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High incidence of optic canal involvement in clinoidal meningiomas: rationale for aggressive skull base approach

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Abstract

Introduction

Literature specifically focusing on clinoidal meningiomas is scant, particularly with regards to the postoperative visual outcome. In this study, we aimed to document the incidence of optic canal involvement (OCI) by the tumor, its management using a skull base technique, and its significance with relation to the visual outcome.

Materials and methods

Fifty-two patients with clinoidal meningiomas were retrospectively analyzed. In 47 patients, skull base technique consisting of extradural anterior clinoidectomy with falciform ligament and optic nerve sheath opening was performed. Pre-operative visual status and post-operative outcome were analyzed with respect to OCI.

Results

The incidences of OCI was present in 19 (36%) and pre-operative visual deficit (VD) in 24 (46%) patients. With regard to pre-operative visual status, OCI was seen in 14 (58%) of 24 patients with VD, as compared to five (18%) in 28 patients without (p = 0.004). Among the 22 patients with VD and detailed postoperative neuro-ophthalmological evaluation, 17 (77%) had visual improvement, and in five patients (23%), vision was unchanged. In the presence of OCI in 11 patients, vision improved in seven (64%), and remained unchanged in four patients (36%), whereas all but one of the 11 patients (91%) without OCI improved and in the remaining one (9%), remained unchanged. Simpson Grade I and II resection was achieved in 71%.

Conclusion

OCI is observed in 36% of clinoidal meningiomas, and it correlates well with pre-operative visual status. With the use of the skull base technique, without which the tumor in the optic canal could not have been removed completely and safely, visual improvement of 77% and stability of 23% was achieved.

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Acknowledgements

This study was presented in part at the 75th Annual Meeting of the American Association of Neurological Surgeons in Washington, DC on April 17, 2007, and received the Synthes Skull Base Award.

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Authors and Affiliations

  1. Brain Tumor and Neuro-Oncology Center/Neurological Institute, Cleveland Clinic, Cleveland, OH, USA

    Burak Sade & Joung H. Lee

  2. Brain Tumor and Neuro-Oncology Center/Desk R-20, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA

    Joung H. Lee

Authors
  1. Burak Sade
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  2. Joung H. Lee
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Corresponding author

Correspondence to Joung H. Lee.

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Comment

This is an extension of previously published data on the issue of clinoidal menigiomas. Nonetheless, the information and discussion drawn from this considerable sample with regard to optic canal involvement and clinoidal hyperostosis are interesting for the reader of Acta Neurochirurgica.

H.-.J Steiger

University of Dusseldorf

Comment

In this article the authors report a retrospective series of 52 patients operated for clinoid meningioma. The emphasis is on the involvement of the optic nerve and the visual outcome after surgery. Burak et al. exclude other meningiomas from the “parasellar” region like tuberculum sella and sphenoid wing meningioma a factor which makes the group of patients more homogenous. I agree with the technique of drilling the optic canal and decompressing the optic nerve. Not only does it help identify the normal anatomy in an early stage of tumor resection, but it also allows the manipulation of the nerve with less damage.

Like the authors, I also find it hard to predict the involvement of the optic canal based on the preoperative MRI and CT.

The weak point of the study is the number of patients that actually had a detailed visual exam before and after surgery. There were only 22 out of the 52 patients in the series who had the complete visual exam, without which it is hard to interpret the results of the visual status of the patients as a result of surgery.

Nevo Margalit

Tel Aviv Medical Center

Comment

We agree with the authors that the skull base technique described in this article allows for the early identification and decompression of the optic nerve as well as early identification of the carotid artery. The opening of the optic canal and the removal of intracanalicular extensions of the tumor creates the best conditions for visual improvement. We have used the same technique in over 80 patients and obtained similar results. The presence of temporary postoperative oculomotor palsy in 10% of the patients is related to the proximity of the nerve to the anterior clinoid process when coursing through the superior orbital fissure. Careful drilling and copious irrigation should avoid this serious complication.

Felix Umansky

Hadassah Hebrew University Medical Center

Jerusalem, Israel

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Sade, B., Lee, J.H. High incidence of optic canal involvement in clinoidal meningiomas: rationale for aggressive skull base approach. Acta Neurochir (Wien) 150, 1127–1132 (2008). https://doi.org/10.1007/s00701-008-0143-y

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  • DOI: https://doi.org/10.1007/s00701-008-0143-y

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