Surgery of tumors invading the cavernous sinus

370

Surg Neural 1988;30:370-81

Surgery of Tumors Ossama

Al-Mefty,

Department

Invading the Cavernous Sinus

M.D., and Robert

of Neurosurgery,

University

Al-Mefty 0, Smith RR. Surgery of tumors sinus. Surg Neural 1988;30:370-81.

R. Smith, M.D.

of Mississippi Medical Center, Jackson, Mississippi

invading

the cavernous

Potential injury to neurovascular structures within the cavernous sinus often prohibits total removal of various cranial base tumors. This report discusses the rationale of direct cavernous sinus surgery and describes a surgical technique refinement as evolved from experience in 18 histologically benign operative cases. The nature of tumor extension mandated entry to the sinus, either through the superior or lateral wall or both. The operative microscope facilitated dissecting and preserving the carotid artery and cranial nerves traversing the sinus. Ve-

nous bleeding was controlled by packing. There was one death unrelated to cavernous sinus surgery. Five patients, however, had complications related to cavernous sinus surgery, including hemiplegia in one patient and cranial nerve palsy in four. KEY

WORDS:

Meningioma;

Brain tumor; Carotid artery; Cavernous Surgery

sinus;

The misnomer “cavernous sinus” is credited to Winslow who, in 1732, compared it to the corpus cavernosum of the penis [6,40]. Controversy continues to surround this space concerning the anatomy, pathologic involvement, and management of lesions involving it. Surgical excision of a tumor in the cavernous sinus is by no means a new venture; Krogius directly approached what was presumably a neuroma in 1895 [32]. Recently Dolent et al [12} gained such confidence in cavernous sinus surgery that they used a transcavernous approach en route to basilar aneurysms. Tumors originating in or invading the cavernous sinus, however, have generally been considered inoperable. The fear of profuse venous hemorrhage and injury to the cavernous portion of the carotid artery and the cranial nerves made this space a “no man’s land” in the opinion of many surgeons. Options in the management of a neoplasm involving

Address reprint reque.r?JIO:Ossama Al-Mefty, M.D., Department of Neurosurgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216-4505. Received April 18, 1988; accepted July 14, 1988. 0 1988 by Else&r

Science Publishing Co., Inc.

the cavernous sinus currently include observation only, operative excision, and radiation therapy alone or following surgery. Unfortunately there are no conclusive data concerning the effectiveness, morbidity, and longterm results of these various approaches. Hence, the management decision is at present individualized according to (a) factors related to the patient (condition, age, neurologic deficits, and the anatomy of his/her arterial circulation), (6) factors related to the tumor (pathology, behavior, previous therapy, extent of tumor involvement), and (c) surgical experience and judgment. A direct operative approach to the cavernous sinus space is indicated when it is anticipated that the lesion can be removed. Parkinson and West [29] believed that only preoperative diagnosis of an aneurysm, a meningioma, or a neurofibroma justify a direct surgical approach to the cavernous sinus. Surgical removal of neurinomas seems to produce the best results. Lesoin and Jomin [24] were able to do extensive but incomplete resection in 18 of 21 cases, among which were 16 meningiomas. They concluded that it is not possible to completely remove an intracavernous meningioma without disturbing oculomotor nerves. Zozulia et al 1441 reported on 247 tumors involving the cavernous sinus (167 meningiomas and 80 pituitary tumors), concluding that tumors having only lateral wall involvement can be surgically removed. During our pursuit to achieve total removal of parasellar tumors, we have directly removed intracavernous tumor extensions in 18 patients. A planned surgical technique has evolved that incorporates or modifies previously reported surgical steps [ 11,29,361.

