CLINICAL STUDIES LARGE SPHENOID WING MENINGIOMAS INVOLVING THE CAVERNOUS SINUS:CONSERVATIVE SURGICAL STRATEGIES FOR BETTER FUNCTIONAL OUTCOMES Khaled M. Abdel Aziz, M.D., Ph.D. Department of Neurosurgery, The Neuroscience Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio Sebastien C. Froelich, M.D. Department of Neurosurgery, The Neuroscience Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio Elias Dagnew, M.D. Department of Neurosurgery, The Neuroscience Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio Walter Jean, M.D. Department of Neurosurgery, The Neuroscience Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio John C. Breneman, M.D. Department of Radiology- Oncology, The Neuroscience Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio Mario Zuccarello, M.D. Department of Neurosurgery, The Neuroscience Institute, University of Cincinnati College of Medicine, and the Mayfield Clinic, Cincinnati, Ohio Harry R. van Loveren, M.D. Department of Neurosurgery, University of South Florida, Tampa, Florida John M. Tew, Jr., M.D. Department of Neurosurgery, The Neuroscience Institute, University of Cincinnati College of Medicine, and the Mayfield Clinic, Cincinnati, Ohio Reprint requests: John M. Tew, Jr., M.D., c/o Editorial Office, Department of Neurosurgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, P.O. Box 670515, Cincinnati, OH 45267-0515. Email: editor@mayfieldclinic.com Received, May 9, 2004. Accepted, February 11, 2004. OBJECTIVE: The ability to resect meningiomas that involve the medial and anterior compartments of the cavernous sinus has been refuted. In this retrospective study, we determined the efficacy of total resection of meningiomas that invade the cavernous sinus but are restricted to the lateral compartment. METHODS: We reviewed the charts of 38 consecutive patients with sphenocavernous, clinoidocavernous, and sphenoclinoidocavernous meningiomas who underwent sur- gical treatment. We assessed early and late cranial nerve morbidity, extent of resec- tion, and long-term outcome (mean, 96 mo). RESULTS: In all patients, tumors exceeded 3 cm diameter. In 22 of 24 patients, total microscopic excision was achieved in tumors that involved only the lateral compart- ment of the cavernous sinus and touched or partially encased the cavernous internal carotid artery (i.e., modified Hirsch Grades 0 and 1, respectively). In 2 of 24 patients, remaining tumor infiltrated the superior orbital fissure. All 14 patients who had tumors that encased (with or without narrowing) the cavernous segment of the internal carotid artery (Hirsch Grades 2–4) underwent incomplete resection. Among 38 patients, mortality was 0%, late cranial nerve deficits remained in 6 (16%), and late Karnofsky Performance Scale scores exceeded 90 in 34 patients (90%). Four patients (10.5%) developed a recurrence or regrowth. Of 20 patients who were treated with either linear accelerator-based stereotactic radiosurgery or fractionated conformal radiotherapy, 11 had residual tumor and a moderate to high proliferative index, 4 had atypical tumors and 1 had angioblastic meningioma after total excision, 2 had regrowth, and 2 had recurrent tumors. In 18 (90%) of the 20 patients who underwent radiation, tumor size was reduced or controlled. CONCLUSION: On the basis of this study and a review of the literature, we demon- strate that sphenocavernous, clinoidocavernous, and sphenoclinoidocavernous me- ningiomas of Hirsch Grades 0 and 1 can be excised from the lateral compartment of the cavernous sinus without postoperative mortality and with acceptable rates of morbidity. Residual tumor in the medial compartment (Hirsch Grades 2–4) may be treated with some form of radiation therapy or observation. KEY WORDS: Clinoidocavernous, DeMonte grade, Functional outcome, Hirsch grade, Meningiomas, Ocular cranial nerves, Sphenocavernous, Sphenoclinoidocavernous Neurosurgery 54:1375-1384, 2004 DOI: 10.1227/01.NEU.0000125542.00834.6D www.neurosurgery-online.com I n 1910, Frotscher and Becker (21) first re- ported a case of sphenocavernous menin- gioma at autopsy; later it was termed an endothelioma psammosum of the sphenocavern- ous angle of Vincent. In 1938, Cushing and Eisenhardt (10) classified sphenoid ridge me- ningiomas as deep inner or clinoidal; middle or alar; and outer or pterional. We consider pterional meningiomas to be convexity me- ningiomas that are characterized by signifi- cant hyperostosis. Middle and deep sphenoid ridge meningiomas can be turned into an upside-down convexity meningioma by the addition of an orbital or orbitozygomatic os- teotomy, as a strategic component, to the con- ventional pterional approach (63). Inner sphe- NEUROSURGERY VOLUME 54 | NUMBER 6 | JUNE 2004 | 1375