Acta Neurochirurgica

, 150:865 | Cite as

Surgical strategies for giant medial sphenoid wing meningiomas: a new scoring system for predicting extent of resection

  • Sanjay Behari
  • Pramod J. Giri
  • Dinesh Shukla
  • Vijendra K. Jain
  • Deepu Banerji
Clinical Article

Abstract

Background

Surgical management of giant medial sphenoid meningiomas (≥5 cm in maximum dimension) is extremely challenging due to their intimate relationship with vital neural structures like the optic nerve, cranial nerves of the cavernous sinus and the cavernous internal carotid artery. Their surgical management is presented incorporating a radiological scoring system that predicts the grade of tumour excision.

Materials and methods

20 patients of giant medial sphenoidal wing meningioma (maximum tumour dimension range: 5.2 to 9.5 cm; mean maximum dimension = 6.12 ± 1.06 cm) with mainly visual and extraocular movement deficits, and raised intracranial pressure, underwent surgery. A preoperative radiological scoring system (range 1–12) was proposed considering tumour volume (using Kawamoto’s method); extension into the surrounding surgical corridors; extent of cavernous sinus invasion (based on the tumour relationship to the cavernous internal carotid artery); associated hyperostosis and/or >50% calcification; and, associated brain oedema. Both the conventional frontotemporal craniotomy (n = 13) and its extension to orbitozygomatic osteotomy (n = 7) were utilized. The cavernous sinus was explored in 4 patients and the hyperostotic sphenoid ridge drilled in five patients.

Findings

Total excision was achieved in nine patients; small tumour remnants within the cavernous sinus, interpeduncular fossa or suprasellar cistern were left in eight patients; and less than 10% of tumour was left in three patients. A patient with a completely calcified meningioma died due to myocardial infarction. When the preoperative radiological score was ≥7, there was considerable difficulty in achieving total tumour excision. A mean follow of 17.58 ± 15.05 months revealed improvement in visual acuity/field defects in three, stabilisation in 11, and deterioration of ipsilateral visual acuity in five patients. Symptoms of raised pressure, cognitive dysfunction, aphasia and proptosis showed improvement.

Conclusion

A relatively conservative approach to these extensive lesions resulted in good outcome in a majority of our patients. Both the standard as well as skull base approaches may be utilized for successful removal of giant medial sphenoidal wing meningiomas. A preoperative radiological score of ≥7 predicts a greater degree of difficulty in achieving complete surgical extirpation.

Keywords

Caverenous sinus Scoring system Meningioma Sphenoid wing Surgical approach Skull base 

