Cavernous sinus surgery is considered neurosurgically feasible. A systematic review of patients undergoing cavernous sinus procedures for meningioma was undertaken to determine whether cavernous sinus surgery could be performed with an acceptable level of iatrogenic-induced dysfunction.

Fifty-six patients undergoing 57 cavernous sinus surgical procedures performed by a single senior neurosurgeon were systematically evaluated to determine the consequences of surgery. Quantitative assessment of afferent (acuity, fields, pupil) and efferent function was stressed.

Five of 20 patients (25%) with preoperative optic nerve dysfunction improved, but vision worsened in 6 (30%), including 4 (20%) whose vision deteriorated to no light perception. Four (11%) of 37 patients developed newly acquired optic neuropathy. No patients with preoperative third nerve palsies (19) cleared, although one improved. All 57 patients had evidence of some cranial nerve dysfunction (III, IV, V, or VI) immediately after surgery. Eight patients with long-term follow-up had complete sixth nerve palsies (7 preoperatively), and 4 had complete third nerve dysfunction (none in patients normal preoperatively). Nine (16%) had evidence of aberrant regeneration of the third nerve, and 12 (21%) developed neurotrophic keratitis.

Cavernous sinus surgery results in transient worsening of third, fourth, fifth, and sixth cranial nerve function. Cavernous sinus surgery carries a high risk of worsening ocular motor disorders and producing new ones. Preexisting cranial nerve dysfunction (other than optic nerve) rarely improves. Patients and physicians should be aware of the potential for ophthalmic complications in addition to the more generalized risks of neurosurgery (eg, cerebrospinal fluid leak, infection, stroke).