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Objective/Importance: Hemangiomas of the cavernous sinus are rare lesions. Complete removal through a transcranial route often causes ocular motor palsies. Because the cranial nerves in the cavernous sinus are lateral to the carotid, a medial approach to the cavernous sinus may be less traumatic to the cranial nerves. Clinical Presentation: A 50-year-old man with headaches, dizziness, diplopia, and magnetic resonance imaging that demonstrated a right cavernous sinus mass expanding into the sella and sphenoid sinus. Intervention: A gross total removal of a cavernous sinus hemangioma was performed through an extended endoscopic transsphenoidal approach. Conclusion: This is the first report of a complete removal of a cavernous sinus hemangioma using an endoscopic transnasal approach. The endoscopic transnasal approach to the medial cavernous sinus may be less traumatic than the transcranial route based on the lateral location of the cranial nerves.
Cavernous sinus hemangiomas (CSHs) are extremely rare lesions and have been reported to account for less than 2% of all cavernous sinus tumors.1,2,3,4,5 The highly vascular nature of these tumors, proximity to crucial cranial nerves, and relationship to the intracavernous internal carotid artery (ICA) make them particularly difficult to surgically resect. Typically occurring in the fifth decade of life, predominantly in women, they are benign neoplasms of nonmeningeal origin. Of the 77 previously reported cases in the past 15 years of literature, 65 were treated with craniotomy, one with microscopic transsphenoidal partial resection, nine with radiosurgery, and two with endoscopic transnasal resection (Table 1).1,3,4,5,6,7,8,9,10,11,12,13,14,15,16 The previously reported endoscopic resections were subtotal.9,17 We present a case in which a purely endosopic transnasal approach was employed and a gross total resection (GTR) achieved without new oculomotor palsies. Transnasal endosopic approaches to select pathology within the medial cavernous sinus may offer an alternative to craniotomy that places the cranial nerves at less risk.
A 50-year-old man presented complaining of dizziness, intermittent severe headaches, and mild diplopia. He denied galactorrhea, palpitations, heat/cold intolerance, changes in visual acuity, and changes in libido, erections, or sexual habits. His neurological examination was nonfocal. Magnetic resonance imaging (MRI) read by a neuroradiologist demonstrated an expansile sella/parasellar mass that extended into the left suprasellar cistern and into the cavernous sinus, with inferior displacement of the cavernous segment of the left ICA (Fig. 1A). Endocrinologic studies were normal except for a mildly elevated prolactin level (36.6 ng/mL). Given the location and size of the mass, endoscopic transnasal resection was recommended for diagnostic, cytoreductive, and therapeutic purposes.
The patient was placed supine on the table and the head was placed in cranial fixation, neck slightly extended, for stereotactic navigation (BrainLab, Feldkirchen, Germany). An endonasal, transethmoidal, transsphenoidal approach to the sella and medial cavernous sinus was performed.18,19,20,21,22 The bone over the anterior wall of the cavernous sinus was removed with a high-speed pneumatic diamond drill (Anspach, Palm Beach Gardens, FL) and a Kerrison rongeur. The course of the carotid artery was identified with a micro-Doppler. The dura over the sella was opened with a sickle knife and extended to the expose the medial border of the carotid artery (Fig. 2). The tumor was identified as a firm, fibrous vascular mass. The tumor was resected from within the sella and, using angled endoscopes, the internal decompression was continued into the medial cavernous sinus. Under direct visualization, the remaining rim of tumor was mobilized from the cavernous sinus, and adhesions were cut sharply with microscissors.
Adequate hemostasis from cavernous sinus bleeding was obtained using thrombin-soaked gelfoam. The sella was then covered with DuraSeal (Confluent Surgical, Inc., Waltham, MA) and the sphenoidal sinus was filled with FloSeal (Baxter, Deerfield, IL).
The patient recovered from surgery well without evidence of postoperative cranial neuropathy, pituitary dysfunction, or cerebrospinal fluid leak. Postoperative MRI was read by a neuroradiologist and demonstrated a GTR of the lesion, with no T2 fluid attenuated inversion recovery (FLAIR)-hyperintensity suggestive of residual tumor. A thin margin of postcontrast enhancement was noted to be consistent with granulation tissue (Fig. 3). Pathology demonstrated a CSH (Fig. 2C).