Notes

References

  1. 1.
    Abdel Aziz KM, Froliech SC, Cohen PL, Sanam A, Keller IT, Van Loveran HR (2002) The one piece orbitozygomatic approach: the MaCarty burr hole and the inferior orbital fissure as keys to technique and application. Acta Neurochir (Wien) 144:15–42CrossRefGoogle Scholar
  2. 2.
    Al-Mefty O (1990) Clinoidal meningiomas. J Neurosurg 73:840–849PubMedGoogle Scholar
  3. 3.
    Al-Mefty O, Anand VK (1990) Zygomatic approach to skull-base lesions. J Neurosurg 73:668–673PubMedCrossRefGoogle Scholar
  4. 4.
    Al-Mefty O, Ayoubi S, Smith RR (1991) Direct surgery of the cavernous sinus: patient selection. Acta Neurochir Suppl (Wien) 53:117–121Google Scholar
  5. 5.
    Al-Mefty O, Smith RR (1988) Surgery of tumours invading the cavernous sinus. Surg Neurol 30:370–381PubMedCrossRefGoogle Scholar
  6. 6.
    Bonnal J, Thibaut A, Brotchi J, Born J (1980) Invading meningiomas of the sphenoid ridge. J Neurosurg 53:587–599PubMedGoogle Scholar
  7. 7.
    Cook A (1971) Total removal of large global meningiomas of the medial aspect of the sphenoid ridge: technical note. J Neurosurg 34:107–113PubMedGoogle Scholar
  8. 8.
    Cushing H, Eisenhardt L (1938) Meningiomas: their classification, regional behavior, life history, and surgical end results. Charles C Thomas, Springfield, pp 311–319Google Scholar
  9. 9.
    Cusimano M, Sekhar LN, Sen CN, Pomonis S, Wright DC, Biglan A, Jennetta P (1995) The results of surgery for benign tumours of the cavernous sinus. Neurosurgery 37:1–10PubMedCrossRefGoogle Scholar
  10. 10.
    Day JD (2000) Skull base surgical techniques for large sphenocavernous meningiomas: technical note. Neurosurgery 46:754–760PubMedCrossRefGoogle Scholar
  11. 11.
    Day JD, Ginnotta SL, Fukushima T (1994) Extradural temporopolar approach to lesions of the upper basilar artery and infrachiasmatic regions. J Neurosurg 81:230–235PubMedGoogle Scholar
  12. 12.
    De Jesus O, Sekhar LN, Parikh HK, Wright DC, Wagner DP (1996) Long-term follow-up of patients with meningiomas involving the cavernous sinus: recurrence, progression, and quality of life. Neurosurgery 39:915–920PubMedCrossRefGoogle Scholar
  13. 13.
    DeMonte F, Smith H, Al-Mefty O (1994) Outcome of aggressive removal of cavernous sinus meningiomas. J Neurosurg 81:245–251PubMedGoogle Scholar
  14. 14.
    Dolenc VV (1979) Microsurgical removal of large sphenoidal bone meningiomas. Acta Neurochir (Wien) 28(Suppl):391–396Google Scholar
  15. 15.
    Dolenc VV (1983) Direct microsurgical repair of intracavernous vascular lesions. J Neurosurg 58:824–831PubMedGoogle Scholar
  16. 16.
    Dolenc VV (1989) Anatomy of the cavernous sinus. In: Dolenc VV (ed) Anatomy and surgery of the cavernous sinus. Springer, Berlin Heidelberg New York, pp 3–7Google Scholar
  17. 17.
    Dolenc VV, Kregar T, Ferluga M, Fettich M, Morina A (1987) Treatment of tumours invading the cavernous sinus. In: Dolenc VV (ed) The cavernous sinus: a multidisciplinary approach to tumorous and vascular lesions. Springer, Berlin Heidelberg New York, pp 377–391Google Scholar
  18. 18.
    Dufour H, Murracciole X, Metellus P, Regis J, Chinot O, Grisoli F (2001) Long-term tumour control and functional outcome in patients with cavernous sinus meningiomas treated by radiotherapy with or without previous surgery: is there an alternative to aggressive tumour removal? Neurosurgery 48:285–294PubMedCrossRefGoogle Scholar
  19. 19.
