Strategy and technique of endonasal endoscopic bony decompression and selective tumor removal in symptomatic skull base meningiomas of the cavernous sinus and Meckel's cave.

BACKGROUND: Parasellar meningiomas involving the cavernous sinus and Meckel's cave pose a management challenge because of invasion around neurovascular structures and the pituitary gland. Management options range from aggressive resection to focused radiotherapy alone. Herein we present a strategy for these tumors of endonasal bony decompression, partial tumor removal, and stereotactic radiotherapy in select cases.

METHODS: Tumor location, prior treatments, cranial neuropathies, pituitary dysfunction, tumor control rates, use of stereotactic radiosurgery (SRS), radiotherapy (SRT) and complications were retrospectively evaluated.

RESULTS: Twenty patients (age range 43-81 years; 65% women; 90% WHO grade I; median follow-up 57 months; 14 without prior debulking and radiation, and 6 with prior debulking and radiation) underwent endonasal bony decompression and partial tumor removal. Most common tumor locations were cavernous sinus (95%), Meckel's cave (95%), sella (75%), petroclival (60%), and optic canal/orbit (30%). Three patients with large meningiomas underwent staged transcranial and endonasal debulking. Of 14 patients without prior debulking and radiation, 11 had postoperative SRT, with tumor shrinkage in 3 (27%). At last follow-up, comparing these 14 patients to the 6 patients with prior surgery and radiotherapy, tumor control was 100% versus 33% (p

CONCLUSIONS: Endonasal bony decompression and selective tumor removal followed by SRT appears to be a reasonable treatment option for most previously untreated parasellar meningiomas. For patients with prior debulking and radiotherapy, new targeted treatment strategies are needed.