Conquer Your Hesitation and Show the Neurosurgeon’s Valor in “No Man’s Land”! Surgical Tips and Nuances on Giant Cavernous Sinus Hemangioma

Abstract: Background: Because of their location and vascularity, cavernous sinus hemangiomas (CSH) are uncommon, benign vascular diseases that present considerable surgical problems. Even if stereotactic radiosurgery (SRS) is being used more often, surgical excision is still essential for big lesions. One of the large single-center surgical series on CSH utilizing transcavernous microsurgical techniques, and interdural splitting is presented in this work. Methods: A retrospective review of 15 patients who underwent surgery between January 2023 and April 2025 and had CSH confirmed by radiological and histological means was carried out. Analyses were conducted on the following data: Surgical technique, intraoperative blood loss, tumor volume, clinical presentation, demographics, amount of resection, and complications. Additionally included were qualitative observations from the surgeon’s reflections and the operation notes. SPSS 24.0 was used for statistical analysis. Results: Gross total resection (GTR) was achieved in 80% ( n = 12) of patients, and near-total resection (NTR) was achieved in 20% ( n = 3). The mean intraoperative blood loss was significantly lower in the GTR group (1133.3 ± 427.7 mL) compared to the NTR group (1766.7 ± 208.2 mL; P = 0.03). Larger tumor volume positively correlated with higher intraoperative blood loss (r = 0.52, P = 0.04). At 6-month follow-up, 66.7% ( n = 10) of patients showed symptomatic improvement. Postoperative cranial nerve deficits occurred in 13.3% ( n = 2), with no mortality. The extent of resection was not significantly associated with short-term functional outcome ( P = 0.58). Conclusion: The interdural and transcavernous approach is a safe and effective microsurgical technique for resection of gCSH, enabling high rates of total resection with minimal morbidity. Although larger tumor size increases intraoperative bleeding risk, GTR can still be achieved with proper anatomical planning and technique. In select cases, NTR may be a reasonable alternative without compromising short-term neurological outcomes.