Elsevier

World Neurosurgery

Volume 101, May 2017, Pages 315-324
World Neurosurgery

Original Article
Transfrontal-Sinus-Subcranial Approach to Olfactory Groove Meningiomas: Surgical Results and Clinical and Functional Outcome in a Consecutive Series of 21 Patients

https://doi.org/10.1016/j.wneu.2017.02.039Get rights and content

Background

The transfrontal-sinus-subcranial approach (TFSSA) allows for direct exposure and removal of olfactory groove meningiomas (OGMs), without any brain retraction. Compared with other skull base approaches (e.g., fronto-orbitobasal, transbasal, subcranial, fronto-orbitozygomatic, and one-and-half approach), it could offer the same advantages but is less invasive.

Objective

We report the results in a series of 21 consecutive patients with OGMs and operated on through TFSSA, to propose a viable alternative approach.

Methods

Mean maximum tumor diameter was 45.9 ± 3.4 mm (range, 25–70 mm). The aim of surgery was Simpson grade I removal. Surgical, clinical, and functional outcomes were reported. Mean follow-up was 87 ± 7 months (range, 36–176 months).

Results

In all patients, magnetic resonance imaging after surgery confirmed complete tumor removal. The recurrence-free survival rate was 100% and 85.7% at 5 and 10 years, respectively. Surgery-related mortality and major morbidity were 0% and 4.8%, respectively. Risk of anosmia significantly correlates with meningioma size (P < 0.001) and smell sense was preserved only in patients with tumors less than 4 cm in maximum diameter (4/7; 57.1%). A significant improvement of Mini Mental Standard Examination score was recorded at follow-up (P < 0.001) and no patients worsened their cognitive profile. Visual function improved in 7/8 (87.5%). Karnofsky Performance Scale score after surgery significantly increased (P < 0.001). According to the Glasgow Outcome Score, good outcome was achieved in 20 patients (95.2%).

Conclusions

Based on reported results, TFSSA allows complete tumor removal with good outcome and low complication rate. It may be proposed as a safe and effective approach to treat large and giant OGMs.

Introduction

After the first successful resection of an olfactory groove meningioma (OGM) in 1885,1 many approaches have been adopted: from bifrontal and pterional routes to skull base approaches to minimize brain retraction, even if the skull base approaches are too time consuming and technically demanding.2, 3, 4, 5, 6, 7, 8, 9 Furthermore other techniques, such as the endoscopic endonasal approach (EEA) and supraorbital approach have been proposed.10, 11, 12, 13, 14, 15, 16, 17, 18 There are 2 main strategies in the treatment of OGMs. Several investigators recommended the removal of only the visible tumor and dural coagulation,19, 20, 21, 22, 23, 24, 25 whereas others suggested an extensive resection of the meningioma, dura, and bone, particularly in young patients, because recurrence is frequent when a massive tumor infiltration into the ethmoid is evident.2, 5, 6, 7, 9, 26, 27

Hyperostosis of underlying bone in OGMs occurred commonly, and it was reported in 17%–78% of cases.6, 10, 16, 25, 28, 29, 30 It is generally accepted that hyperostosis is the result of tumor microinvasion.31 The histologic examinations have shown bone tumor cell infiltration in more than 70% of meningiomas with hyperostosis, probably mediated by a specific pattern of matrix metalloproteinase.32, 33 The frequency of ethmoidal bone invasion (occurring in 15%–73.7% of OGMs) may be supported by the thinness of the cribriform plate.3, 4, 5, 7, 9, 10, 16, 27, 29 The involved bone has to be considered a potential point of recurrence after surgery, shown by the recurrence rate of 30% and 41% reported after 5 and 10 years, respectively.34

Bone invasion is not considered among the World Health Organization (WHO) criteria for grading meningiomas; however, there is some evidence that the extent of bone invasion can influence the clinical behavior of meningiomas and patient outcome.31, 33, 34

Section snippets

Objective and Study Size

Since 2001, the senior author has been using the transfrontal-sinus-subcranial approach (TFSSA), already described,35 to achieve Simpson grade I (SGI) removal in midline anterior cranial base meningiomas, as a less invasive route, compared with other skull base techniques previously adopted. We report a series of 21 OGMs operated through TFSSA, analyzing surgical results, complications, and clinical and functional outcome.

Population and Setting

Twenty-one consecutive patients harboring OGM, operated on through TFSSA from 2001 to 2014 at our institute, were considered. Inclusion criteria were 1) meningiomas originating from the midline anterior cranial fossa, along the dura of the crista galli, cribriform plate, and frontoethmoidal suture, and 2) newly diagnosed meningiomas. Medical charts, surgical records, and radiologic studies of the patients were prospectively collected and retrospectively analyzed. Informed surgical and research

Participants and Descriptive Data

Twelve patients were female (57.1%) and 9 male (42.9%). Patients' age ranged from 28 to 69 years (mean, 54.1 ± 2.5 years). The mean maximum diameter was 45.9 ± 3.4 mm (range, 25–70 mm). Tumors were classified according to their maximum diameter on MRI in small (<4 cm), large (4–6 cm), and giant meningiomas (>6 cm).

Clinical symptoms and signs at presentation are summarized in Table 1. Anosmia was the most frequent sign (11/21; 52.4%) and was related with tumor size (P = 0.02). Visual impairment

Key Results

TFSSA allows removal of the infiltrated dural attachment and drilling the bone beneath the tumor insertion, achieving an SGI resection in all patients in our series, as confirmed at postoperative MRI. The only relapse occurred after long time and the recurrence-free survival at 5 years and 10 years was excellent (100% and 85.7%, respectively).

Reviewing the literature, the heterogeneity of approaches, the lack of distinction in SGI and II for each approach, together with the extreme variability

Conclusions

Given the high rate of complete tumor removal (100%), the relatively few recurrences (4.8%), low major morbidity (4.8%), and no surgery-related mortality, TFSSA seems to be a safe and effective surgical approach when dealing with OGMs. This approach is easy to perform, giving an early direct view of the lesion and early tumor devascularization and obviating brain retraction. Adopting TFSSA, the MMSE, KPS, and GOS scores increased, and visual function recovered in almost all patients. Based on

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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