    Duma CM, Lunsford LD, Kondziolka D, Harsh GR IV, Flickinger JC (1993) Stereotactic radiosurgery of cavernous sinus meningiomas as an addition or alternative to microsurgery. Neurosurgery 32:699–705PubMedCrossRefGoogle Scholar
  20. 20.
    El-Kalliny M, van Loveren HR, Keller JT, Tew JM Jr (1992) Tumours of the lateral wall of the cavernous sinus. J Neurosurg 77:508–514PubMedGoogle Scholar
  21. 21.
    Hakuba A, Tanaka K, Suzuki T, Nishimura S (1989) A combined orbitozygomatic infratemporal epidural and subdural approach for lesions involving the entire cavernous sinus. J Neurosurg 71:699–704PubMedGoogle Scholar
  22. 22.
    Hirsch WL, Sekhar LN, Lanzino G, Pomonis S, Sen CN (1993) Meningiomas involving the cavernous sinus: value of imaging for predicting surgical complications. AJR Am J Roentgenol 160:1083–1088PubMedGoogle Scholar
  23. 23.
    Inoue T, Rhoton AL Jr, Theele D, Barry ME (1990) Surgical approaches to the cavernous sinus: a microsurgical study. Neurosurgery 26:903–932PubMedCrossRefGoogle Scholar
  24. 24.
    Kawamoto Y, Uozumi T, Kiya K, Fujioka Y, Kurisu K, Kawamoto K, Sugiyama K (1995) Clinicopathologic growth factors of acoustic neuromas. Surg Neurol 43:546–52PubMedCrossRefGoogle Scholar
  25. 25.
    Kawase T, Toya S, Shiobara R, Kimura C, Nakajima H (1987) Skull base approaches for the meningiomas invading the cavernous sinus. In: Dolenc VV (ed) The cavernous sinus: multidisciplinary approach to vascular and tumorous lesions. Springer-Verlag, Vienna, pp 346–354Google Scholar
  26. 26.
    Kleinpeter G, Bock F (1990) Invasion of the cavernous sinus by medial sphenoid meningioma: “Radical” surgery and recurrence. Acta Neurochir (Wien) 103:87–91CrossRefGoogle Scholar
  27. 27.
    Klink D, Sampath P, Miller NR, Brem H, Long DM (2000) Long-term visual outcome after nonradical microsurgery in patients with parasellar and cavernous sinus meningiomas. Neurosurgery 47:24–31PubMedCrossRefGoogle Scholar
  28. 28.
    Knosp E, Perneczky A, Koos WT, Fries G, Matula C (1996) Meningiomas of the space of the cavernous sinus. Neurosurgery 38:434–442PubMedCrossRefGoogle Scholar
  29. 29.
    Kotapka MJ, Kalia KK, Martinez AJ, Sekhar LN (1994) Infiltration of the carotid artery by cavernous sinus meningiomas. J Neurosurg 81:252–255PubMedGoogle Scholar
  30. 30.
    Krisht A, Barnett DW, Barrow DL, Bonner G (1994) The blood supply of the intracavernous cranial nerves: an anatomic study. Neurosurgery 34:275–279PubMedCrossRefGoogle Scholar
  31. 31.
    Lanzino G, Hirsch WL, Pomonis S, Sen CN, Sekhar LN (1992) Cavernous sinus tumours: neuroradiologic and neurosurgical considerations on 150 operated cases. J Neurosurg Sci 36:183–196PubMedGoogle Scholar
  32. 32.
    Larsen JJ, van Loveren HR, Balko MG, Tew JM Jr (1995) Evidence of meningioma infiltration into cranial nerves: clinical implications for cavernous sinus meningiomas. J Neurosurg 83:596–599CrossRefGoogle Scholar
  33. 33.
    Lee JH, Jeun SS, Evans J, Kosmorsky G (2001) Surgical management of clinoidal meningiomas. Neurosurgery 48:1012–1021PubMedCrossRefGoogle Scholar
  34. 34.
    Maroon J, Kennerdell HS, Vidovich DV, Abla A, Sternau L (1994) Recurrent spheno-orbital meningioma. J Neurosurg 80:202–208PubMedGoogle Scholar
  35. 35.
    Mathiesen T, Lindquist C, Kihlstorm L, Karlsson B (1996) Recurrence of cranial base meningiomas. Neurosurgery 39:2–7PubMedCrossRefGoogle Scholar
  36. 36.
