Cavernous sinus meningiomas: Treatment strategy in the stereotactic irradiation era - A review

Although microsurgical gross total removal remains the treatment of choice in intracranial meningiomas, numerous reports have shown that total resection of cavernous sinus (CS) meningiomas is not always feasible and whenever possible is associated with high morbidity and mortality rate. In other respects, even in series with high rate of gross total removal, the recurrence rate remains relatively important. The disappointing results of the unilateral microsurgical approach have led to the evaluation of a more conservative strategy. In this aim, fractionated radiotherapy and secondarily stereotactic radiosurgery (SRS) as first line treatment or in combination with subtotal or partial previous microsurgical excision have been performed. More recently several series of CS meningiomas treated by fractionated stereotactic radiotherapy (FSR) have been reported. These therapeutic options afford better results than microsurgical treatment alone providing a satisfactory tumor growth control and acceptable morbidity rate. Fractionated radiotherapy or FSR and SRS are safe and efficient techniques in treatment of CS meningiomas affording comparable satisfactory long-term tumor control. Extracavernous microsurgical debulking should be reserved in case of voluminous tumors showing mass effect or severe optic apparatus compression with visual impairment. SRS which is more convenient than FSR cannot be performed for voluminous tumors or lesion close to the optic apparatus. FSR can be performed for voluminous lesion showing close relationship with the optic apparatus. These two therapeutic modalities are not alternative but complementary tools in CS meningioma treatment strategy.