2026 Proffered Presentations
S028: CRANIAL NEUROPATHY OUTCOMES IN SYMPTOMATIC CAVERNOUS SINUS MENINGIOMAS: ENDOSCOPIC ENDONASAL DECOMPRESSION PLUS STEREOTACTIC RADIOSURGERY COMPARED TO STEREOTACTIC RADIOSURGERY ALONE
Kara A Parikh, MD; James Mamaril-Davis, MD; Ryan B Juncker; Mark Damante, MD; Eric Nisenbaum, MD; Kyle C Wu, MD; Ricardo L Carrau, MD; Daniel M Prevedello, MD, MBA; The Ohio State University
Background: Cavernous sinus meningiomas (CSM) commonly cause cranial neuropathies due to tumor compression of the optic nerve and cavernous sinus cranial nerves (CSCN). While stereotactic radiosurgery (SRS) achieves excellent long-term tumor control, it typically does not provide immediate relief of cranial nerve dysfunction. Endoscopic endonasal decompression (EED) of the optic canal and cavernous sinus has emerged as a complementary strategy to alleviate extradural mass effect before SRS. There are few studies showing the functional outcomes of this treatment strategy for symptomatic patients, or how it compares to treatment with SRS alone.
Objective: To evaluate early cranial nerve outcomes after EED followed by SRS in symptomatic CSM, and to contextualize safety and efficacy against benchmarks from a systematic review of SRS treatment alone for symptomatic CSM.
Methods: We performed a single-center retrospective cohort study over a 6-year period including patients with CSM and physician-documented tumor related cranial neuropathies who underwent EED followed by planned SRS. All patients had histological confirmation of diagnosis and radiographical demonstration of at least 50% of tumor contained in the cavernous sinus. The primary endpoint was nerve-specific recovery at 6 months after EED, prior to SRS. Safety endpoints included intraoperative and postoperative complications. In parallel, a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guided systematic review was conducted. PubMed MEDLINE (National Library of Medicine) and Scopus (Elsevier) were queried using keywords “cavernous sinus meningioma” and “cranial neuropathy” and “stereotactic radiosurgery.” Analysis of results included 4 studies that reported cranial nerve outcomes in symptomatic CSM patients treated with stereotactic radiation as the sole tumor-directed therapy. Extracted benchmarks included cranial nerve improvement, timeline of cranial neuropathy recovery, and new neuropathy.
Results: Seventeen symptomatic patients underwent EED. Eight presented with CN II deficits, 12 with CSCN, and 3 with both. Symptoms included diplopia (71%), visual loss (47%), pain (41%), and facial numbness (18%). EED demonstrated safety, with no intraoperative complications or new postop neuropathies, and one postoperative low-flow cerebrospinal fluid leak (5.9%). At 6 months post-EED (prior to SRS), 100% of patients with CN II deficits (n=8) improved (63% complete, 37% partial). Among patients with CSCN deficits (n=12), 92% improved (34% complete, 58% partial). In contrast, systematic review of CSM patients treated with SRS alone showed a much lower median rate of CN II improvement (21.4%), and median rate of CSCN deficit improvement (43.8%). The median rate of developing new cranial neuropathy after SRS was 4.5%, compared to no new cranial neuropathies in the institutional review of patients who underwent EED. Outcomes for patients treated with only SRS were reported at a mean of 8 months after SRS.
Conclusion: In symptomatic CSM, EED was safe and demonstrated notable rates of improvement in optic and cavernous sinus cranial neuropathies before initiation of SRS. Compared with benchmarks from SRS alone, staged EED prior to SRS appears to be an adjunct to facilitate functional improvement of cranial nerves. These findings support consideration of EED in select patients with disabling cranial neuropathies and compressive CSM pathology.