Operative Tecbniqz4e The cavernous sinus is easily reached through several cranial approaches: subtemporal [29], pterional [ 1 l), and orbito-zygomaticomalar 1241. Although the transsphenoidal approach has been used C&23], it offers only restrictive exposure and does not allow proximal and distal control of the carotid artery. We have found the supraorbital-pterional approach provides excellent access to the cavernous sinus and permits dealing with a variety of lesions [2]. 0090-3019/88/$3.50

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371

nerves along with the scalp flap. The frontal fascia is cut in a triangular segment between two incisions, one along the superior temporal line and the other over the frontal bone. The base of this triangular segment is continuous with the periorbita. This fascial flap is then elevated from the frontal bone and is dissected free from the margin of the roof and the lateral wall of the orbit. The temporal muscle is detached anteriorly from its insertion to the medial surface of the zygomatic bone and frontal zygomatic process. The zygomatic arch is dissected in subperiosteal fashion, sectioned in the most anterior and posterior ends, using the C1 attachment of the Midas Rex drill, and displaced downward with the masseter attachment (Figure 1 A). This maneuver allows a more basal approach to the floor of middle fossa, obviating obstruction by the bulky temporal muscle. The temporal muscle is then retracted posteriorly and inferiorly, exposing the junction of the zygomatic, sphenoidal, and frontal bone. Removal of the supraorbital pterional flap and drilling of the sphenoid ridge then proceeds as described previously 121 (Figure 1 B). Cavernous sinus entry is preceded by two steps:

(1) The internal

B 1. (A) Artist’s illustration demonstrating sectioning of the zygomatic arch in order to obtain a more basal approach. (B) Skull model. The supraorbital-pterional bone flap is removed and the zygoma is sectioned. The exposure obtained is demonstrated.

Figure

The scalp incision is begun 1 cm anterior to the tragus, proceeding in a curvilinear fashion behind the hairline to the level of the superior temporal line on the opposite side. In this manner, the superficial temporal artery courses posterior to the incision while the facial nerve branches are located anteriorly. As the scalp is turned anteriorly, the temporal muscle gives way to a temporal fat pad projecting anteriorly between the muscle and the frontozygomatic surface. The temporalis fascia actually splits into two layers which contain the fat pad and the facial nerve branches. The temporalis fascia are incised and reflected anteriorly with the fat layer and

(2)

carotid artery (in the neck or the intrapetrous segment) is exposed to obtain proximal control of the artery. The surgical anatomy for the latter maneuver has been well described [15,3 11. Starting posteriorly and working forward, the dura of the temporal fossa is elevated off the floor. The three landmarks are the middle meningeal artery, the arcuate eminence, and the greater superficial petrosal nerve. The middle meningeal artery is coagulated and sectioned. The greater superficial petrosal nerve is also sectioned with microscissors, preventing traction that could result in facial nerve paralysis. The horizontal portion of the petrous internal carotid artery is deep, parallel to the greater superficial petrosal nerve, and posterior to the mandibular division of the trigeminal nerve. The internal carotid artery is unroofed with a diamond drill for a length of l-2 cm. To mobilize and prepare the artery for temporary clipping, if needed, the periosteum covering is opened. The geniculate ganglion of the facial nerve, which lies just posterior and lateral to the exposed area, should be protected. It may be necessary in some cases to open the eustachian tube, located lateral to the intrapetrous carotid canal, to obtain better exposure of the lateral aspect of the artery (Figure 2). When opened, the eustachian tube is occluded with bone wax and a piece of fascia to avoid a cerebrospinal fluid leak. The anterior clinoid process, the optic canal, and the remainder of the roof of the superior orbital fissure are drilled away with a diamond high speed

372

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Al-Mefty

and Smith

Figure 3. Artist’s illustration demonstrating the exposure of the superior and anterior portion oj the cavernous sinus. The anterior clinoid, the optic canal, and the roofof the superior OrbitaIfissure are drilled away. 2, optic nerve; -C.a., carotid artery; El, oculomotor nerve.

