Operative management of tumors involving the cavernous sinus

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✓ In the past, neurosurgeons have been reluctant to operate on tumors involving the cavernous sinus because of the possibility of bleeding from the venous plexus or injury to the internal carotid artery (ICA) or the third, fourth, or sixth cranial nerves. The authors describe techniques for a more aggressive surgical approach to neoplasms in this area that are either benign or locally confined malignant lesions.

During the last 2 years, seven tumors involving the cavernous sinus have been resected: six totally and one subtotally. The preoperative evaluation included axial and coronal computerized tomography, cerebral angiography, and a balloon-occlusion test of the ICA. Intraoperative monitoring of the third, fourth, sixth, and seventh cranial nerves was used to assist in locating the nerves and in avoiding injury to them. The first major step in the operative procedure was to obtain proximal control of the ICA at the petrous apex and distal control in the supraclinoid segment. The cavernous sinus was then opened by a lateral, superior, or inferior approach for tumor resection. Temporary clipping and suture of the ICA was necessary in one patient.

None of the patients died or suffered a stroke postoperatively. Permanent trigeminal nerve injury occurred in three patients; in two, this was the result of tumor invasion. One patient suffered temporary paralysis of the third, fourth, and sixth cranial nerves, and in another the sixth cranial nerve was temporarily paralyzed. Preoperative cranial nerve deficits were improved postoperatively in three patients. Radiation therapy was administered postoperatively to four patients. These seven patients have been followed for 6 to 18 months to date and none has shown evidence of recurrence of the intracavernous tumor.

Article Information

Address reprint requests to: Laligam N. Sekhar, M.D., Department of Neurological Surgery, Room 9402, Presbyterian-University Hospital, 230 Lothrop Street, Pittsburgh, Pennsylvania 15213.

© AANS, except where prohibited by US copyright law.

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Figures

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    Drawing of the placement of intraoperative monitoring devices. A bicoronal incision (shown here) or a curvilinear incision extending in front of the hairline is utilized for these procedures. The locations of all monitoring devices except that of the light-emitting diode contact lens used for optic nerve monitoring are shown. BSER = brain-stem evoked responses.

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    Drawing of the anatomy of the cavernous sinus and the important vascular and neural relationships. The various operative approaches employed during tumor resection are shown with arrows. II, III, IV, V, VI, VII, and VIII = cranial nerves; ICA = internal carotid artery; MM = middle meningeal artery; MA = meningohypophyseal artery; P = pituitary gland; DC = Dorello's canal; GSPN = greater superficial petrosal nerve; GG = geniculate ganglion; SF = superior orbital fissure.

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    Preoperative coronal (left) and axial (right) computerized tomography scans in Case 1. A large enhancing mass is seen filling the right infratemporal fossa, sphenoid sinus, cavernous sinus, middle fossa, and the petroclival area.

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    Exposure of the cavernous sinus in Case 1. Left: Inferior approach during the first-stage operation. The intracavernous internal carotid artery (ICA), the ophthalmic nerve (V1), the maxillary nerve (V2), the abducens nerve (VI), and the tumor (T) are exposed. Right: The second stage of the resection. Note the completely dissected oculomotor (III) and trochlear (IV) nerves, the tumor (T), and the pons (P).

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    Axial (left) and coronal (right) contrast-enhanced computerized tomography scans in Case 2 showing a tumor involving the cavernous sinus, middle fossa, and infratemporal fossa. The posterior fossa extension is not shown.

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    Exposure of the intracavernous tumor after dural opening and the location of the intracavernous structures as seen after tumor removal in Case 2. ICA = internal carotid artery; MCA = middle cerebral artery; III, IV, V, VI, and VII = cranial nerves; F = frontal lobe; T = temporal lobe; FO = foramen ovale (markedly enlarged); D = dura; Tu = tumor.

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    Preoperative computerized tomography scan in Case 3. A tumor is seen involving the sphenoid sinus, sella, suprasellar area, and right cavernous sinus.

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    Intraoperative photographs before removal of tumor from within the cavernous sinus in Case 3. Left: The oculomotor nerve (III) is stretched and splayed over the tumor (T) which is extruding superiorly from the cavernous sinus. The oculomotor nerve was partially decompressed by opening the dura of the lateral wall of the cavernous sinus. Right: The opening of the cavernous sinus is seen in its lateral (white arrow) and the superior (black arrow) aspects. The oculomotor nerve (III) is now well decompressed. The internal carotid artery (ICA) and the optic nerve (II) are also seen.

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    Axial (left) and coronal (right) computerized tomography scans in Case 4 showing a low-density lesion located in the cavernous sinus and the petrous apex. The lesion is enhanced after administration of contrast material (right).

