Neurosurgical Review

, Volume 43, Issue 1, pp 27–40 | Cite as

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

  • Manjul TripathiEmail author
  • Aman Batish
  • Narendra Kumar
  • Chirag Kamal Ahuja
  • Arun S. Oinam
  • Rupinder Kaur
  • Rajasekhar Narayanan
  • Jenil Gurnaani
  • Amanjot Kaur


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.


Cavernous Gamma knife Hemangioma Meningioma Schwannoma Radiosurgery 



We would like to acknowledge and thank late Professor Kanchan Kumar Mukherjee for his clinical work and treatment of these patients of cavernous sinus tumors.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Institute Ethics Committee, Postgraduate Institute of Medical Education and Research, Chandigarh, India) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

10143_2018_975_MOESM1_ESM.docx (514 kb)
ESM 1 (DOCX 514 kb)
10143_2018_975_MOESM2_ESM.docx (19 kb)
ESM 2 (DOCX 19 kb)


  1. 1.
    Abeloos L, Levivier M, Devriendt D, Massager N (2007) Internal carotid occlusion following gamma knife radiosurgery for cavernous sinus meningioma. Stereotact Funct Neurosurg 85:303–306PubMedGoogle Scholar
  2. 2.
    Bansal S, Suri A, Singh M, Kale SS, Agarwal D, Sharma MS, Mahapatra AK, Sharma BS (2014) Cavernous sinus hemangioma: a fourteen year single institution experience. J Clin Neurosci 21:968–974PubMedGoogle Scholar
  3. 3.
    Borruat FX, Schatz NJ, Glaser JS et al (1996) Radiation optic neuropathy: report of cases, role of hyperbaric oxygen therapy, and literature review. Neuroophthalmology 16:255–266Google Scholar
  4. 4.
    Bristol R, Santoro A, Fantozzi L, Delfini R (1997) Cavernoma of the cavernous sinus: case report. Surg Neurol 48:160–163Google Scholar
  5. 5.
    Chang SD, Adler JR Jr, Martin DP (1998) LINAC radiosurgery for cavernous sinus meningiomas. Stereotact Funct Neurosurg 71:43–50PubMedGoogle Scholar
  6. 6.
    Chen JC, Ginannotta SL, Yu C, Petrovich Z, Levy ML, Apuzzo ML (2001) Radiosurgical management of benign cavernous sinus tumors: dose profiles and acute complications. Neurosurgery 48:1022–1032PubMedGoogle Scholar
  7. 7.
    Chou CW, WU HM, Huang CI, Chung WY, Gun WY et al (2010) Gamma knife surgery for cavernous hemangioma in the cavernous sinus. Neurosurgery 67:611–616PubMedGoogle Scholar
  8. 8.
    Cusimano MD, Sekhar LN, Sen CN, Pomonis S, Wright DC, Biglan AW, Jannetta PJ (1995) The results of surgery for benign tumors of the cavernous sinus. Neurosurgery 37:1–10PubMedGoogle Scholar
  9. 9.
    De Jesus O, Sekhar LN, Parish HK, Wright DC, Wagner DO (1996) Long-term follow up of patients with meningiomas involving the cavernous sinus: recurrence, progression, and quality of life. Neurosurgery 39:915–920PubMedGoogle Scholar
  10. 10.
    DeMonte F, Smith HK, al-Mefty O (1994) Outcome of aggressive removal of cavernous sinus meningiomas. J Neurosurg 81:245–251PubMedGoogle Scholar
  11. 11.
    Duma CM, Lunsford LD, Kondziolka D et al (1993) Stereotactic radiosurgery of cavernous sinus meningiomas as an addition or alternative to microsurgery. Neurosurgery 32:699–705PubMedGoogle Scholar
  12. 12.
