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

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  • 1 Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Université Claude-Bernard de Lyon, France; and Department of Neurosurgery, Tulane University, New Orleans, Louisiana
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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.

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Contributor Notes

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.
  • 1

    Auque J: [Venous sacrifice in neurosurgery: risk assessment and management.]. Neurochirurgie 42:Suppl 1 1996. (Fr)

  • 2

    Baird M, & Gallagher PJ: Recurrent intracranial and spinal meningiomas: clinical and histological features. Clin Neuropathol 8:4144, 1989

    • Search Google Scholar
    • Export Citation
  • 3

    Bauman GS, & Wong E: Re: new radiotherapy technologies for meningiomas: 3D conformal radiotherapy? Radiosurgery? Stereotactic radiotherapy? Intensity modulated radiotherapy? Proton beam radiotherapy? Spot scanning proton radiation therapy? Or nothing at all?. Radiother Oncol 73:251252, 2004

    • Search Google Scholar
    • Export Citation
  • 4

    Bederson JB, & Eisenberg MB: Resection and replacement of the superior sagittal sinus for treatment of a parasagittal meningioma: technical case report. Neurosurgery 37:10151019, 1995

    • Search Google Scholar
    • Export Citation
  • 5

    Black PM: Meningiomas. Neurosurgery 32:643657, 1993

  • 6

    Black PM, , Villavicencio AT, , Rhouddou C, & Loeffler JS: Aggressive surgery and focal radiation in the management of meningiomas of the skull base: preservation of function with maintenance of local control. Acta Neurochir 143:555562, 2001

    • Search Google Scholar
    • Export Citation
  • 7

    Bonnal J: [Conservative and reconstructive surgery of the superior longitudinal sinus.]. Neurochirurgie 28:147172, 1982. (Fr)

  • 8

    Bonnal J, & Brotchi J: Surgery of the superior sagittal sinus in parasagittal meningiomas. J Neurosurg 48:935945, 1978

  • 9

    Bonnal J, , Brotchi J, , Stevenaert A, , Petrov VT, & Mouchette R: [Excision of the intrasinusal portion of rolandic parasagittal meningiomas, followed by plastic surgery of the superior longitudinal sinus.]. Neurochirurgie 17:341354, 1971. (Fr)

    • Search Google Scholar
    • Export Citation
  • 10

    Bonnal J, & Buduba C: Surgery of the central third of the superior sagittal sinus. Experimental study. Acta Neurochir 30:207215, 1974

  • 11

    Brawley BW: Determination of superior sagittal sinus patency with an ultrasonic Doppler flow detector in parasagittal meningioma. Technical note. J Neurosurg 30:315316, 1969

    • Search Google Scholar
    • Export Citation
  • 12

    Chan RC, & Thompson GB: Morbidity, mortality and quality of life following surgery for intracranial meningiomas. A retrospective study in 257 cases. J Neurosurg 60:5260, 1984

    • Search Google Scholar
    • Export Citation
  • 13

    Chang JH, , Chang JW, , Choi JY, , Park YG, & Chung SS: Complications after gamma knife radiosurgery for benign meningiomas. J Neurol Neurosurg Psychiatry 74:226230, 2003

    • Search Google Scholar
    • Export Citation
  • 14

    Chin LS, , Szerlip NJ, & Regine WF: Stereotactic radiosurgery for meningiomas. Neurosurg Focus 14:5 E6, 2003

  • 15

    Czernicki Z, , Grochowski W, , Uchman G, , Tychmanowicz K, & Razumowski AE: [Occlusion of the superior sagittal sinus caused by meningioma, intracranial volume-pressure relations and brain edema.]. Neurol Neurochir Pol 25:580586, 1991. (Pol)

    • Search Google Scholar
    • Export Citation
  • 16

    Di Meco F, , Li KW, , Casali C, , Ciceri E, , Giombini S, & Filippini G, : Meningiomas invading the superior sagittal sinus: surgical experience in 108 cases. Neurosurgery 55:12631274, 2004

    • Search Google Scholar
    • Export Citation
  • 17

    Donaghy RMP, , Wallman LJ, , Flanagan MJ, & Numoto M: Sagittal sinus repair. Technical note. J Neurosurg 38:244248, 1973

  • 18

    Flickinger JC, , Kondziolka D, , Maitz AH, & Lunsford LD: Gamma knife radiosurgery of imaging-diagnosed intracranial meningioma. Int J Radiat Oncol Biol Phys 56:801806, 2003

    • Search Google Scholar
    • Export Citation
  • 19

    Gagibov GA, , Karaseva TA, , Kuklina AS, , Naidin VL, & Sokolovskaia IE: [Disorders of motor functions after removal of parasagittal meningiomas.]. Zh Vopr Neirokhir Im N N Burdenko 2:2430, 1985. (Rus)