CSHs are benign skull base lesions that invade locally and cause symptoms primarily from local mass effect. Though benign, they can be debilitating due to their location within the cavernous sinus, causing cranial nerve deficits from compression of intracavernous cranial nerves. Common clinical symptoms and signs include persistent and/or progressive ocular pain, ophthalmoparesis, and headaches.4 Less commonly, endocrinopathies, exophthalmos, or trigeminal neuralgia may occur.10,23,24 They can expand laterally into the middle fossa, superiorly toward the optic chiasm, and medially into the sella.25
A variety of treatment approaches toward CSH has been reported in the literature. Table Table11 summarizes the 77 reports of CSHs that have been presented in the literature after 1990. Of them, 87% have used a frontotemporal, often orbitozygomatic, surgical approach for resection. Due to the high possibility of profuse bleeding during surgical intervention combined with potential for long-term cranial nerve deficits, some practitioners have focused upon stereotactic radiosurgery for treatment of these lesions.8,10,11 Although radiosurgery has been shown to reduce the size of tumors, total gross resection, when safe, is preferable. Short-term complication rates after craniotomy were 72%, most often representing cranial nerve deficits, compared with 22% after radiosurgery. Overall, long-term morbidity rates were found to be 20%.
Techniques for resection of hemangiomas have been previously reported in detail.4,16 Types of craniotomy vary by central location of the tumor and local invasion (to sella versus middle fossa). Some important surgical tenants include planning for potential transfusion and thorough understanding of the anatomic relationships within the cavernous sinus. Some have advocated proximal control of the ICA, especially if tumor resection requires significant manipulation of the vessel. This may be chiefly important in cases where the vessel is encased circumferentially. As noted by Linskey and Sekhar, CSHs typically have a pseudocapsule that, if properly dissected, will provide a plane between the tumor and surrounding cranial nerves and ICA.4 The exception to this is the abducens nerve, which, as a result of its natural anatomy within the cavernous sinus, may course through the tumor substance proper. Thus, preoperative planning for resection, regardless of method, demands meticulous study of preoperative radiographic studies to fully understand the relationship of the tumor to these structures. This anatomy is vital, as it may guide surgical approach.
We report the first GTR of a CSH through an endoscopic transnasal approach. The anatomy of the tumor, medial in the cavernous sinus, extending into the sella with no significant extension into the middle fossa, made this patient an appropriate candidate for transnasal endoscopic resection. The endoscopic approach permitted identification of the normal pituitary gland, the cavernous sinus, and the intracavernous ICA prior to any resection of tumor. Furthermore, it provided access to the cavernous sinus through the medial wall, which, unlike the lateral wall traversed via craniotomy, contains no cranial nerves. Endonasal endoscopic and microscopic transsphenoidal approaches to the medial cavernous sinus are well described in the literature, although mostly utilized for the resection of pituitary adenomas with intracavernous extension.18,20,21,22,26,27,28 Although two previously reported cases of endoscopic transsphenoidal resection have been published, this case demonstrates the feasibility of a GTR. In the previously published cases by Jeon et al and by Cobbs and Wilson, the authors intentionally performed a subtotal resection, recommending that, if frozen section confirms hemangioma, the surgeon should perform only a subtotal resection because “these lesions are dural based and complete resection may result in serious bleeding.”9,17 In one case, the primary concern with the extent of resection was the tearing of arachnoid and a resultant cerebrospinal fluid leak. Based upon our experience, we would extend the application of the transnasal endoscopic approach to appropriate CSHs.29 In particular, this approach is especially useful for cavernous hemangiomas with significant extension medially into the sella. With advances and experience in endoscopic approaches, resection nuances, angled scope tools, and skull base closure techniques, GTR of appropriately selected lesions may be safe and feasible through an endoscopic approach.
CSHs are rare benign tumors traditionally treated with an open craniotomy. Recent studies have shown some utility to radiosurgery. We report for the first time a GTR of a CSH via a purely endoscopic transnasal approach, highlighting the importance of advances in minimal access neurosurgery to the treatment of such complicated lesions of the skull base.