    Gonzalez LF, Lekovic GP, Eschbacher J, Coons S, Porter RW, Spetzler RF (2006) Are cavernous sinus hemangiomas and cavernous malformation different entities? Neurosurg Focus 21:e6PubMedGoogle Scholar
  13. 13.
    Hafez RF, Morgan MS, Fahmy OM (2015) Stereotactic gamma knife surgery safety and efficacy in the management of symptomatic benign confined cavernous sinus meningioma. Acta Neurochir 157:1559–1564PubMedGoogle Scholar
  14. 14.
    Hasegawa T, Kida Y, Yoshimoto M, Koike J, Iizuka H, Ishii D (2007) Long-term outcomes of gamma knife surgery for cavernous sinus meningioma. J Neurosurg 107:745–751PubMedGoogle Scholar
  15. 15.
    Hayashi M, Chernov M, Tamura N, Tamura M, Horiba A, Konishi Y et al (2012) Gamma knife radiosurgery for benign cavernous sinus tumors: treatment concept and outcomes in 120 cases. Neurol Med Chir (Tokyo) 52:714–723Google Scholar
  16. 16.
    Ivanov P, Chernov M, Hayashi M, Nakaya K, Izawa M, Murata N, Kubo O, Ujiie H, Muragaki Y, Nakamura R, Iseki H, Hori T, Takakura K (2008) Low dose gamma knife radiosurgery for cavernous sinus hemangioma: a report of 3 cases and literature review. Minim Invasive Neurosurg 51:140–146PubMedGoogle Scholar
  17. 17.
    Iwai Y, Yamanka K, Nakajima H, Yasui T (1999) Stereotactic radiosurgery for cavernous sinus hemangioma—a case report. Neurol Med Chir (Tokyo) 39:288–290Google Scholar
  18. 18.
    Iwai Y, Yamanaka K, Ishiguro T (1996) Gamma knife radiosurgery for treatment of cavernous sinus meningiomas. Neurosurgery 38:434–444Google Scholar
  19. 19.
    Khan AA, Niranjan A, Kano H, Kondziolka D, Flickenger JC, Lunsford LD (2009) Stereotactic radiosurgery for cavernous sinus or orbital hemangioma. Neurosurgery 65:914–918PubMedGoogle Scholar
  20. 20.
    Kida Y, Kobayashi T, Mori Y (2001) Radiosurgery of cavernous hemangioma in the cavernous sinus. Surg Neurol 56:117–123PubMedGoogle Scholar
  21. 21.
    Kuo JS, Chen JC, Yu C et al (2004) Gamma knife radiosurgery for benign cavernous sinus tumors: quantitative analysis of treatment outcomes. Neurosurgery 54:1385–1394PubMedGoogle Scholar
  22. 22.
    Larson JJ, van Loveren HR, Balko MG, Tew JM (1995) Evidence of meningioma infiltration into cranial nerve: clinical implications for cavernous sinus meningiomas. J Neurosurg 83:596–599PubMedGoogle Scholar
  23. 23.
    Leavitt JA, Stafford SL, Link ML, Pollock BE (2013) Long-term evaluation of radiation-induced optic neuropathy after single fraction stereotactic radiosurgery. Int J Radiation Once Biol Phys 87:524–527Google Scholar
  24. 24.
    Leber KA, Berghoff J, Pendl G (1998) Dose-response tolerance of the visual pathways and cranial nerves of the cavernous sinus to stereotactic radiosurgery. J Neurosurg 88:43–50PubMedGoogle Scholar
  25. 25.
    Lee CC, Sheehan JP, Kano H, Akpinar B, Martinez-Alvarez R, Martinez-Moreno N, Guo WY, Lunsford LD, Liu KD (2017) Gamma knife radiosurgery for hemangioma of the cavernous sinus. J Neurosurg 126:1498–1505PubMedGoogle Scholar
  26. 26.
    Lee JH, Sade B, Choi E, Golubic M, Prayson R (2006) Meningothelioma as the predominant histological subtype of midline skull base and spinal meningiomas. J Neurosurg 105:60–64PubMedGoogle Scholar
  27. 27.
