Results of attempted radical tumor removal and venous repair in 100 consecutive meningiomas involving the major dural sinuses

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Object

Radical removal of meningiomas involving the major dural sinuses remains controversial. In particular, whether the fragment invading the sinus must be resected and whether the venous system must be reconstructed continue to be issues of debate. In this paper the authors studied the effects, in terms of tumor recurrence rate as well as morbidity and mortality rates, of complete lesion removal including the invaded portion of the sinus and the consequences of restoring or not restoring the venous circulation.

Methods

The study consisted of 100 consecutive patients who had undergone surgery for meningiomas originating at the superior sagittal sinus in 92, the transverse sinus in five, and the confluence of sinuses in three. A simplified classification scheme based on the degree of sinus involvement was applied: Type I, lesion attachment to the outer surface of the sinus wall; Type II, tumor fragment inside the lateral recess; Type III, invasion of the ipsilateral wall; Type IV, invasion of the lateral wall and roof; and Types V and VI, complete sinus occlusion with or without one wall free, respectively. Lesions with Type I invasion were treated by peeling the outer layer of the sinus wall. In cases of sinus invasion Types II to VI, two strategies were used: a nonreconstructive (coagulation of the residual fragment or global resection) and a reconstructive one (suture, patch, or bypass). Gross-total tumor removal was achieved in 93% of cases, and sinus reconstruction was attempted in 45 (65%) of the 69 cases with wall and lumen invasion. The recurrence rate in the study overall was 4%, with a follow-up period from 3 to 23 years (mean 8 years). The mortality rate was 3%, all cases due to brain swelling after en bloc resection of a Type VI meningioma without venous restoration. Eight patients—seven of whom harbored a lesion in the middle third portion of the superior sagittal sinus—had permanent neurological aggravation, likely due to local venous infarction. Six of these patients had not undergone a venous repair procedure.

Conclusions

The relatively low recurrence rate in the present study (4%) favors attempts at complete tumor removal, including the portion invading the sinus. The subgroup of patients without venous reconstruction displayed statistically significant clinical deterioration after surgery compared with the other subgroups (p = 0.02). According to this result, venous flow restoration seems justified when not too risky.

Abbreviations used in this paper:CT = computed tomography; DS = digital subtraction; GKS = Gamma Knife surgery; KPS = Karnofsky Performance Scale; MR = magnetic resonance; SRT = stereotactic radiotherapy; WHO = World Health Organization.

Article Information

Address reprint requests to: Marc P. Sindou, M.D., D.Sc., Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Université de Lyon, 59 Boulevard Pinel, 69003 Lyon, France. email: marc.sindou@chu-lyon.fr.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Drawings illustrating a classification scheme for meningiomas according to the type of sinus invasion. Type I, meningioma attached to the outer surface of the sinus wall; Type II, lateral recess invaded; Type III, ipsilateral wall invaded; Type IV, ipsilateral wall and roof of the sinus both invaded; Type V, sinus totally occluded, but the contralateral wall free of invasion; and Type VI, sinus totally invaded with no walls free of invasion.

  • View in gallery

    Representative parasagittal meningioma with Type VI invasion in the posterior third of the sinus. Left: Plain x-ray film, lateral view, showing a major intraosseous collateral venous pathway (ICVP). Right: Venous-phase DS angiogram, lateral view, demonstrating the collateral venous circulation from the superior sagittal sinus (SSS) to the sigmoid sinus (SS). Note complete occlusion (asterisk) of the posterior third of the SSS by the meningioma (M).

  • View in gallery

    Illustrations of parasagittal meningioma with Type IV sinus invasion showing steps in the patching technique. A: Exploration of the sinus lumen through a 3-cm-long opening, which allows identification of the intrasinusal tumor fragment. B: Control of venous bleeding using pledgets of Surgicel. C: Venous reconstruction performed using an autologous patch (Fascia temporalis in this case). F = falx cerebri; LW = lateral wall of SSS; P = patch; R = roof of SSS; S = Surgicel.

  • View in gallery

    Bar graph showing the different surgical modalities performed in our study according to the type of sinus invasion (SI). Ext. = external (or outer).

  • View in gallery

    Type III parasagittal meningioma. A: Preoperative coronal Gd-enhanced T1-weighted MR image showing a right middle-third parasagittal meningioma with Type III invasion from the lateral wall of the sagittal sinus. B: Preoperative venous-phase angiogram, lateral view, demonstrating a patent sinus and tumor blush (star). C: Postoperative coronal Gd-enhanced T1-weighted MR image exhibiting no evidence of tumor remnant. The lateral sinus wall was resected and patched. D: Postoperative venous-phase angiogram, lateral view, showing sinus patency (arrows).

  • View in gallery

    Drawing (left) and postoperative angiogram (right) showing a surgical bypass from the SSS to the external jugular vein (EJV) with an autologous saphenous vein. The patient had harbored a confluence of sinus meningiomas with Type VI invasion, which caused severe intracranial hypertension syndrome with headaches, papilledema, and demential manifestations. The patient experienced a recovery after bypass surgery. VB = venous bypass (saphenous vein).

  • View in gallery

    Graph showing the postoperative functional outcome according to types of tumor invasion and surgical modalities. In Type I, outer layer invasion by the tumor, a simple peeling was accomplished in all cases. In Types II to VI, the different modalities used were classified, for practical purposes, as tumor removal with or without venous reconstruction (VR). Functional status was categorized as follows: good, patient able to carry on normal working activity (KPS Score 80–100); fair, patient unable to work but able to live at home and care for most personal needs (KPS Score 50–70); or bad, patient unable to care for self and requires equivalent of institutional or hospital care (KPS Score < 40).

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