    • Search Google Scholar
    • Export Citation
  • 20

    Giombini S, , Solero CL, , Lasio G, & Morello G: Inmediate and late outcome of operations for parasagittal and falx meningiomas. Report of 342 cases. Surg Neurol 21:427435, 1984

    • Search Google Scholar
    • Export Citation
  • 21

    Hakuba A, Reconstruction of dural sinus involved in meningiomas. Al-Mefty O: Meningiomas New York, Raven Press, 1991. 371382

  • 22

    Hakuba A: Surgery of the Intracranial Venous System: Embryology, Anatomy, Pathophysiology, Neuroradiology, Diagnosis, Treatment Berlin, Springer, 1996. 619

    • Search Google Scholar
    • Export Citation
  • 23

    Hakuba A, , Huh CW, , Tsujikawa S, & Nishimura S: Total removal of a parasagittal meningioma of the posterior third of the sagittal sinus and its repair by autogenous vein graft. Case report. J Neurosurg 51:379382, 1979

    • Search Google Scholar
    • Export Citation
  • 24

    Hakuba A, , Tsurund T, , Ohata K, , Nagai K, & Matsuoka Y, Microsurgical reconstruction of the intracranial venous system. Hakuba A: Surgery of the Intracranial Venous System: Embryology, Anatomy, Pathophysiology, Neuroradiology, Diagnosis, Treatment Berlin, Springer, 1996. 220225

    • Search Google Scholar
    • Export Citation
  • 25

    Hoessly GF, & Olivecrona H: Report on 280 cases of verified parasagittal meningioma. J Neurosurg 12:614626, 1955

  • 26

    Jaaskelainen J: Seemingly complete removal of histologically benign intracranial meningioma: late recurrence rate and factors predicting recurrence in 657 patients. A multivariate analysis. Surg Neurol 26:461469, 1986

    • Search Google Scholar
    • Export Citation
  • 27

    Kang JK, , Jun SS, , Sung WH, , Park CK, , Kim MC, & Choi CR, Surgical management of meningioma involving the superior sagittal sinus. Hakuba A: Surgery of the Intracranial Venous System: Embryology, Anatomy, Pathophysiology, Neuroradiology, Diagnosis, Treatment Berlin, Springer, 1996. 252259

    • Search Google Scholar
    • Export Citation
  • 28

    Kapp JP, , Gielchinsky I, & Deardourff SL: Operative techniques for management of lesions involving the dural venous sinuses. Surg Neurol 7:339342, 1977

    • Search Google Scholar
    • Export Citation
  • 29

    Kapp JP, , Gielchinsky I, , Petty C, & McClure C: An internal shunt for use in the reconstruction of dural venous sinuses. Technical note. J Neurosurg 35:351354, 1971

    • Search Google Scholar
    • Export Citation
  • 30

    Kondziolka D, , Flickinger JC, & Perez B: Judicious resection and/or radiosurgery for parasagittal meningiomas: outcomes from a multicenter review. Gamma Knife Meningioma Study Group. Neurosurgery 43:405414, 1998

    • Search Google Scholar
    • Export Citation
  • 31

    Kondziolka D, , Nathoo N, , Flickinger JC, , Niranjan A, , Matiz AH, & Lunsford LD: Long-term results after radiosurgery for benign intracranial tumors. Neurosurgery 53:815822, 2003

    • Search Google Scholar
    • Export Citation
  • 32

    Kropp F, , La Motta A, , Landucci C, , Sagratella S, & Scarano P: [Recurrence of parasagittal meningioma after surgical treatment.]. Riv Neurobiol 24:236242, 1978. (Ital)

    • Search Google Scholar
    • Export Citation
  • 33

    Levoshko LI, , Voinov VI, & Korotin VS: [Experience with surgery of parasagittal meningioma.]. Vopr Onkol 45:520522, 1999. (Rus)

  • 34

    Linskey ME, , Davis SA, & Ratanatharathorn V: Relative roles of microsurgery and stereotactic radiosurgery for the treatment of patients with cranial meningiomas: a single-surgeon 4-year integrated experience with both modalities. J Neurosurg 102:Suppl 5970, 2005

    • Search Google Scholar
    • Export Citation
  • 35

    Logue V: Parasagittal meningiomas. Adv Techn Stand Neurosurg 2:171198, 1975

  • 36

    Lunsford LD: Contemporary management of meningiomas: radiation therapy as an adjuvant and radiosurgery as an alternative to surgical removal?. J Neurosurg 80:187190, 1994