    Lee JY, Niranjan A, McInerney J, Kondziolka D, Flickenger JC, Lunsford LD (2002) Stereotactic radiosurgery providing long term tumor control of cavernous nerve function. J Neurosurg 97:65–72PubMedGoogle Scholar
  28. 28.
    Lim YJ, Leem W, Park JT, Kim TS, Rhee BA, Kim GK (1999) Cerebral infarction with ICA occlusion after gamma knife radiosurgery for pituitary adenoma: a case report. Stereotact Funct Neurosurg 72:132–139PubMedGoogle Scholar
  29. 29.
    Linskey ME, Sekhar LN (1992) Cavernous sinus hemangiomas: a series, a review, and an hypothesis. Neurosurgery 30:101–108PubMedGoogle Scholar
  30. 30.
    Li P, Ren H, Zhang S, Wang W (2012) Clinical results of gamma knife surgery for cavernous sinus hemangiomas. J Neurosurg 117:89–95PubMedGoogle Scholar
  31. 31.
    Liscak R, Simonova G, Vyamazal J, Janouskova L, Vladyka V (1999) Gamma knife radiosurgery of meningiomas in the cavernous sinus region. Acta Neurochir 141:473–480PubMedGoogle Scholar
  32. 32.
    Liu AL, Wang C, Sun S, Wang M, Liu P (2005) Gamma knife radiosurgery for tumors involving the cavernous sinus. Stereotact Funct Neurosurg 83:45–51PubMedGoogle Scholar
  33. 33.
    Maguire PD, Clough R, Friedman AH, Halperin EC (1999) Fractionated external-beam radiation therapy for meningiomas of the cavernous sinus. Int J Radiat Oncol Biol Phys 44:75–79PubMedGoogle Scholar
  34. 34.
    Mathiesen T, Lindquist C, Kihlstrom L et al (1996) Recurrence of cranial base meningiomas. Neurosurgery 39:2–9PubMedGoogle Scholar
  35. 35.
    Mayo C, Nartel MK, Mark LB et al (2010) Radiation dose-volume effects of optic nerves and chiasm. Int J Radiat Once Biol Phys 76:S28–S35Google Scholar
  36. 36.
    Meyer FB, Lombardi D, Scheithauer B, Nichols DA (1990) Extra-axial cavernous hemangiomas involving dural sinuses. J Neurosurg 73:187–192PubMedGoogle Scholar
  37. 37.
    Morita A, Coffey RJ, Foote RL, Schiff D, Gorman D (1999) Risk of injury to cranial nerves after gamma knife radiosurgery for skull base meningiomas: experience in 88 patients. J Neurosurg 90:42–49PubMedGoogle Scholar
  38. 38.
    Nakamura N, Shin M, Tago M, Terahara A, Kurita H, Nakagawa K, Ohtomo K (2002) Gamma knife radiosurgery for cavernous hemangioma in the cavernous sinus. Report of three cases. J Neurosurg 97:477–480PubMedGoogle Scholar
  39. 39.
    Nicolato A, Foroni R, Alessandrini F, Bricolo A, Gerosa M (2002) Radiosurgical treatment of cavernous sinus meningiomas: experience with 122 treated patients. Neurosurgery 51:1153–1159PubMedGoogle Scholar
  40. 40.
    Niranjan A, Kano H, Lunsford LD (2013) Gamma knife radio surgery for brain vascular malformations. Prog Neurol Surg 27:119–129Google Scholar
  41. 41.
    O’Sullivan MG, van Loveren HR, New JM (1997) The surgical respectability of meningiomas of the cavernous sinus. Neurosurgery 40:238–247PubMedGoogle Scholar
  42. 42.
    Pollock BE, Stafford SL, Link MJ, Garces YI, Foote RL (2013) Single-fraction radiosurgery of benign cavernous sinus meningiomas. J Neurosurg 119:675–682PubMedGoogle Scholar
  43. 43.
    Roche PH, Regis J, Dufour H et al (2002) Gamma knife radiosurgery in the management of cavernous sinus meningiomas. J Neurosurg 93:68–73Google Scholar
  44. 44.
