Meningiomas Involving the Sphenoid Wing Outcome after Microsurgical Treatment – A Clinical Review of 73 Cases

Abstract

Objective: Sphenoid wing meningiomas represent a difficult to access subtype of intracranial meningiomas involving important neurovascular structures such as the optic nerve, cavernous sinus or carotid artery. They cause neurological compromises by direct compression of adjacent cranial nerves. Insidious and aggressive dural, bony, and orbital involvement produces several difficulties for adequate resection leading to higher rates of recurrence.

Methods: This retrospective case analysis consists of 73 patients who were surgically treated for meningiomas involving the sphenoid wing, where a pterional approach was performed between April 2001 and February 2006. 51 women and 22 men with a mean age of 59.4 years were operated on. The follow-up period ranged from 3–75 months (mean 29.8 months). Patients were divided into the following groups based on the site of the tumor: group 1: outer part of the sphenoid ridge (lateral, n=16); group 2: middle part of the sphenoid ridge (intermediate, n=5); group 3: inner part of the sphenoid ridge (medial, n=22); and group 4: spheno-orbital meningioma (n=30).

Results: The majority of patients presented with visual impairment (55%), followed by generalized headaches (36%) and visual field defects (33%). Total microscopic tumor resection was achieved in 35 patients (47.9%). Visual acuity improved in 58% of the patients, with 23% returning to normal vision. Preexisting cranial nerve deficits remained unchanged in the majority of patients (79%) and improved in 18%. Temporary new cranial nerve deficits occurred in 6 cases, and 1 patient (1%) developed permanent third nerve palsy. The mortality rate was 3% (2 patients) and the rate of permanent nonvisual morbidity was 7% (5 patients). 12 patients (16%) received postoperative radiotherapy. In 6 of 7 patients who were observed for at least 1 year after radiotherapy, stable tumor volume was noted at the follow-up review (mean 30.2 months, range 16–50 months), which provides a tumor growth control rate of 86%. The overall recurrence rate was 15% (11 of 73 patients).

Conclusion: The result of this study affirms the safety of microsurgical treatment strategies, so that sufficient tumor control can be achieved with minimal morbidity and satisfying functional results in most cases.