Figure 2. Artist’s illustration demonstrating exposure of the horizontal segment ojthe intrapetrous carotid artery. G.p.n., greater petrosal nerve; V,, third trigeminal division; E.t., eusta%Zitube; M.m.a., middle mezngeal artey; -G.g., Gasserian-&glion; -C.a., carotimartety.

air drill. The dura propria is opened and the optic nerve is mobilized. This maneuver permits further visualization of the superior aspect of the sinus and the internal carotid artery, and the exposure of the ophthalmic artery and the anterior portion of the cavernous sinus (Figure 3). Entering the cavernous sinus depends on both the lesion and its origin. The conventional entry, especially for a lesion confined to the cavernous sinus space, is the lateral approach through the triangle of Parkinson 128,291. The free margin of the tentorium and the third and fourth nerves are identified. The fourth nerve, which is harder to visualize, courses below the third. An incision is made in the outer layer of the lateral wall of the cavernous dura, and the outer layer is peeled away from the first and second division of the trigeminal nerve. The positions of the third and fourth cranial nerves, in the superior lateral wall of the cavernous sinus, are relatively constant. The incision is made beneath the projected course of the third nerve, centering

at the point where the third nerve appears over the horizon of the free margin of the tentorium. The incision is extended about 8 mm anteriorly and posteriorly (Figure 4). The cavernous sinus may also be entered via its superior surface; this is better exposed after mobilization of the optic nerve following the drilling of its canal as described above. The internal carotid artery emerges through the superior wall surrounded and firmly an-

Figure 4. Artist’s illustration demonstrating cavernous sinus entry through the lateral wall. VI, V2, V,, divisions of the trigeminal nerves; II, III, IV, VI, cranial newce, Zrotid artery; a, Gasserian ganglion. ---

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In the cavernous sinus space, the tumor is dissected using the bipolar coagulation technique along with microdissectors. Venous hemorrhage is not encountered until near the completion of tumor removal because of the compressed venous plexus. The sixth cranial nerve is the only one that courses through the middle of the space, lateral to the carotid artery. Its identification, dissection, and preservation demand particular attention. Once the tumor is separated from the carotid artery, the plane of dissection can be continued. Developing a plane of cleavage was possible in all our cases and we have not encountered actual invasion of the carotid adventitia. If a tear occurs in the arterial wall, the surgeon should be prepared to apply temporary vascular clips of 30-40 g/mm* pressure and repair the arterial injury with fine microsuture. If sacrifice of the artery is necessary, the artery can be reconstructed using a venous graft or an EC-IC anastomosis can be performed.

Figure 5. Retouched operative photograph during the removal of a meningioma invading the cagernotes sinus. Entry to the sinus was through the superior wall, following the tumor along the carotid artery. I, olfactory nerve; Ll, optic nerve; C, carotid artery; T, tumor; !, cotton patty; -R, retractor on frontal lobe:V, - syluian vein. -

Case Material During the period of January 1983 through March 1988, 18 histologically benign tumors involving the cavernous sinus were surgically removed. Table 1 summarizes tumor type, location, extension, craniotomy approach, cavernous sinus entry, morbidity, date of surgery, and outcome. Cases l-5 were treated at the University of Mississippi Medical Center and Jackson Veterans Administration Hospital. Cases 6- 18 were treated at King Faisal Specialist Hospital in Saudia Arabia, and the last available follow-up on the latter cases is

chored by the dural ring. Starting at this emergence, an incision is made in the exposed dura and extended posteriorly toward the posterior clinoid process. The internal carotid artery is then followed in retrograde fashion into the cavernous sinus, where it is dissected. This pathway gives better exposure to the anterior and medial aspect of the cavernous sinus, as well as better visualization and orientation with regard to the internal carotid artery (Figure 5).

Table 1. Benign Cavernous Sinus Tumors: Summary of Data Complications CaVer”O”S

and extension

Origin

GS.2

“0.

Age/sex

Tumor

fype

1 2

17 /M 34/M

Angiofibroma Myxochondrofibroma

3

36/F

Hemangiopericytoma

4

43/M

Meningioma

5

35/ M

Meningioma

Nasopharynx Dorsum sella Suprasellar, sphenoid sinus Temporal fossa Interpeduncular fossa Bitemporal clivus, Bilateral cavernous sinus Anterior Clinoid Sylvian Parasellar

Craniotomy

sinus entry

Removal

Related t” sinus surgery

Unrelated t” sinus surgery

Surgery date

Oufcome

04-88 01-88

Good

Transient V2 and V, palsy

11-87

Good

Partial

Worsening of III and IV nerve palsy

08-87

Good

Total

III Nerve

05-87

Good

Zygomatic Supraorbital Pterional

Inferior Superior

Total Total

Subtemporal

Lateral

Total

Combined Subtemporal and Petrosal

Lateral

Supraorbital Pterional

Superior, lateral

Transient III Nerve palsy

palsy

Good

374

Table

&Se IlO.

