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

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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.

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Authors and Affiliations

  1. Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India

    Sanjay Behari, Pramod J. Giri, Dinesh Shukla, Vijendra K. Jain & Deepu Banerji

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  1. Sanjay Behari
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  2. Pramod J. Giri
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  3. Dinesh Shukla
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  4. Vijendra K. Jain
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Correspondence to Sanjay Behari.

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Comment

This article describes the neurosurgical practice concerning the management of MMC in Nigeria. Although the authors describe a selected population of MMC patients, several aspects draw attention. First the number of patients with MMC is considerable compared to European countries. The timing of treatment is relatively late (after 7 days), and 5 patients died before treatment. Four patients died of ventriculitis and one patient died of a symptomatic Chiari. Only 18 out of 36 patients required treatment of hydrocephalus of whom 13 patients could be treated with third ventriculostomy. This is a very high success rate of primary endoscopic treatment of hydrocephalus in this patient group while apparently a large number of patients do not develop hydrocephalus at all. The follow-up of these patients has not been mentioned by the authors which may be due to the local circumstances.

The characteristic features of this Nigerian series of patients with MMC treated after one week differs from most series in the literature.Selection bias may be the most probable explanation, but the authors contribute valuable data about their Nigerian practice.

E Hoving

University of Groningen Hospital

Behari et al. reported their experience in the management of giant (max diameter > 5 cm) medial sphenoid wing meningiomas. The series includes 20 patients treated from  January 2003 till January 2007. A gross total excision (grade II in the modified De Monte grading scale) was obtained in 9 patients and a subtotal excision in 11 (Grade IVa in 8 and IVb in 3). The outcome was good in 13 patients, fair in 6. One patient died for a massive myocardial infarction three days after reoperation for an extradural hematoma evacuation. The authors propose a preoperative neuroradiologic scoring system to predict extent of resection.

In my experience medial sphenoid wing meningiomas are an heterogeneous group of tumors. Clinoidal and sphenocavernous both are comprised among medial sphenoid wings, but they have different origin, different clinical and neuroradiological features and need different surgical strategy.

Sphenocavernous meningiomas tend to spread lateral-inferiorly into the middle cranial fossa so that ICA and optic and oculomotor nerves are generally involved later. This difference may explain the huge dimensions they may attain before becoming symptomatic. Moreover, they usually spare the paraclinoid segment of the ICA and proximal control of this vessel can be safely achieved through a pure intradural strategy. These lesions are a formidable challenge for the neurosurgeons and their optimal treatment strategy is nowadays controversial. Some authors advocate a so called conservative approach with resection of the intracranial portion of the tumor without attempting to remove the intracavernous tumor; others suggest a more aggressive approach with extensive bone work, extradural dissection for proximal neurovascular control and resection of the tumor included the intracavernous portion. In my experience a pure intradural strategy aimed at the resection of the intracranial portion gives the patient the best chance of a good neurological outcome, with long-term tumor control provided that the remnant, if present, can be followed up and treated with radiosurgery in case of tumor progression.

The authors stated that their preoperative scoring system is able to predict resectability of these lesions. The score is composed by 5 subheadings: tumor volume, Hyperostosis/calcification, edema, cavernous sinus extension, and extension of the meningioma to extra regions (Sellar/parasellar, Superior orbital fissure-orbit, prepontine-Interpeduncolar cistern-posterior fossa). I believe that this score may be useful although it is not balanced because of the different weight of each subheading. Presence of a hyperostosis or a calcified mass > 50% of the whole tumor volume is per se always, in their series, cause of subtotal resection, while peritumoral edema is not correlated to the degree of resection. Moreover even tumor volume has, in the authors series, and also in my experience, a minor weight in the extent of surgical excision.

However their attempt of identifying factors able to predict extent of resection deserves great consideration by the neurosurgical community. Unfortunately, it is impossible at present to achieve preoperative information on consistency and firm adherence of the tumor to major arteries and perforators. These are important variables limiting often radicality in tumor removal. Although, the authors clearly stated the limitation of such a scoring system, they are to be acknowledged for their experience.

F. Tomasello

Messina, Italy

F.F. Angileri

Messina, Italy

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Behari, S., Giri, P.J., Shukla, D. et al. Surgical strategies for giant medial sphenoid wing meningiomas: a new scoring system for predicting extent of resection. Acta Neurochir (Wien) 150, 865–877 (2008). https://doi.org/10.1007/s00701-008-0006-6

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