Primary Versus Adjuvant Stereotactic Radiosurgery for Cavernous Sinus Meningiomas: A Propensity Score-Matched Comparative Analysis.

BACKGROUND AND OBJECTIVES: The initial management of symptomatic cavernous sinus meningioma (CSM) remains a matter of debate. This study compares long-term tumor control and neurological outcomes in patients who underwent either primary stereotactic radiosurgery (SRS) or initial surgery followed by adjuvant SRS for both residual and progressive disease. METHODS: We identified 292 patients with CSM who underwent Gamma Knife radiosurgery between 1987 and 2024 (median follow-up, 77 months). The initial management included 167 patients who underwent primary SRS and 125 patients who had adjuvant SRS after surgical resection. Propensity score matching (1:1) was performed to control for potential selection bias differences, resulting in 150 matched patients. The primary outcomes included tumor control, neurological improvement, and neurological worsening. Kaplan-Meier analysis and logistic regression were performed. RESULTS: Compared with adjuvant SRS, primary SRS was associated with enhanced tumor control (log-rank P = .049) at 5 years (96.5% vs 90.5%) and 10 years (89.5% vs 77.8%). Neurological improvement rates were greater in the primary SRS group (10-year: 39.3% vs 25.2%, log-rank P = .008; odds ratio = 2.84, 95% CI: 1.33-6.07, P = .01), often related to improved abducens nerve function (log-rank P = .025) in primary SRS patients. The risk of neurological worsening was no different between primary and adjuvant SRS patients (P = .995). CONCLUSION: This study provides further evidence that primary SRS is a better option than initial surgery followed by adjuvant SRS for the initial management of patients with symptomatic CSM.