Radiosurgical Management of Cavernous Sinus Hemangioma: Systematic Review, Meta-analysis, and International Stereotactic Radiosurgery Society Practice Guideline.

Cavernous sinus hemangiomas (CSHs) are rare benign vascular tumors and surgical resection carries substantial risks of morbidity and mortality. Stereotactic radiosurgery (SRS) and fractionated SRS (FSRS) have emerged as an effective non-invasive surgical alternative; however, appropriate patient selection, dosing, and outcomes remain unclear and underreported. A systematic review and meta-analysis was conducted following PRISMA guidelines to evaluate the efficacy and safety of SRS/FSRS for CSHs. A comprehensive literature search of PubMed and EMBASE was performed of peer-reviewed studies reporting outcomes of SRS or FSRS (≤5 fractions) in patients with histologically or radiographically-confirmed CSH published from January 1999 to August 2024. Primary outcomes included local tumor control (LC) and radiographic response, while secondary outcomes assessed symptom improvement and treatment-related toxicities. A total of 16 studies comprising 324 patients were included: 14 SRS (282 patients) and 2 FSRS (42 patients). The crude LC was 100% in the entire cohort and the pooled substantial radiographic response rate (>50% reduction) was 85.0% (95% CI: 68-94%, I = 67%) for 14 studies. Among those with symptoms (13 studies, 202 patients), the pooled symptom improvement rate was 98.0% (95% CI: 87.0-100.0%, I2 < 1%). Meta-regression revealed a significant positive association between definitive SRS/FSRS and symptom improvement (vs. adjuvant treatment). Treatment-related toxicity was minimal, with only three reported cases of late toxicity and no occurrences of optic neuropathy. Despite significant heterogeneity among the included studies, excellent tumor control was achieved with minimal toxicity. On behalf of the International Stereotactic Radiosurgery Society, consensus clinical practice recommendations are provided to guide patient selection, treatment techniques, and dosing. In summary, we recommend a dose of 12-16 Gy in 1 fraction for tumor control for this entity.