Surg Neurol 1988;30:370-81

Al-Mefty

1. Continued

Age/sex

Tumor type

Origin and extension

Craniotomy

Cavernous sinus entry

Complications Removal

6

17/M

Craniopharyngioma

Suprasellar and intrasellar

Subfrontal

Medial

Total

7

48/F

Meningioma

Anterior Clinoid Parasellar Sylvian Fissure

Supraorbital Pterional

Superior, lateral

Partial

8

56/M

Meningioma

Tuberculum Sella

Bifrontal

Superior

Total

9

52/F

Meningioma

Anterior Clinoid Parasellar Ethmoid sinus

Pterional

Superior

Total

10

611~

Meningioma

Anterior Clinoid Parasellar

Pterional

Lateral

Total

Tuberculum Sella Suprasellar and parasellar

Bifrontal

11

and Smith

50/M

Meningioma

Superior

Total

Related to sinus surgery

hemiplegia

Unrelated to sinus surgery

Surgery date

outcome

Diabetes insipidus

l-83

Good

Pulmonary embolism

12-83

Fair

12-83

Good

12-83

Good

Pulmonary embolism

8-83

Good

Diabetes insipidus

4-82

Good

Pulmonary embolism

12

55/M

Meningioma

Anterior Clinoid Parasellar

Supraorbital Pterional

Superior

Total

8-85

Good

13

44/F

Meningioma

Anterior Clinoid Parasellar, Orbital

Supraorbital Pterional

Lateral wall only

Total

11-85

Good

14

60/M

Meningioma

Anterior Clinoid Suprasellar and parasellar

Supraorbital Pterional

Superior

Partial

3-85

Death

15

40/F

Meningioma

Diaphragm sellae, Suprasellar, parasellar, and retrosellar

Bifrontal

Superior

Total

11-85

Good

16

48/F

Meningioma

Anterior clinoid, Suprasellar and parasellar

Bifrontal

Superior, Lateral

Total

6-82

Good

17

53/F

Meningioma

Tuberculum Bifrontal sella, Suprasellar Interpeduncular

Superior

Total

l-85

Good

18

49/F

Meningioma

Anterior Clinoid Suprasellar and parasellar

Superior

Total

11-85

Good

Supraorbital Pterional

Vasospasm

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375

1986. All cases were studied by computed tomography (CT) scan, which demonstrated the tumor and its extension (Figures 6 A, 7 A, 8 A). Scans were repeated postoperatively to confirm total removal or depict residual tumor (Figures 6 23, 7 B, 8 B). Angiography was reliable in predicting intracavernous carotid artery encasement (Figures 9 and 10); however, it was not a sensitive indicator of cavernous sinus invasion. Magnetic resonance imaging (MRI), performed in the last five cases, proved to be superior in demonstrating tumor invasion and its relation to the intracavernous carotid artery (Figures 1 l-l 3). A signal void of moving fluids outlined the arterial course. There was one death subsequent to hypothalamic infarction in a patient harboring a meningioma who developed postoperative vasospasm. Other complications are detailed in Table 1.

January

Discussion

Figure 6. Case #12, contrast-enhanced CT scan of anterior clinoid naeningioma invading the cavernous sinus. (A)preoperative; (B) postoperative.