    Rong HT, Hui XH, Ju Y, Ma L, Zhang Q, Chen J (2013) Gamma knife radiosurgery for cavernous sinus tumor: a case report of 84 cases. Neurosurg Q 23:239–243Google Scholar
  45. 45.
    Sen C, Hague K (1997) Meningiomas involving the cavernous sinus: histological factors affecting the degree of resection. J Neurosurg 87:535–543PubMedGoogle Scholar
  46. 46.
    Shi J, Hang C, Pan Y, Liu C, Zhang Z (1999) Cavernous hemangioma in the cavernous sinus. Neurosurgery 45:1308–1314PubMedGoogle Scholar
  47. 47.
    Shin M, Kurita H, Sasaki T, Kawamoto S, Tago M, Kawahara N, Morita A, Ueki K, Kirino T (2001) Analysis of treatment outcome after stereotactic radiosurgery for cavernous sinus meningiomas. J Neurosurg 95:435–439PubMedGoogle Scholar
  48. 48.
    Skeie BS, Enger PO, Skeie GO, Thorsen F, Pedersen PH (2010) Gamma knife surgery of meningiomas involving the cavernous sinus: long-term follow-up of 100 patients. Neurosurgery 66:661–669PubMedGoogle Scholar
  49. 49.
    Song SW, Kim DG, Chung HT, Paek SH, Han JH, Kim YH, Kim JW, Kim YH, Jung HW (2014) Stereotactic radiosurgery for cavernous sinus hemangioma. J Neuro-Oncol 118:163–168Google Scholar
  50. 50.
    Tang X, Wu H, Wang B, Zhang N, Dong YF, Ding J, Dai J, Yu T, Pan L (2015) A new classification and clinical results of gamma knife radiosurgery for cavernous sinus hemangioma: a report of 53 cases. Acta Neurochir 157:961–969PubMedGoogle Scholar
  51. 51.
    Thompson TP, Lunsford LD, Flickenger JC (2000) Radiosurgery for hemangiomas of the cavernous sinus and orbit: technical case report. Neurosurgery 47:778–783PubMedGoogle Scholar
  52. 52.
    Wang X, Mei G, Liu X, Dai J, Li P, Wang E (2012) The role of stereotactic radiosurgery in cavernous sinus hemangioma: a systematic review and meta-analysis. J Neuro-Oncol 107:239–245Google Scholar
  53. 53.
    Yamamoto M, Kida Y, Fukuoka S, Iwai Y, Jokura H, Akabane A, Serizawa T (2010) Gamma knife radiosurgery for hemangiomas of the cavernous sinus: a seven-institute study in Japan. Clinical article. J Neurosurg 112:772–779PubMedGoogle Scholar
  54. 54.
    Yang SY, Park CK, Park SH, Kim DG, Chung YS, Jung HW (2008) Atypical and anaplastic meningiomas: prognostic implications of clinicopathological features. J Neurol Neurosurg Psychiatry 79:574–580PubMedGoogle Scholar
  55. 55.
    Wang Y, Li P, Xin JZ, Yang YX, Wang W (2016) Gamma knife surgery for cavernous sinus hemangioma: a report of 32 cases. World Neurosurg 94:18–25PubMedGoogle Scholar
  56. 56.
    Zhou LF, Mao Y, Chen L (2003) Diagnosis and surgical treatment of cavernous sinus hemangiomas: an experience of 20 cases. Surg Neurol 60:31–36PubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of NeurosurgeryPostgraduate Institute of Medical Education and Research (PGIMER)ChandigarhIndia
  2. 2.Department of Neurosurgery, Nehru HospitalPostgraduate Institute of Medical Education and Research (PGIMER)ChandigarhIndia
  3. 3.Department of RadiotherapyPostgraduate Institute of Medical Education and Research (PGIMER)ChandigarhIndia
  4. 4.Department of Radiodiagnosis and ImagingPostgraduate Institute of Medical Education and Research (PGIMER)ChandigarhIndia
  5. 5.Department of Medical PhysicsPanjab UniversityChandigarhIndia

Personalised recommendations