A new classification and clinical results of Gamma Knife radiosurgery for cavernous sinus hemangiomas: a report of 53 cases

Diagnostic value of cavernous sinus swelling and extrusion sign in cavernous sinus hemangioma

BACKGROUND AND PURPOSE

To examine the diagnostic value of imaging features in cavernous sinus hemangioma (CSH).

MATERIALS AND METHODS

The clinical and imaging data of patients with pathologically confirmed CSH, cavernous sinus meningioma, trigeminal schwannoma and pituitary adenoma invading the cavernous sinus between May 2017 and May 2022 were retrospectively analyzed. The cases were divided into the CSH and non-CSH groups to summarize the magnetic resonance imaging (MRI) characteristics of CSH. Univariate χ2 analysis was performed to assess five indexes, including signal intensity on T2WI, homogeneity of T2WI, enhancement of enhanced T1, enhanced T1 with dural tail sign, and cavernous sinus swelling and extrusion sign.

RESULTS

There were significant differences in four features, including hyperintensity on T2WI, homogeneity of T2WI, T1-enhanced without meningeal tail sign, and cavernous sinus swelling and extrusion sign between the CSH and non-CSH groups, with cavernous sinus swelling and extrusion sign showing the most pronounced distinction, with a sensitivity of 100%, a specificity of 93.02%, and an accuracy of 94.23%. The four features could be jointly used as diagnostic criteria, with a sensitivity of 94.44%, a specificity of 100.00%, and an accuracy of 99.04%.

CONCLUSION

Cavernous sinus swelling and extrusion sign is a reliable imaging index for CSH diagnosis. Homogenous hyperintensity or marked hyperintensity on T2WI, enhanced T1 without dural tail sign, and cavernous sinus swelling and extrusion sign could be jointly used as diagnostic criteria, which may improve the accuracy of CSH diagnosis.

The Treatment Outcomes of Radiotherapy and Surgical Treatment for Patients with Cavernous Sinus Hemangioma: A Meta-Analysis

OBJECTIVE

Cavernous sinus hemangiomas (CSHs) are infrequent benign neoplasms. This meta-analysis was conducted with the objective of examining the prognostic outcomes of surgical interventions and radiotherapy (RT) in patients diagnosed with CSHs.

METHODS

A comprehensive literature search was performed across PubMed, Embase, and Web of Science databases, with traceability up to June 22, 2021. The evaluation of continuous variables was conducted by applying the weighted mean difference (WMD) and 95% confidence interval. A one-arm meta-analysis was used to scrutinize the tumor control rate, clinical improvement rate, recovery rates of abducens nerve palsy and visual disturbance, total resection rate, and the incidence rate of permanent nerve palsy post-treatment.

RESULTS

In total, 29 articles were incorporated into the meta-analysis. Post-RT for CSHs, a significant reduction in tumor volume was observed (WMD [95% confidence interval] = -17.16 [-21.52, -12.80] cm3). The tumor control rate, clinical improvement rate, recovery rate of abducens nerve palsy, and the recovery rate of visual disturbance were 97.1% (92.9, 99.7), 91.9% (82.3, 98.5), 95.6% (83.2, 100.0), and 86.3% (65.0, 99.5), respectively. Following surgical treatment, the total resection rate, mean intraoperative blood loss, recovery rate of visual disturbance, incidence rate of permanent nerve palsy, and recovery rate of abducens nerve palsy were 73.2% (57.1, 86.9), 971.17 mL (584.07, 1358.27), 66.4% (32.4, 0.942), 16.0% (4.6, 31.1), and 70.6% (51.0, 87.7), respectively. Notably, the recovery rate of abducens nerve palsy post-RT was markedly higher than postsurgical treatment.

CONCLUSIONS

The results of this meta-analysis underscore that RT is an effective and safe treatment modality for CSHs. Furthermore, the prognostic outcomes of RT demonstrated superiority over surgical intervention.

Endoscopic endonasal transsphenoidal surgery for the cavernous sinus hemangioma: Surgical application and review of the literature

Aim

Cavernous sinus hemangiomas (CSHs) are hypervascular malformations and the surgical treatment is technically demanding. Although some articles have reported resection of CSHs using endoscopic endonasal transsphenoidal surgery (EETS), most of them were encountered for a lack of preoperative strategy guidance. Herein, we reported gross total resection (GTR) of intrasellar CSHs in two patients undergoing strategical EETS and compared EETS with frontotemporal craniotomy (FC) and stereotactic radiosurgery by literature review.

