Meningiomas involving the cavernous sinus may start in the sinus or grow into it as part of a larger tumor involving the medial sphenoid wing, orbit. other areas of the middle fossa, clivus. and petrous bone. The extent of the tumor is defined by MRI. If a major surgical procedure is planned, angiography is needed to define the position and involvement of the internal carotid artery and its branches, and to evaluate the possibility of occluding the internal carotid artery if the need arises.
The decision regarding treatment is often difficult because the symptoms may be mild or nonprogressive. the natural history in some patients may be one of minimal or no growth for long periods of time, there is risk of significant cranial nerve morbidity with surgical treatment, and the long-term results of new surgical treatments and radiation therapy modalities are unknown.
At the present time. surgery is indicated in younger patients with worsening symptoms. Radiation therapy is used when there is regrowth following subtotal removal and in older patients with worsening symptoms. Patients of any age with nonprogressive or mild symptoms are followed.
The anatomy of the cavernous sinus must be understood in order to treat these tumors. The approach is through a frontotemporal craniotomy. When the tumor involves Meckel's cave, the tentorium is opened posterior to the entrance of the fourth nerve, and the fifth nerve is followed anteriorly to aid dissection of the tumor from the nerve.
Females are more affected than males. It is difficult to be sure of a total removal. Postoperative complications included temporary and persistent third-nerve palsy, a wound infection, and a pulmonary embolus. 50% of patients undergo radiation therapy.
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