Outcome of aggressive removal of cavernous sinus meningiomas

Despite recent advances in surgery of the cavernous sinus, meningiomas in that area offer a formidable challenge. The rationale for aggressive surgical removal of cavernous sinus meningiomas is based on the presumption that the extent of removal is inversely related to the rate of recurrence. Over the past 10 years, 41 patients with histologically benign meningiomas involving the cavernous sinus underwent aggressive surgery. Total removal, as confirmed by intraoperative inspection and postoperative radiological studies, was achieved in 31 patients (76%). Twelve patients have been followed for more than 5 years; 10 underwent total tumor removal and only one of these experienced recurrence (5 years after surgery). The other two patients underwent subtotal removal and had symptomatic and radiological evidence of regrowth 3 and 4 years after surgery. Pre-existing cranial nerve deficits improved in only 14% of the patients, remained unchanged in 80%, and worsened permanently in 6%. Seven patients experienced a total of 10 new cranial nerve deficits, four of which involved the nerves subserving ocular motor function. Extraocular muscle function did not worsen in the 25 patients with a seeing eye ipsilateral to the tumor, and no instance of visual worsening occurred. Two patients died 4 months after surgery, one from severe delayed vasospasm and hypothalamic infarction and the other because of a myocardial infarction. Another patient died from a pulmonary embolus on the 9th postoperative day. There were three instances of cerebral ischemia; one was transient, lasting less than 24 hours, while two were related to injury of the middle cerebral artery and resulted in residual hemiplegia. Other complications included three cases of nonfatal pulmonary emboli, two cerebrospinal fluid leaks, and one instance each of exposure keratitis, acute hypothyroidism, and cerebral edema.