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Page 12 of 15 Cossu et al. Mini-invasive Surg 2020;4:60 I http://dx.doi.org/10.20517/2574-1225.2020.52

follow-up, transcranial or endoscopic surgery according to the extension of the tumor, radiation therapy,
or the combination of both. The main goal of the treatment is to prevent growth and to avoid or prevent
neurological deficits. For symptomatic meningiomas extending into the antero-inferior portion of the
cavernous sinus, a direct endoscopic transcavernous approach should be preferred. It represents a safe
procedure, with a very low complication rate when patients are carefully selected in a tertiary level
center, with good improvement rates or at least stabilization of cranial neuropathies and endocrinopathy.
Multidisciplinary recommendations for a specific treatment carries an important ethical responsibility and
it is the duty of each surgeon to propose the best management to each patient keeping in mind the risk-
benefit analysis.

TRICKS
1. An endoscopic transcavernous biopsy/partial removal is easily performed when the meningioma is
located in the antero-inferior portion of the CS.
2. Intraoperative neuronavigation and careful understanding of preoperative anatomy are key factors in
safely performing the procedure.
3. Fully endoscopic procedures should be preferred to microscopic procedures performed under
endoscopic assistance for the better panoramic view allowed by the endoscope.
4. Doppler ultrasound is invaluable in localizing the carotid artery inside the tumor and guide tumor
removal.
5. Bony decompression of the optic canal is a key step of the procedure to increase the chance of visual
improvement.
6. Autologous fat can be interposed between the residual tumor and the pituitary gland to limit the risks of
hypopituitarism after adjuvant radiation therapy.
7. A careful reconstruction should be performed to avoid postoperative CSF leakage.
8. Meningiomas better respond to higher dose/fraction of radiation therapy, and a gamma knife/
Cyberknife/Linac treatment should be preferred.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis: Cossu G,
Berhouma M, Messerer M
Performed data acquisition, as well as provided administrative, technical, and material support: Abarca J,
Levivier M, Starnoni D, Daniel RT

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.