Material and methods

Two patients with CSHs who underwent EETS were reported. The literature review was conducted to exhaust studies that reported surgical treatment for CSHs. The tumor resection rate, and the postoperative short-term and long-term newly-developed or deteriorative cranial-nerve function rates were extracted.

Results

GTR was achieved with no postoperative complications in the two cases. Nine articles reported 14 cases undergoing EETS for CSHs and twenty-three articles reported 195 cases undergoing FC for CSHs. The GTR rates of EETS and FC were 57.14% (8/14) and 78.97% (154/195) respectively. The postoperative short-term and long-term newly-developed or deteriorative cranial-nerve function rates were 0% (0/7) and 0% (0/6) for the EETS group, and 57% (57/100) and 18.18% (18/99) for the FC group. According to the previous meta-analysis, stereotactic radiosurgery resulted in remarkable tumor shrinkage in 67.80% (40/59) of patients and partial shrinkage in 25.42% of patients.

Discussion

The results showed that the intrasellar type of CSHs could be removed safely by EETS without crossing the nerves in the CS.

Cavernous haemangioma of cavernous sinus causing diagnostic dilemma: a case report with review of literature

Background

Cavernous haemangioma of the cavernous sinus is an uncommon vascular malformation. It is often confused with other parasellar masses like schwannomas and meningiomas due to overlap in imaging appearance. It is important to pre-operatively diagnose this condition as it is associated with severe intra-operative bleeding.

Case presentation

Here, we report a case of an octogenarian female who presented with left sided progressive ptosis and diminution of vision for one year. Cross-sectional imaging includes computed tomography and magnetic resonance imaging which were not conclusive of cavernous sinus haemangioma. Digital subtraction angiography was done which showed a vascular blush. After corroborating the findings of these imaging investigations, a diagnosis of cavernous sinus haemangioma was concluded. Patient underwent surgery which showed a hypervascular mass. Histopathology was consistent with the imaging diagnosis. Patient was discharged in good stable condition and doing well and is on follow-up in Neurosurgery Out-Patient Department.

Conclusions

The cavernous sinus Haemangiomas are uncommon benign vascular masses. They pose a diagnostic challenge when seen in the parasellar region as the imaging findings of a haemangioma, meningioma and schwannoma in this location can have a significant overlap in the imaging findings. Cross-sectional imaging, digital subtraction angiography and nuclear imaging help in pre-operative diagnosis which is a crucial as the surgery is associated with significant blood loss.

Personalized Gamma Knife radiosurgery for cavernous sinus hemangiomas: A Chinese single-center retrospective study for 10 years of 187 patients

Background

The aim of this study is to retrospectively review the effectiveness and safety of personalized Gamma Knife radiosurgery (GKRS) for cavernous sinus hemangiomas (CSHs) and to summarize experience of personalized GKRS treatment for different volume of CSHs.

Methods

187 CSHs patients who received personalized GKRS treatment in our center from January 1, 2011 to December 31, 2020 were enrolled in this study and classified into small and medium CSHs (<20 ml), large CSHs (20–40 ml) and giant CSHs (≥40 ml) according to tumor volume. The personalized GKRS treatment strategy included single GKRS and staged GKRS. Tumor shrinkage rate, clinical symptoms response, and complications after GKRS were recorded during the follow-up period. Multivariate factors influencing clinical symptoms response were analyzed after personalized GKRS treatment.

Results

After a mean follow-up duration of 28 months (range 12–124 months), the tumor control rate was 100%, and the mean shrinkage rate of CSHs was 93.2% (61.3%–100%) in the last follow-up. Of the 115 patients with preexisting symptoms, 43 (37.5%) patients showed symptom disappearance, 17 (14.7%) patients demonstrated improvement, and 55 (47.8%) patients remained with no change. Previous surgical resection of CSHs (OR = 0.025, 95% CI 0.007–0.084, P = .000) was identified to be an independent risk factor for no symptom improvement after GKRS treatment.

Conclusions

Personalized GKRS is an effective and safe treatment for different volume of CSHs, which is capable of shrinking the tumor and improving symptoms with extremely low incidence of adverse effects and might be considered as the primary treatment strategy for CSHs.

