnett SL. Meningiomas are benign tumors of the meninges that can compress adjacent brain tissue. DeMonte F, Smith HK, al-Mefty O. 66: 661-8, 12. Over a period of several years, he developed partial IIIrd nerve palsy with mild drooping of the eyelid, but retained normal vision. It diminishes self- image and makes it difficult to find employment despite all qualifications; it can hinder desired social life and personal relationships. 82: 702-3, 4. Evidence-based treatment of cavernous sinus meningioma. Treatment may include excision, stereotactic radiosurgery, and sometimes radiation therapy. In each patient, the potential treatment risks were assessed and presented to the patient, and a treatment plan was made for what was thought to likely offer the lowest chances for morbidity and mortality. A period of “wait and see” may be best, until, based on the evidence, operation, radiation, or both become needed. If one is uncertain of the diagnosis, either waiting or a performing a biopsy is a reasonable choice to make in deciding risks. These are lessons to be learned to become an outstandng physician. Not every meningioma requires immediate treatment. Introduction. CSM is usually treated by operation, radiation, or both. Morisako H, Goto T, Ohata H, Goudihalli SR, Shirosaka K, Ohata K. Neurosurg Focus. 1990. Would you like email updates of new search results? Treatments for meningiomas vary, depending on the type and location. [ 4 ] reported that 31 (76%) of their 41 CSM patients had “total removal.” Three patients died; in the remaining 38 patients, preexisting cranial nerve deficits improved in 14%, remained unchanged in 80%, and worsened permanently in 6%. That seems to be standard effect of radiation. It is difficult to understand the bias and stigma a person with even lesser facial disfigurement goes through. Because the tumor grows slowly over years, it is difficult to assess the degree of the prevention of growth due to radiation treatment. Careers. In 1975, a CT scan showed a tumor in the cavernous sinus on the left side [ Figure 2a ]. One was treated conservatively for 15 years before requiring craniotomy and radiation. The tumor removal of Cavernous Sinus Meningiomas usually results in severe neurological deficits. The patients presented here are too few to be able to come up with a general guideline; yet, they indicated that when spontaneous ophthalmoplegia occurs, it does so slowly and gradually. J Neurosurg. The neurosurgical team at UPMC may recommend a combination of surgical and non-surgical approaches for treating meningiomas: Endoscopic Endonasal Approach (EEA): The preferred surgical treatment for meningiomas at the base of the skull is the Endoscopic Endonasal Approach. The main goal of any treatment for CSM is to prevent growth of the tumor and to prevent occurrence of ophthalmoplegia. Besides visual limitation, ophthalmoplegia causes emotional stress and disability. Despite the small patient number, the results together with a review of pertinent available information from the literature may be of help in planning treatment measures. An individual with a cavernous sinus meningioma may notice blurred or double vision. Despite a detailed presentation of potential outcome, few patients can truly understand the impact of the physical disability and facial disfigurement caused by ophthalmoplegia before they actually undergo the operation. Complete resection was achieved in 41.5% of cases and was not significantly assoc… After partial or subtotal tumour removal, the probability of recurrence remains significant (13% at 3 years; 38% at 5 years) 7) In the 1980s and early 1990s, with advancements in microsurgical techniques, increasing knowledge of the relevant microsurgical neuroanatomy, and the advent of advanced skull base surgical approaches, the treatment of CSMs involved attempts at gross-total resection (GTR). Amelot A, van Effenterre R, Kalamarides M, Cornu P, Boch AL. The operative and radiological appearance of patients 4 and 5 are very similar. Epub 2020 Sep 17. This returned the visual field in the right eye to near normal. Long-term follow-up after surgical removal of meningioma of the inner third of the sphenoidal wing: outcome determinants and different strategies. Part of the tumor was removed without entering deep into the cavernous sinus, and she received postoperative radiation treatment. However, the complications of surgery usually present shortly after the operation, but with radiation, complications can occur long after. 