Sphenoorbital meningioma: surgical technique and outcome

Clinical article

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Object

The aim of this study was to describe the surgical technique used for removal of sphenoorbital meningiomas in the authors' practice and to review the operative outcome.

Methods

Review of the senior author's practice between 1994 and 2009 revealed 39 patients (mean age 48 years) eligible for this study. Clinical presentation, surgical technique, postoperative outcome, and follow-up data are presented. Surgical technique is detailed, with an emphasis on aggressive removal consisting of drilling of the hypertrophied sphenoid bone, orbital wall, and anterior clinoid process, followed by tumor removal and a wide resection of the involved dura. A simple dural closure without reconstruction of the orbital roof or the lateral wall of the orbit is also described.

Results

Gross-total resection was achieved in 15 cases (38.5%), near-total resection with small residual in the cavernous sinus or periorbita in 20 cases (51.3%), and subtotal resection in 4 cases (10.3%). Postoperative complications included trigeminal hypesthesia in 9 patients, oculomotor palsy in 3 patients, and seizure in 2 patients. Seven patients had recurrence within the mean follow-up period of 40.7 months. Preoperative visual deficits were present in 21 patients (53.8%). Of these, 14 (66.7%) experienced visual recovery to normal levels postoperatively. Statistical analyses revealed preoperative severe visual deficit and sphenoid bone hypertrophy as an independent risk factor and an independent favorable factor, respectively, for a favorable visual outcome. Proptosis was resolved (≤ 2 mm) in 73.5% of the authors' patients. No patient had postoperative enophthalmos.

Conclusions

In the authors' practice, surgery for sphenoorbital meningiomas consists of resection of the orbital/sphenoid intraosseous, intraorbital, and intradural tumor components. The authors believe that aggressive removal of the orbital/sphenoid intraosseous tumor is critical for a favorable visual outcome and tumor control. Furthermore, satisfactory cosmetic results can be achieved with simple reconstruction techniques as described.

Abbreviations used in this paper: ACP = anterior clinoid process; CN = cranial nerve; IMRT = intensity-modulated radiation therapy; SOF = superior orbital fissue; SOM = sphenoorbital meningioma.

Article Information

Address correspondence to: Joung H. Lee, M.D., Brain Tumor and Neuro-oncology Center, Cleveland Clinic, 9500 Euclid Avenue, Desk R20, Cleveland, Ohio 44195. email: leej@ccf.org.

Please include this information when citing this paper: published online December 24, 2010; DOI: 10.3171/2010.10.JNS101128.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Typical radiological features of SOM. Axial (A and B) and coronal (C and D) T1-weighted MR images obtained in a patient with recurrent SOM showing a tumor arising from the sphenoid wing with orbital extension and remarkable hyperostosis.

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    Series of T1-weighted MR images obtained in a patient with a SOM demonstrating significant periorbital involvement (arrowhead in A). Note that the tumor extends into the orbit through the SOF (arrow in B).

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    Intraoperative view of hypertrophied bony protrusion in the pterion.

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    “Interdural” dissection of the temporopolar dura on the left side. Exposure of the middle cranial fossa before (left) and after (right) the sectioning of the meningoorbital band. FL = frontal lobe; GG = Gasserian ganglion; L. Orbit = left orbit; ON = optic nerve; TL = temporal lobe; V1 = ophthalmic nerve; V2 = maxillary nerve; V3 = mandibular nerve.

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    Case 4. Complete total resection of an SOM. A and B: Preoperative CT scans showing hyperostosis in the sphenoid bone and the orbital wall. Hyperostosis extends to the floor of the middle fossa (arrow in B). C: Axial MR image revealing a thin but wide area of dural enhancement along the sphenoid wing. D and E: Immediate postoperative CT scans demonstrating extensive removal of hypertrophied bone. The lesion in the floor of the middle fossa was also removed (arrowhead in E). F: All enhanced lesions at the dura were removed up to the superior orbital fissure and the optic canal.

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    Coronal T1-weighted MR images with enhancement showing the site of recurrence. A and B: Follow-up MR images revealing tumor recurrences (arrows in B) from the dura unresected at the initial surgery. C and D: Postoperative MR images obtained after the second surgery demonstrating complete removal of tumors at the dura.

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    Intraoperative views of resection and dural reconstruction showing wide resection of the intradural tumor with its dural attachment (A), complete removal of the hypertrophied bone and the intradural tumor (B), and dural reconstruction using Dura-Gen reinforced with Gelfoam (C).

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