Less common extracerebral tumors

This chapter examines the results of GKNS on a variety of extraparenchymal skull base tumors some benign and some malignant. For the benign tumors there is good evidence on the effectiveness of the method for pretty much all diagnoses. For malignant extraparenchymal tumors the results are more limited and GKNS only has a supportive role in these lesions.

Long-term outcomes of staged Gamma Knife radiosurgery for giant cavernous sinus hemangiomas: a single-center retrospective study

OBJECTIVE

Cavernous sinus hemangiomas (CSHs) are rare benign tumors originating from the cavernous sinus. Gamma Knife radiosurgery (GKRS) has been recommended as a primary treatment for small- to medium-sized CSHs. The optimal treatment for giant CSHs is still controversial. In this study, the authors retrospectively reviewed the effectiveness and safety of staged GKRS treatment for giant CSHs.

METHODS

Twenty-two patients with giant CSH who received staged GKRS treatment in the Gamma Knife Treatment Center of Henan Province during the period from January 1, 2011, to December 31, 2018, were enrolled in this study. Six patients had received microsurgery before GKRS, the other 16 patients were diagnosed according to clinical symptoms and MR images. All of the enrolled patients received 2-stage GKRS, and the mean interval between the two GKRS treatments was 6.5 months (range 6-12 months). For the first GKRS, the median isodose line was 48% (range 45%-50%), the median marginal dose was 13 Gy (range 11.5-14 Gy), and the median coverage of CSHs was 80% (range 70%-88%). For the second GKRS treatment, the median isodose line was 50% (range 45%-55%), the median marginal dose to the CSHs was 10.5 Gy (range 9-12.5 Gy), and the median coverage of the CSHs was 88% (range 80%-94%).

RESULTS

All of the patients received an outpatient review of an enhanced MR image of the head and a clinical physical check every 6 months after the first GKRS treatment. The mean follow-up duration was 52 months (range 24-84 months). The tumor control rate was 100% 24 months after staged GKRS, and at the last follow-up the mean tumor shrinkage rate was 96.7% (range 90.6%-100%) and the mean residual CSH volume was 2.1 ml (range 0-8.5 ml). Twenty patients suffered central nervous system (CNS) injury symptoms to varying degrees before staged GKRS treatment. Complete symptom recovery was found in 11 (55%) patients, improved symptoms in 5 (25%) patients, and no change in 4 (20%) patients after treatment. Only 1 patient suffered temporary preexisting headache aggravation and 1 patient suffered temporary preexisting diplopia aggravation 1 week after receiving the first GKRS treatment. Subacute or chronic complications were not detected after staged GKRS.

CONCLUSIONS

Staged GKRS is an effective treatment for giant CSHs. Because of the impressively low incidence of adverse effects, staged GKRS may be considered as a primary treatment for giant CSHs.

Imaging characteristics of Intrasellar cavernous hemangioma: A case report

RATIONALE

Intrasellar cavernous hemangiomas (ICHs) are rare vascular lesions that arise in the sellar region. ICHs are usually misdiagnosed and treated as pituitary adenomas. Therefore, a preoperative diagnosis is particularly important, especially when the goal is complete resection.

PATIENT CONCERNS

A 55-year-old woman presented with a 1-month history of intermittent dizziness. Magnetic resonance imaging (MRI) revealed a well-demarcated abnormal ellipsoid signal in the sellar region (size: 2.7 cm × 1.7 cm), with a mulberry-like enhancement after gadolinium injection. Computed tomography revealed an intrasellar mass without calcification that extended into the left cavernous sinus and was faintly contrast-enhanced. Angiography revealed a tumor with mildly delayed staining fed by the C5 segment of the right internal carotid artery.

DIAGNOSIS

An intrasellar cavernous hemangioma based on neuroradiological examinations.

INTERVENTIONS

The patient underwent surgery with an endoscopic endonasal transsphenoidal approach to debulk the lesion and obtain tissue for the pathological diagnosis.

OUTCOMES

Blood spurting was observed after puncture, and the capsule was stained blue. Lesion removal was stopped, and the patient underwent gamma knife surgery 1 week later. She remained in good condition during the follow-up.

LESSONS

Sponge-like or mulberry-like lesions can be identified on MRI after gadolinium injection and can facilitate a preoperative diagnosis of ICH. Currently, surgical debulking with cranial nerve decompression during the acute stage and subsequent gamma knife radiosurgery are considered to be a safe and effective treatment.

