Single-fraction radiosurgery of benign cavernous sinus meningiomas

Clinical article

Restricted access


Stereotactic radiosurgery (SRS) is an important treatment option for patients with cavernous sinus meningiomas (CSM). To analyze factors associated with local tumor control and complications after single-fraction SRS, the authors reviewed cases involving patients treated with Gamma Knife SRS between 1990 and 2008.


Excluded were patients with WHO Grade II or III tumors, radiation-induced tumors, multiple meningiomas, neurofibromatosis Type 2, and prior or concurrent radiotherapy. Five patients were lost to follow-up and 3 patients refused research authorization. The remaining 115 patients (29 men, 86 women) had either histologically confirmed WHO Grade I (n = 46, 40%) or presumed (n = 69, 60%) CSM. The median treatment volume was 9.3 cm3 (range 1.3–42.2 cm3). The median margin dose was 16 Gy (range 12–20 Gy). The median follow-up after SRS was 89 months (range 12–251 months). Thirty-nine patients (34%) had 10 or more years of follow-up after SRS.


Six patients (5%) had tumor progression (in field, n = 3; marginal, n = 3) at a median of 74 months (range 42–145 months) after SRS. The local tumor control rate was 99% at 5 years and 93% at 10 years after SRS. No analyzed factor was associated with local control after SRS. Fourteen patients (12%) had permanent complications at a median onset of 23 months (range 2–146 months) including trigeminal dysfunction (n = 9), diplopia (n = 2), ischemic stroke (n = 2), and hypopituitarism (n = 1). The 2-year, 5-year, and 10-year rates of complications were 7%, 10%, and 15%, respectively. Multivariate analysis found larger treatment volume (HR 1.1, 95% CI 1.02–1.2, p = 0.01) to be associated with complications after SRS. The complication rate for patients with a treatment volume of 9.3 cm3 or less was 3% (2 of 58 cases) compared with 21% (12 of 57 cases) for patients with a treatment volume greater than 9.4 cm3.


Single-fraction SRS at the radiation doses used in this series provided durable tumor control for patients with benign CSM. Larger tumor volume remains the primary factor associated with complications after single-fraction SRS of benign CSM despite advancements in SRS technique.

Abbreviations used in this paper:CSM = cavernous sinus meningioma; EBRT = external beam radiation therapy; LC = local tumor control; PIV = prescription isodose volume; RRC = radiation-related complications; SRS = stereotactic radiosurgery.

Article Information

Address correspondence to: Bruce E. Pollock, M.D., Department of Neurological Surgery, Mayo Clinic, Rochester, MN 55905. email:

Please include this information when citing this paper: published online June 28, 2013; DOI: 10.3171/2013.5.JNS13206.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Graph showing local tumor control after single-fraction SRS of benign CSM. The dashed lines indicate 95% confidence intervals. The y axis indicates the percentage of patients with local tumor control; the x axis indicates time in months.

  • View in gallery

    Axial MR images obtained in a woman who presented with left-sided ptosis and diplopia and underwent SRS (PIV 35.5 cm3, tumor margin dose 14 Gy) at the age of 57 years. A: Post-gadolinium MR image obtained at the time of radiosurgery. B: Post-gadolinium MR image obtained 8 years after radiosurgery. The tumor has decreased in size but the patient's diplopia did not improve. C: Long-TR MR image obtained 12 years after radiosurgery showing a rostral pontine infarct.



Abdel-Aziz KMFroelich SCDagnew EJean WBreneman JCZuccarello M: Large sphenoid wing meningiomas involving the cavernous sinus: conservative surgical strategies for better functional outcomes. Neurosurgery 54:137513842004


Colombo FCasentini LCavedon CScalchi PCora SFrancescon P: Cyberknife radiosurgery for benign meningiomas: short-term results in 199 patients. Neurosurgery 64:2 SupplA7A132009


Couldwell WTKan PLiu JKApfelbaum RI: Decompression of cavernous sinus meningioma for preservation and improvement of cranial nerve function. Technical note. J Neurosurg 105:1481522006


De Jesús OSekhar LNParikh HKWright DCWagner DP: Long-term follow-up of patients with meningiomas involving the cavernous sinus: recurrence, progression, and quality of life. Neurosurgery 39:9159201996


DeMonte FSmith HKal-Mefty O: Outcome of aggressive removal of cavernous sinus meningiomas. J Neurosurg 81:2452511994


Di Maio SRamanathan DGarcia-Lopez RRocha MHGuerrero FPFerreira M Jr: Evolution and future of skull base surgery: the paradigm of skull base meningiomas. World Neurosurg 78:2602752012


Dufour HMuracciole XMétellus PRégis JChinot OGrisoli F: Long-term tumor control and functional outcome in patients with cavernous sinus meningiomas treated by radiotherapy with or without previous surgery: is there an alternative to aggressive tumor removal?. Neurosurgery 48:2852962001


Hasegawa TKida YYoshimoto MKoike JIizuka HIshii D: Long-term outcomes of Gamma Knife surgery for cavernous sinus meningioma. J Neurosurg 107:7457512007


Hashimoto NRabo CSOkita YKinoshita MKagawa NFujimoto Y: Slower growth of skull base meningiomas compared with non-skull base meningiomas based on volumetric and biological studies. Clinical article. J Neurosurg 116:5745802012