It is difficult to attain accurate incidence of tumors involving the cavernous sinus space that may be treated surgically because the definition of involvement is not quite clear. As might be expected, the available reported series is biased by the pattern, specialty, and referral bases of their authors. A tumor originating primarily within the cavernous sinus is rare. Aneurysms constitute 80% of intracavernous primary lesions, meningiomas lo%, and neurofibromas lOTo, with pituitary tumors accounting for < 1% C29J. Approximately 0. l0.25% of intracranial tumors involve the cavernous sinus [4,29,34]. Nasopharyngeal carcinoma and metastasis are the most common of those tumors originating in adjacent areas and invading the cavernous sinus space (16). Tumors that invade the sinus include meningiomas, pituitary tumors, neurinomas, chordomas, chondramas, chondrosarcomas, esthesioneuroblastomas, and angiofibromas. Direct exposure and removal of a tumor from the cavernous sinus has been more frequently attempted in the last decade. Several surgeons have reported favorable, though limited, experience (Table 2) {3,11,14,18,19,22-29,33,36,44], and the authors share their enthusiasm and encouraging experience. It has yet to be proved, however, that treatment by radical operation of tumors involving the cavernous sinus, with or without radiation therapy, is superior to radiation therapy alone. Only further experience and a longer follow-up will answer this question. All complications encountered in this series are detailed regardless of whether they were related or unrelated to cavernous sinus surgery, major or minor, transient or permanent. The apparent high rate of complications is at least in part related to the complex nature of tumors in this

Surg Neural 1988;30:370-81

Al-Mefty

and Smith

B

series. With experience, better results may be expected. The follow-up period is admittedly short; there can be recurrences of these tumors in spite of the radical approach to remove them. Meningiomas are known to recur even when totally removed from easily accessible locations [3 7 J. The following factors should encourage experienced surgeons who contemplate a direct attack on a tumor involving the cavernous sinus. First, there is compelling evidence favoring the view that the cavernous sinus is a plexus of veins rather than a large venous space with multiple trabeculations [2830,401. Second, the lateral wall of the sinus is formed by two layers: a superficial dural layer and a deep layer. The deep layer contains the third and fourth cranial nerves, and the first and second divisions of the trigeminal nerve. This layer is formed by the sheaths of these nerves that are connected by a reticular membrane. This membrane has a gap between the third and fourth nerves above, and the fifth below [28,30,41]. Third, the development of skull base approaches al-

Figure 7. Case #S, contrast-enhanced CT scan ofparaselkzr meningioma involving the cavernous sinus. (A) preoperative; (B) postoperative.

lows proximal and distal control of the carotid artery and reduces the risk of intraoperative catastrophes I1 1,24,361. Fourth, hemorrhage from the venous plexus occurs only during the later stages of tumor removal because the tumor compresses those veins. Venous bleeding is controlled with packing and head elevation. Fifth, the development of preoperative testing, such as balloon occlusion tests, measurement of cerebral blood flow [36], and intraoperative monitoring assist in better patient selection and safer results. Sixth, the availability of EC-IC anastomosis and arterial reconstruction may provide a means of restoring cerebral circulation should the carotid artery be severed intraoperatively. Seventh, microsurgery assists in the identification, dissection, and preservation of the neural and vascular structures within the cavernous sinus.

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377

1988;30:370-81

B Figure 8. Case #7, contrast-enhanced CT scan of anterior clinoid neningiomas invading the cavernous sinus with partial remoual. (A) preoperative, (B) postoperative showing residual tumor in the cavernous sinus. A

Eighth, involvement of the cavernous sinus has been a limiting factor of radical tumor resection, and thus the cause of recurrence in several tumors such as meningiomas f I, 7,10,3 73. Although radiation therapy of an intracavernous meningioma reduces symptomatic recurrence [5}, the tumor shows no apparent change in size

on a CT scan C433. Arnold and Herrmann 131, citing disappointing results with the palliative treatment of skull base chordoma, advocated radical tumor removal at the first attempt, including cavernous sinus involvement. Similarly, invasion of the cavernous sinus has been an adverse and limiting factor in the management

Figure 9. Case #7, lateral carotid artery arteriogram demonstrating the narrowing of the intracavernous carotid (arrowheads) due to tumor encasement.