References

1.

Adegbite ABKhan MIPaine KWEet al: The recurrence of intracranial meningiomas after surgical treatment. J Neurosurg 58:51561983Adegbite AB Khan MI Paine KWE et al: The recurrence of intracranial meningiomas after surgical treatment. J Neurosurg 58:51–56 1983

2.

Bonnal JThibaut ABrotchi Jet al: Invading meningiomas of the sphenoid ridge. J Neurosurg 53:5875991980Bonnal J Thibaut A Brotchi J et al: Invading meningiomas of the sphenoid ridge. J Neurosurg 53:587–599 1980

3.

Chapman PCarter RLClifford P: The diagnosis and surgical management of olfactory neuroblastoma: the role of craniofacial resection. J Laryngol Otol 95:7857991981Chapman P Carter RL Clifford P: The diagnosis and surgical management of olfactory neuroblastoma: the role of craniofacial resection. J Laryngol Otol 95:785–799 1981

4.

Chetiyawardana AD: Chordoma: results of treatment. Clin Radiol 35:1591611984Chetiyawardana AD: Chordoma: results of treatment. Clin Radiol 35:159–161 1984

5.

Cianfriglia FPompili AOcchipinti E: Intracranial malignant cartilaginous tumours. Report of two cases and review of literature. Acta Neurochir 45:1631751978Cianfriglia F Pompili A Occhipinti E: Intracranial malignant cartilaginous tumours. Report of two cases and review of literature. Acta Neurochir 45:163–175 1978

6.

Ciric IMikhael MStafford Tet al: Transsphenoidal microsurgery of pituitary macroadenomas with long-term follow-up results. J Neurosurg 59:3954011983Ciric I Mikhael M Stafford T et al: Transsphenoidal microsurgery of pituitary macroadenomas with long-term follow-up results. J Neurosurg 59:395–401 1983

7.

Cophignon JLucena JClay Cet al: Limits to radical treatment of spheno-orbital meningiomas. Acta Neurochir Suppl 28:3753801979Cophignon J Lucena J Clay C et al: Limits to radical treatment of spheno-orbital meningiomas. Acta Neurochir Suppl 28:375–380 1979

8.

Cummings BJHodson DIBush RS: Chordoma: the results of megavoltage radiation therapy. Int J Radiat Oncol Biol Phys 9:6336421983Cummings BJ Hodson DI Bush RS: Chordoma: the results of megavoltage radiation therapy. Int J Radiat Oncol Biol Phys 9:633–642 1983

9.

Dolenc V: Direct microsurgical repair of intracavernous vascular lesions. J Neurosurg 58:8248311983Dolenc V: Direct microsurgical repair of intracavernous vascular lesions. J Neurosurg 58:824–831 1983

10.

Fisch U: The infratemporal fossa approach for nasopharyngeal tumors. Laryngoscope 93:36441983Fisch U: The infratemporal fossa approach for nasopharyngeal tumors. Laryngoscope 93:36–44 1983

11.

Gay IElidan JKopolovic J: Chondrosarcoma at the skull base. Ann Otol Rhinol Laryngol 90:53551981Gay I Elidan J Kopolovic J: Chondrosarcoma at the skull base. Ann Otol Rhinol Laryngol 90:53–55 1981

12.

Gordy PD: Neurinoma of the gasserian ganglion. Report of a case and review of the literature. J Neurosurg 22:90941965Gordy PD: Neurinoma of the gasserian ganglion. Report of a case and review of the literature. J Neurosurg 22:90–94 1965

13.

Hakuba ANishimura SShirakata Set al: [Surgical approaches to the cavernous sinus. Report of 19 cases.] Neurol Med Chir 22:2953081982 (Jpn)Hakuba A Nishimura S Shirakata S et al: [Surgical approaches to the cavernous sinus. Report of 19 cases.] Neurol Med Chir 22:295–308 1982 (Jpn)

14.

Harris FSRhoton AL Jr: Anatomy of the cavernous sinus. A microsurgical study. J Neurosurg 45:1691801976Harris FS Rhoton AL Jr: Anatomy of the cavernous sinus. A microsurgical study. J Neurosurg 45:169–180 1976

15.

Jafek BWKrekorian EAKirsch WMet al: Juvenile nasopharyngeal angiofibroma. Management of intracranial extension. Head Neck Surg 2:1191281979Jafek BW Krekorian EA Kirsch WM et al: Juvenile nasopharyngeal angiofibroma. Management of intracranial extension. Head Neck Surg 2:119–128 1979

16.