Kano HPark KIyer ANiranjan AFlickinger JCKondziolka D: Cranial nerve function before and after stereotactic radiosurgery for cavernous sinus meningiomas: a twenty-three year assessment. Neurosurgery 71:E571E5722012


Kimball MMFriedman WAFoote KDBova FJChi YY: Linear accelerator radiosurgery for cavernous sinus meningiomas. Stereotact Funct Neurosurg 87:1201272009


Klink DFSampath PMiller NRBrem HLong DM: Long-term visual outcome after nonradical microsurgery patients with parasellar and cavernous sinus meningiomas. Neurosurgery 47:24322000


Kollová ALiscák RNovotný J JrVladyka VSimonová GJanousková L: Gamma Knife surgery for benign meningioma. J Neurosurg 107:3253362007


Kondziolka DMathieu DLunsford LDMartin JJMadhok RNiranjan A: Radiosurgery as definitive management of intracranial meningiomas. Neurosurgery 62:53602008


Kotapka MJKalia KKMartinez AJSekhar LN: Infiltration of the carotid artery by cavernous sinus meningioma. J Neurosurg 81:2522551994


Larson JJvan Loveren HRBalko MGTew JM Jr: Evidence of meningioma infiltration into cranial nerves: clinical implications for cavernous sinus meningiomas. J Neurosurg 83:5965991995


Lee JHSade BChoi EGolubic MPrayson R: Meningothelioma as the predominant histological subtype of midline skull base and spinal meningioma. J Neurosurg 105:60642006


Lee JYKNiranjan AMcInerney JKondziolka DFlickinger JCLunsford LD: Stereotactic radiosurgery providing long-term tumor control of cavernous sinus meningiomas. J Neurosurg 97:65722002


Maruyama KShin MKurita HKawahara NMorita AKirino T: Proposed treatment strategy for cavernous sinus meningiomas: a prospective study. Neurosurgery 55:106810752004


Mathiesen TLindquist CKihlström LKarlsson B: Recurrence of cranial base meningiomas. Neurosurgery 39:291996


Metellus PBatra SKarkar SKapoor SWeiss SKleinberg L: Fractionated conformal radiotherapy in the management of cavernous sinus meningiomas: long-term functional outcome and tumor control at a single institution. Int J Radiat Oncol Biol Phys 78:8368432010


Metellus PRegis JMuracciole XFuentes SDufour HNanni I: Evaluation of fractionated radiotherapy and gamma knife radiosurgery in cavernous sinus meningiomas: treatment strategy. Neurosurgery 57:8738862005


Oya SKim SHSade BLee JH: The natural history of intracranial meningiomas. Clinical article. J Neurosurg 114:125012562011


Pollock BEStafford SLLink MJGarces YIFoote RL: Single-fraction radiosurgery for presumed intracranial meningiomas: efficacy and complications from a 22-year experience. Int J Radiat Oncol Biol Phys 83:141414182012


Pollock BEStafford SLLink MJGarces YIFoote RL: Stereotactic radiosurgery of WHO grade II and III intracranial meningiomas: treatment results based on a 22-year experience. Cancer 118:104810542012


Santacroce AWalier MRégis JLiščák RMotti ELindquist C: Long-term tumor control of benign intracranial meningiomas after radiosurgery in a series of 4565 patients. Neurosurgery 70:32392012


Sen CHague K: Meningiomas involving the cavernous sinus: histological factors affecting the degree of resection. J Neurosurg 87:5355431997


Simpson D: The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 20:22391957


Skeie BSEnger POSkeie GOThorsen FPedersen PH: Gamma knife surgery of meningiomas involving the cavernous sinus: long-term follow-up of 100 patients. Neurosurgery 66:6616692010


Slater JDLoredo LNChung ABush DAPatyal BJohnson WD: Fractionated proton radiotherapy for benign cavernous sinus meningiomas. Int J Radiat Oncol Biol Phys 83:e633e6372012


Spiegelmann RCohen ZRNissim OAlezra DPfeffer R: Cavernous sinus meningiomas: a large LINAC radiosurgery series. J Neurooncol 98:1952022010


Stafford SLPerry ASuman VJMeyer FBScheithauer BWLohse CM: Primarily resected meningiomas: outcome and prognostic factors in 581 Mayo Clinic patients, 1978 through 1988. Mayo Clin Proc 73:9369421998


Stafford SLPollock BEFoote RLLink MJGorman DASchomberg PJ: Meningioma radiosurgery: tumor control, outcomes, and complications among 190 consecutive patients. Neurosurgery 49:102910382001


Stafford SLPollock BELeavitt JAFoote RLBrown PDLink MJ: A study on the radiation tolerance of the optic nerves and chiasm after stereotactic radiosurgery. Int J Radiat Oncol Biol Phys 55:117711812003


Sughrue MEKane AJShangari GRutkowski MJMcDermott MWBerger MS: The relevance of Simpson Grade I and II resection in modern neurosurgical treatment of World Health Organization Grade I meningiomas. Clinical article. J Neurosurg 113:102910352010


Zada GPagnini PGYu CErickson KTHirschbein JZelman V: Long-term outcomes and patterns of tumor progression after gamma knife radiosurgery for benign meningiomas. Neurosurgery 67:3223292010




All Time Past Year Past 30 Days
Abstract Views 33 33 31
Full Text Views 89 89 23
PDF Downloads 107 107 36
EPUB Downloads 0 0 0


Google Scholar