    • Search Google Scholar
    • Export Citation
  • 37

    Masuzawa H: [Superior sagittal sinus plasty using flax flap in parasagittal meningioma.]. No Shinkei Geka 5:707713, 1977. (Jpn)

  • 38

    Meirowsky AM: Wounds of the dural sinuses. J Neurosurg 10:496514, 1953

  • 39

    Menovsky T, & De Vries J: Cortical vein end-to-end anastomosis after removal of a parasagittal meningioma. Microsurgery 22:2729, 2002

  • 40

    Merrem G: Parasagittal meningiomas. Fedor Krause memorial lecture. Acta Neurochir 23:203216, 1970

  • 41

    Mirimanoff RO: New radiotherapy technologies for meningiomas: 3D conformal radiotherapy? Radiosurgery? Stereotactic radiotherapy? Intensity modulated radiotherapy? Proton beam radiotherapy? Spot scanning proton radiation therapy? Or nothing at all?. Radiother Oncol 71:247249, 2004

    • Search Google Scholar
    • Export Citation
  • 42

    Mirimanoff RO, , Dosoretz DE, , Linggood RM, , Ojemann RG, & Martuza RL: Meningioma: analysis of recurrence and progression following neurosurgical resection. J Neurosurg 62:1824, 1985

    • Search Google Scholar
    • Export Citation
  • 43

    Murata J, , Sawamura Y, , Saito H, & Abe H: Resection of a recurrent parasagittal meningioma with cortical vein anastomosis: technical note. Surg Neurol 48:592597, 1997

    • Search Google Scholar
    • Export Citation
  • 44

    Nagashima H, , Kobayashi S, , Takemae T, & Tanaka Y: Total resection of torcular herophili hemangiopericytoma with radial artery graft: case report. Neurosurgery 36:10241027, 1995

    • Search Google Scholar
    • Export Citation
  • 45

    Oka K, , Go Y, , Kimura H, & Tomonaga M: Obstruction of the superior sagittal sinus caused by parasagittal meningiomas: the role of collateral venous pathways. J Neurosurg 81:520524, 1994

    • Search Google Scholar
    • Export Citation
  • 46

    Philippon J, , Bataini JP, , Cornu P, , Grob R, , Kujas M, & Poisson M, : [Recurrent meningioma.]. Neurochirurgie 32:Suppl 1 184, 1986. (Fr)

  • 47

    Pollock BE: Stereotactic radiosurgery for intracranial meningiomas: indications and results. Neurosurg Focus 14:5 E4, 2003

  • 48

    Pollock BE, , Stafford SL, , Utter A, , Giannini C, & Schreiner SA: Stereotactic radiosurgery provides equivalent tumor control to Simpson Grade 1 resection for patients with small- to medium-size meningiomas. Int J Radiat Oncol Biol Phys 55:10001005, 2003

    • Search Google Scholar
    • Export Citation
  • 49

    Rogers L, , Jensen R, & Perry A: Chasing your dural tail: Factors predicting local tumor control after gamma knife stereotactic radiosurgery for benign intracranial meningiomas: in regard to Di-Biase, et al: (Int J Radiat Oncol Biol Phys 60:1515–1519, 2004). Int J Radiat Oncol Biol Phys 62:616619, 2005

    • Search Google Scholar
    • Export Citation
  • 50

    Sakaki T, , Morimoto T, , Nakase H, , Hakisaki T, & Hiramatsu K, Revascularization of the dural sinus occluded by a meningioma using the saphenous vein graft. Hakuba A: Surgery of the Intracranial Venous System: Embryology, Anatomy, Pathophysiology, Neuroradiology, Diagnosis, Treatment Berlin, Springer, 1996. 237243

    • Search Google Scholar
    • Export Citation
  • 51

    Sakaki T, , Morimoto T, , Takemura K, , Miyamoto S, , Kyoi K, & Utsumi S: Reconstruction of cerebral cortical veins using silicone tubing. Technical note. J Neurosurg 66:471473, 1987

    • Search Google Scholar
    • Export Citation
  • 52

    Schmid-Elsaesser R, , Steiger HJ, , Yousry T, , Seelos KC, & Reulen HJ: Radical resection of meningiomas and arteriovenous fistulas involving critical dural sinus segments: experience with intraoperative sinus pressure monitoring and elective sinus reconstruction in 10 patients. Neurosurgery 41:10051018, 1997

    • Search Google Scholar
    • Export Citation
  • 53

    Sekhar LN, The exposure, preservation and reconstruction of cerebral arteries and veins during the resection of cranial base tumors. Sekhar LN, & Schmamm VL Jr: Tumors of the Cranial Base: Diagnosis and Treatment Mount Kisko, NY, Futura Publishing Co, 1987. 213226