Johnston I: Direct surgical treatment of bilateral intracavernous internal carotid artery aneurysms. J Neurosurg 51:981021979Johnston I: Direct surgical treatment of bilateral intracavernous internal carotid artery aneurysms. J Neurosurg 51:98–102 1979

17.

Kline LBGalbraith JG: Parasellar epidermoid tumor presenting as painful ophthalmoplegia. Case report. J Neurosurg 54:1131171981Kline LB Galbraith JG: Parasellar epidermoid tumor presenting as painful ophthalmoplegia. Case report. J Neurosurg 54:113–117 1981

18.

Krekorian EAKato RH: Surgical management of nasopharyngeal angiofibroma with intracranial extension. Laryngoscope 87:1541641977Krekorian EA Kato RH: Surgical management of nasopharyngeal angiofibroma with intracranial extension. Laryngoscope 87:154–164 1977

19.

Laws ER JrOnofrio BMPearson BWet al: Successful management of bilateral carotid-cavernous fistulae with a transsphenoidal approach. Neurosurgery 4:1621671979Laws ER Jr Onofrio BM Pearson BW et al: Successful management of bilateral carotid-cavernous fistulae with a transsphenoidal approach. Neurosurgery 4:162–167 1979

20.

MacKay AHosobuchi Y: Treatment of intracavernous extensions of pituitary adenomas. Surg Neurol 10:3773831978MacKay A Hosobuchi Y: Treatment of intracavernous extensions of pituitary adenomas. Surg Neurol 10:377–383 1978

21.

Møller ARJannetta PJ: Preservation of facial function during removal of acoustic neuromas. Use of monopolar constant-voltage stimulation and EMG. J Neurosurg 61:7577601984Møller AR Jannetta PJ: Preservation of facial function during removal of acoustic neuromas. Use of monopolar constant-voltage stimulation and EMG. J Neurosurg 61:757–760 1984

22.

Nakahara AAsakura TKawabatake Het al: [A giant aneurysm of the internal carotid artery treated by intracranial direct surgery — with a special reference to the anatomical relationship between the cavernous sinus and the internal carotid artery.] No Shinkei Geka 3:7837891975 (Jpn)Nakahara A Asakura T Kawabatake H et al: [A giant aneurysm of the internal carotid artery treated by intracranial direct surgery — with a special reference to the anatomical relationship between the cavernous sinus and the internal carotid artery.] No Shinkei Geka 3:783–789 1975 (Jpn)

23.

Nelson PB: Large tumors of the pituitary gland in Sekhar LNSchramm V (eds): Tumors of the Cranial Base: Diagnosis and Treatment. Philadelphia: Futura (In press1986)Nelson PB: Large tumors of the pituitary gland in Sekhar LN Schramm V (eds): Tumors of the Cranial Base: Diagnosis and Treatment. Philadelphia: Futura (In press 1986)

24.

Northfield DWC: The Surgery of the Central Nervous System. A Textbook for Postgraduate Students. Oxford: Blackwell Scientific1973 p 285Northfield DWC: The Surgery of the Central Nervous System. A Textbook for Postgraduate Students. Oxford: Blackwell Scientific 1973 p 285

25.

Parkinson D: A surgical approach to the cavernous portion of the carotid artery. Anatomical studies and case report. J Neurosurg 23:4744831965Parkinson D: A surgical approach to the cavernous portion of the carotid artery. Anatomical studies and case report. J Neurosurg 23:474–483 1965

26.

Parkinson DWest M: Lesions of the cavernous plexus region in Youmans JR (ed): Neurological Surgeryed 2. Philadelphia: WB Saunders1982 Vol 5 pp 30043023Parkinson D West M: Lesions of the cavernous plexus region in Youmans JR (ed): Neurological Surgery ed 2. Philadelphia: WB Saunders 1982 Vol 5 pp 3004–3023

27.

Schubiger OValavanis AHayek Jet al: Neuroma of the cavernous sinus. Surg Neurol 13:3133161980Schubiger O Valavanis A Hayek J et al: Neuroma of the cavernous sinus. Surg Neurol 13:313–316 1980

28.

Sekhar LNJannetta PJ: Cerebellopontine angle meningiomas. Microsurgical excision and follow-up results. J Neurosurg 60:5005051984Sekhar LN Jannetta PJ: Cerebellopontine angle meningiomas. Microsurgical excision and follow-up results. J Neurosurg 60:500–505 1984

29.

Shah JPFeghali J: Esthesioneuroblastoma. Am J Surg 142:4564581981Shah JP Feghali J: Esthesioneuroblastoma. Am J Surg 142:456–458 1981

30.