Surg Neural 1988:30:370-81

Al-Mefry and Smith

I

Figure 10. Case #X4, anteroposterior carotid arteriogram demonstrating intracavernous carotid artery narrowing by encasing tumor (pointer).

of nasopharyngeal tumors [9,13,38). Some authors have pointed out that a major cause of the recurrence of pituitary tumors is the residual intracavernous or extra-

Table

2. Published Reports of Direct Operations for Intracawernous Aneqsms Authors

Number of aneurysms

Gordy 1171 Parkinson and West [29] Nakahara et al [27] MacKay and Hosobuchi [25] Zozulia et al 1441” Johnston E20) Unsold et al [42] Schubiger et al 1351 Kline and Galbraith 122) Hakuba et al 118)

19 10 0 0 1 0 0 0 6

Dolenc, 1983 Fox 1141 Malis [26] Sekhar and Moller

Arnold

Lesoin

dural portion of the tumor Hosobuchi [25] advocated tension into the cavernous

[36]

and Herrmann

and Jomin

0

C3J’

1241

San0 et al 1331 Al-Mefty and Smith (1988) (this issue)

0

0

and Neoplasms

Number and type of neoplasms

Outcome

1 Trigeminal neurinoma 12 0 Pituitary adenomas 167 Meningiomas, 80 Pituitary adenomas 0 I Metastatic carcinoma (biopsy) 1 Neurinoma 1 Epidermoid 4 Meningiomas, 1 Neurinoma, 1 Teratoma, 3 Pituitary adenomas, 2 Chordomas 0 Not given 2 Meningiomas, 1 Neurinoma, 1 Pituitary adenoma, 1 Chordoma, 2 Chondrosarcomas 8 Chordoma, 6 bilateral involvement, 6 Cranial surgery, 4 Multiple operations 16 Meningioma, Chondroma,

3 Metastasis, 1 Neurinoma

[25,39}. Hence, MacKay and radical excision including exsinus.

1

Good (VI palsy) 2 Deaths Good 1 Good, 1 poor (1 III Palsy) Not given Fair Fair Good Good 1 Death, 1 Hemiplegia, 3 Cranial palsies, 13 Good

nerve

2 Good, 1 fair Good Not given 6 Good, 1 Fair (2 Vs Palsies)

2 Deaths postop, 3 Hemiplegia & meningitis, 5 Deaths in l-7 years from recurrent tumor 5 Transient worsening of III function

1

18

14 Meningiomas, 1 Craniopharyngioma, 1 Myxochondrofibroma, 1 Hemangiopericytoma, 1 Angiohbroma

* Operated cases of moors involving the sinus. Exact number of direct approaches is not given. b Disease outcome of the cases. III, V, VI = cranial nerves.

1 Death, 1 Hemiparesis III Palsy (1 Anatomical, IV Palsy (1 anatomical) V Palsy (1 transienr)

2 functional)

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379

Figure 11. Caxe #3, recurrent hemangioperirytoma invading the right cavernous SinwJ. (A) preoperative CT Jean; (B) postoperative CT scan; (C) sagittal MR (TE: 30; TR 600) depicting the course of the intracavernouJ carotid artery (arrows) surrounded by the tumor in the Lowerpart of the cavernous sinus.

Ninth, advanced imaging techniques provide confirmation and the extent of cavernous sinus involvement by a tumor and, in the majority of cases, the probable pathology 12 11. Bilateral involvement of the cavernous sinus can also be depicted. We have been reluctant to perform direct surgery in this condition. Detailed arteriographic study demonstrates the anatomy of the cere-

bral circulation and the presence or absence of crossfilling via the Circle of Willis. In conclusion, direct surgery on tumors involving the cavernous sinus space is feasible with acceptable mortality and morbidity. Certain preplanned steps make surgery safer than it once was. Early experience with MRI indicates its superiority in identifying intracavernous tu-

380

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Al-Mefty and Smith

Figure 13. Case #2, coronal MR (TE: 20; TR 600) of myxochondrojibroma invading the left cavewtons sinus. Carotid arteries are apparent as a black signal void.

mor extension. Angiographic carotid narrowing is a reliable is infrequently present.

demonstration sign; however,

of internal narrowing

Drawings were done by Mr. Michael P. Schenk, medical illustrator, University Medical Center, Jackson, Mississippi. The authors would like to thank Ms. Julie Hipp for editorial assistance.

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