Case description

The patient is a 49-year-old female who presented with nipple discharge, no neurological deficit, and a mildly elevated prolactin level at 60 ng/mL (normal range 2–29 ng/mL). Brain magnetic resonance imaging (MRI) showed a homogenously enhancing suprasellar mass causing pituitary stalk deviation with contiguous extension to the left cavernous sinus ( Figure 4.18.1 ). Hormone replacement with hydrocortisone of 20 mg in the morning and 10 mg in the evening was initiated for 2 weeks prior to surgery. The approach was a surgical debulking via neuronavigated endonasal endoscopy. Postoperative recovery was uneventful, and histopathology confirmed the diagnosis of a meningioma WHO grade I. Residual tumor, which was mostly inside the left cavernous sinus ( Figure 4.18.2 ), was then treated with stereotactic radiosurgery (SRS) 3 months after surgery ( Figure 4.18.3 ).

Postcontrast axial and coronal images showing a homogenously enhancing suprasellar mass with left cavernous sinus invasion, left carotid artery of normal caliber, and mild uplifting of the optic chiasm.

Postcontrast axial, sagittal, and coronal images showing postsurgical changes following resection of the suprasellar meningioma. A residual tumor is also seen mostly within and around the left cavernous sinus. The optic chiasm and pituitary stalk complex are adequately decompressed.

Imaging of the treatment plan and critical dosing.

Critical Structure	Dose Tolerance
Optic nerve/chiasm	25 max per 5 fractions / <0.2cc>20 Gy
Brainstem	31 max per 5 fractions / <1cc>26 Gy
Cranial nerves in cavernous sinus	Unknown but significantly more resistant than optic nerve Can be more sensitive if stereotactic radiosurgery (SRS) follows another form of radiation
Cavernous carotid artery	Very tolerant No evidence of SRS-induced stenosis

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