Sheline GE: Radiation therapy of brain tumors. Cancer 39:8738811977Sheline GE: Radiation therapy of brain tumors. Cancer 39:873–881 1977

31.

Simpson D: The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 20:22391957Simpson D: The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 20:22–39 1957

32.

Spetzler RFCarter LP: Revascularization and aneurysm surgery: current status. Neurosurgery 16:1111161985Spetzler RF Carter LP: Revascularization and aneurysm surgery: current status. Neurosurgery 16:111–116 1985

33.

Standefer JHolt GRBrown WE Jret al: Combined intracranial and extracranial excision of nasopharyngeal angiofibroma. Laryngoscope 93:7727791983Standefer J Holt GR Brown WE Jr et al: Combined intracranial and extracranial excision of nasopharyngeal angiofibroma. Laryngoscope 93:772–779 1983

34.

Stern WEBatzdorf U: Intracranial removal of pituitary adenomas. An evaluation of varying degrees of excision from partial to total. J Neurosurg 33:5645731970Stern WE Batzdorf U: Intracranial removal of pituitary adenomas. An evaluation of varying degrees of excision from partial to total. J Neurosurg 33:564–573 1970

35.

Suit HDGoitein MMunzenrider Jet al: Definitive radiation therapy for chordoma and chondrosarcoma of base of skull and cervical spine. J Neurosurg 56:3773851982Suit HD Goitein M Munzenrider J et al: Definitive radiation therapy for chordoma and chondrosarcoma of base of skull and cervical spine. J Neurosurg 56:377–385 1982

36.

Symon LJakuboski JKendall B: Surgical treatment of giant pituitary adenomas. J Neurol Neurosurg Psychiatry 42:9739821979Symon L Jakuboski J Kendall B: Surgical treatment of giant pituitary adenomas. J Neurol Neurosurg Psychiatry 42:973–982 1979

37.

Taptas JN: The so-called cavernous sinus: a review of the controversy and its implications for neurosurgeons. Neurosurgery 11:7127171982Taptas JN: The so-called cavernous sinus: a review of the controversy and its implications for neurosurgeons. Neurosurgery 11:712–717 1982

38.

Umansky FNathan H: The lateral wall of the cavernous sinus, with special reference to the nerves related to it. J Neurosurg 56:2282341982Umansky F Nathan H: The lateral wall of the cavernous sinus with special reference to the nerves related to it. J Neurosurg 56:228–234 1982

39.

Unsold RSafran ABSafran Eet al: Metastatic infiltration of nerves in the cavernous sinus. Arch Neurol 37:59611980Unsold R Safran AB Safran E et al: Metastatic infiltration of nerves in the cavernous sinus. Arch Neurol 37:59–61 1980

40.

van Effenterre RBataïni JPCabanis EAet al: High energy radiotherapy in the treatment of meningiomas of the cavernous sinus. Acta Neurochir Suppl 28:4644671979van Effenterre R Bataïni JP Cabanis EA et al: High energy radiotherapy in the treatment of meningiomas of the cavernous sinus. Acta Neurochir Suppl 28:464–467 1979

41.

Wold LELaws ER Jr: Cranial chordomas in children and young adults. J Neurosurg 59:104310471983Wold LE Laws ER Jr: Cranial chordomas in children and young adults. J Neurosurg 59:1043–1047 1983

42.

Yaşargil MGMortara RWCurcic M: Meningiomas of the basal posterior cranial fossa in Krayenbühl H (ed): Advances and Technical Standards in Neurosurgery. Wien/New York: Springer-Verlag1980 Vol 7 pp 3115Yaşargil MG Mortara RW Curcic M: Meningiomas of the basal posterior cranial fossa in Krayenbühl H (ed): Advances and Technical Standards in Neurosurgery. Wien/New York: Springer-Verlag 1980 Vol 7 pp 3–115

43.

Yonas HWolfson SK JrGur Det al: Clinical experience with the use of xenon-enhanced CT blood flow mapping in cerebral vascular disease. Stroke 15:4434501984Yonas H Wolfson SK Jr Gur D et al: Clinical experience with the use of xenon-enhanced CT blood flow mapping in cerebral vascular disease. Stroke 15:443–450 1984

44.

Zozulia YARomodanov SAPatsko YV: Diagnosis and surgical treatment of benign craniobasal tumours involving the cavernous sinus. Acta Neurochir Suppl 28:3873901979Zozulia YA Romodanov SA Patsko YV: Diagnosis and surgical treatment of benign craniobasal tumours involving the cavernous sinus. Acta Neurochir Suppl 28:387–390 1979

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