Gamma Knife Radiosurgery on the Trigeminal Root Entry Zone for Idiopathic Trigeminal Neuralgia: Results and a Review of the Literature

Trigeminal neuralgia (TN) is a chronic disorder of the trigeminal nerve characterized by repeated electrical shock-like sensations on one side of the face. It can cause severe pain in the face and disrupt or impair quality of life in patients. Options for the management of TN consist of pharmacological and surgical treatments, including Gamma Knife radiosurgery (GKRS). GKRS has been used for TN for a long time because of its low rate of complications and high success rate. Moreover, GKRS can be of use for drug-resistant TN patients who are poor surgical candidates due to medical comorbidities, patients of older age, or patients who refuse invasive therapy. We reviewed the rationale, effects, safety, and current treatment policies of GKRS for TN in view of our institution's results and a review of the literature to date.

Stereotactic radiosurgery for trigeminal neuralgia: a systematic review

OBJECTIVES

The aims of this systematic review are to provide an objective summary of the published literature specific to the treatment of classical trigeminal neuralgia with stereotactic radiosurgery (RS) and to develop consensus guideline recommendations for the use of RS, as endorsed by the International Society of Stereotactic Radiosurgery (ISRS).

METHODS

The authors performed a systematic review of the English-language literature from 1951 up to December 2015 using the Embase, PubMed, and MEDLINE databases. The following MeSH terms were used in a title and abstract screening: "radiosurgery" AND "trigeminal." Of the 585 initial results obtained, the authors performed a full text screening of 185 studies and ultimately found 65 eligible studies. Guideline recommendations were based on level of evidence and level of consensus, the latter predefined as at least 85% agreement among the ISRS guideline committee members.

RESULTS

The results for 65 studies (6461 patients) are reported: 45 Gamma Knife RS (GKS) studies (5687 patients [88%]), 11 linear accelerator (LINAC) RS studies (511 patients [8%]), and 9 CyberKnife RS (CKR) studies (263 patients [4%]). With the exception of one prospective study, all studies were retrospective.The mean maximal doses were 71.1-90.1 Gy (prescribed at the 100% isodose line) for GKS, 83.3 Gy for LINAC, and 64.3-80.5 Gy for CKR (the latter two prescribed at the 80% or 90% isodose lines, respectively). The ranges of maximal doses were as follows: 60-97 Gy for GKS, 50-90 Gy for LINAC, and 66-90 Gy for CKR.Actuarial initial freedom from pain (FFP) without medication ranged from 28.6% to 100% (mean 53.1%, median 52.1%) for GKS, from 17.3% to 76% (mean 49.3%, median 43.2%) for LINAC, and from 40% to 72% (mean 56.3%, median 58%) for CKR. Specific to hypesthesia, the crude rates (all Barrow Neurological Institute Pain Intensity Scale scores included) ranged from 0% to 68.8% (mean 21.7%, median 19%) for GKS, from 11.4% to 49.7% (mean 27.6%, median 28.5%) for LINAC, and from 11.8% to 51.2% (mean 29.1%, median 18.7%) for CKR. Other complications included dysesthesias, paresthesias, dry eye, deafferentation pain, and keratitis. Hypesthesia and paresthesia occurred as complications only when the anterior retrogasserian portion of the trigeminal nerve was targeted, whereas the other listed complications occurred when the root entry zone was targeted. Recurrence rates ranged from 0% to 52.2% (mean 24.6%, median 23%) for GKS, from 19% to 63% (mean 32.2%, median 29%) for LINAC, and from 15.8% to 33% (mean 25.8%, median 27.2%) for CKR. Two GKS series reported 30% and 45.3% of patients who were pain free without medication at 10 years.

CONCLUSIONS

The literature is limited in its level of evidence, with only one comparative randomized trial (1 vs 2 isocenters) reported to date. At present, one can conclude that RS is a safe and effective therapy for drug-resistant trigeminal neuralgia. A number of consensus statements have been made and endorsed by the ISRS.

Therapeutic Effect of Hypofractionated Stereotactic Radiotherapy Using CyberKnife for High Volume Cavernous Sinus Cavernous Hemangiomas

OBJECTIVE

To evaluate the efficacy and safety of hypofractionated stereotactic radiotherapy using CyberKnife for high volume cavernous sinus cavernous hemangiomas.

