Cavernous Sinus Meningioma Resection Through Orbitozygomatic Craniotomy

Abstract

Meningiomas of the cavernous sinus (CS) present a neurosurgical challenge. The anatomic complexity of the area can create a potential for injury to neurovascular structures. This has traditionally limited total tumor removal. A thorough understanding of the cavernous sinus surgical anatomy can help overcome this problem. Patients with CS meningiomas generally present with cranial nerve deficits (III-VI), proptosis, and visual disturbances. Management of CS tumors is controversial and includes observation, stereotactic radiosurgery, and surgical resection. We present the case of a 43-year-old right-handed male who presented with right facial numbness. A magnetic resonance imaging scan of the brain showed a right cavernous sinus tumor. He underwent stereotactic radiosurgery at an outside hospital. His facial numbness gradually improved. Four years later he had recurrence of the right facial numbness in the V3 distribution associated with right eyelid ptosis and diplopia. On neurologic examination he had decreased sensation to light touch in the 3 branches of the trigeminal nerve. He had a right eyelid ptosis and a 6-VI cranial nerve palsy. A new magnetic resonance imaging scan of the brain showed radiologic progression of the tumor. An orbitozygomatic craniotomy was performed and gross total tumor resection was achieved through lateral wall of the cavernous sinus working mainly between V2 and V3. The facial numbness he had preoperatively gradually improved, and his extraocular movements and eyelid ptosis recovered completely. Histopathology showed a clear cell grade 2 meningioma. The patient received adjuvant radiosurgery. At 3-year follow-up, the patient was free of disease recurrence. CS surgery for meningioma is feasible with low morbidity and can provide benefits in improving preexisting cranial nerve dysfunction (Video 1).^1-4 Complete resection of the CS meningiomas is possible in most cases. CS tumors remain a surgical challenge, but accurate knowledge of surgical neuroanatomy and surgical approaches facilitates their safe and effective treatment. The patient gave informed consent for surgery, use of images, and video publication.

Keywords: Cavernous sinus; Cavernous sinus meningioma; Orbitozygomatic approach.