Key words

meningioma - tumor recurrence - morbidity - radiotherapy - sphenoid wing

References

• 1 Abdel-Aziz KM, Froelich SC, Dagnew E. et al . Large sphenoid wing meningioms involving the cavernous sinus: conservative surgical strategies for better functional outcomes.  Neurosurgery. 2004;  54 1375-1383 ; discussion 1383–1384
• 2 Adegbite AB, Khan MI, Paine KW. et al . The recurrence of intracranial meningiomas after surgical treatment.  J Neurosurg. 1983;  58 51-56
• 3 Bikmaz K, Mrak R, Al-Mefty O. Management of bone-invasive, hyperostotic sphenoid wing meningiomas.  J Neurosurg. 2007;  107 905-912
• 4 Bonnal J, Thibaut A, Brotchi J. et al . Invading meningiomas of the sphenoid ridge.  J Neurosurg. 1980;  53 587-599
• 5 Carrizo A, Basso A. Current surgical treatment for spheno-orbital meningiomas.  Surg Neurol. 1998;  50 574-578
• 6 Castellano F, Guidetti B, Olivecrona H. Pterional meningiomas “en plaque”.  J Neurosurg. 1952;  9 188-196
• 7 Chan SM, Miles JM. The pathology of meningiomas. In: Al-Mefty O (ed) Meningiomas. 2nd ed. New York, Raven Press; 1995: 37-56
• 8 Chung SB, Kim CY, Park CK. et al . Falx meningiomas: surgical results and lessons learned from 68 cases.  J Korean Neurosurg Soc. 2007;  42 276-280
• 9 Colli BO, Assirati JA, Deriggi DJ. et al . Tentorial meningiomas: follow-up review.  Neurosurg Rev. 2008;  31 421-430
• 10 Colli BO, Carlotti Jr CG, Assirati Jr JA. et al . Parasagittal meningiomas: follow-up review.  Surg Neurol. 2006;  66 ((Suppl. 3)) 20-27 ; discussion 27–28
• 11 Cook AW. Total removal of large global meningiomas at the medial aspect of the sphenoid ridge.  Technical note. J Neurosurg. 1971;  34 107-113
• 12 Cophignon J, Lucena J, Clay C. et al . Limits to radical treatment of spheno-orbital meningiomas.  Acta Neurochir Suppl (Wien). 1979;  28 375-380
• 13 Cristante L. Surgical treatment of meningiomas of the orbit and optic canal: a retrospective study with particular attention to the visual outcome.  Acta Neurochir (Wien). 1994;  126 27-32
• 14 Crompton MR, Gautier-Smith PC. The prediction of recurrence in meningiomas.  J Neurol Neurosurg Psychiatry. 1970;  33 80-87
• 15 Cushing H. The cranial hyperostoses produced by meningeal endotheliomas.  Arch Neurol Psychiatry. 1922;  8 139-154
• 16 Cushing H, Eisenhardt L. Meningiomas: Their Classification, Regional Behaviour, Life History, and Surgical and Results. Springfield, IL, Charles C Thomas; 1938
• 17 Day JD. Cranial base surgical techniques for large sphenocavernous meningiomas: technical note.  Neurosurgery. 2000;  46 754-760
• 18 De Jesús O, Toledo MM. Surgical management of meningioma en plaque of the sphenoid ridge.  Surg Neurol. 2001;  55 265-269
• 19 DeMonte F, Smith HK, al-Mefty O. Outcome of aggressive removal of cavernous sinus meningiomas.  J Neurosurg. 1994;  81 245-251
• 20 Dolenc V. Microsurgical removal of large sphenoidal bone meningiomas.  Acta Neurochir Suppl (Wien). 1979;  28 391-396
• 21 Ducic Y. Orbitozygomatic resection of meningiomas of the orbit.  Laryngoscope. 2004;  114 164-170
• 22 Fohanno D, Bitar A. Sphenoidal ridge meningioma.  Adv Tech Stand Neurosurg. 1986;  14 137-174
• 23 Heufelder MJ, Sterker I, Trantakis C. et al . Reconstructive and ophthalmologic outcomes following resection of spheno-orbital meningiomas.  Ophthal Plast Reconstr Surg. 2009;  25 223-226
• 24 Honeybul S, Neil-Dwyer G, Lang DA. et al . Sphenoid wing meningioma en plaque: a clinical review.  Acta Neurochir (Wien). 2001;  143 749-757
• 25 Jellinger K, Slowik F. Histological subtypes and prognostic problems in meningiomas.  J Neurol. 1975;  208 279-298
• 26 Karnofsky DA, Burchenal JH. The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeod CM (ed). Evaluation of Chemotherapeutic Agents. Columbia Univ Press; 1949: 196
• 27 Mariniello G, Maiuri F, Strianese D. et al . Spheno-orbital meningiomas: surgical approaches and outcome according to the intraorbital tumor extent.  Zentrallbl Neurochir. 2008;  69 ((4)) 175-181
• 28 Maroon JC, Kennerdell JS, Vidovich DV. et al . Recurrent spheno-orbital meningioma.  J Neurosurg. 1994;  80 202-208
• 29 Mathiesen T, Lindquist C, Kihlström L. et al . Recurrence of cranial base meningiomas.  Neurosurgery. 1996;  39 2-7 ; discussion 8–9
• 30 Melamed S, Sahar A, Beller AJ. The recurrence of intracranial meningiomas.  Neurochirurgia (Stuttg). 1979;  22 47-51
• 31 Morokoff AP, Zauberman J, Black PM. Surgery for convexity meningiomas.  Neurosurgery. 2008;  63 427-433 ; discussion 433–434
• 32 Mourits M Ph, Berkelbach van der Sprenkel JW. Orbital meningiomas, the Utrecht experience.  Orbit. 2001;  20 25-33
• 33 Nakamura M, Roser F, Jacobs C. et al . Medial sphenoid wing meningiomas: clinical outcome and recurrence rate.  Neurosurgery. 2006;  58 ((4)) 626-639 ; discussion 626–639
• 34 Nanda A, Vannemreddy P. Recurrence and outcome in skull base meningiomas: do they differ from other intracranial meningiomas?.  Skull Base. 2008;  18 243-252
• 35 Pompili A, Derome PJ, Visot A. et al . Hyperostosing meningiomas of the sphenoid ridge – clinical features, surgical therapy, and long-term observations: review of 49 cases.  Surg Neurol. 1982;  17 411-416
• 36 Reinert M, Babey M, Curschmann J. et al . Morbidity in 201 patients with small sized meningioma treated by microsurgery.  Acta Neurochir (Wien). 2006;  148 1257-1266
• 37 Ringel F, Cedzich C, Schramm J. Microsurgical technique and results of a series of 63 spheno-orbital meningiomas.  Neurosurgery. 2007;  60 214-221 ; discussion 221–222
• 38 Russell SM, Benjamin V. Medial sphenoid ridge meningiomas: classification, microsurgical anatomy, operative nuances, and long-term surgical outcome in 35 consecutive patients.  Neurosurgery. 2008;  62 ((3 Suppl. 1)) 38-50 discussion 50
• 39 Russell DS, Rubinstein LJ. Pathology of Tumors of the Nervous System. London, Edward Arnold; 1977
• 40 Sandalcioglu IE, Gasser T, Mohr C. et al . Spheno-orbital meningiomas: interdisciplinary surgical approach, resectability and long-term results.  J Craniomaxillofac Surg. 2005;  33 260-266
• 41 Scarone P, Leclerq D, Héran F. et al . Long-term results with exophthalmus in a surgical series of 30 sphenoorbital meningiomas.  J Neurosurg. 2009;  111 ((5)) 1069-1077
• 42 Schick U, Bleyen J, Bani A. et al . Management of meningiomas en plaque of the sphenoid wing.  J Neurosurg. 2006;  104 208-214
• 43 Schick U, Dott U, Hassler W. Surgical management of meningiomas involving the optic nerve sheath.  J Neurosurg. 2004;  101 951-959
• 44 Shrivastava RK, Sen C, Costantino PD. et al . Spheno-orbital meningiomas: surgical limitations and lessons learned in their long-term management.  J Neurosurg. 2005;  103 491-497
• 45 Skullerud K, Löken AC. The prognosis in meningiomas.  Acta Neuropathol. 1974;  29 337-344
• 46 Verheggen R, Markakis E, Mühlendyck H. et al . Symptomatology, surgical therapy and postoperative results of spheno-orbital, intraorbital-intracanalicular and optic sheath meningiomas.  Acta Neurochir Suppl. 1996;  65 95-98
• 47 Waga S, Yamashita J, Handa H. [Recurrence of meningiomas (author's transl)].  Neurol Med Chir (Tokyo). 1977;  17 203-208
• 48 Wilson WB. Meningiomas of the anterior visual system.  Surv Ophthalmol. 1981;  26 109-127
• 49 Wright JE, Call NB, Liaricos S. Primary optic nerve meningioma.  Br J Ophthalmol. 1980;  64 553-558
• 50 Yamashita J, Handa H, Iwaki K. et al . Recurrence of intracranial meningiomas, with special reference to radiotherapy.  Surg Neurol. 1980;  14 33-40

Correspondence