    • Search Google Scholar
    • Export Citation
  • 54

    Sekhar LN, , Tzortzidis FN, , Bejjani GK, & Schessel DA: Saphenous vein graft bypass of the sigmoid sinus and jugular bulb during the removal of glomus jugulare tumors. Report of two cases. J Neurosurg 86:10361041, 1997

    • Search Google Scholar
    • Export Citation
  • 55

    Simpson D: The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 20:2239, 1957

  • 56

    Sindou M: Meningiomas invading the sagittal or transverse sinuses, resection with venous reconstruction. J Clin Neurosci 8:Suppl 1 811, 2001

    • Search Google Scholar
    • Export Citation
  • 57

    Sindou M, , Alaywan F, & Hallacq P: [Main dural sinuses surgery.]. Neurochirurgie Suppl 1:4587, 1996. (Fr)

  • 58

    Sindou M, & Auque J: The intracranial venous system as a neurosurgeon’s perspective. Adv Tech Stand Neurosurg 26:131216, 2000

  • 59

    Sindou M, & Hallacq P, Microsurgery of the venous system in meningiomas invading the major dural sinuses. Hakuba A: Surgery of the Intracranial Venous System: Embryology, Anatomy, Pathophysiology, Neuroradiology, Diagnosis, Treatment Berlin, Springer, 1996. 226236

    • Search Google Scholar
    • Export Citation
  • 60

    Sindou M, & Hallacq P: Venous reconstruction in surgery of meningiomas invading invading the sagittal and transverse sinuses. Skull Base Surg 8:5764, 1998

    • Search Google Scholar
    • Export Citation
  • 61

    Sindou M, , Hallacq P, , Ojemann RG, & Laws ER, Aggressive vs. conservative treatment of parasagittal meningiomas involving the superior sagittal sinus. Al Mefty O, , Origitano TC, & Harkey HL: Controversies in Neurosurgery New York, Thieme, 1996. 8089

    • Search Google Scholar
    • Export Citation
  • 62

    Sindou M, , Mazoyer JF, , Fischer G, , Pialat J, & Fourcade C: Experimental bypass for sagittal sinus repair. Preliminary report. J Neurosurg 44:325330, 1976

    • Search Google Scholar
    • Export Citation
  • 63

    Sindou M, , Mazoyer JF, , Pialat J, , Fischer G, , Fourcade C, & Descotes J, : [Experimental intracranial venous microsurgery. Bypass of the sagittal sinus for arterial or venous repair and preoperative measurement of the cerebral impedance in the dog.]. Neurochirurgie 21:177189, 1975. (Fr)

    • Search Google Scholar
    • Export Citation
  • 64

    Sindou M, , Mercier P, , Bokor J, & Brunon J: Bilateral thrombosis of the transverse sinuses: microsurgical revascularization with venous bypass. Surg Neurol 13:215220, 1980

    • Search Google Scholar
    • Export Citation
  • 65

    Singh VP, , Kansai S, , Vaishya S, , Julka PK, & Mehta VS: Early complications following gamma knife radiosurgery for intracranial meningiomas. J Neurosurg 93:Suppl 3 5761, 2000

    • Search Google Scholar
    • Export Citation
  • 66

    Stafford SL, , Pollock BE, , Foote RL, , Link MJ, , Gorman DA, & Schomberg PJ, : Meningioma radiosurgery: tumor control, outcomes, and complications among 190 consecutive patients. Neurosurgery 49:10291038, 2001

    • Search Google Scholar
    • Export Citation
  • 67

    Steiger HJ, , Reulen HJ, , Huber P, & Boll J: Radical resection of superior sagittal sinus meningioma with venous interposition graft and reimplantation of the rolandic veins. Case report. Acta Neurochir 100:108111, 1989

    • Search Google Scholar
    • Export Citation
  • 68

    Torres RC, , Frighetto L, , De Salles AA, , Goss B, , Medin P, & Solberg T, : Radiosurgery and stereotactic radiotherapy for intracranial meningiomas. Neurosurg Focus 14:5 E5, 2003

    • Search Google Scholar
    • Export Citation
  • 69

    Waga S, & Handa H: Scalp veins as collateral pathway with parasagittal meningiomas occluding the superior sagittal sinus. Neuroradiology 11:199204, 1976

    • Search Google Scholar
    • Export Citation
  • 70

    Wilkins RH, Parasagittal meningiomas. Al-Mefty O: Meningiomas New York, Raven Press, 1991. 329344

  • 71

    Yamashita J, , Handa H, , Iwaki K, & Abe M: Recurrence of intracranial meningiomas with special reference to radiotherapy. Surg Neurol 14:3340, 1980

    • Search Google Scholar
    • Export Citation

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