MATERIALS AND METHODS

We collected data from 12 patients with high volume cavernous sinus cavernous hemangiomas treated with hypofractionated stereotactic radiotherapy using CyberKnife in our institute, including 2 men and 10 women/female child, aged 4 to 60 years. Initial tumor volumes ranged from 11.8 to 96.6 cm³ with a median of 24.3 cm³. Irradiation doses were 19.5 Gy with 3 fractions in 2 patients, 21 Gy with 3 fractions in 8 patients, 25 Gy with 5 fractions in 1 patient, and 30 Gy with 3 fractions in 1 patient. We used 109 to 155 beams during treatment, and target volumes reached over 95% of the prescribed dose. Follow-up ranged from 3 to 54 months. We evaluated the efficacy and safety of the CyberKnife system based on changes in the diagnostic images and involved cranial nerves or symptoms.

RESULTS

Of the 12 patients, 11 were followed for 3 to 54 months with a mean follow-up of 16.3 months; 1 patient was lost to in-person follow-up. Lesion volumes in the followed 11 patients were calculated after fractionated radiotherapy. All tumor volumes decreased (28.6%-94.1%) and symptoms improved (including blurred vision, visual field defects, diplopia, headaches, and facial numbness) after therapy. Postoperative magnetic resonance images revealed a tumor volume range of 2.8 to 41.0 cm³ (median, 6.5 cm³), significantly lower compared with the pretreatment range of 11.8 to 70.1 cm³ (median, 24.3 cm³; T = 0.00, P = .003 < .05). A single patient experienced radiotherapy-related cerebral edema, which resolved after 5 days of mannitol and dexamethasone.

CONCLUSIONS

Based on the current results, though preliminary, hypofractionated stereotactic radiotherapy using CyberKnife is an effective and safe alternative for high volume cavernous sinus cavernous hemangiomas and is the recommended primary treatment in high-risk patients with this condition.

Surgical Management and Outcomes of Cavernous Sinus Hemangiomas: A Single-Institution Series of 47 Patients

OBJECTIVE

The purpose of this study was to analyze the outcomes of cavernous sinus hemangiomas (CSHs) treated surgically, and to investigate factors that affect the gross total resection (GTR), newly developed or deteriorated cranial nerve injury (NDDCNI), and follow-up neurologic performance, and to further discuss the optimal treatment for CSHs.

METHODS

Clinical data of 47 patients with CSHs treated surgically at our institution between 2012-2018 were retrospectively reviewed.

RESULTS

GTR was achieved in 26 (55.3%) patients. Significant relations were identified between the invasion of the sella turcica (odds ratio [OR] = 0.012; 95% confidence interval [CI], 0.001-0.213; P = 0.002), skull base ward (OR = 27.838; 95% CI, 2.995-258.748; P = 0.003), and GTR. The preoperative Karnofsky Performance Scale (KPS) score (OR = 2.966, per 10 score increase; 95% CI, 1.136-7.743; P = 0.026) and the invasion of the sella turcica (OR = 7.137; 95% CI, 1.282-39.726; P = 0.025) were factors that significantly affected the incidence of NDDCNI. The average follow-up KPS score, which increased significantly compared with the pre (P < 0.001) and postoperative KPS scores (P < 0.001), was 89.1. Increased tumor size (OR = 0.044, per 1cm increase; 95% CI, 0.004-0.477; P = 0.010) was a risk factor for unfavorable follow-up KPS score.

CONCLUSIONS

Being treated by an experienced skull base surgeon favors the total removal of CSHs, whereas the invasion of the sella turcica does just the opposite. Increased tumor size is a risk factor for unfavorable follow-up KPS score. The invasion of the sella turcica was related to NDDCNI and unfavorable follow-up KPS score.

Cranial nerve deficits in giant cavernous carotid aneurysms and their relation to aneurysm morphology and location

BACKGROUND

Giant cavernous carotid aneurysms (GCCAs) usually exert substantial mass effect on adjacent intracavernous cranial nerves. Since predictors of cranial nerve deficits (CNDs) in patients with GCCA are unknown, we designed a study to identify associations between CND and GCCA morphology and the location of mass effect.

METHODS

This study was based on data from the prospective clinical and imaging databases of the Giant Intracranial Aneurysm Registry. We used magnetic resonance imaging and digital subtraction angiography to examine GCCA volume, presence of partial thrombosis (PT), GCCA origins, and the location of mass effect. We also documented whether CND was present.

