Anterior clinoidal meningiomas: functional outcome after microsurgical resection in a consecutive series of 106 patients

Clinical article

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Object

In this study, the authors' goal was to analyze a series of patients treated microsurgically for an anterior clinoid process (ACP) meningioma in regard to long-term functional outcome.

Methods

The authors retrospectively analyzed clinical data in a consecutive series of 106 patients who underwent microsurgical treatment for an ACP meningioma at 2 neurosurgical institutions between 1987 and 2005. The main presenting symptoms of the 84 female and 22 male patients (mean age 56 years) were visual impairment in 54% and headache in 28%. Physical examination revealed decreased visual acuity in 49% and a visual field deficit in 26%. Tumors were primarily resected via a pterional approach. Meningioma extensions invading the cavernous sinus, present in 29% of the patients, were not removed. Complete tumor resection (Simpson Grade I and II) was achieved in 59% of the cases.

Results

Postoperatively, visual acuity improved in 40%, was unchanged in 46%, and deteriorated in 14%. A new oculomotor palsy was observed in 8 patients (8%). Clinical and MR imaging data were available in 95 patients for a mean postsurgical period of 6.9 years (1.5–18 years) and revealed tumor recurrence in 10% and tumor progression after subtotal resection in 38%. Clinical deterioration on long-term follow-up consisting primarily of ophthalmological deficits was observed in 14% of the cases.

Conclusions

Acceptable functional results can be achieved after microsurgical resection of ACP meningiomas; however, long-term treatment remains challenging due to a high tumor recurrence and progression rate.

Abbreviations used in this paper: ACP = anterior clinoid process; CN = cranial nerve; CS = cavernous sinus; EBRT = external-beam radiation therapy; GKS = Gamma Knife surgery; ICA = internal carotid artery; KPS = Karnofsky Performance Scale; MCA = middle cerebral artery; MMA = middle meningeal artery.

Article Information

Address correspondence to: Hischam Bassiouni, M.D., Department of Neurosurgery, Westpfalz-Klinikum GmbH, 67655 Kaiserslautern, Germany. email: hibassiouni@yahoo.de.

Please include this information when citing this paper: published online April 17, 2009; DOI: 10.3171/2009.3.17685.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Sketch showing the main tumor extensions in ACP meningiomas encountered in this series. Anterior extension to the planum sphenoidale and posterior orbital roof in 26% (1). Lateral spread along the sphenoid ridge in 15% (2). Complete involvement of the CS in 29% and of its lateral wall in 13% of the cases. Tumor spread along the petroclival ligament in 27% and extension to the superior orbital fissure in 9% of the patients (3). Growth into the optic canal in 15% of patients (4).

  • View in gallery

    Preoperative T1-weighted axial (A) and coronal (B) contrast-enhanced MR images revealing an ACP meningioma growing into the medial optic canal and involving the CS. The patient had lost vision in the right eye and had a slight exophthalmos. Postoperative 3D CT scan (C) showing resection of the ACP and posterolateral orbital wall with unroofing of the optic canal and superior orbital fissure. Blindness was unchanged, but the exophthalmos regressed after surgery.

  • View in gallery

    Preoperative 3D CT angiogram (A) and contrast-enhanced coronal MR image (B) demonstrating an ACP meningioma displacing the ICA bifurcation and M1 and A1 segments posteriorly. The optic nerve (not shown) was pushed medially. Preoperative bone-window CT scan (C) showing hyperostosis of the ACP on the tumor side (arrow) and aeration of the ACP on the contralateral side (open arrow). Although not required in this case, the latter may be a potential site for CSF fistula if removal of the ACP is anticipated. Coronal contrast-enhanced MR image (D) demonstrating complete removal of the tumor via a pterional craniotomy and resection of the ACP.

  • View in gallery

    Preoperative axial (A) and coronal (B) contrast-enhanced MR images demonstrating a large ACP meningioma that encased the ICA and infiltrated the CS. Anteroposterior view of the left ICA on preoperative catheter angiography (C) demonstrating stretching of the ICA and elevation of the MCA and showing the main vascular supply of the tumor from the meningohypophysial trunk of the intracavernous carotid artery. Postoperative CT scan (D) revealing complete removal of the tumor, except for its intracavernous portion, via a pterional craniotomy; the tumor is being followed up by observation and has not progressed clinically 7.5 years after surgery.

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