176: 177-81, 9. Operations, especially radical or aggressive ones, are associated with high mortality and morbidity. Clipboard, Search History, and several other advanced features are temporarily unavailable. His approach to the treatment of Caveronus Sinus Meningiomas (CSM) is reasonable. eCollection 2020. The histology done in 1991 Figure 5d . A summary of each patient is presented, and the results are compared with those available in the literature. 2018. Amol Raheja, William T. Couldwell, in Handbook of Clinical Neurology, 2020. Out of the 10 patients who had total removal, one had recurrence 5 years after the operation. They originate from the lining of the cavernous sinus, which is a venous cavity that contains the internal carotid artery and several nerves that control the eye muscles. Meningioma is the most common type of tumor that forms in the head.Most meningiomas grow very slowly, often over many years without causing symptoms. Neurosurgery. These treatment options generally include observation, primary radiosurgery, or STR, with either continued observation or On the other hand, the improvement of the anatomical knowledge and the microsurgical techniques together with diffusion of radiosurgery changed the treatment strategy, … At times, one like patient 1 may be unreasonably hesitant to accept an operation due to older age or other reasons and suffers serious consequences of blindness. Minor symptoms, such as slight diplopia of lateral gaze, can be treated with corrected eyeglasses or shortening of the lateral rectus muscle of the eye. Especially when radical or aggressive removal of the tumor is involved, these can be associated with relatively higher mortality and morbidity[ 4 ] than other intracranial tumors. Radiation treatment slows down and shrinks some tumors but can have some complications over a long time. (a) 1975, (b) 1983, (c) 1984, (d) 1989, (e) 2002. Because of their slow growth, not all meningiomas need to be treated immediately. A cavernous sinus meningioma can cause pain behind the eye, as well as abnormal eye movement. One was followed for 45 years without needing craniotomy or radiation, despite enlargement of the tumor. Meningiomas that arise in the skull base region of the cavernous sinus or Meckel’s cave where the nerves that control eye movements and facial sensation, can cause double vision or facial pain and numbness. [ 6 ], DeMonte et al. The participants demonstrated strong behavioral avoidance to handle the prop when it had been handled by the influenza or birthmark confederates and showed “facial displays of disgust.” Ryan et al. The advent of radiosurgery and its documented success for tumor growth control and limited morbidity in cavernous lesions has helped to shift the treatment goals for CSMs from GTR to tumor control and symptom relief while minimizing treatment- and lesion-associated morbidity. Surg Neurol Int. Symptoms typically appear gradually and vary depending on the tumor location. Furthermore, because the onset of diplopia is independent of the size of the tumor, we do not know when diplopia will occur. Cerebral angiography showed no specific related abnormality. Facial disfigurement is treated like an infectious disease. Purely extracavernous approaches that leave the sinus unopened represent an optimal treatment for the major part of cavernous sinus meningiomas. Conclusion: The patient number is not large enough to make a broad conclusion. J Neurosurg. © Copyright Surgical Neurology International. Thus, recommendation for a treatment carries an awesome ethical responsibility. Gamma knife radiosurgery for the treatment of cavernous sinus meningiomas: post-treatment long-term clinical outcomes, complications, and volume changes GKRS provides good long-term tumor control and is associated with low cranial nerve-related morbidity development rates in patients with small- to medium-sized CS meningiomas. 33: 639-46, 11. Handb Clin Neurol. The cavernous sinus is a crowded anatomic region. In most patients, it is preferable to wait until there is evidence for the need of operation, radiation, or both. A 38-year-old woman with mild proptosis, double vision from IIIrd nerve palsy, and decreased visual acuity in the left eye, was admitted for evaluation in 1981 [ Figure 3a ]. [ 1 ] described one case of a patient who developed a clival tumor 30 years postirradiation. Facial disfigurement can cause adverse effects in the patient’s self-image, social status, ability to find employment, and personal relationships. No specific routine or guideline was used, for at the time there was none. The diplopia was corrected with glasses. Proper evaluation and patient counseling are required. J Neurol Surg B Skull Base. Without coercion, such a patient needs encouragement if the planned operation is not as risky as the patient perceives. Evol Hum Behav. Neurosurg Focus. Perhaps, in occasional patients with malignant, aggressive, or