case_images: PMC11799716_01
case_images: The images of magnetic resonance imaging (MRI) revealed that the size of the cavernous tumor had increased in the process remarkably. (a and b) The image of MRI at the time of the initial examination. (a) The mass within the cavernous sinus is contrasted on enhanced T1-weighted images (yellow arrowheads). (b) Evan's index was 0.29 at the time of the initial examination of the fluid-attenuated inversion recovery image. (c) The image of MRI before the initial stereotactic radiotherapy. The tumor extends to the right middle cranial fossa. (d-f) The image of MRI before the initial surgery. (d) The tumor extends into the orbit and right middle cranial fossa-enhanced T1-weighted image. (e) Evan's index was 0.35 at the time of the appearance of hydrocephalus. Ventriculomegaly and sylvian fissure dilation were confirmed. (f) On the coronal image, the narrowing of the high convexity/midline subarachnoid spaces and steepening of the callosal angle were confirmed at the time of the appearance of hydrocephalus.
case_images: SNI-16-9-g001.jpg
case_images: PMC11799716_01_SNI-16-9-g001.jpg
case_images: F1
case_images: He was referred to our department with bilateral superior quadrantanopia on physical examination and confirmed right cavernous sinus meningioma (22 mm) [Figure 1a]. Brain magnetic resonance imaging (MRI) revealed no ventricular enlargement [Figure 1b]. MRI showed an increased tumor size of 32 mm [Figure 1c]; hence, stereotactic radiotherapy (SRT) was performed (50.4 Gy/28 Fr). MRI showed a marked increase in the right intraorbital tumor and a slight increase in the right sphenoid wing lesion, with a tumor diameter of 73 mm [Figure 1d]. In addition, the patient presented with gait apraxia by communicating hydrocephalus [Figures 1e and f].
case_images: Operative findings of the initial surgery and immunohistology were revealed. (a) After removing as much of the optic nerve and periocular tumor as possible, the optic nerve transection was performed. (b) The tumor in the middle cranial fossa was removed. (c) Findings in the surgical field after tumor removal. Dura mater was sutured directly as much as possible. (d) Finally, DuraGen  was used to repair the dura mater. (e and f) Pathologic findings of the tumor. (e) Hematoxylin and eosin staining of the tumor revealed meningioma, and original magnification x200, and (f) The MIB-1 labeling index was high at 25%. The immunohistology revealed anaplastic meningioma. The scale bar in (e) and (f) indicates 100 mum. Rt: Right, FL: frontal lobe, TL: Temporal lobe, ICA: Internal carotid artery.
case_images: SNI-16-9-g002.jpg
case_images: PMC11799716_01_SNI-16-9-g002.jpg
case_images: F2
case_images: Preoperative examination revealed a completely blind right eye, so orbital exenteration was performed [Figure 2a]. Concurrently, part of the right middle skull base dura mater to which the tumor had adhered was resected [Figure 2b]. DuraGen  (Integra Life Sciences Corp., Princeton, NJ, USA), which is an artificial dural substitute, was placed over the optic nerve canal for intraorbital repair, and the osteoperiosteal flap was laid and covered over the intraorbital floor, then fixed with fibrin glue [Figures 2c and d]. The postoperative pathology was atypical meningioma [Figures 2e and f].
case_images: (a) The day after his initial surgery, cerebrospinal fluid (CSF) leakage from the right orbit appeared. (b) The tumor was removed except those in the cavernous sinus on enhanced T1-weighted images (left: axial image, right: sagittal image). On the other hand, there was a CSF retention in the orbit (asterisk). (c) Operative findings of the CSF leakage closure. The DuraGen  was not adherent to the optic nerve, and the frontal lobe was exposed. (d) The intraorbital was filled with fat and fascial. (e) Postoperative magnetic resonance imaging confirmed that the orbit was filled with fat (yellow arrowhead). FL: frontal lobe.
case_images: SNI-16-9-g003.jpg
case_images: PMC11799716_01_SNI-16-9-g003.jpg
case_images: F3
case_images: The intraorbital tumor was completely removed, leaving the right cavernous sinus, but there was a postoperative CSF leakage in the orbit [Figures 3a and b]. The middle fossa dural defect and the opened optic nerve canal were replaced with an artificial dural substitute during the initial operation, but they did not adhere and became defective, resulting in a leakage [Figure 3c]. Therefore, the dural defective region was sutured as much as possible, and the intraorbital space was occupied with fat and fascial graft, which was not performed in the initial operation [Figures 3d and e]. Finally, eyelid sutures and lumboperitoneal shunt were performed for hydrocephalus, which eliminated the CSF leakage and improved the hydrocephalus [Figure 3e].