RESULTS

We included 36 GCCA in 34 patients, which had been entered into the registry by eight participating centers between January 2009 and March 2016. The prevalence of CND was 69.4%, with one CND in 41.7% and more than one in 27.5%. The prevalence of PT was 33.3%. The aneurysm origin was most frequently located at the anterior genu (52.8%). The prevalence of CND did not differ between aneurysm origins (p = 0.29). Intracavernous mass effect was lateral in 58.3%, mixed medial/lateral in 27.8%, and purely medial in 13.9%. CND occurred significantly more often in GCCA with lateral (81.0%) or mixed medial/lateral (70.0%) mass effect than in GCCA with medial mass effect (20.0%; p = 0.03). After adjusting our data for the effects of the location of mass effect, we found no association between the prevalence of CND and aneurysm volume (odds ratio (OR) 1.30 (0.98-1.71); p = 0.07), the occurrence of PT (OR 0.64 (0.07-5.73); p = 0.69), or patient age (OR 1.02 (95% CI 0.95-1.09); p = 0.59).

CONCLUSIONS

Distinguishing between medial versus lateral location of mass effect may be more helpful than measuring aneurysm volumes or examining aneurysm thrombosis in understanding why some patients with GCCA present with CND while others do not.

CLINICAL TRIAL REGISTRATION NO

NCT02066493 ( clinicaltrials.gov ).

Hemangioma of the Cavernous Sinus: A Case Series

Introduction  Cavernous sinus hemangiomas (CSHs) are rare, vascular, extra-axial tumors that are diagnosed with a combination of imaging and biopsy. We describe the clinical presentations, imaging findings, and management of two male patients with CSHs. Case Report  Case 1 describes a 57-year-old man who presented with vision changes and cranial nerve palsies. Initial imaging and surgical biopsy were nondiagnostic. Follow-up Tc-99m tagged red blood cell (RBC) imaging supported CSH diagnosis. He was treated with surgical resection and radiotherapy. Case 2 describes a 57-year-old man who presented with chronic headache. Imaging findings were suggestive of CSH. He underwent endoscopic endonasal surgical resection and a final diagnosis of CSH was made via biopsy. Discussion  CSHs often present with headache, vision changes, and cranial nerve palsies. Characteristic findings of a T2 hyperintense lesion with homogeneous contrast enhancement has been described in the literature. There is also a role for tagged RBC imaging studies in the setting of nondiagnostic imaging and biopsy. Surgical resection can be difficult due to tumor vascularity and encasement of internal carotid arteries. Stereotactic radiosurgery and adjuvant radiotherapy can play a role in the treatment of patients who have inoperable lesions or subtotal resections.

Safety and efficacy of single-fraction gamma knife radiosurgery for benign confined cavernous sinus tumors: our experience and literature review

Gamma knife radiosurgery (GKRS) has emerged as a suitable primary treatment option for confined cavernous sinus tumors (CSTs) and residual/recurrent benign tumors extending from the surrounding neighborhood. The aim of this review was to further investigate the safety and efficacy of single-fraction GKRS for primary confined CSTs (hemangioma, meningioma, and schwannoma). This was a retrospective analysis of 16 patients of CSTs, primarily treated with GKRS between 2009 and 2017. The patients underwent follow-up clinical and radiological evaluation at a regular interval. Data on clinical and imaging parameters were analyzed. The published literature on GKRS for CSTs was reviewed. There were total 16 patients (eight meningiomas, seven hemangiomas, and one schwannoma). Patients presented with a headache (56.3%), ptosis (50%), and/or restricted extraocular movements (50%). There was 46.6% tumor volume (TV) reduction after single-fraction GKRS. Hemangiomas showed best TV reduction (64% reduction at > 3-year follow-up) followed by schwannoma (41.5%) and meningioma (25.4%). 56.3% of patients developed transient hypoesthesia in trigeminal nerve distribution. 44.4% of patients became completely pain-free. Among cranial nerves, the superior division of the oculomotor nerve showed best outcome (ptosis 62.5%) followed by an improved range of EOM. There was no adverse event in the form of new-onset deficit, vascular complication, or malignant transformation except for one out of the field failures. Among available treatment options, GKRS is the most suitable option by virtue of its minimally invasive nature, optimal long-term tumor control, improvement in cranial neuropathies, cost-effectiveness, favorable risk-benefit ratio, and minimal long-term complications.