fast-growing tumors, radical operation can be helpful. Outcomes were better when this protocol was adopted at the initial diagnosis for patients with smaller tumors that did not compress the brainstem. However, due to the elevated prolactin in patient 5 and somewhat different histology, it is of specific interest. [ 5 ] studied 150 CSM patients, excluding atypical or malignant meningiomas, in whom 111 could be followed with neuroimaging and for a median period of 62 months, and found that gamma knife radiation (GKR) was associated with progression-free survival rates of 87% and 73%, and tumor control rates of 94% and 92% at 5 and 10 years, respectively. Preoperative CN dysfunction was evident in 64.6% of patients. Stereotactic Radiosurgery of Cavernous Sinus Meningiomas. Of those I know to have cavernous sinus meningioma treatment can be a combination of surgery and radiation for areas to dangerous to remove surgically. There is no charge to read or download any SNI content, but registering for a free membership will provide you with additional special features. Cavernous sinus or spheno-cavernous meningiomas These are among the most complex meningiomas to treat. Ryan S, Oaten M, Stevenson RJ, Case TI. Stereotactic radiosurgery (SRS) and fractionated Stereotactic radiotherapy (SRT) are advanced modalities of radiotherapy for treatment of patients with inoperable and symptomatic CSMs. Your email address will not be published. (1)Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas. Gamma knife surgery of meningiomas involving the cavernous sinus: Long-term follow-up of 100 patients. 2009 May;92(3):307-16. doi: 10.1007/s11060-009-9824-5. Or, a patient may accept operation hoping that an existing ophthalmoplegia recovers. I agree with everything he says. CN II deficits were most common. Surgery and Recovery Surgery is the primary treatment for meningiomas. The surgeon should remember that a multitude of processes may affect the cavernous sinus and mimic a meningioma, including sarcoidosis and … Unable to load your collection due to an error, Unable to load your delegates due to an error. Cavernous Sinus Meningioma with Orbital Involvement: Algorithmic Decision-Making and Treatment Strategy. Epub 2018 Sep 5. Some highly invasive and extensive meningiomas may extend into multiple compartments and into the sella itself, surrounding the pituitary gland. Improving Function in Cavernous Sinus Meningiomas: A Modern Treatment Algorithm. In 1976, what then was called an Electric and Musical Industries (EMI) scan showed a lesion lateral to the sella that could not be easily interpreted [ Figure 1a ], so conservative management was continued. Thank you, Javad, for another example of your excellence as a physician and person. However, a radical removal was avoided. A magnetic resonance imaging (MRI) scan from an outside institution (not available) showed a dense lesion lateral to the sella on the right side. Epub 2019 Mar 12. Bethesda, MD 20894, Copyright FOIA Three years later, the diplopia did interfere with her daily activities, so the left lateral rectus muscle was shorted by an ophthalmologist, which corrected her diplopia. MR imaging of intrasellar meningiomas simulating pituitary adenomas. Treatment choices should be made on the basis of Risk and Benefit for the patient. In another case, a CyberKnife treatment is carried out; an urgent surgical treatment is necessary in a case of intracranial pressure. Factors affecting outcome following treatment of patients with cavernous sinus meningiomas. [ 10 ] performed a study where 98 participants were instructed to handle props previously handled by either a healthy confederate or by a confederate simulating medical conditions affecting the face-birthmark and influenza. Her condition remained stable without the appearance of any related symptoms, despite enlargement of the tumor. In follow-ups, except for the IIIrd nerve palsy, she did not develop any other complications despite the tumor growing slowly [ Figure 3b - d ]. She did not have any radiation treatment. The results of an operation on reducing tumor volume and its therapeutic effects are immediately apparent, but the complication rate is higher and growth still can continue. 35: E8-, 7. As a consequence, the literature is comprised of similar small series, and it is unlikely that a randomized trial will ever be feasible. Prevention and treatment information (HHS). Radiation may also be considered to treat small remainders of the tumor after surgery. There were no mortalities or complications. J Laryngol Otol. The patient was able to return to work and a scan from 2017 shows no significant enlargement of the tumor. 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