Hypofractionated stereotactic radiotherapy/radiosurgery versus single-session stereotactic radiosurgery for patients with hemangioma of cavernous sinus: a systematic review, single-arm meta-analysis, and an indirect comparison

BACKGROUND: Cavernous sinus hemangiomas (CSHs) are rare, benign vascular tumors with high morbidity due to their critical location and vascularity. While microsurgical resection was the historical standard, its risks of intraoperative bleeding and cranial nerve deficits have led to the adoption of stereotactic radiosurgery (SRS) and hypofractionated stereotactic radiotherapy (HSRT). This systematic review and meta-analysis evaluate outcomes of these modalities, focusing on tumor control, symptom relief, and safety. METHODS: Following PRISMA guidelines, a systematic search of PubMed, Embase, Web of Science, and Scopus (up to March 2024) identified studies reporting outcomes of SRS or HSRT in CSHs. Eligible studies were assessed for quality using the Joanna Briggs Institute checklist. All statistical analysis was performed using STATA v.17. RESULTS: Twenty studies with 682 patients were included. Tumor volume reduction was substantial, with a pooled estimate of 71% (95% CI: 57-84%) and a standardized mean difference of -2.07 (95% CI: -2.47 to -1.67). Symptom recovery rates were highest with HSRT (64%, 95% CI: 9-119%) compared to SRS (44%, 95% CI: 21-67%). Adverse radiation effects were minimal, with an overall rate of 5% (95% CI: 2-7%). Cranial nerve improvement was observed but varied by nerve and treatment type. CONCLUSION: SRS and HSRT are effective and safe for CSHs, with HSRT showing particular benefits for larger tumors due to fractionation. Future studies should optimize protocols and refine patient selection to maximize therapeutic outcomes. Radiation-based therapies now represent a cornerstone in CSH management.