    McDermott MW, Durity FA, Rootman J, Woodhurst WB (1990) Combined frontotemporal-orbitozygomatic approach for tumours of the sphenoid wing and orbit. Neurosurgery 26(1):107–116PubMedCrossRefGoogle Scholar
  37. 37.
    Miralbell R, Lingwood RM, De La Monte S, Mirinmanoff RO (1992) The role of radiotherapy in the subtotally resected meningiomas. J Neurooncol 13:157–164PubMedCrossRefGoogle Scholar
  38. 38.
    Nakamura M, Roser F, Jakobs C, Vorkapic P, Samii M (2006) Medial sphenoid wing meningiomas: clinical outcome and recurrence rate. Neurosurgery 58:626–629PubMedCrossRefGoogle Scholar
  39. 39.
    Ojemann R (1992) Medial sphenoid wing (clinoidal) meningiomas. Clin Neurosurgery 40:321–383Google Scholar
  40. 40.
    O’Sullivan MG, van Loveren HR, Tew JM Jr (1997) The surgical resectibility of meningiomas of the cavernous sinus. Neurosurgery 40:238–244PubMedCrossRefGoogle Scholar
  41. 41.
    Perneczky A, Knosp E, Matula C (1988) Cavernous sinus surgery: approach through the lateral wall. Acta Neurochir (Wien) 92:76–82CrossRefGoogle Scholar
  42. 42.
    Pieper DR, Al-Mefty O, Hanada Y, Buechner D (1999) Hyperostosis associated with meningioma of the cranial base: secondary changes or tumour invasion. Neurosurgery 44:742–747PubMedCrossRefGoogle Scholar
  43. 43.
    Risi P, Uske A, de Tribolet N (1994) Meningiomas involving the anterior clinoid process. British J Neurosurg 8:295–305CrossRefGoogle Scholar
  44. 44.
    Roser F, Nakamura M, Jacobs C, Vorkapic P, Samii M (2005) Sphenoid wing meningiomas with osseous involvement. Surg Neurol 64:37–43PubMedCrossRefGoogle Scholar
  45. 45.
    Seifert V, Dietz H (1992) Combined orbito-frontal, sub- and infratemporal fossa approach to skull base neoplasms: surgical technique and clinical application. Acta Neurochir (Wien) 114:139–144CrossRefGoogle Scholar
  46. 46.
    Sekhar LN, Moller AR (1986) Operative management of tumours involving the cavernous sinus. J Neurosurg 64:879–889PubMedGoogle Scholar
  47. 47.
    Sen C, Hague K (1997) Meningiomas involving the cavernous sinus: histological factors affecting the degree of resection. J Neurosurg 87:535–543PubMedGoogle Scholar
  48. 48.
    Shaffrey ME, Dolenc VV, Lanzino GL, Wolcott WP, Shaffrey CI (1999) Invasion of the internal carotid artery by cavernous sinus meningiomas. Surg Neurol 52:167–71PubMedCrossRefGoogle Scholar
  49. 49.
    Tomasello F, de Divitiis O, Angileri F, Salpietro M, d’Avella D (2003) Large sphenocavernous meningiomas: is there still a role for the intradural approach via the pterional-transsylvian route? Acta Neurochir (Wein) 145:273–282CrossRefGoogle Scholar
  50. 50.
    Umansky F, Valarezo A, Elidan J (1994) The superior wall of the cavernous sinus A microanatomical study. J Neurosurg 81:914–920PubMedGoogle Scholar
  51. 51.
    Van Loveren HR, Keller JT, El-Kalliny M, Scodary D, Tew JM Jr (1991) The Dolenc technique for cavernous sinus exploration (cadaveric prosection). J Neurosurg 74:837–844PubMedCrossRefGoogle Scholar
  52. 52.
    Yasargil MG (1996) Microneurosurgery of CNS tumours. In: Yasargil MG (ed) Microneurosurgery, vol. IVB. George Thieme Verlag, New York, p 136Google Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Sanjay Behari
    • 1
  • Pramod J. Giri
    • 1
  • Dinesh Shukla
    • 1
  • Vijendra K. Jain
    • 1
  • Deepu Banerji
    • 1
  1. 1.Department of NeurosurgerySanjay Gandhi Postgraduate Institute of Medical SciencesLucknowIndia

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