Diagnosis And Surgical Treatment Of Cavernous Sinus Hemangiomas

BACKGROUND AND PURPOSE:Surgical management of cavernous sinus hemangiomas (CSHs) is extremely challenging because of the low rates of total removal and the high rates of neurological morbidity after surgery. However, fractionated radiotherapy is currently being considered for the primary management of patients with CSHs, thus, a relatively clear diagnosis may be the most important aspect of therapeutic modification for this condition.METHODS:This cohort study included133histologically proven space-occupying lesions in the cavernous sinus of133patients of age ranging from3-80years, in the past three years. The lesions were detected using clinical symptoms, computerized tomography and magnetic resonance imaging (MRI). Using univariate and multivariate analyses the diagnostic values of several MRI features were compared.RESULTS:The sensitivity of the parameters is near or higher than90%in univariate analysis, however the specificity is not ideal. In multivariate analysis, the best model for predicting CSHs is a combination of shape, the sellar invasion and the signal on T2WI. These parameters generated the most accurate diagnosis of CSHs, with sensitivity, specificity and accuracy87.5%,94.7%and96.3%respectively.CONCLUSION:The MRI characteristics including super-hyperintensity lesion on T2WI with a dumbbell-like or acutilingual appearance infiltration from the parasellar to the sellar regions with marked homogeneous or trend-homogeneous enhancement provides great confidence in diagnosing cavernous sinus hemangiomas. PURPOSE:To evaluate the possible treatment strategies of CSHs focusing on the better surgical results and post treatment life quality.Methods:A retrospective study of all patients admitted to Huashan Hospital with CSHs diagnosed by pathology or imaging from Jan.1996to Jun.2010.75patients were enrolled, Patients were divided into two groups:the earlier and later groups. x2test were used by SPSS16.0statistics software to analyze the prognosis of CSHs.Results:There were22men and53women. Their mean age was51.0years (range,11-74yrs). Of these patients,35presented with headache or retroorbital pain,15with facial numbness,18with blepharoptosis,18with diplopia, six with abnormal menstruation.In the earlier group,29patients received open surgery as primary therapy. Total tumor removal was achieved in17cases and additional gamma knife radiosurgery (GKR) was performed in2cases. During a meanly11.0years’ follow-up (from8.0to14.0years,(24/27)88.9%cases followed), tumor recurrence occurred in4(14.3%) patients who had partial or subtotal tumor removal and did not receive any kind of radiotherapy. Patients treated with an extra-dural transcavernous approach had more extent of tumor removal and better neurological rehabilitation than those with intra-dural approach.In the latter group, tumor removal via the extra-dural approach was performed in24cases as primary therapy, while direct radiosurgery, GKR or fractionated Cyberknife radiosurgery (CKR), was used in the remaining22cases. In the operated cases, total tumor removal was achieved in19cases (79.2%), subtotal in2cases and partial in3. Adjuvant GKR or CKR for tumor remnant was applied in1case. In all the primarily radiosurgically treated patients, direct GKR was performed in6cases and CKR in16cases. GKR with a mean dose of13.3Gy (from10to16Gy) applied to the50%isodose line was administrated. CKR was delivered in three sessions and a cumulative average marginal dose of21.0Gy.In the latter group, patients were meanly followed up for3.5years (from1.0to7.0years,22/24,91.6%cases followed). During the follow-up, enlargement of the tumor remnant occurred in1cases (4.5%), one underwent a second operation while the other received GKR. In the primarily GKR or CKR treated patients, the tumor volume shrinked over50%in20cases and there was no enlargement during the follow-up. Preoperative symptom disappeared or relieved in all of the patients and there was no additional neurological dysfunction except for2who developed hypopsia.CONCLUSION:Our experience has reinforced the attitude that the epidural approach is superior to the intradural approach in ways of tumor removal and neurovascular protection. Direct radiosurgery can be more often used as first choice to treat the CSHs. Fractioned Cyber knife therapy has shown its potential to treat CSHs of large volume. Surgical resection via epidural transcavernous approach with adjuvant radiosurgery for the remnant is optimal for patients with extremely large CSHs.