Gamma Knife surgery for a hemangioma of the cavernous sinus in an adult: Case report and short review of the literature

Cavernous sinus hemangiomas (CSH) are rare benign extra-axial vascular lesions. Both radiological and clinical aspects are important, for deciding a therapeutic modality, including medical treatment, radiation therapy or microsurgery. In the particular case of CSH, a radical removal of the tumor often cannot be achieved and is associated with a considerable risk for intraoperative uncontrollable bleeding. An alternative treatment modality is radiosurgery. Here we report the case of a 45-year-old patient, who presented with diplopia due to left abducens nerve palsy. A left-sided cavernous sinus lesion was found, initially considered to be a meningioma. However, after serial MR acquisitions, a progressive and heterogeneous enhancement was observed. In order to clarify the diagnosis between meningioma and hemangioma, a diagnostic Tc-99m labeled red blood cells (RBC) scintigraphy (Tc-99m RBC scintigraphy) was performed and showed a typical perfusion blood pool mismatch, with accumulation of the RBC at the level of the left CS, which is typical for a hemangioma. The patient underwent Gamma Knife surgery. The CSH showed a significant reduction in size starting 6 months after treatment and a full regression of the left abducens nerve palsy was observed within 1 year. These clinical and radiological results persisted over the next 3 years.

Clinical-radiological-pathological correlation of cavernous sinus hemangioma: Incremental value of diffusion-weighted imaging

AIM

To elucidate the clinical, magnetic resonance imaging (MRI), pathological features of these lesions and asses the incremental value of diffusion-weighted imaging (DWI) in diagnosing them.

METHODS

Fifteen consecutive patients (11 females and 4 males; mean age 40.93 years; age range 13-63 years) with cavernous sinus hemangiomas (CSH) who underwent examination between November 2008 and May 2016 were included for the analysis. MRI, clinical and surgical findings of each patient was retrospectively reviewed. DWI were also analysed and mean-apparent diffusion coefficient (ADC) value was calculated. Eleven patients underwent surgical removal of the lesion and 2 patients had biopsy only. Diagnosis of CSH was confirmed histologically in 13 patients.

RESULTS

Eleven patients (73%) presented with headaches and 10 (66%) had cranial nerve involvement. Extra cavernous sinus extension was noted in 14 (94%). Surgery was performed in 13 (87%) and post-operative radiation was given to 4 (28%) patients. Thirteen patients remained asymptomatic on follow up. Three conspicuous imaging features were highly suggestive of the diagnosis: Lack of diffusion restriction (100%), homogeneous hyperintensity on T2 weighted image sequences (93.3%) and intense post-contrast enhancement (100%). The mean ADC was 1.82 × 10^-3 ± 0.2186 cm²/s.

CONCLUSION

T1-weighted hypointensity with homogeneous hyperintensity on T2-weighted sequences, intense enhancement and absence of hemosiderin within the lesion on GRE sequence favour the diagnosis. Facilitated diffusion on DWI differentiates CSH from other solid cavernous sinus lesions and significantly improves the diagnostic accuracy, a critical factor for planning surgery.

Radiosurgical considerations for cavernous sinus hemangioma: long-term clinical outcomes

BACKGROUND

Cavernous hemangiomas are rare vascular tumors in the cavernous sinus. Cranial neuropathies induced by cavernous sinus hemangiomas (CSH) necessitate tumor reduction, but surgery is extremely difficult due to the abundant vascularization of the lesion. We studied the effectiveness and safety of Gamma Knife radiosurgery (GKRS) for CSH.

METHODS

We performed a retrospective analysis of 25 patients with CSH who were treated by GKRS between March 1992 and December 2014. Age, sex, target volume, and irradiation dose were analyzed as prognostic factors for CSH treated by GKRS.

RESULTS

Eleven (84.6 %) patients had tumor shrinkage within 12 months after GKRS. Two patients experienced tumor progression, but tumor size decreased over 2 years after GKRS. No patients had permanent complications, and all patients experienced symptomatic improvement. There were no significant factors that predicted the prognosis of CSH.

CONCLUSIONS

The optimal treatment for CSH has been unclear; however, in this study, GKRS was an effective and safe treatment for CSH. Thus, GKRS may be a primary treatment for CSHs in high-risk surgery patients.