Percutaneous biopsy of lesions in the cavernous sinus region through the foramen ovale: diagnostic accuracy and limits in 50 patients

Clinical article

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The cavernous sinus and surrounding regions—specifically the Meckel cave, posterior sector of the cavernous sinus itself, and the upper part of the petroclival region—are the location of a large variety of lesions that require individual consideration regarding treatment strategy. These regions may be reached for biopsy by a percutaneous needle inserted through the foramen ovale. The aim of this retrospective study was to evaluate the diagnostic accuracy of percutaneous biopsy in a consecutive series of 50 patients referred for surgery between 1991 and 2010.


Seven biopsies (14%) were unproductive and 43 (86%) were productive, among which 28 lesions subsequently underwent histopathological examination during a second (open) surgery. To evaluate the diagnostic accuracy of the procedure, results from surgery were compared with those from the biopsy.


Sensitivity of the percutaneous biopsy was 0.83 (95% CI 0.52–0.98), specificity was 1 (95% CI 0.79–1), and κ coefficient was 0.81.


Because of its valuable diagnostic accuracy, percutaneous biopsy of the cavernous sinus and surrounding regions should be performed in patients with parasellar masses when neuroimaging does not provide sufficient information of a histopathological nature. This procedure would enable patients to obtain the most appropriate therapy, such as resective surgery, corticosteroids, chemotherapy, radiotherapy, or radiosurgery.

Abbreviations used in this paper: DS = digital subtraction; ICA = internal carotid artery.

Article Information

Address correspondence to: Mahmoud Messerer, M.D., Université de Lyon, Lyon I, Département de Neurochirurgie, Hôpital Neurologique Pierre Wertheimer, Groupement Hospitalier Est, Hospices civils de Lyon, 59 Boulevard Pinel, Bron, France F-69677. email:

Please include this information when citing this paper: published online November 18, 2011; DOI: 10.3171/2011.10.JNS11783.

© AANS, except where prohibited by US copyright law.



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    Photograph showing the biopsy needle. For the outer needle, the cannula is 10-cm long with 14-gauge diameter. The 16-gauge inner stylet is used for puncturing. The inner needle used to aspirate tissue samples has a 16-gauge cannula. After the outer needle (together with the inner stylet) has been introduced and reached the targeted region, the stylet is withdrawn. The inner needle is then placed inside the outer needle, and is connected to a 20-ml syringe. Tissue samples are aspirated with a strong negative pressure applied to the syringe. Star = maxillosinus angle; solid line = clivus; dashed line = superior border of petrous bone; arrows = foramen ovale.

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    Coronal T1-weighted MR image with Gd enhancement showing a lesion in the right cavernous sinus with extension to the floor of the middle fossa. Meningioma at percutaneous biopsy was confirmed by open surgery.

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    Axial T1-weighted MR image with Gd enhancement showing a lesion in the right cavernous sinus extending to the tentorial scissure, suggesting a meningioma. At percutaneous biopsy, histopathological examination indicated an inflammatory pseudotumor. The lesion regressed after corticosteroid treatment.

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    Coronal T1-weighted MR image with Gd enhancement showing a lesion in the right cavernous sinus. The patient was referred for diplopia due to right oculomotor nerve palsy. A pseudotumoral inflammatory lesion was found at percutaneous biopsy, and the lesion regressed after corticosteroid treatment.

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    Coronal T1-weighted MR image with Gd enhancement showing a lesion in the right cavernous sinus with extension to the pterygomaxillary fossa. This lesion was found to be an adenocarcinoma at percutaneous biopsy and was treated using chemotherapy.

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    Flow diagram of patient management.

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    Postbiopsy probabilities of the malignancy risk as a function of percutaneous biopsy results and prebiopsy probabilities. This figure demonstrates the diagnostic contribution of the biopsy procedure. For example, using clinical and investigative tools, if the clinician estimates that the probability of malignancy is 20% (center line) before performing the biopsy, this probability increases to 100% (upper line) if the biopsy indicates the tumor is malignant. Conversely, if the biopsy indicates that the tumor is benign, this probability decreases to 2% (lower line).



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